Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part VI - Health Care Cost Containment Council › Chapter 913 - PAYOR DATA REPORTING REQUIREMENTS › Subchapter A - GENERAL PROVISIONS › Section 913.3 - Definitions

Current through Register Vol. 54, No. 28, July 13, 2024
The following words and terms, when used in this chapter,
					 have the following meanings, unless the context clearly indicates
					 otherwise:
Act
-The Health Care Cost Containment Act
					 (35
					 P. S. §§
											449.1-449.19).
Ambulatory service facility
-A facility
					 licensed in this Commonwealth, not part of a hospital, which provides medical,
					 diagnostic or surgical treatment to patients not requiring hospitalization. The
					 term includes, but is not limited to, ambulatory surgical facilities,
					 ambulatory imaging or diagnostic centers, birthing centers, freestanding
					 emergency rooms and other facilities providing ambulatory care which charge a
					 separate facility charge.
Charge
-The amount billed by a provider
					 for specific goods or services provided to a patient, prior to adjustment for
					 contractual allowances.
Covered services
-Health care services or
					 procedures connected with episodes of illness that require either inpatient
					 hospital care or major ambulatory service, such as surgical, medical or major
					 radiological procedures, including initial and follow-up outpatient services
					 associated with the episode of illness before, during or after inpatient
					 hospital care or major ambulatory service. The term does not include routine
					 outpatient services connected with episodes of illness that do not require
					 hospitalization or major ambulatory service.
Data elements
-Data identified by the
					 Council to be submitted to the Council as part of the Pennsylvania Uniform
					 Claims and Billing Form format.
Executive Director
-The Executive Director
					 of the Council.
Health care facility
or
facility
-The term includes the following:
(i) A general or special hospital, including
				  tuberculosis and psychiatric hospitals.
(ii) Ambulatory service facilities as defined
				  in this section.
Health care insurer
-A person, corporation
					 or other entity that offers administrative, indemnity or payment services for
					 health care in exchange for a premium or service charge under a program of
					 health care services, including:
(i)
				  An insurance company, association or exchange with a certificate of authority
				  to issue health insurance policies in this Commonwealth under sections 616-630
				  of The Insurance Company Law of 1921 (40 P. S. §§
											751-764(a)) but the policies
				  may not include those providing supplemental or indemnity coverage, or
				  both.
(ii) A hospital plan
				  corporation as defined in 40 Pa.C.S. Chapter 61 (relating to hospital plan
				  corporations).
(iii) A professional
				  health services plan corporation as defined in 40 Pa.C.S. Chapter 63 (relating
				  to professional health services plan corporations).
(iv) A health maintenance
				  organization.
(v) A preferred
				  provider organization.
(vi) A
				  fraternal benefit society.
(vii) A
				  beneficial society.
(viii) A
				  third-party administrator.
Health maintenance organization
-An
					 organized system which combines the delivery and financing of health care and
					 which provides basic health services to voluntarily enrolled subscribers for a
					 fixed prepaid fee, as defined in the Health Maintenance Organization Act
					 (40
					 P. S. §§
											1551-1567).
Hospital
-An institution, licensed in this
					 Commonwealth, which is a general, tuberculosis, mental, chronic disease or
					 other type of hospital, or kidney disease treatment center, whether profit or
					 nonprofit. The term includes institutions operated by an agency of State or
					 local government.
Major ambulatory service
-Surgical or
					 medical procedures, including diagnostic and therapeutic radiological
					 procedures, commonly performed in hospitals or ambulatory service facilities,
					 which are not of a type commonly performed or which cannot be safely performed
					 in physicians' offices and which require special facilities such as operating
					 rooms or suites or special equipment such as fluoroscopic equipment or computed
					 tomographic scanners, or a postprocedure recovery room or short-term
					 convalescent room.
Payor
-A person or entity, including health
					 care insurers, purchasers, the Medical Assistance Program in the Department of
					 Public Welfare, and the Federal Medicare Program, that makes direct payments to
					 providers for covered services. With respect to an insurance company,
					 association or exchange, the term includes only those insurers issuing health
					 insurance policies in this Commonwealth under sections 616-630 of The Insurance
					 Company Law of 1921. The health insurance policies may not include those
					 providing supplemental or indemnity coverage, or both.
Pennsylvania Uniform Claims and Billing Form
					 format
-The Uniform Hospital Billing Form UB-82/HCFA-1450, and the HCFA
					 1500, or their successors, as developed by the National Uniform Billing
					 Committee, with additional fields as necessary to provide the data in section 6
					 (c) and (d) of the act (35 P. S. §
											449.6(c) and
					 (d)).
Physician
-An individual licensed under
					 the laws of this Commonwealth to practice medicine and surgery within the scope
					 of the Osteopathic Medical Practice Act (63 P. S.
					 §§
											271.1-271.18) or the Medical
					 Practice Act (63 P. S. §§
											422.1-422.45).
Preferred provider organization
-An
					 arrangement between a health care insurer and providers of health care services
					 which specifies rates of payment to the providers which differ from their usual
					 and customary charges to the general public and which encourage enrollees to
					 receive health services from the providers.
Provider
-A hospital, ambulatory service
					 facility or a physician.
Purchaser
-Corporations, labor
					 organizations and other entities that purchase benefits which provide covered
					 services for their employes or members either through a health care insurer or
					 by means of a self-funded program of benefits, and a certified bargaining
					 representative that represents a group of employes for whom employers purchase
					 a program of benefits which provide covered services. The term does not include
					 health care insurers.