Pennsylvania Code › Title 28 - HEALTH AND SAFETY › Part VI - Health Care Cost Containment Council › Chapter 911 - DATA SUBMISSION AND COLLECTION › Subchapter A - STATEMENT OF POLICY › Section 911.1 - 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. The term does not include the offices of private
					 physicians or dentists, whether for individual or group practice.
Council
-The Health Care Cost Containment
					 Council.
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 source
-The term includes, but is not
					 limited to, the following:
(i) A
				  hospital.
(ii) An ambulatory
				  service facility.
(iii) A
				  physician.
(iv) A health
				  maintenance organization as the term is defined in the Health Maintenance
				  Organization Act (40 P. S. §§
											1551-1567).
(v) A hospital, medical or health service
				  plan with a certificate of authority issued by the Insurance Department,
				  including, but not limited to, hospital plan corporations as defined in 40
				  Pa.C.S. Chapter 61 (relating to hospital plan corporations) and professional
				  health services plan corporations as defined in 40 Pa.C.S. Chapter 63 (relating
				  to professional health services plan corporations).
(vi) A commercial insurer with a certificate
				  of authority issued by the Insurance Department providing health or accident
				  insurance.
(vii) A self-insured
				  employer providing health or accident coverage or benefits for employes
				  employed in this Commonwealth.
(viii) An administrator of a self-insured or
				  partially self-insured health or accident plan providing covered services in
				  this Commonwealth.
(ix) A health
				  and welfare fund that provides health or accident benefits or insurance
				  pertaining to covered service in this Commonwealth.
(x) The Department of Public Welfare for
				  those covered services it purchases or provides through the Medical Assistance
				  program under the Public Welfare Code (62 P. S. §§
											101-1411).
(xi) Other payors for covered services in
				  this Commonwealth other than an individual.
External cause code (E code)
-The
					 classification of environmental events, circumstances and conditions as the
					 cause of injury, poisoning and other adverse effects. An external cause of
					 injury is an injury which can be assigned an E code. The E code classification
					 should be used as an additional code for more detailed analysis.
Health care facility
-The term includes,
					 but is not limited to, the following:
(i) A general or special hospital, including
				  tuberculosis and psychiatric hospitals.
(ii) Kidney disease treatment centers,
				  including freestanding hemodialysis units.
(iii) Ambulatory service facilities as
				  defined in this section.
(iv)
				  Hospices, both profit and nonprofit, and including those operated by an agency
				  of State or local government.
Hispanic/Latino origin or
					 descent
-Hispanic/Latino refers to people whose origins are from Spain,
					 Mexico or the Spanish-speaking countries of Central or South America. Origin
					 can be viewed as the ancestry, nationality, lineage or country in which the
					 person or the person's ancestors were born before arrival in the United
					 States.
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, and including those operated by an agency of State or local
					 government.
Major ambulatory service
-Surgical or
					 medical procedures. The term includes, but is not limited to, 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 a physician's office 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.
Patient severity
-A measure of severity of
					 illness as defined by the Council using appropriate clinical findings, such as
					 physician examinations, radiology findings, laboratory findings and pathology
					 findings or any other relevant clinical factors.
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 statutes of the 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).
Provider
-A hospital, or an ambulatory
					 service facility or a physician.
The provisions of this §
												911.1 amended under the Health
						Care Cost Containment Act (35 P. S. §§
													449.1-449.19).