10A N.C. Admin. Code 14H.0103

Current through Register Vol. 39, No. 12, December 1, 2024

Section 14H .0103 - REQUIREMENTS FOR CERTIFICATION

A party desiring to be certified as a statewide data processor shall make a written application to the Division that complies with the following requirements:

(1) The applicant must make a satisfactory showing that it is capable of making available annually to the Division, at no charge, a report which compares the 35 most frequently reported charges of the hospitals and freestanding ambulatory surgical facilities reporting patient data to the applicant during the calendar year. Each annual report shall be due to the Division within 180 days after the end of the calendar year.

(2) The applicant must make a satisfactory showing that it is capable of receiving from hospitals and freestanding ambulatory surgical facilities throughout the State the patient data elements specified in Items (3) through (5) of this Rule.

(3) With regard to patient data concerning inpatients discharged by hospitals, the applicant must make a satisfactory showing that is capable of compiling and maintaining a uniform set of data from the patient data which shall include the following HCFA 1450 (UB-92) data elements for every inpatient discharged regardless of payor:

DATA ELEMENT	DESCRIPTION
(1)	Patient Control Number	Form Locator 3 - As stated in the North Carolina HCFA 1450 Manual
(2)	Bill Type	Form Location 4 - As Stated in the North Carolina HCFA 1450 Manual
(3)	Provider Identification
(A)	Medicaid Base Provider Number	The number assigned to the provider by Medicaid or as assigned by the certified statewide data processor (for batching only)
(B)	Federal Tax Number	Form Locator 5 - As stated in the North Carolina HCFA 1450 Manual
(4)	Zip Code of Patient Address	Form Locator 13 - Only the zip code portion of this field is required. Code as stated in the North Carolina HCFA 1450 Manual
(5)	Patient Birth Date	Form Locator 14 - As stated in the North Carolina HCFA 1450 Manual
(6)	Patient Sex	Form Locator 15 - As stated in the North Carolina HCFA 1450 Manual
(7)	Admission Date	Form Locator 17 - As stated in the North Carolina HCFA 1450 Manual
(8)	Admission Type	Form Locator 19 - As stated in the North Carolina HCFA 1450 Manual
(9)	Source of Admission	Form Locator 20 - As stated in the North Carolina HCFA 1450 Manual
(10)	Patient Status	Form Locator 22 - As stated in the North Carolina HCFA 1450 Manual
(11)	Discharge Date (Statement Covers Period)	Form Locator 6 - As stated in the North Carolina HCFA 1450 Manual
(12)	All Revenue Codes and Associate Charges	Forms Locators 42 and 47 - As stated in the North Carolina HCFA 1450 Manual
(13)	Payer Identification	Form Locator 50a - Classifications code and specific carrier identification code for primary payer
(14)	Certificate/Social Security/Health	Form Locator 60a - As stated in the Insurance Claim/Identification Number North Carolina HCFA 1450 Manual
(15)	Insurance Group Number	Form Locator 62a - As stated in the North Carolina HCFA 1450 Manual
(16)	Principal Diagnosis	Form Locator 67 - As stated in the North Carolina HCFA 1450 Manual
(17)	Other Diagnoses 8	Form Locators 68-75 - As stated in the North Carolina HCFA 1450 Manual
(18)	External Cause of Injury Code (E Code)	Form Locator 77 - As stated in the North Carolina HCFA 1450 Manual/whenever the principal diagnosis is an injury, poisoning or adverse effect
(19)	Principal Procedure and Date	Form Locator 80 - As stated in the North Carolina HCFA 1450 Manual
(20)	Other Procedures and Dates	Form Locator 81a-e - As stated in the North Carolina HCFA 1450 Manual
(21)	Attending Physician Identification	Form Locator 82 - Only the UPIN is required. Code as stated in the North Carolina HCFA 1450 Manual
(22)	Other Physician Identification	Form Locator 83 - Only the UPIN is required. Code as stated in the North Carolina HCFA 1450 Manual

(4) With regard to patient data concerning ambulatory surgery patients released from hospitals and freestanding ambulatory surgical facilities, the applicant must make a satisfactory showing that it is capable of compiling and maintaining a uniform set of data from the patient data which shall include the following HCFA 1450 (UB-92) data elements for every ambulatory surgical patient released regardless of payor:

DATA ELEMENT	DESCRIPTION
(1)	Patient Control Number	Form Locator 3 - As stated in the North Carolina HCFA 1450 Manual
(2)	Bill Type	Form Locator 4 - As stated in the North Carolina HCFA 1450 Manual
(3)	Provider Identification
(A)	Medicaid Base Provider Number	The number assigned to the provider by Medicaid or as assigned by the certified statewide data processor (for batching only)
(B)	Federal Tax Number	Form Locator 5 - As stated in the North Carolina HCFA 1450 Manual
(4)	Zip Code of Patient Address	Form Locator 13 - Only the zip code portion of this field is required. Code as stated in the North Carolina HCFA 1450 Manual
(5)	Patient Birth Date	Form Locator 14 - As stated in the North Carolina HCFA 1450 Manual
(6)	Patient Sex	Form Locator 15 - As stated in the North Carolina HCFA 1450 Manual
(7)	Admission Date	Form Locator 17 - As stated in the North Carolina HCFA 1450 Manual
(8)	Admission Type	Form Locator 19 - As stated in the North Carolina HCFA 1450 Manual
(9)	Source of Admission	Form Locator 20 - As stated in the North Carolina HCFA 1450 Manual
(10)	Patient Status	Form Locator 22 - As stated in the North Carolina HCFA 1450 Manual
(11)	Discharge Date (Statement Covers Period)	Form Locator 6 - As stated in the North Carolina HCFA 1450 Manual
(12)	All Revenue Codes and Associated Charges	Form Locators 42 and 47 - As stated in the North Carolina HCFA 1450 Manual
(13)	Payer Identification	Form Locator 50a - Classification code and specific carrier identification
(14)	Certificate/Social Security/Health	Form Locator 60a - As stated in the Insurance Claim/Identification Number North Carolina HCFA 1450 Manual
(15)	Insurance Group Number	Form Locator 62a - As stated in the North Carolina HCFA 1450 Manual
(16)	Principal Diagnosis	Form Locator 67 - As stated in the North Carolina HCFA 1450 Manual
(17)	Other Diagnoses	8 Form Locators 68-75 - As stated in the North Carolina HCFA 1450 Manual
(18)	External Cause of Injury Code (E-Code)	Form Locator 77 - As stated in the North Carolina HCFA 1450 Manual/whenever the principal diagnosis is an injury, poisoning or adverse effect
(19)	Principal Procedure and Date	Form Locator 80 - As stated in the North Carolina HCFA 1450 Manual
(20)	Other Procedures and Dates	Form Locators 81a-e - As stated in the North Carolina HCFA 1450 Manual
(21)	Attending Physician Identification	Form Locator 82 - Only the UPIN is required. (Code as stated in the North Carolina HCFA 1450 Manual
(22)	Other Physician Identification	Form Locator 83 - Only the UPIN is required. Code as stated in the North Carolina HCFA 1450 Manual

(5) With regard to patient data concerning ambulatory surgery patients released from hospitals and freestanding ambulatory surgical facilities, the application must make a satisfactory showing that it is capable of compiling and maintaining a uniform set of data from the patient data which shall include the following HCFA 1500 data elements for every ambulatory surgical patient released regardless of payor:

(1)	Payer Identification
(2)	Insured's ID Number
(3)	Patient's Date of Birth
(4)	Gender of Patient
(5)	Zip Code of Patient Address
(6)	Diagnosis or Nature of Illness or Injury (1-4)
(7)	Dates of Service
(8)	Place of Service
(9)	Type of Service
(10)	Procedures, Services, and Supplies (including modifiers if applicable)
(11)	Charges
(12)	Days or Units
(13)	Federal Tax ID
(14)	Patient's Account Number
(15)	Total Charge
(16)	Attending Physician's UPIN Number
(17)	Medicaid Base Provider Number or Number Assigned by Certified Statewide Data Processor

(6) The applicant must make a satisfactory showing that it is capable of examining the patient data it receives for accuracy, informing the hospital or freestanding ambulatory surgical facility submitting the patient data of all potential errors in the patient data which are discovered as a result of the examination for accuracy, and correcting the patient data as directed by the hospital or freestanding ambulatory surgical facility. An applicant shall be deemed to have satisfactorily shown that it is capable of examining patient data for accuracy if the applicant has made a satisfactory showing that it is capable of designating a record as an error record when:

(a) A record reported on a HCFA 1450 (UB-92) form contains an invalid or all-blank field for any of the following HCFA 1450 (UB-92) data elements: Patient Control Number, Bill Type, Federal Tax I.D., Zip Code, Date of Birth, Sex, Admission Date, Admission Type, Source of Admission, Patient Status, Statement Covers Period, Revenue Codes and Charges, Primary Payer, Principal Diagnosis, Attending Physician Identification.

(b) A record reported on a HCFA 1500 form contains an invalid or all-blank field for any of the following HCFA 1500 data elements: Payor Identification, Insured's I.D. Number, Federal Tax I.D., Zip Code, Date of Birth, Sex, Dates of Service, Place of Service, Type of Service, Procedures Defined with CPT-HCPCS Code with Modifiers, Principal Diagnosis Codes, Principal and Secondary Surgical Procedure, Patient's Account Number, Attending Physician Identification.

(c) The sum indicated by the data element concerning total charges does not equal the sum of all other charges reported on the record.

(d) An inpatient record reported on a HCFA 1450 (UB-92) contains any of the following data elements which contain an invalid code: Other Diagnoses, Principal Procedure Code and Date, Other Procedure Codes and Dates, External Cause of Injury Code, Other Physician Identification (if a procedure was performed).

(e) An ambulatory surgical patient record reported on a HCFA 1450 (UB-92) form contains any of the following data elements which contain an invalid code: Other Diagnoses, Other Procedure Codes and Dates, External Cause of Injury Code.

(7) The applicant shall make satisfactory showing that it is capable of:

(a) compiling reports from patient data which shall further the purposes of the Medical Care Data Act, as set forth in G.S. 131E-214(b), such as reports enabling a review and comparison of charges, utilization patterns, and quality of medical services;

(b) producing such reports at least on a calendar quarter basis, with reports concerning patients discharged or released during a specific calendar quarter being published at least within 180 days after the end of said calendar quarter;

(c) making such reports available upon request to all interested persons at a reasonable charge.

(8) The applicant shall make a satisfactory showing that it is capable of ensuring that adequate measures will be taken to provide system security for all data and information received from hospitals and freestanding ambulatory surgical facilities.

(9) The applicant shall make a satisfactory showing that it is capable of protecting the confidentiality of patient records and complying with applicable laws and regulations concerning patient confidentiality, including the confidentiality of patient-identifying information, and that it shall not disclose patient-identifying information unless:

(a) the information was originally submitted by the party requesting disclosure; or

(b) the State Health Director requests specific individual records for the purpose of protecting and promoting the public health under G.S. 130A, and the disclosure is not otherwise prohibited by federal law or regulation.

The applicant shall also make a satisfactory showing that it shall make such records available to the State Health Director at a reasonable charge.

10A N.C. Admin. Code 14H .0103

Authority G.S. 131E-214.1(6);
Temporary Adoption effective October 1, 1995 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;
Eff. February 1, 1996;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. January 9, 2018.

Filed as a Temporary Adoption effective October 1, 1995 for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;
Authority G.S. 131E-214.1(6);
Eff. February 1, 1996.