§ 3305 — Data submission and collection

(a) Submission of data.--

(1) The council is authorized to collect and data sources are required to submit, upon request of the council, all data required in this section, according to uniform submission formats, coding systems and other technical specifications necessary to render the incoming data substantially valid, consistent, compatible and manageable using electronic data processing according to data submission schedules. The schedules shall avoid, to the extent possible, submission of identical data from more than one data source. The uniform submission formats, coding systems and other technical specifications may be established by the council pursuant to its authority under section 3304(b) (relating to powers and duties of council). If payor data is requested by the council, it shall, to the extent possible, be obtained from primary payor sources. The council shall not require any data source to contract with any specific vendor for submission of any specific data elements to the council.

(2) In carrying out its responsibilities, the council shall not require health care facilities to report data elements which are not included in the manual developed by the National Uniform Billing Committee. The council shall publish in the Pennsylvania Bulletin a list of no more than 35 diseases, procedures and medical conditions for which data under subsections (c)(22) and (d) shall be required. The list shall not represent more than 50% of total hospital discharges, based upon the previous year's hospital discharge data. Subsequent to the publication of the list, any data submission requirements under subsections (c)(22) and (d) previously in effect shall be null and void for diseases, procedures and medical conditions not found on the list. All other data elements under subsection (c) shall continue to be required from data sources. The council shall review the list and may add no more than a net of three diseases, procedures or medical conditions per year over a five-year period. The adjusted list of diseases, procedures and medical conditions shall at no time be more than 50% of total hospital discharges.

(b) Pennsylvania Uniform Claims and Billing Form.--The council shall maintain a Pennsylvania Uniform Claims and Billing Form format. The council shall furnish the claims and billing form format to all data sources, and the claims and billing form shall be utilized and maintained by all data sources for all services covered by this chapter. The Pennsylvania Uniform Claims and Billing Form shall consist of the Uniform Hospital Billing Form, as developed by the National Uniform Billing Committee, with additional fields as necessary to provide all of the data set forth in subsections (c) and (d).

(c) Data elements.--For each covered service performed in this Commonwealth, the council shall be required to collect the following data elements:

(1) uniform patient identifier, continuous across multiple episodes and providers;

(2) patient date of birth;

(3) patient sex;

(4) patient race, consistent with the method of collection of race/ethnicity data by the United States Bureau of the Census and the United States Standard Certificates of Live Birth and Death;

(5) patient zip code number;

(6) date of admission;

(7) date of discharge;

(8) principal and secondary diagnoses by standard code, including external cause of injury, complication, infection and childbirth;

(9) principal procedure by council-specified standard code and date;

(10) up to three secondary procedures by council-specified standard codes and dates;

(11) uniform health care facility identifier, continuous across episodes, patients and providers;

(12) uniform identifier of admitting physician, by unique physician identification number established by the council, continuous across episodes, patients and providers;

(13) uniform identifier of consulting physicians, by unique physician identification number established by the council, continuous across episodes, patients and providers;

(14) total charges of health care facility, segregated into major categories, including, but not limited to, room and board, radiology, laboratory, operating room, drugs, medical supplies and other goods and services according to guidelines specified by the council;

(15) actual payments to health care facility, segregated, if available, according to the categories specified in paragraph (14);

(16) charges of each physician or professional rendering service relating to an incident of hospitalization or treatment in an ambulatory service facility;

(17) actual payments to each physician or professional rendering service under paragraph (16);

(18) uniform identifier of primary payor;

(19) zip code number of facility where health care service is rendered;

(20) uniform identifier for payor group contract number;

(21) patient discharge status; and

(22) provider service effectiveness and provider quality under section 3304(d).

(d) Provider quality and provider service effectiveness data elements.--In carrying out its duty to collect data on provider quality and provider service effectiveness under subsection (c)(22) and section 3304(d)(5), the council shall define a methodology to measure provider service effectiveness, which may include additional data elements to be specified by the council sufficient to carry out its responsibilities under section 3304(d)(5). The council shall not require health care insurers to report on data elements that are not reported to nationally recognized accrediting organizations, to the Department of Health, the Department of Human Services or the Insurance Department, in quarterly or annual reports. The council shall not require reporting by health care insurers in different formats than are required for reporting to nationally recognized accrediting organizations or on quarterly or annual reports submitted to the Department of Health, the Department of Human Services or the Insurance Department. The council may adopt the quality findings as reported to nationally recognized accrediting organizations. Additional quality data elements must be defined and released for public comment prior to use.

(e) Reserve field utilization and addition or deletion of data elements.--The council shall include in the Pennsylvania Uniform Claims and Billing Form a reserve field. The council may utilize the reserve field by adding other data elements beyond those required to carry out its responsibilities under subsections (c) and (d) and section 3304(d)(4) and (5), or the council may delete data elements from the Pennsylvania Uniform Claims and Billing Form only by a majority vote of the council and only pursuant to the following procedure:

(1) The council shall obtain a cost-benefit analysis of the proposed addition or deletion which shall include the cost to data sources of any proposed additions.

(2) The council shall publish notice of the proposed addition or deletion, along with a copy or summary of the cost-benefit analysis, in the Pennsylvania Bulletin, and the notice shall include a provision for a 60-day comment period.

(3) The council may hold additional hearings or request such other reports as it deems necessary and shall consider the comments received during the 60-day comment period and any additional information gained through the hearings or other reports in making a final determination on the proposed addition or deletion.

(f) Other data required to be submitted.--Each provider is required to submit, and the council is authorized to collect, in accordance with submission dates and schedules established by the council, the following additional data in its possession, provided the data is not available to the council from public records:

(1) Audited annual financial reports of all hospitals and ambulatory service facilities providing covered services as defined in section 3302 (relating to definitions).

(2) The Medicare cost report for Medical Assistance or successor forms, including the settled Medicare cost report.

(3) Additional data, including, but not limited to, data which can be used in reports about:

(i) the incidence of medical and surgical procedures in the population for individual providers;

(ii) physicians who provide covered services and accept medical assistance patients;

(iii) physicians who provide covered services and accept Medicare assignment as full payment;

(iv) mortality rates for specified diagnoses and treatments, grouped by severity, for individual providers;

(v) rates of infection for specified diagnoses and treatments, grouped by severity, for individual providers;

(vi) morbidity rates for specified diagnoses and treatments, grouped by severity, for individual providers;

(vii) readmission rates for specified diagnoses and treatments, grouped by severity, for individual providers;

(viii) rate of incidence of postdischarge professional care for selected diagnoses and procedures, grouped by severity, for individual providers; and

(ix) data from other public sources.

(4) Any other data the council requires to carry out its responsibilities under section 3304(d).

(g) Review and correction of data.--The council shall provide a reasonable period for data sources to review and correct the data submitted under this section which the council intends to prepare and issue in reports to the General Assembly, to the general public or in special studies and reports under section 3309 (relating to special studies and reports). When corrections are provided, the council shall correct the appropriate data in its data files and subsequent reports.

(h) Allowance for clarification or dissents.--The council shall maintain a file of written statements submitted by data sources who wish to provide an explanation of data that they feel might be misleading or misinterpreted. The council shall provide access to the file to any person and shall, where practical, in its reports and data files indicate the availability of such statements. When the council agrees with such statements, it shall correct the appropriate data and comments in its data files and subsequent reports.

(i) Allowance for correction.--The council shall verify the patient safety indicator data submitted by hospitals under subsection (c)(8) within 60 days of receipt. The council may allow hospitals to make changes to the data submitted during the verification period. After the verification period, but within 45 days of receipt of the adjusted hospital data, the council shall risk adjust the information and provide reports to the patient safety committee of the relevant hospital.

(j) Availability of data.--Nothing in this chapter shall prohibit a purchaser from obtaining from its health care insurer, nor relieve the health care insurer from the obligation of providing the purchaser, on terms consistent with past practices, data previously provided or additional data not currently provided to the purchaser by the health care insurer pursuant to any existing or future arrangement, agreement or understanding.

Legislative History

Cross References.Section 3305 is referred to in sections 3302, 3304, 3306, 3308, 3310 of this title.