proposed rule(s) filing form · (b) each astc and odc must report to the department all cms-1500...

Department of State Division of Publications 312 Rosa L Parks Avenue, 8th Floor SnodgrassfTN Tower Nashville, TN 37243 Phone: 615-7 41-2650 Fax: 615-741-5133 Email: [email protected]

----------------

For Department of State Use Only

Sequence Number: D / ~ )__0 --{ J Rule ID(s): ,520 7 File Date: I/ 2fl/(]

Effective Date: /12/ ~ 0 / 13

Proposed Rule(s) Filing Form Proposed rufes are submitted pursuant to T. C.A. §§ 4-5-202, 4-5-207 in Heu of a rulemaking hearing. It is the intent of the Agency to promulgate these rules without a rulemaking hearing unless a petition requesting such hearing is filed within sixty (60) days of the first day of the month subsequent to the filing of the proposed rule with the Secretary of State. To be effective, the petition must be filed with the Agency and be signed by twenty-five (25) persons who will be affected by the amendments, or submitted by a municipality which will be affected by the amendments, or an association of twenty-fwe (25) or more members, or any standing committee of the General Assembly. The agency shall fonvard such petition to the Secretary of State.

~gency/Board/Commission: I Offic~-Off'91icy, Planning_ Division: Health Statistics

and Assessment

Contact Person: Teresa Hendricks Address: 425 5th A_venue North, Na shville T,.N-'--------

Zip: 37243 Phone: 615-741-1954 Email: [email protected]

~------

Revision Type (check all that apply): Amendment

X New _L__ Repeal

Rule(s) Revised (ALL chapters and rules contained in filing must be listed here. If needed, copy and paste additional tables to accommodate multiple chapters. Please enter only ONE Rule Number/Rule Title per row)

Chapter Number Chapter Title 1200-07-04 Ambulatory SurQical Treatment Center Data System ---.. .- ---Rule Number Rule Title 1200-07-04-.01 Definitions 1200-07-04-.02 Purpose ~;--

Reporting Requirements - _.,_ --

1200-07-04-.03 1200-07-04-.04 Required Data Elements 1200-07-04-.05 Submission Schedule -·-- _,. --1200-07-04-.06 Penalty Assessment 1200-07-04-.07 Vendor Requirements 1200-07-04-.08 \ Processing and Verification

----·

~:07-04-.09 Data Availability 1200-07-04-.10 I Confidential Information

SS-7038 (September 2011) 1 RDA 1693

(Place substance of rules and other info here. Statutory authority must be given for each rule change. For information on formatting rules go to http://state.tn.us/soslrules/1360/1360.htm)

Rules of Tennessee Department of Health

Bureau of Health Informatics Office of Health Statistics

Chapter 1200-07-04 Ambulatory Surgical Treatment Center Data System is repealed.

Authority: T.C.A. §§ 68-1-103 and 68-1-119.

New

Rules of Tennessee Department of Health

Office of Policy, Planning and Assessment Division of Health Statistics

Chapter 1200-07-04 Ambulatory Surgical Treatment Center Data System and

Outpatient Diagnostic Center Data System

1200-07-04-.01 Definitions 1200-07-04-.02 Purpose 1200-07-04-.03 Reporting Requirements 1200-07-04-.04 Required Data Elements 1200-07-04-.05 Submission Schedule 1200-07-04-.06 Vendor Requirements 1200-07-04-.07 Processing and Verification 1200-07-04-.08 Penalty Assessment 1200-07-04-.09 Data Availability 1200-07-04-.1 0 Confidential Information

1200-07-04-.01 Definitions

(1) "Ambulatory Surgical Treatment Center" shall have the same definition as contained in T.C.A. § 68-11-201.

(2) "ASTC" is the acronym for ambulatory surgical treatment center.

(3) "Claim" shall mean a charge or bill for services rendered, billed to the patient, to another private individual, or to a third party payer, public or private.

(4) "Claims Data" shall mean all data elements collected for all patients for whom an ASTC or ODC provides services that are entered on any claim form prepared by the ASTC or ODC and shall always include those required data elements identified in the subparagraphs listed in rule 1200-07-04-.04, paragraphs (1) and (2).

(5) "CMS-1500" shall mean the claim form "Centers for Medicare & Medicaid Services 1500" or its successor form.

(6) "Commissioner" shall mean the commissioner of the Tennessee Department of Health.

(7) "Data Element" shall mean any individual piece of information collected from a patient by an


ASTC or ODC during the process of providing services to that patient for which the ASTC or ODC will file a claim.

(8) "Department" shall mean the Tennessee Department of Health.

(9) "Erro~· shall mean data that are incomplete or inconsistent with the specifications in the ASTC Data System Procedural Manual, the ODC Data System Procedural Manual, or these rules.

(1 0) "Final Joint Annual Report" shall mean the most recent Joint Annual Report filed by an ASTC or ODC where the data contained in the report have been edited, queried, and updated when appropriate, by the Department.

(11) "JAR" is the acronym for Joint Annual Report.

(12) "ODC" is the acronym for outpatient diagnostic center.

(13) "Outpatient Diagnostic Cente~· shall have the same definition as contained in T.C.A. §68-11-201.

(14) "Personal Identifiers" shall be defined to include all the identifiers contained in 45 C.F.R. § 164.514 (b) or (e).

(15) "Processed Data" shall mean data that have been analyzed by the Department or the Department's designated data vendor(s) and errors, inconsistencies, and/or incomplete elements in the data set, if any, have been identified.

(16) "Public" shall mean anyone other than the Tennessee Department of Health, its vendors, and its contracted agencies.

(17) "Record Level Data" shall mean a set of data that is specific to individual patient claims.

(18) "State" shall mean the government of the State of Tennessee including all its agencies.

(19) "UB-04" shall mean the CMS Form 1450, [a.k.a. "the Uniform Hospital Billing Form'], or its successor forms as established by the National Uniform Billing Committee and the State Uniform Billing Implementation Committee.

(20) "Vendor' shall mean a third party entity, approved by the Department, through whom an ASTC or ODC submits its claims data for the purpose of compilation and editing according to these rules and the instructions of the Department.

(21) "Verified Data" shall mean data that have been processed by the Department after the ASTCs or ODCs have had the opportunity to suggest corrections and/or deletions, and all appropriate revisions have been made to the data and approved by the Department.


1200-07-04-.02 Purpose

(1) The reporting of ambulatory surgical and outpatient diagnostic data will provide two statewide databases and permit assessment of variations in utilization, practice parameters, access to care, and charges.


1200-07-04-.03 Reporting Requirements

(1) Each ASTC and ODC shall contract with one of the approved vendors and shall report through its vendor all its claims data. Claims data for all free or charity services provided by any ASTC or ODC that otherwise submits claims for reimbursement shall also be reported to the vendor.


(2) No claim reporting is required for any of the following:

(a) From a licensed ASTC or ODC that provides only free care and never bills for any services.

(b) Regarding any procedures already reported by an ASTC or ODC to the Department under T.C.A. § 68-3-505 or services ancillary thereto such as counseling, testing, or follow-up.

(3) The Department will prepare the ASTC and ODC Data System-Procedural Manuals that will list the variables to be reported, their descriptions and reporting format, and other information associated with data submission. The Department shall issue revisions to the Procedural Manuals when the Commissioner deems it necessary. The Department will notify each ASTC, ODC, and vendor of all revisions. These revisions become effective one hundred and eighty (180) days following the date of notification. At that time, failure to meet the amended requirements is subject to the penalties as prescribed by T.C.A. §68-1-119.

(4) Each ASTC or ODC shall report all data elements using the actual values used for billing by the ASTC or the ODC. No data elements shall be encrypted or otherwise altered. This rule shall not be interpreted to prevent encryption of entire files for security in transmission to parties having the appropriate decryption software.

(5) Each ASTC and ODC shall be responsible for submitting its data to the approved vendor in a format and medium approved by the State.

(6) Each ASTC and ODC shall be responsible for the costs associated with the processing of the data by the approved vendors.

(7) Each ASTC and ODC shall report in a format using the data elements which correspond with the claim form used by the ASTC or ODC for billing. If an ASTC or ODC submits claims using both the CMS-1500 and UB-04 forms, the claims data shall be submitted in separate data sets for each form.

(8) Each ASTC and ODC shall report the claims data at least quarterly, pursuant to rule 1200-07-04-.05, to its approved vendor with a separate data set for each facility location.

(9) Each ASTC and ODC shall designate one staff member to be responsible for reporting the claims data and shall notify the Department and its approved vendor of the name, title, work address, work telephone number, and e-mail address of the designated staff member.


1200-07-04-.04 Required Data Elements

(1) CMS-1500 Claims Forms

(a) Each ASTC and ODC must report to the Department all the following data elements for each and every claim based on the CMS-1500 form:

1. Patient's Birth Date

2. Patient's Sex

3. Patient's Address (State)

4. Patient's Address (Zip Code)

5. Dates of Service (Through Date)


6. Diagnosis or Nature of Illness or Injury

7. Total Charge

8. Patient's Social Security Number

9. Patient's Race/Ethnicity

(b) Each ASTC and ODC must report to the Department all CMS-1500 data elements listed in the relevant ASTC or ODC Procedural Manual whenever the data element is collected by the ASTC or ODC and/or used for billing.

(2) UB-04 Claims Forms

(a) Each ASTC and ODC must report to the Department all the following data elements for each and every claim based on the UB-04 form:

1. Statement Covers Period



4. Patient's Date of Birth

5. Patient's Sex

6. Revenue Codes

7. Total Charges (By Revenue Code Category)

8. Principal Diagnosis Code



(b) Each ASTC and ODC must report to the Department all UB-04 data elements listed in the relevant ASTC or ODC Procedural Manual whenever the data element is collected by the ASTC or ODC and/or used for billing.

(3) Each ASTC and ODC shall report to the Department all data elements that it collected from patients and which it reported by making an entry in any or all of the data element spaces contained on any form other than the CMS-1500 or UB-04 on which it submits a claim. However, the data elements identified in paragraphs (1)(a) and (2)(a) above that must be collected, entered and reported to the Department by the ASTC or ODC for the identified claim form shall also be reported to the Department when any other claim form is used.

(4) Data elements collected by the ASTC or ODC that are not specifically identified in either paragraphs (1) through (3) of this rule or in the procedural manual shall not be reported to the vendor or the Department.


1200-07-04-.05 Submission Schedule

(1) Each ASTC or ODC shall submit all required claims to its approved vendor according to the following quarterly schedule:


Quarter Time Soan Submission Due Date Q1 Januarv 1 -March 31 Mav30 Q2 APril1 -June 30 Au~ust29

Q3 Julv 1 - Seotember 30 November 29 Q4 October 1 -December 31 March 1


1200-07-04-.06 Vendor Requirements

(1) An applicant desiring to be approved as a statewide data processing vendor shall make written application to the Department. To be selected as a statewide vendor by the Department the applicant must demonstrate the ability to do all of the following:

(a) Process the claims data as specified by the Department using the codes and the standards for completeness and quality specified by the Department.

(b) Include in each claims data record the JD number approved by the Department for the reporting ASTC or ODC and all vendor-generated fields specified by the Department.

(c) Examine the claims data it receives for accuracy, inform the ASTC or ODC submitting the data of all potential errors in the data which are discovered as a result of the examination of accuracy, and correct the data as directed by the ASTC, the ODC, and/or the Department.

(d) Submit the claims data to the Department in an electronic or magnetic medium or process approved by the Department.

(e) Report to the Department each ASTC or ODC that has either failed to submit claims data or is tardy in doing so.

(f) Affirm that it is familiar with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its accompanying regulations, and will comply with all applicable and current HIPAA requirements in the course of doing business with the State. The applicant shall affirm that it will cooperate with the State in the course of its performance so that both parties will be in compliance with HIPAA, including cooperation and coordination with State privacy officials and other compliance officers required by HIPAA and its regulations. The applicant will sign any documents that are reasonably necessary to keep both parties in compliance with HIPAA, including, but not limited to, business associate agreements.

(2) If any approved vendor fails to carry out its requirements as specified in the rules of the Tennessee Department of Health, the Department may remove its approval as a statewide data processing vendor.


1200-07-04-.07 Processing and Verification

(1) Each vendor must review all claims data submitted for completeness and accuracy. If errors, inconsistencies or incomplete elements are identified by the vendor, the vendor must report the errors to the ASTC or ODC in writing.

(2) Upon receiving written notification of errors, the ASTC or ODC shall investigate the problem and shall supply correct information to the vendor within fifteen (15) days from notification.


(3) Each approved vendor must report quarterly to the Department the reporting status of all ASTCs or ODCs utilizing its services. The status of facilities that failed to report, that were delinquent in reporting, or that exceeded the acceptable error rate shall be provided to the Department quarterly and then updated at the initiative of the vendor or upon request of the Department. Each vendor shall maintain and report to the Department any information the Department deems necessary for penalty assessment.

(4) Each approved vendor must report all data received each quarter, including additions and corrections, to the Department no more than sixty (60) days following the submission due date specified in rule 1200-07-04-.05.

(5) Each ASTC and ODC shall be given a ten (10) day period to review the quarterly data set relating to their facility after the quarterly data have been computerized, edited, updated, and determined to be the final corrected set by the Department. Upon the expiration of the ten (10) day period, absent receipt of corrections and/or revisions from an ASTC or ODC, the quarterly data is considered verified. If corrections and/or revisions are received by the Department within the ten day period, the quarterly data is considered verified only after the Department has made any corrections and/or revisions it considers appropriate.


1200-07-04-.08 Penalty Assessment

(1)

(2)

(3)

(4)

(5)

(6)

The Department will assess the civil penalties authorized by T.C.A. § 68-1-119(b) each day claims data are reported later than the submission due date identified in rule 1200-07-04-.05 or not reported at all up to the statutory maximum for each claim record.

Any ASTC or ODC not submitting any claims data by the submission deadline will have the number of quarterly unreported claims records calculated, for purposes of civil penalty assessment, by dividing by four (4), the number of total discharges or admissions reported on Schedule D (Availability and Utilization of Services) of the most current final JAR of the ASTC or ODC on file with the Department for that facility.

An ASTC or ODC not submitting any claims data by the submission deadline will begin accruing penalties the day immediately following the submission deadline and ending the day when the actual claims data are received by the vendor or the maximum penalty is reached.

The Department will report the rate of error it identifies to the ASTC or ODC in writing. The acceptable error rate will be two percent (2%). Records that fall within the acceptable error rate will not be subject to penalties. ASTCs or ODCs that exceed the acceptable error rate will be penalized based on total errors.

An ASTC or ODC that does not timely submit corrected claims records will accrue delinquent penalties starting the sixteenth (161

h) day after error notification and ending the day when the actual corrected claims data are received by the Department or the maximum penalty is reached.

Upon receipt of the notice of civil penalty assessment the ASTC or ODC has the right to an informal conference with the Commissioner or a formal hearing to contest the assessment.

(a) Informal conferences are governed by T.C.A. § 68-1-119(b) and (c).

(b) A request for a formal hearing must be made in writing and received by the Department within thirty (30) days of the receipt of the notice of assessment or, if an informal conference pursuant to subparagraph (a) was requested, within thirty (30) days of the receipt of the written disposition of the informal conference. Proceedings involving formal contests of civil penalties are subject to the contested case provisions of the Uniform Administrative Procedures Act.

(c) Civil penalties for any ASTC or ODC that continues to violate the law during the pendency of the informal conference will continue to accrue until either the violation ends


or the maximum civil penalty is reached.

(d) Waiver of penalties is governed by T.C.A. § 68-1-119(c). However, the ASTC or ODC must make a request for the waiver in its request for an informal conference pursuant to subparagraph (a) or in its request for a formal hearing pursuant to subparagraph (b).

(7) Unless a request for a formal hearing pursuant to subparagraph (6)(b) is timely received, the civil penalties become final and collectable either on the date that the time for requesting an informal conference has expired without a request being filed, or on the date on which the written final disposition of the informal conference is received.


1200-07-04-.09 Data Availability

(1) If the Commissioner determines that the quality or completeness of the information is not acceptable, he or she has the authority to delay release of any particular data element(s).

(2) The Department may create reports for public release using any available processed and verified data. It may also provide custom reports, as requested by the public, using any available processed and verified data. Facility specific data reports will not be released to the public based on Jess than four (4) consecutive quarters of data.

(3) The State, its agents and the vendors may receive reports of any record necessary, together with any needed patient identifiers, to carry out their contractual duties. This includes any organization contracted with to provide editing, quality control, database management services, or research for the State, or to provide keying of paper claims forms for the vendors. Any such contractual agent must agree in writing to establish and maintain appropriate controls to protect the confidentiality of the data and must agree to return or destroy any data or records at the termination of the contract.

(4) The Department will make record level data files available for public release and purchase under the following conditions. The fee for a quarter of data for each data system will be two hundred fifty dollars ($250.00). The fee for a subset of a quarter of data for each data system will be two hundred fifty dollars ($250.00) The Department maintains a proprietary interest in all record level data it sells or distributes and such data are made available solely for use by the purchaser and may not be given or sold to another entity.


1200-07-04-.10 Confidential Information

(1) All information reported to the Commissioner under this part is confidential until processed and verified by the Department.

(2) The Commissioner may use or authorize use of this data, including the personal identifiers, for purposes that are necessary to provide for or protect the health of the population and as permitted by Jaw. In no event may personal identifiers be released to the public.

(3) Information regarding the name of an employer will not be released to the public. Information about any employer may be released to the employer identified in the data record. A facility may receive information regarding the name of an employer for its claims only.

(4) The data may be released pursuant to the provisions of 45 C. F. R. § 164.514 (b) or (e). However, any data released to the public, in addition to those items required by Jaw to be deleted, will also not contain any of the following:

(a) Any patient's address city;

(b) An insured's address city;


(c) The month and day of all dates;

(d) Any numbers after the first three numbers of all zip codes for areas having a population under 20,000;

(e) Any numbers after the first five numbers of all zip codes for areas having a population 20,000 or more;

(f) The year of birth and the actual age of any person over eighty nine (89) years of age; and

(g) Information that reasonably could be expected to reveal the identity of a patient, including those items contained in 45 C.F.R. § 164.514 (a) and (b)(2)(i).

(5) Any agency of the State of Tennessee seeking confidential ASTC or ODC claims data or reports containing such confidential information, must agree in writing to follow all confidentiality restrictions of the Department concerning use of this data. The agency must also agree in writing to release no record level information to any other entity, and shall forward all such requests for record level information to the Department.



• If a roll-call vote was necessary, the vote by the Agency on these rules was as follows:

Board Member Aye No Abstain Absent Signature (If required)

N/A

I certify that this is an accurate and complete copy of proposed rules, lawfully promulgated and adopted by the Commissioner of Health on~'f/6'+/J.ot;!.. (dale as mmlddlyyyy), and is in compliance with the provisions of T.C.A § 4-6-222. The Secretary of State is hereby instructed that, In the absence of a petition for proposed rules being filed under the conditions set out herein and In the locations described, he is to treat the proposed rules as being placed on file in his office as rules at the expiration of sixty {60) days of the first day of the month subsequent to the filing of the proposed rule with the Secretary of State.

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!¥! OF \: iE ! TENNESSEE l li ~ \ NOTARY ! ~ \ o\ PUBl.~C ,/ / "!':~··· ... ~ 'l~t,rW,"_•"•"' ':!.''"

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Title of Officer: -=D-"e"'p"'ut,y-'G"'e"'n"'e"'ra,I_,C"'o"'u"'n"'s"el._ __________ _

MY COMMISSION EXPIRE§:ubscribed and sworn to before me on·· 0 .. , I 0 y I a. 0 I a May 5, 2015 • -;::::-...c_J.. __ ..:._,_c..::... __ ==---:-------

Notary Public Signature: _.fu'"""',_.t\_,.taJu'"""""-'"""--T""".""'('""),_""""')&~).._t'-----My commission expires on: _()o:;£:L..,)f..lO"''L.L.IJ.c.ct"""'DCJI"-!)..__· _______ _

All proposed rules provided for herein have been examined by the Attorney General and Reporter of the State of Tennessee and are approved as to legality pursuant to the provisions of the Administrative Procedures Act, Tennessee Code Annotated, Title 4, Chapter 5. ~ / /

(_~\/ Robert EJ Cooper, Jr.

/ Attorney General and Reporter -22..-(3

Department of State Use Only

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SS-7038 {September 2011)

Date

Filed with the Department of State on: _,_J_,_/_2-:-'-Cj_,/_1_3,.-' _______ _

Effective on: __,h'-"-/~J'-"'O"-'-'/t""~);L_71 ___ , _/ __ , __ _

10

J/~#f 1 Tre Hargett Secretary of State

RDA 1693

Regulatory Flexibility Addendum Pursuant to T.C.A. §§ 4-5-401 through 4-5-404, prior to initiating the rule making process as described in T.C.A. § 4-5-202(a)(3) and T.C.A. § 4-5-202(a), all agencies shall conduct a review of whether a proposed rule or rule affects small businesses.

This proposed rule does not affect small businesses.

SS-7038 (September 2011) 11 RDA 1693

Impact on Local Governments

Pursuant to T.C.A. §§ 4-5-220 and 4-5-228 "any rule proposed to be promulgated shall state in a simple declarative sentence, without additional comments on the merits of the policy of the rules or regulation, whether the rule or regulation may have a projected impact on local governments.' (See Public Chapter Number 1070 (http://state.tn. us/sos/acts/1 06/pub/pc1 070.pdf) of the 2010 Session of the General Assembly)

This rule will have no impact on local governments.

SS-7038 (September 2011) 12 RDA 1693

Additional Information Required by Joint Government Operations Committee

All agencies, upon filing a rule, must also submit the following pursuant to T.C.A. § 4-5-226(i)(1).

(A) A brief summary of the rule and a description of all relevant changes in previous regulations effectuated by such rule;

(B) A citation to and brief description of any federal law or regulation or any state Jaw or regulation mandating promulgation of such rule or establishing guidelines relevant thereto;

(C) Identification of persons, organizations, corporations or governmental entities most directly affected by this rule, and whether those persons, organizations, corporations or governmental entitles urge adoption or rejection of this rule;

Outpatient diagnostic centers are most directly affected by this rule, as are potential vendors. The Tennessee Hospital Association and Potential vendors urge the adoption of this rule. No comment has been heard from the Outpatient DiaQnostic Centers themselves.

(D) Identification of any opinions of the attorney general and reporter or any judicial ruling that directly relates to the rule;

None

(E) An estimate of the probable increase or decrease in state and local government revenues and expenditures, if any, resulting from the promulgation of this rule, and assumptions and reasoning upon which the estimate is based. An agency shall not state that the fiscal impact is minimal if the fiscal impact is more than two percent (2%) of the agency's annual budget or five hundred thousand dollars ($500,000), whichever Is less;

None

(F) Identification of the appropriate agency representative or representatives, possessing substantial knowledge and understanding of the rule;

I Teresa Hendricks, Health Statistics, 425 5'" Avenue North, 6"' Floor, Nashville TN 37243

(G) Identification of the appropriate agency representative or representatives who will explain the rule at a scheduled meeting of the committees;

I Teresa Hendricks, Health Statistics, 425 5'" Avenue North, em Floor, Nashville TN 37243

(H) Office address, telephone number, and email address of the agency representative or representatives who will explain the rule at a scheduled meeting of the committees; and

Teresa Hendricks, Health Statistics, 425 5'" Avenue North, 6'" Floor, Nashville TN 37243 615-253-3535 [email protected]; Mary Kennedy, Deputy General Counsel, 425 5th Avenue North, 3rd Floor, Nashville TN 37243 615-253-4878 Marv.Kennedvtilitn.qov

(I) Any additional information relevant to the rule proposed for continuation that the committee requests.

SS-7038 (September 2011) 13 RDA 1693

RULES OF

TENNESSEE DEPARTMENT OF HEALTH BUREAU OF HEALTH INFORMATICS

OFFICE OF HEALTH STATISTICS

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CHAPTER 1200-7-4

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CHAPTER 1200-7-4

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CHAPTER 1200-7-4

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Chapter 1200-07-04

CHAPTER 1200-7-4

Ambulatory Surgical Treatment Center Data System and Outpatient Diagnostic Center Data System

1200-07-04-.01 Definitions i 200-07-04-.02 Purpose 1200-07-04-.03 Reporting Requirements i 200-07-04-.04 Required Data Elements 1200-07-04-.05 Submission Schedule i 200-07-04-.06 Vendor Requirements 1200-07-04-.01 Processing and Verification i 200-07-04-.08 Penalty Assessment 1200-07-04-.09 Data Availability 1200-07-04-.10 Confidential Information

1200-07-04-01 Definitrons

(1) "Ambulatory Surgical Treatment Center" shall have the same definition as contained in T.CA §68-11-201.

(2) "ASTC" is the acronym for ambulatory surgical treatment center.

(3) "Claim" shall mean a charge or bill for services rendered, billed to the patient to another private individual, or to a third party payer. public or private.

(4) "Ciarms Data' shall mean all data elements collected for all patients for whom an ASTC or· ODC provides services that are entered on any claim form prepared by the ASTC or ODC and shall always include those required data elements identified in the subparagraphs listed in rule 1200-07-04-.04. paragraphs (1) and (2).

(5) "CMS-1500" shall mean the claim form "Centers for Medicare & Medicaid Services 1500" or its successor form.

(6) "Commrssioner" shall mean the commissioner of the Tennessee Department of Health.

(7) 'Data Element" shall mean any individual piece of information collected from a patient by an ASTC or ODC dunng the process of providing services to that patient for which the ASTC or ODC will file a claim.

(8) "Department" shall mean the Tennessee Department of Health.

(9) "Error" shall mean data that are incomplete or inconsistent with the specifications in the ASTC Data System Procedural Manual. the ODC Data System Procedural Manual. or these rules

(10'1 "Final Joint Annual Report" shall mean the most recent Joint Annual Report filed by an ASTC or ODC where the data contained in the report have been edited, queried, and updated when appropriate by the Department.

(11) "JAR' is the acronym !or Joint Annual Report.

(12) "ODC" is the acronym for outpatient diagnostic center.




CHAPTER 1200-7-4

(13) "Outpatient Diagnostic Center" shall have the same definition as contained in TCA §68-11-201.

(14) "Persona! Identifiers" shall be defined to include all the identifiers contarned in 45 CFR. § 164.514 (b) or (e)

(15) "Processed Data" shall mean data that have been analyzed by the Department or the Department's designated data vendor(s) and errors, inconsistencies. and/or incomplete elements in the data set, if any, have been identified.

(16) "Public" shall mean anyone other than the Tennessee Department of Health, rts vendors. and its contracted agencies.

(17) "Record level Data" shall mean a set of data that is specific to individual patient claims

(18) "State" shall mean the government of the State of Tennessee including ali its agencies ..

(19) "UB-04" shall mean the CMS Form 1450, [a.ka "the Uniform Hospital Billing Form"] or its successor forms as established by the National Uniform Billing Committee and the State Uniform Billing Implementation Committee.

(20) "Vendor" shall mean a third party entity, approved by the Department, through whom an ASTC or ODC submits its claims data for the purpose of compilation and editing according to these rules and the instructions of the Department.

(21) "Verified Data" shall mean data that have been processed by the Department after the · ASTCs or oocs have had the opportunity to suggest corrections and/or deletions. and all appropnate revisions have been made to the data and approved by the Department

Authority T. CA §§ 68-1-103 and 68-1-119.

1200-07-04-.02 Purpose

(1) The reporting of ambulatory surgical and outpatient diagnostic data will provide NVo statewide databases and permit assessment of variations in utilization, practice parameters, access to care. and charges.

Authority T.CA §§ 68-1-103 and 68-1-119.

1200-07-04-.03 Reporting Requirements

(1) Each ASTC and ODC shall contract with one of the approved vendors and shall report through its vendor all its claims data. Claims data for all free or charity services provided by any ASTC or ODC that otherwise submits claims for reimbursement shall also be reported to the vendor.

(2) No clarm reporting is required for any of the following:

(a) From a licensed ASTC or ODC that provides onlv free care and never bills for any services.




CHAPTER 1200-7-4

(b) Regarding any procedures already reported bv an ASTC or ODC to the Department under T.CA § 68-3-505 or services ancillary thereto such as counseling. testing, or follow-up.

(3) The Department will prepare the ASTC and ODC Data System-Procedural Manuals that will iist the variables to be reported, their descriptions and reporting format and other Information associated with data submission. The Department shall issue revisions to the Procedural Manuals when the Commissioner deems It necessary. The Department will notify each ASTC. ODC. and vendor of all revisions. These revisions become effective one hundred and eighty (180) days following the date of notification. At that time, failure to meet the amended requirements is subject to the penalties as prescribed by T.CA §68-1-119,

(4) Each ASTC or ODC shall report all data elements using the actual values used for billing by the ASTC or the ODC. No data elements shall be encrypted or otherwise altered, This rule shall not be interpreted to prevent encryption of entire files for security in transmission to parties having the appropriate decryption software.

15) Each ASTC and ODC shall be responsible for submitting its data to the approved vendor in a format and medium approved by the State.

(6) Each ASTC and ODC shall be responsible for the costs associated with the processing of the data by the approved vendors.

(7) Each ASTC and ODC shall report in a format using the data elements which correspond with the claim form used by the ASTC or ODC for billing. If an ASTC or ODC submits claims using both the CMS-1500 and UB-04 forms the claims data shall be submitted in separate data sets for each form.

(81 Each ASTC and ODC shall report the clarms data at least quarterly. pursuant to rule 1200-07-04-.05. to its approved vendor with a separate data set for each facility location.

(9) Each ASTC and ODC shall designate one staff member to be responsible for reporting the claims data and shall notify the Department and its approved vendor of the name. title work address. work telephone number. and e-mail address of the designated staff member.

Authority T.CA §§ 68-1-103 and 68-1-119.

1200-07-04-.04 Required Data Elements

ii) CMS-1500 Claims Forms

(a) Each ASTC and ODC must report to the Department all the following data elements for each and everv claim based on the CMS-1500 form:

1. Patient's Birth Date

2. Patrent's Sex






5. Dates of Service (Through Date)

6. Diagnosis or Nature of Illness or Injury

7. Total Charge



CHAPTER 1200-7-4

(b) Each ASTC and ODC must report to the Department all CMS-1500 data elements listed in the relevant ASTC or ODC Procedural Manual whenever the data element is collected by the ASTC or ODC and/or used for billing.

(2\ UB-04 Claims Forms

(a) Each ASTC and ODC must report to the Department all the following data elements for each and every claim based on the UB-04 form:

1. Statement Covers Period



4. Patient's Date of Birth

·5. Patient's Sex

6. Revenue Codes

7 Total Charges (By Revenue Code Category)

8. Principal Diagnosis Code



(b) Each ASTC and ODC must report to the Department all UB-04 data elements listed in the relevant ASTC or ODC Procedural Manual whenever the data element is collected by the ASTC or ODC and/or used for billing.

(3) Each ASTC and ODC shall report to the Department all data elements that it collected from patients and which it reported by making an entry in any or all of the data element spaces contained on any form other than the CMS-1500 or UB-04 on which it submits a claim. However the data elements identified in paragraphs (1)(a) and (2)(a) above that must be collected. entered and reported to the Department by the ASTC or ODC for the identified claim form shall also be reported to the Department when any other claim form is used.

(4) Data elements collected by the ASTC or ODC that are not specifically identified in either paragraphs (1) through (3) of this rule or in the procedural manual shall not be reported to the vendor or the Department



CHAPTER 1200-7-4


Authority T CA §§ 68-1-103 and 68-1-119.

1200-07-04-.05 Submission Schedule

(1) Each ASTC or ODC shall submit all required claims to its approved vendor according to the following quarterly schedule:

Quarter Time S[lan Submission Due Date 01 Janua[Y i -March 31 Mav 30 02 AQril 1 -June 30 Auoust 29 03 July 1 -September 30 November 29 04 October 1 -December 31 March 1

Authority T.CA §§ 68-1-103 and 68-1-119

1200-07-04-.06 Vendor Requirements

(1) An applrcant desiring to be approved as a statewide data processing vendor shall make written application to the Department To be selected as a statewide vendor by the Department the applicant must demonstrate the ability to do all of the following:

(a)

(b)

(c)

(d)

(e)

(f)

April, 2005 (Revised)

Process the claims data as specified by the Department using the codes and the standards for completeness and quality specified by the Department

Include in each claims data record the ID number approved by the Department for the reporting ASTC or ODC and all vendor-generated fields specified by the Department

Examme the claims data it receives for accuracy, inform the ASTC or ODC submitting the data of all potential errors in the data which are discovered as a result of the examination of accuracy, and correct the data as directed by the ASTC. the ODC, and/or the Department

Submit the claims data to the Department in an electronrc or magnetic medium or process approved by the Department.

Report to the Department each ASTC or ODC that has either failed to submit claims data or is tardy in doing so.

Affirm that it is familiar with the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its accompanying regulations. and will comply with all applicable and current HIPAA requirements in the course of doing business with the State. The applicant shall affirm that It will cooperate with the State in the course of its performance so that both parties wili be in compliance with HIPAA, including cooperation and coordination with State privacy officials and other compliance ofiicers required by HIPAA and its regulations. The applicant will sign any documents that are reasonably necessa[V to keep both parties in compliance with HIPAA, including, but not limited to. business associate agreements.

12



CHAPTER 1200-7-4

(2) If any approved vendor fails to carry out its requirements as specified In the rules of the Tennessee Department of Health. the Department may remove its approval as a statew1de data processing vendor.

Authority: T.CA §§ 68-1-'103 and 68-1-119.

1200-07-04- 07 Processing and Verification

(1) Each vendor must review all claims data submitted for completeness and accuracy. If errors. inconsistencies or incomplete elements are identified by the vendor the vendor must report the errors to the ASTC or ODC in writing.

(2) Upon receiving written notification of errors. the ASTC or ODC shall investigate the problem and shall supply correct information to the vendor within fifteen (15) days from notification

13) Each approved vendor must report quarterly to the Department the reporting status of ail ASTCs or ODCs utilizing its services. The status of facilities that failed to report. that were delinquent in reporting or that exceeded the acceptable error rate shall be provided to the Department quarterly and then updated at the initiative of the vendor or upon request of the Department. Each vendor shall maintain and report to the Department any Information the Department deems necessary for penalty assessment.

(4) Each approved vendor must report all data received each quarter, including additions and corrections, to the Department no more than sixty (60) days following the submission due date specified in rule 1200-07-04- 05.

(5) Each ASTC and ODC shall be given a ten (10) day period to review the quarterly data set relating to their facility after the quarterly data have been computerized, edited. updated and determined to be the final corrected set by the Department Upon the expiration of the ten (10) day period, absent receipt of corrections and/or revisions from an ASTC or ODC, the quarterly data is considered verified. If corrections and/or revisions are received by the Department within the ten day period, the quarterly data is considered verified only after the Department has made any corrections and/or revisions it considers appropriate.

Authonty: T.CA §§ 68-1-103 and 68-1-119.

1200-07-04-08 Penalty Assessment

11) The Department will assess the civil penalties authorized by T.CA § 68-1-119(bJ each day claims data are reported later than the submission due date identified in rule 1200-07-04-.05 or not reported at all up to the statutory maximum for each claim record.

(2) Any ASTC or ODC not submitting any claims data by the submission deadline will have the number of quarterly unreported claims records calculated, for purposes of civil penalty assessment by dividing by four (4) the number of total discharges or admissions reported on Schedule D (Availability and Utilization of Services) of the most current final JAR of the ASTC or ODC on file with the Department for that facility

(3) An ASTC or ODC not submitting any claims data by the submission deadline will beg1n accru1ng penalties the day immediately following the submission deadline and ending the day when the actual claims data are received by the vendor or the maximum penalty is



CHAPTER 1200-7-4


(4)

(5)

(6)

reached.

The Department will report the rate of error it identifies to the ASTC or ODC 1n writing. The acceptable error rate will be two percent (2%). Records that fall within the acceptable error rate will not be subject to penalties ASTCs or ODCs that exceed the acceptable error rate will be penalized based on total errors.

An ASTC or ODC that does not timely submit corrected claims records will accrue delinquent penalties starting the sixteenth (161

h) day after error notification and ending the day when the actual corrected claims data are received by the Department or the maximum penalty is reached.

Upon receipt of!he notice of civil penalty assessment the ASTC or ODC has the right to an informal conference with the Commissioner or a formal hearing to contest the assessment

(a) Informal conferences are governed by T.CA § 68-1-119(b) and (c)

(b) A request for a formal hearing must be made in writing and received by the Department within thirty 130) days of the receipt of the notice of assessment or. if an informal conference pursuant to subparagraph (a) was requested, within thirty (30) days of the receipt of the written disposition of the informal conference. Proceedings involving formal contests of civil penalties are subject to the contested case provisions of the Uniform Administrative Procedures Act.

(c) Civil penalties for any ASTC or ODC that continues to violate the law during the pendency of the informal conference will continue to accrue until either the violation ends or the maximum civil penalty is reached.

(d) Waiver of penalties is governed by T.CA § 68-1-119!c) However. the ASTC or ODC must make a request for the waiver in its request for an informal conference pursuant to subparagraph (a) or in its request for a formal hearing pursuant to subparagraph (b).

(7) Unless a request for a formal hearing pursuant to subparagraph (6)(b)rs timely recerved. the civil penalties become final and collectable either on the date that the time for requesting an informal conference has expired without a request be1ng filed or on the date on which the written final disposition of the informal conference is received

Authority: T. C A §§ 68-1-1 03 and 68-1-'119.

1200-07-04-09 Data Availability

(1) If the Commissioner determines that the quality or completeness of the information is not acceptable, he or she has the authority to delay release of any particular data element(s),

(2j The Department may create reports for public release using any available processed and verified data. It mav also provide custom reports. as requested by the public using any available processed and verified data. Facility specific data reports will not be released to the public based on less than four (4) consecutive quarters of data.

(3) The State. its agents and the vendors may receive reports of any record necessary together with any needed patient ident1frers. to carry out their contractual duties. This includes any organization contracted with to provide editing. quality control. database management services, or research for the State. or to provrde key1ng of paper claims




CHAPTER 1200-7-4

forms for the vendors. Any such contractual agent must agree in writing to establish and maintain appropriate controls to protect the confidentiality of the data and must agree to return or destroy any data or records at the termination of the contract

(4) The Department wili make record level data files available for public release and purchase under the following conditions. The fee for a quarter of data for each data system will be two hundred fifty dollars ($250.00). The fee for a subset of a quarter of data for each data system will be two hundred fifty dollars ($250 00) The Department maintains a proprietary interest in all record level data it sells or distributes and such data are made available solely for use by the purchaser and may not be given or sold to another entity.

Authority: T. CA §§ 68-1-103 and 68-1-119.

1200-07-04-.10 Contidentiallnformation

(1) All information reported to the Commissioner under this part is confidential until processed and verified by the Department

(2) The Commissioner may use or authorize use of this data including the personal identifiers. for purposes that are necessary to provide for or protect the health of the population and as permitted by law. In no event may personal identifiers be released to the public.

(3) Information regarding the name of an employer will not be released to the public Information about any employer may be released to the employer identified in the data record. A facility may receive information regarding the name of an employer for its claims only

(4) The data may be released pursuant to the provisions of 45 C..F. R. § 164.514 (b) or (e) However. any data released to the public in addition to those items required by law to be deleted. will also not contain any of the following

(a) Any patient's address city:

(b) An insured's address city:

(c) The month and day of all dates:

(d) Any numbers after the first three numbers of all zip codes fm areas havrng a population under 20,000·

je) Any numbers after the first five numbers of all zip codes for areas having a population 20,000 or more:

(f) The year of birth and the actual age of any person over eighty nine (89) years of age; and

(g) Information that reasonably could be expected to reveal the identity of a patient including those items contained in 45 C.FR § 164.514 ja) and lb)(2)1i)

(5) Any agency of the State of Tennessee seeking confidential ASTC or ODC claims data or reports containing such confidential information, must agree in writing to follow all confidentiality restrictions of the Department concerning use of this data. The agency must also aaree in writing to release no record level information to any other entity. and




CHAPTER 1200-7-4

shall forward all such requests for record level information to the Department.

Authority T.CA §§ 68-1-103 and 68-1-1'19.


proposed rule(s) filing form · (b) each astc and odc must report to the department all cms-1500...

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