Section 911.1. Definitions

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 adopted August 14, 1987, effective August 15, 1987, 17 Pa.B. 3409; amended October 30, 1987, effective October 31, 1987, 17 Pa.B. 4447; amended February 26, 1993, effective upon submittal of data elements to the Council beginning with data from the second quarter of 1993, which begins April 1, 1993, 23 Pa.B. 971; amended October 1, 1999, effective October 2, 1999, 29 Pa.B. 5109. Immediately preceding text appears at serial pages (242545) to (242547).

Notation

Authority

The provisions of this § 911.1 amended under the Health Care Cost Containment Act (35 P. S. § § 449.1—449.19).