Table A. PENNSYLVANIA UNIFORM CLAIMS AND BILLING FORM DATA ELEMENTS

Field	Data Element	Definition
1	Uniform Patient Identifier	Patient’s Social Security Number.
2	Patient Date of Birth	The date of birth of the patient.
3	Patient Sex	The sex of the patient as recorded at the date of admission, outpatient service, or start of care.
4	Patient Zip Code	Zip code of patient taken from the patient name and address field.
5	Date of Admission	The date that the patient was admitted to the provider for inpatient care, outpatient services or start of care.
6	Date of Discharge	The ending service date of patient care. The date that the patient was discharged from the provider’s care.
7a	Principal Diagnosis	The code that identifies the principal diagnosis (i.e., the condition established after study to be chiefly responsible for causing this hospitalization) that exists at the time of admission or develops subsequently that has an effect on the length of stay.
7b, c, d, e	Secondary Diagnosis	The diagnosis code corresponding to additional conditions that co-exist at the time of admission, or develop subsequently, and which have an effect on the treatment received or the length of stay.
8a, b	Principal Procedure Code and Date	The code that identifies the principal procedure performed during the period between admission and discharge and the date on which the principal procedure described was performed.
9a1 through 9c2	Secondary Procedure	The code identifying the procedures other than the principal procedure, performed during the patient’s stay and the dates on which the procedures (identified by the codes) were performed.
10	Uniform Identifier of Health Care Facility	Number identifying the provider facility as developed and used by Medicaid.
11	Attending Physician Identifier	The PA state license number of the physician who would normally be expected to certify and recertify the medical necessity of the services rendered and/or who has primary responsibility for the patient’s medical care and treatment.
12	Operating Physician Identifier	The PA state license number of the physician other than the attending physician who performed the principal procedure.
13a1 through 13w1	Revenue Description	A narrative description of the related revenue categories included for a patient.
13a2 through 13w2	Revenue Code	A code which identifies a specific accommodation, ancillary service or billing calculation.
13a3 through 13w3	Units of Service	A quantitative measure of services rendered by revenue category to or for the patient to include items such as number of accommodation days, pints of blood, or renal dialysis treatments, etc.
13a4 through 13w4	Total Charges	Total charges pertaining to the related revenue code for the current billing period as entered in the statement covers period.
13a5 through 13w5	Noncovered Charges	Those charges that are not covered by a payor for this patient.
14a	Actual Payments to the Health Care Facility	Payments for services performed by the provider from the payor segregated according to Revenue Code.
14b	Payor Identification	Name and Pennsylvania Insurance Department number identifying each payor organization from which the provider might expect some payment for the bill.
14c	Deductible Amount	The amount assumed by the hospital to be applied to the patient’s deductible amount involving the indicated payor.
14d	Co-Insurance Amount	The amount assumed by the hospital to be applied toward the patient’s co-insurance amount involving the indicated payor.
14e	Estimated Responsibility	The amount estimated by the hospital to be paid by the indicated payor.
14f	Prior Payments— Payor and Patient	The amount the hospital has received toward payment of this bill prior to the billing date by the indicated payor.
14g	Estimated Amount Due	The amount estimated by the hospital to be due from the indicated payor (estimated responsibility less prior payments).
15a	Physician Identification	License number of the physician who charged the patient for a service related to an episode of illness for the period indicated in Fields 5 and 6.
15b	Type of Physician/ Professional Service	The type of service performed for which payment is expected.
15a3	Physician/ Professional Services Charge	Amount charged for services rendered to the patient for the procedure indicated in HCFA 1500, item 24d.
16	Physician/ Professional Services Payment	Payments received for services performed for the procedures indicated in Field 8a.
17	Uniform Identifier of Primary Payor	Pennsylvania Department of Insurance number. If the number is not available, the Health Care Cost Containment Council will assign a number based on the name in Field 14b.
18	Zip Code of Facility	XXXXXYYYY. Five character zip code with a four character extension. If the four character extension is unknown, fill with blanks.
19	Payor Group Number	The identification number, control number, or code assigned by the carrier or plan administrator to identify the group under which the individual is covered.
20	Patient Discharge Status	The status of the patient at discharge.
21c	Unusual Occurrence	Infections acquired while in the hospital. Nosocomial infections are defined as those infections that are clinically manifested after 72 hours in the hospital, unless: 1. They are evident within 72 hours after admission and are related to a previous hospitalization; 2. They are related to a hospital procedure performed within the first 72 hours.
21d	Unusual Occurrence	Patient readmission to the hospital within 30 days.
22	Type of Bill	A code indicating the specific type of bill (inpatient, outpatient, adjustments, voids, etc.)
23	Patient Control Number	Patient’s unique alphanumeric number assigned by the provider to facilitate retrieval of individual case records and posting of the payment.
24	Diagnosis Related Group (DRG)	The condition established after study as being chiefly responsible for the admission of a patient to the hospital for care that exists at the time of admission or develops subsequently that has an effect on the length of stay.
25	Procedure Coding Method Used	An indicator that identifies the coding method used for procedure coding on this bill.
26	Type of Admission	A code indicating the priority of this admission.
27	Source of Admission	A code indicating the source of this admission.
28	Patient’s Relationship to Insured	A code indicating the relationship of the patient to the identified insured.
29	Certificate/Social Security Number/Health Insurance Claim/ Identification Number	Insured’s unique identification number assigned by the payor organization.
30	Principal and Other Diagnoses Descriptions	Narrative description of the principal diagnosis (i.e., the condi-tion established after study to be chiefly responsible for causing the hospitalization or use of hospital services) and other diagnoses.
31	Principal and Other Procedure Descriptions	A narrative description of the principal procedure (i.e., the procedure that was performed for definitive treatment rather than the one performed for diagnostic or exploratory purposes or the procedure most related to the principal diagnosis) and other procedures. The principal procedure is to be shown first.
32	Employer Name	The name of the employer that might or does provide health care coverage for the individual identified in Field 33.
33	Employment Information	A code that indicates whether the employment information given in the related areas applies to an insured, the patient or the patient’s spouse.
34	Employment Status Code	A code used to define the employment status of the individual identified in Field 33.
35	Patient Race	This code indicates the patient’s racial/ethnic background.
36	Reserve Field	To be reserved for future use by the Council.

Source

The provisions of this § 911.4 amended October 1, 1999, effective October 2, 1999, 29 Pa.B. 5109. Immediately preceding text appears at serial pages (242549) to (242556).