Section 127.3. Definitions

The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:

ASC—Ambulatory Surgery Center—A center that operates exclusively for the purpose of furnishing outpatient surgical services to patients. These facilities are referred to by HCFA as ASCs and by the Department of Health as ASFs. For consistency with the application of Medicare regulations, these facilities are referred to in this chapter as ASCs.

ASF—Ambulatory Surgical Facility—An ASC.

Accredited speciality board—A speciality board recognized by the American Board of Medical Specialties, the American Osteopathic Association or by the Chiropractic Council on Education.

Act—The Workers’ Compensation Act (77 P. S. § § 1—1041.4).

Act 44—The act of July 2, 1993 (P. L. 190, No. 44).

Actual charge—The provider’s usual and customary charge for a specific treatment, accommodation, product or service.

Acute care—The inpatient and outpatient hospital services provided by a facility licensed by the Department of Health as a general or tertiary care hospital, other than a specialty hospital, such as rehabilitation and psychiatric provider.

Approved teaching program—A hospital teaching program which is accredited in its field by the appropriate approving body to provide graduate medical education or paramedical education services, or both. Accreditation for medical education programs shall be as recognized by one of the following:

(i) The Accreditation Council for Graduate Medical Education of the American Medical Association.

(ii) The Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association.

(iii) The Council on Dental Education of the American Dental Association.

(iv) The Council of Podiatric Medicine Education of the American Podiatric Association.

(v) An appropriate approving body of paramedical educational and training programs.

Audited Medicare cost report—The Medicare cost report, settled by the Medicare fiscal intermediary through the conduct of either a field audit or desk review resulting in the issuance of the Notice of Program Reimbursement.

Bureau—The Bureau of Workers’ Compensation of the Department.

Burn facility—A facility which meets the service standards of the American Burn Association.

CCO—Coordinated Care Organization—An organization certified under Act 44 by the Secretary of Health for the purpose of providing medical services to injured employes.

CDT-1—The Current Dental Terminology, as defined by the American Dental Association.

CPT-4—The physician’s ‘‘Current Procedural Terminology, Fourth Edition,’’ as defined and published by the American Medical Association.

Capital related cost—The health care provider’s expense related to depreciation, interest, insurance and property taxes on fixed assets and moveable equipment.

Charge master—A provider’s listing of current charges for procedures and supplies utilized in the provider’s billing process.

Commissioner—The Insurance Commissioner of the Commonwealth.

DME—Durable medical equipment—The term includes iron lungs, oxygen tents, hospital beds and wheelchairs (which may include a power-operated vehicle that may be appropriately used as wheelchair) used in the patient’s home or in an institution, whether furnished on a rental basis or purchased.

DRG—Diagnostic related groups.

Department—The Department of Labor and Industry of the Commonwealth.

Direct medical education cost—The salaries and other expenses related to the provider’s resident and intern graduate medical education approved teaching program. This amount includes the allocable overhead costs associated with the provider’s maintenance and administration of the resident and intern programs.

Disproportionate share hospital—A hospital providing acute care that serves a significantly disproportionate share of low-income patients.

Fully prospective—Inpatient capital-related cost of an acute care provider included in the DRG payment based on a blend of hospital-specific data and Federal data and excluded from cost report settlements.

HCFA—The Health Care Financing Administration.

HCPCS—HCFA Common Procedure Coding System—The procedure codes and associated nomenclature consisting of numeric CPT-4 codes, and alpha-numeric codes, as developed both Nationally by HCFA and on a Statewide basis by local Medicare carriers.

Health care provider—A person, corporation, facility or institution licensed, or otherwise authorized, by the Commonwealth to provide health care services, including physicians, coordinated care organizations, hospitals, health care facilities, dentists, nurses, optometrists, podiatrists, physical therapists, psychologists, chiropractors, or pharmacists, and officers, employes or agents of the person acting in the course and scope of employment or agency related to health care services.

Hold harmless—Inpatient capital-related cost of an acute care provider which can either be included fully in the DRG payment or partially included in both the DRG and cost-reimbursed payment.

(i) One hundred percent hold harmless means inpatient capital-related cost included fully in the DRG payment at 100% of the Federal capital rate.

(ii) Blended hold harmless means inpatient capital-related cost included in the DRG payment for assets acquired after December 31, 1990, and cost-reimbursed for assets acquired before December 31, 1990.

(iii) Capital-exceptional hospital means a provider receiving payment from Medicare based on cost because payments at either the fully prospective rate or the hold harmless rates are less than or equal to 70% of the provider’s payments based on cost.

ICD-9-CM—(ICD-9) The International Classification of Diseases—Ninth Edition—Clinical Modification

Indirect medical education cost—The expenses related to the use of additional ancillary services and consumption of provider resources related to the provision of a graduate medical education approved teaching program.

Insurer—A workers’ compensation insurance carrier, including the State Workmen’s Insurance Fund, an employer who is authorized by the Department to self-insure its workers’ compensation liability under section 305 of the act (77 P. S. § 501), or a group of employers authorized by the Department to act as a self-insurance fund under section 802 of the act (77 P. S. § 1036.2).

Interim rate notification—The letter, from the Medicare intermediary to the provider, informing the provider of their interim payment rate and its effective date.

Life-threatening injury—As defined by the American College of Surgeons’ triage guidelines regarding use of trauma centers for the region where the services are provided.

Medicare carrier—An organization with a contractual relationship with HCFA to process Medicare Part B claims.

Medicare intermediary—An organization with a contractual relationship with HCFA to process Medicare Part A or Part B claims.

Medicare Part A—Medicare hospital insurance benefits which pay providers for facility-based care, such as care provided in inpatient general and tertiary hospitals, specialty hospitals, home health agencies and skilled nursing facilities.

Medicare Part B—Medicare supplementary medical insurance which pays providers for physician services, outpatient hospital services, durable medical equipment, physical therapy and other services.

NPR—Notice of program reimbursement—The letter of notification from the Medicare intermediary to the provider regarding the final settlement of the Medicare cost report.

New provider—A provider which began administering patient care after receiving initial licensure on or after August 31, 1993.

Notice of biweekly payment rates—The letter of notification from the Medicare intermediary to the provider, informing the provider of their biweekly payment rate for direct medical education and paramedical education costs.

Notice of per resident amount—The letter of notification from the Medicare intermediary to the provider, informing the provider of the annual payment amount per resident or intern full-time equivalent.

PRO—Peer Review Organization—An organization authorized by the Secretary for the purpose of determining the necessity or frequency of medical treatment administered to workers with work-related injuries.

Paramedical education cost—The education cost related to providers’ nongraduate medical education programs including nursing school programs, radiology and laboratory technology training programs and other allied health professional approved teaching programs.

Pass-through costs—Medicare reimbursed costs to a hospital that ‘‘pass through’’ the prospective payment system and are not included in the DRG payments.

Provider—A health care provider.

RCC—Ratio of cost-to-charges—The computed ratio using the Medicare cost report.

Secretary—The Secretary of the Department.

Specialty hospital—A health care facility licensed and approved by the Department of Health as a hospital providing either a comprehensive inpatient rehabilitation program or an acute psychiatric inpatient program.

Transition fee schedule—The Medicare payment amounts as determined by the Medicare carrier, based on the transition rules requiring a blend of the full fee schedule (full implementation of the Resource Based Relative Value Scale, RBRVS) and the original provider fee schedule.

Trauma center—A facility accredited by the Pennsylvania Trauma Systems Foundation under the Emergency Medical Services Act (35 P. S. § § 6921—6938).

UR—Utilization Review.

URO—Utilization Review Organization—An organization authorized by the Secretary for the purpose of determining the reasonableness or necessity of medical treatment administered to workers with work-related injuries.

Unbundling—The practice of separate billing for multiple service items or procedures instead of grouping the services into one charge item.

Urgent injury—As defined by the American College of Surgeons’ triage guidelines regarding use of trauma centers for the region where the services are provided.

Usual and customary charge—The charge most often made by providers of similar training, experience and licensure for a specific treatment, accommodation, product or service in the geographic area where the treatment, accommodation, product or service is provided.

Workers’ Compensation judge—As defined by section 401 of the act (77 P. S. § 701) (definition of ‘‘referee’’) and as appointed by the Secretary.