RELATES TO: KRS 216.2920, 216.2925, 216.2927, 304.14-135
NECESSITY, FUNCTION, AND CONFORMITY: KRS 216.2925 requires that
the Cabinet for Health and Family Services promulgate administrative
regulations requiring specified health care providers to provide the cabinet
with data on cost, quality, and outcomes of health care services provided in
the commonwealth. KRS 216.2923(3) authorizes the cabinet to promulgate
administrative regulations to impose fines for failure to report required data.
This administrative regulation establishes the required data elements, forms,
and timetables for submission of data to the cabinet and fines for
noncompliance.
Section 1. Definitions.
(1) "Ambulatory facility" is defined by KRS 216.2920(1).
(2) "Cabinet" is
defined by KRS 216.2920(2).
(3)
"Coding and transmission specifications", "Kentucky Inpatient and Outpatient
Data Coordinator's Manual for Hospitals", and "Kentucky Data Coordinator's
Manual for Ambulatory Facilities" means the document created and updated by a
contracted vendor selected by the Cabinet that contains the technical
directives the cabinet issues concerning technical matters subject to frequent
change, including codes and data for uniform provider entry into particular
character positions and fields of the standard billing form and uniform
provider formatting of fields and character positions for purposes of
electronic data transmissions.
(4)
"Hospital" is defined by KRS 216.2920(6).
(5) "Hospitalization" means the inpatient
medical episode identified by a patient's admission date, length of stay, and
discharge date, that is identified by a provider-assigned patient control
number unique to that inpatient episode, except for hospice care.
(6) "National Provider Identifier" or "NPI"
means the unique identifier assigned by the Centers for Medicare and Medicaid
Services to an individual or entity that provides health care services and
supplies.
(7) "Outpatient services"
means services performed on an outpatient basis in a hospital with records
requirements in accordance with Section 3(2) of this administrative regulation
or services performed on an outpatient basis by an ambulatory facility with
data requirements in accordance with Section 4 of this administrative
regulation.
(8) "Provider" means a
hospital, ambulatory facility, clinic, or other entity of any nature providing
hospitalizations, mammograms, or outpatient services and is defined accordingly
in the Kentucky Inpatient and Outpatient Data Coordinator's Manual for
Hospitals or the Kentucky Data Coordinator's Manual for Ambulatory
Facilities.
(9) "Record" means the
documentation of a hospitalization or outpatient service in the Kentucky
Inpatient and Outpatient Data Coordinator's Manual for Hospitals or the
Kentucky Data Coordinator's Manual for Ambulatory Facilities on a computer
readable electronic medium.
(10)
"Standard Billing Form" means the uniform health insurance claim form pursuant
to KRS 304.14-135, the Professional 837 (ASC X12N 837) format, the
Institutional 837 (ASC X12N 837) format, or its successor as adopted by the
Centers for Medicare and Medicaid Services, or the HCFA 1500 for use by
hospitals and other providers in billing for hospitalizations and outpatient
services.
Section 2.
Medicare Provider-Based Entity. A licensed outpatient facility that is a
Medicare provider-based entity of a hospital and reports under the hospital's
provider number shall be separately identifiable through a facility-specific
NPI.
Section 3. Data Collection for
Hospitals.
(1) Inpatient hospitalization
records. A hospital shall document every hospitalization it provides on a
Standard Billing Form and shall, for every record, copy and provide to the
cabinet the data established in Section 12 of this administrative
regulation.
(2) Outpatient services
records.
(a) A hospital shall document on a
Standard Billing Form, the outpatient services the hospital provides and shall,
for every record, copy and provide to the cabinet the data established in
Section 12 of this administrative regulation.
(b) A hospital shall submit records that
contain the required outpatient services procedure codes included in the
Kentucky Inpatient and Outpatient Data Coordinator's Manual for
Hospitals.
(3) Data
collection on patients. A hospital shall submit required data on every patient
as established in Section 12 of this administrative regulation, regardless of
the patient's billing or payment status.
Section 4. Data Collection for Ambulatory
Facilities.
(1) Outpatient services records.
(a) An ambulatory facility shall submit
outpatient services records if the ambulatory facility provides one (1) or more
of the following outpatient services:
1.
Surgery;
2. Childbirth;
3. Urgent treatment of minor illness or
injury;
4. Emergency;
5. Mammography;
6. X-ray;
7. Ultrasound;
8. Computed tomography;
9. Magnetic resonance imaging;
10. Cardiac catheterization;
11. Positron emission tomography;
and
12. Megavoltage radiation
therapy.
(b) An
ambulatory facility shall document on a Standard Billing Form, the outpatient
services the ambulatory facility provides and shall, for every record, copy and
provide to the cabinet the data established in Section 13 of this
administrative regulation.
(c) An
ambulatory facility shall submit records that contain the required outpatient
services procedure codes included in the Kentucky Data Coordinator's Manual for
Ambulatory Facilities.
(2) Data collection on patients. An
ambulatory facility shall submit required data on every patient as established
in Section 13 of this administrative regulation, regardless of the patient's
billing or payment status.
Section
5. Data Finalization and Submission by Providers.
(1) Submission of final data.
(a) Data shall be final for purposes of
submission to the cabinet as soon as a record is sufficiently final that the
provider could submit it to a payer for billing purposes, regardless of if the
record has actually been submitted to a payer.
(b) Finalized data shall not be withheld from
submission to the cabinet on grounds that the data could be adjudicated by a
payer.
(c) Data on a
hospitalization shall not be submitted to the cabinet before a patient is
discharged and before the record is sufficiently final that it could be used
for billing.
(2) Data
submission responsibility.
(a) If a patient is
served by a mobile health service, specialized medical technology service, or
another situation by which one (1) provider provides services under contract or
other arrangement with another provider, responsibility for providing the
required data to the cabinet shall reside with the provider that bills for the
service or would do so if a service is unbilled.
(b) Charges for physician services provided
within a hospital shall be reported to the cabinet.
1. Responsibility for reporting the physician
charge data shall rest with the hospital if the physician is an employee of the
hospital.
2. A physician charge
contained within a record generated by a hospital shall be clearly identified
in a separate field within the record so that the cabinet may ensure
comparability if aggregating data with other hospital records that do not
contain physician charges.
(3) Transmission of records.
(a) Records submitted to the cabinet by a
hospital shall be uniformly completed and formatted according to coding and
transmission specifications included in the Kentucky Inpatient and Outpatient
Data Coordinator's Manual for Hospitals.
(b) Records submitted to the cabinet by an
ambulatory facility shall be uniformly completed and formatted according to
coding and transmission specifications included in the Kentucky Data
Coordinator's Manual for Ambulatory Facilities.
(c) Each provider shall submit data by
electronic transmission as included in the Kentucky Inpatient and Outpatient
Data Coordinator's Manual for Hospitals and the Kentucky Data Coordinator's
Manual for Ambulatory Facilities.
(d) Each provider shall provide back-up
security against accidental erasure or loss of the data until all incomplete or
inaccurate records identified by the cabinet have been corrected and
resubmitted.
(4)
Verification and audit trail for electronic data submissions.
(a) Each provider shall maintain a date log
of data submissions and the number of records contained in each submission, and
shall make the log available for inspection upon request by the
cabinet.
(b) The cabinet shall,
within twenty-four (24) hours of submission, verify by electronic message to
each provider, the receipt of the provider's data transmissions and the number
of records in each transmission.
(c) A provider shall immediately notify the
cabinet of a discrepancy between the provider's data log and a verification
notice.
Section
6. Data Submission Timetable for Providers.
(1) Quarterly submissions. Each provider
shall submit data at least once for each calendar quarter. A quarterly
submission shall:
(a) Contain data that during
that quarter became final as established in Section 5(1) of this administrative
regulation; and
(b) Be submitted to
the cabinet not later than forty-five (45) days after the last day of the
quarter.
1. If the 45th day falls on a weekend
or holiday, the submission due date shall be the next working day.
2. Calendar quarters shall be January 1
through March 31, April 1 through June 30, July 1 through September 30, and
October 1 through December 31.
(2) Submissions more frequent than quarterly.
A provider may submit data after records become final as established in Section
5(1) of this administrative regulation and at a reasonable frequency convenient
to a provider for accumulating and submitting batch data.
Section 7. Data Corrections for Providers.
(1) Editing. Data received by the cabinet
shall, upon receipt, be edited to ensure completeness and validity of the data.
Computer editing routines shall identify for correction every record in which
the submitted contents of required fields are not consistent with the cabinet's
coding and transmission specifications contained in the Kentucky Inpatient and
Outpatient Data Coordinator's Manual for Hospitals and the Kentucky Data
Coordinator's Manual for Ambulatory Facilities.
(2) Submission of corrections. The cabinet
shall allow a provider thirty (30) days in which to submit corrected copies of
initially submitted data the cabinet identifies as incomplete or invalid as a
result of edits.
(a) The thirty (30) days
shall begin on the date of the cabinet's notice informing the provider that
corrections are required.
(b) A
provider shall submit to the cabinet corrected data by electronic transmission
within thirty (30) days.
(c)
Corrected data submitted to the cabinet shall be uniformly completed and
formatted according to the cabinet's coding and transmission specifications
included in the Kentucky Inpatient and Outpatient Data Coordinator's Manual for
Hospitals and the Kentucky Data Coordinator's Manual for Ambulatory
Facilities.
(3)
Percentage error rate.
(a) If editing data
upon its initial submission, the cabinet shall identify and return to the
provider for correction every record in which one (1) or more of the required
data elements fails to pass the edit.
(b) If editing data that a provider has
submitted, the cabinet shall check for an error rate per quarter of no more
than one (1) percent of records or not more than ten (10) records, whichever is
greater.
(c) The cabinet may return
for further correction, any submission of allegedly corrected data in which the
provider fails to achieve a corrected error rate per quarter of no more than
one (1) percent of records or not more than ten (10) records, whichever is
greater.
Section
8. Fines for Noncompliance for Providers.
(1) A provider failing to meet quarterly
submission guidelines as established in Sections 6 and 7 of this administrative
regulation shall be assessed a fine of $500 per violation.
(2) The cabinet shall notify a noncompliant
provider by certified mail, return receipt requested, of the documentation of
the reporting deficiency and the assessment of the fine.
(3) A provider shall have thirty (30) days
from the date of receipt of the notification letter to pay the fine, which
shall be made payable to the Kentucky State Treasurer and sent by certified
mail to the Kentucky Cabinet for Health and Family Services, Office of Data
Analytics, 275 East Main Street 4 W-E, Frankfort, Kentucky 40621.
(4) Fines during a calendar year shall not
exceed $1,500 per provider.
Section
9. Extension or Waiver of Data Submission Timelines.
(1) A provider experiencing extenuating
circumstances or a hardship may request from the cabinet, in writing, a data
submission extension or waiver.
(a) A provider
shall request an extension or waiver from the Office of Data Analytics on or
before the last day of the data reporting period to receive an extension or
waiver for that period.
(b) An
extension or waiver shall not exceed a continuous period of greater than six
(6) months.
(2) The
cabinet shall consider the following criteria in determining whether or not to
grant an extension or waiver:
(a) Whether or
not the request was made due to an event beyond the provider's control, such as
a natural disaster, catastrophic event, or theft of necessary equipment or
information;
(b) The severity of
the event prompting the request; and
(c) Whether or not the provider continues to
gather and submit the information necessary for billing.
(3) A provider shall not apply for more than
three (3) extensions or waivers during a calendar year.
Section 10. Appeals for Providers.
(1) A provider notified of its noncompliance
and assessed a fine pursuant to Section 8(1) of this administrative regulation
shall have the right to appeal within thirty (30) days of the date of the
notification letter.
(a) If the provider
believes the action by the cabinet is unfair, without reason, or unwarranted,
and the provider wishes to appeal, the provider shall appeal in writing to the
Secretary of the Cabinet for Health and Family Services, 5th Floor, 275 East
Main Street, Frankfort, Kentucky 40621.
(b) An appeal shall be filed in accordance
with KRS Chapter 13B.
(2)
Upon receipt of the appeal, the secretary cabinet or designee shall issue a
notice of hearing no later than twenty (20) days before the date of the
hearing. The notice of the hearing shall comply with KRS 13B.050. The secretary
shall appoint a hearing officer to conduct the hearing in accordance with KRS
Chapter 13B.
(3) The hearing
officer shall issue a recommendation in accordance with KRS 13B.110. Upon
receipt of the recommended order, following consideration of any exceptions
filed pursuant to KRS 13B.110(4), the secretary shall enter a final decision
pursuant to KRS 13B.120.
Section
11. Working Contacts for Providers.
(1) On or before the last day of the data
reporting period, a provider shall report by electronic transmission to the
cabinet the names and telephone numbers of a designated contact person and one
(1) back-up person to facilitate technical follow-up in data reporting and
submission.
(a) A provider's designated
contact and back-up shall not be the chief executive officer unless no other
person employed by the provider has the requisite technical
expertise.
(b) The designated
contact shall be the person responsible for review of the provider's data for
accuracy prior to the publication by the cabinet.
(2) If the chief executive officer,
designated contact person, or back-up person changes during the year, the name
and telephone number of the replacing person shall be reported immediately to
the cabinet.
Section 12.
Required Data Elements for Hospitals. A hospital shall ensure that each record
submitted to the cabinet contains the data elements included in the Kentucky
Inpatient and Outpatient Data Coordinator's Manual for Hospitals.
Section 13. Required Data Elements for
Ambulatory Facilities. An ambulatory facility shall ensure that each record
submitted to the cabinet contains the data elements included in the Kentucky
Data Coordinator's Manual for Ambulatory Facilities.
Section 14. Required Elements for Manuals.
"Kentucky Inpatient and Outpatient Data Coordinator's Manual for Hospitals", or
"Kentucky Data Coordinator's Manual for Ambulatory Facilities" shall be created
and updated by a contracted vendor selected by the cabinet. The manual shall be
found on the office's Web site at:
https://www.chfs.ky.gov/agencies/ohda/Pages/hfsd.aspx.