Wisconsin Legislature: DHS 120.14(1)(a)12.

(c) Upon written request, the department shall provide consultation to a freestanding ambulatory surgical center to enable the requesting center to submit ambulatory patient surgical data according to the department’s specifications.

(d)

1. To ensure confidentiality, centers using qualified vendors to submit data shall provide to the department an original trading partner agreement that has been signed and notarized by the qualified vendor and the ambulatory surgery center.

2. Centers shall be accountable for their qualified vendor’s failure to submit and edit data in the formats required by the department.

(3) Freestanding ambulatory surgery center data verification, review and comment procedures. The data verification, review and comment procedures specified in s. DHS 120.11 (1) to (3) shall apply.

(4) Physician verification, review and comment on freestanding ambulatory surgery center-submitted data. The data verification, review and comment procedures specified in s. DHS 120.11 (1), (2) and (4) shall apply.

(5) Data adjustment methods. The department shall adjust health care charge information for case mix and severity using commonly acceptable methods and tools designed for administrative claims information to perform adjustments for a class of health care providers.

(6) Waiver from data submission requirements. There shall be no waivers from the data submission requirements under this section.

(7) Compliant data submission.

(a) To be considered compliant with this chapter, a facility’s data submission shall be all of the following:

1. Submitted to the department electronically, as specified in the data submission manual.

2. Consist of an individual facility data file.

3. Meet the department standard of 10% or fewer records that do not pass the department’s error checking procedures on or before the data submission due date.

(b) Facilities that fail to achieve a compliant data submission as required under this subsection may be subject to forfeitures.

History: Cr. Register, December, 2000, No. 540, eff. 1-1-01; CR 01-051: am. (2) (d) 1. and (7) (a) 1., Register September 2001 No. 549 eff. 10-1-01; CR 03-033: am. (2) (a) Register December 2003 No. 576, eff. 1-1-04.

DHS 120.14 Data to be submitted by physician class of provider.

(1) Claims data.

(a) Data to be collected. Physicians shall submit all of the following data elements:

1. Patient’s birth date.

2. Patient’s gender.

3. Patient zip code.

4. Patient condition related to employment.

5. Patient condition related to auto accident.

6. Patient condition related to other accident.

7. Date of current illness, injury or pregnancy.

8. The first date of illness, if patient has had same or similar illness.

9. Primary payer category code.

10. Secondary payer category code.

11. Medical record or chart number.

12. Name of referring physician.

13. Identification number of referring physician.

14. Patient control number.

15. Whether tests were sent to an outside lab.

16. Outside lab charges.

17. Diagnosis or nature of illness or injury.

18. Medical assistance resubmission code.

19. Prior authorization number.

20. Dates of service.

21. Place of service.

22. Type of service.

23. Codes for procedures, services or supplies.

24. Modifiers.

25. Charges.

26. Days or units.

27. Encrypted case identifier.

28. Provider employer identification number.

29. Patient account number.

30. Whether the provider accepts assignment.

31. Total charge.

32. Name of facility where services were rendered.

33. Address of facility where services were rendered.

34. Physician’s and supplier’s billing name.

35. Physician’s and supplier’s billing address.

36. Billing physician’s identification number.

37. Performing physician’s identification number.

(b) Data submission procedures.

1. Non–exempt physicians shall submit claims information to the department in an electronic format using secure methods specified in a data submission manual provided by the department. Physicians who submit data through a qualified vendor shall require their vendor to comply with the requirements specified in this paragraph. In addition, qualified vendors shall sign a trading partner agreement.

2. Each physician shall submit his or her data to the department within 30 calendar days following the close of the reporting period. The department shall provide instructions on submission in a data submission manual.

3. The department may grant an extension of the deadline specified under subd. 2. only when the physician adequately justifies to the department the physician’s need for additional time. In this subdivision, “adequate justification” means a delay due to a strike, fire, natural disaster or catastrophic computer failure. A physician desiring an extension shall submit a request for an extension in writing to the department at least 10 calendar days prior to the date that the data are due. The department may grant an extension for up to 30 calendar days.

a. To ensure confidentiality of the data is maintained, physicians using qualified vendors to submit data shall provide to the department an original trading partner agreement that has been signed and notarized by the qualified vendor and the physician.

b. A physician or his or her delegated representative shall be accountable for his or her qualified vendor’s failure to submit and edit data in the format required by the department.

5. A health care provider that is not a hospital or ambulatory surgery center shall, before submitting information required by the department under this chapter, convert any names of an insured’s payer or other insured’s payer to a payer category code as specified by the department in its data submission manual.

6. A health care provider or qualified vendor may not submit information that uses any of the following as a patient account number:

a. The patient’s social security number or any substantial portion of the patient’s social security number.

b. A number that is related to another patient identifying number.

1. The department shall check the accuracy and completeness of all submitted data.

2. The department may not retain or release any of the following data elements if the department receives the elements:

a. The patient’s name and street address.

b. The insured’s name, street address and telephone number.

c. Any other insured’s name, employer or school name and date of birth.

d. The signature of the patient or other authorized signature.

e. The signature of the insured or other authorized signature.

f. The signature of the physician.

g. The patient’s account number, after use only as verification of data by the department.

h. The patient’s telephone number.

i. The insured’s employer’s name or school name.

j. Data regarding insureds other than the patient, other than the payer category code under par. (b) 5.

k. The patient’s employer’s name or school name.

L. The patient’s relationship to the insured.

m. The insured’s identification number.

n. The insured’s policy or group number.

o. The insured’s date of birth or gender.

p. The patient’s marital, employment or student status.

a. If the department determines data submitted by a physician or qualified vendor to be questionable, the department may return the questionable data in a data summary to the physician or the physician’s qualified vendor with information for revision and resubmission.

b. The physician or the physician’s qualified vendor shall correct data errors identified by the department as requiring correction via the department’s, physician’s or qualified vendor’s data editing system and shall return corrected data to the department within 15 calendar days after the physician or the physician’s qualified vendor received the data summary.

4m. If the data submitted by a physician or qualified vendor passes the department’s editing processes, the department shall send a data profile to the physician or their qualified vendor indicating what has been sent and an affirmation statement. The physician or their qualified vendor shall review the profile and verify the accuracy of the profile’s data.