Chapter DHS 120

DHS 120.13(5) (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.

DHS 120.13(6) (6) Waiver from data submission requirements. There shall be no waivers from the data submission requirements under this section.

DHS 120.13(7) (7) Compliant data submission.

DHS 120.13(7)(a) (a) To be considered compliant with this chapter, a facility’s data submission shall be all of the following:

DHS 120.13(7)(a)1. 1. Submitted to the department electronically, as specified in the data submission manual.

DHS 120.13(7)(a)2. 2. Consist of an individual facility data file.

DHS 120.13(7)(a)3. 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.

DHS 120.13(7)(b) (b) Facilities that fail to achieve a compliant data submission as required under this subsection may be subject to forfeitures.

DHS 120.13 History 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 DHS 120.14 Data to be submitted by physician class of provider.

DHS 120.14(1) (1) Claims data.

DHS 120.14(1)(a) (a) Data to be collected. Physicians shall submit all of the following data elements:

DHS 120.14(1)(a)1. 1. Patient’s birth date.

DHS 120.14(1)(a)2. 2. Patient’s gender.

DHS 120.14(1)(a)3. 3. Patient zip code.

DHS 120.14(1)(a)4. 4. Patient condition related to employment.

DHS 120.14(1)(a)5. 5. Patient condition related to auto accident.

DHS 120.14(1)(a)6. 6. Patient condition related to other accident.

DHS 120.14(1)(a)7. 7. Date of current illness, injury or pregnancy.

DHS 120.14(1)(a)8. 8. The first date of illness, if patient has had same or similar illness.

DHS 120.14(1)(a)9. 9. Primary payer category code.

DHS 120.14(1)(a)10. 10. Secondary payer category code.

DHS 120.14(1)(a)11. 11. Medical record or chart number.

DHS 120.14(1)(a)12. 12. Name of referring physician.

DHS 120.14(1)(a)13. 13. Identification number of referring physician.

DHS 120.14(1)(a)14. 14. Patient control number.

DHS 120.14(1)(a)15. 15. Whether tests were sent to an outside lab.

DHS 120.14(1)(a)16. 16. Outside lab charges.

DHS 120.14(1)(a)17. 17. Diagnosis or nature of illness or injury.

DHS 120.14(1)(a)18. 18. Medical assistance resubmission code.

DHS 120.14(1)(a)19. 19. Prior authorization number.

DHS 120.14(1)(a)20. 20. Dates of service.

DHS 120.14(1)(a)21. 21. Place of service.

DHS 120.14(1)(a)22. 22. Type of service.

DHS 120.14(1)(a)23. 23. Codes for procedures, services or supplies.

DHS 120.14(1)(a)24. 24. Modifiers.

DHS 120.14(1)(a)25. 25. Charges.

DHS 120.14(1)(a)26. 26. Days or units.

DHS 120.14(1)(a)27. 27. Encrypted case identifier.

DHS 120.14(1)(a)28. 28. Provider employer identification number.

DHS 120.14(1)(a)29. 29. Patient account number.

DHS 120.14(1)(a)30. 30. Whether the provider accepts assignment.

DHS 120.14(1)(a)31. 31. Total charge.

DHS 120.14(1)(a)32. 32. Name of facility where services were rendered.

DHS 120.14(1)(a)33. 33. Address of facility where services were rendered.

DHS 120.14(1)(a)34. 34. Physician’s and supplier’s billing name.

DHS 120.14(1)(a)35. 35. Physician’s and supplier’s billing address.

DHS 120.14(1)(a)36. 36. Billing physician’s identification number.

DHS 120.14(1)(a)37. 37. Performing physician’s identification number.

DHS 120.14(1)(b) (b) Data submission procedures.

DHS 120.14(1)(b)1. 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.

DHS 120.14(1)(b)2. 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.

DHS 120.14(1)(b)3. 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.

DHS 120.14(1)(b)4. 4.

DHS 120.14(1)(b)4.a. 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.

DHS 120.14(1)(b)4.b. 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.

DHS 120.14(1)(b)5. 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.

DHS 120.14(1)(b)6. 6. A health care provider or qualified vendor may not submit information that uses any of the following as a patient account number:

DHS 120.14(1)(b)6.a. a. The patient’s social security number or any substantial portion of the patient’s social security number.

DHS 120.14(1)(b)6.b. b. A number that is related to another patient identifying number.

DHS 120.14(1)(c) (c) Data verification, review and comment procedures.

DHS 120.14(1)(c)1. 1. The department shall check the accuracy and completeness of all submitted data.

DHS 120.14(1)(c)2. 2. The department may not retain or release any of the following data elements if the department receives the elements:

DHS 120.14(1)(c)2.a. a. The patient’s name and street address.

DHS 120.14(1)(c)2.b. b. The insured’s name, street address and telephone number.

DHS 120.14(1)(c)2.c. c. Any other insured’s name, employer or school name and date of birth.

DHS 120.14(1)(c)2.d. d. The signature of the patient or other authorized signature.

DHS 120.14(1)(c)2.e. e. The signature of the insured or other authorized signature.

DHS 120.14(1)(c)2.f. f. The signature of the physician.

DHS 120.14(1)(c)2.g. g. The patient’s account number, after use only as verification of data by the department.

DHS 120.14(1)(c)2.h. h. The patient’s telephone number.

DHS 120.14(1)(c)2.i. i. The insured’s employer’s name or school name.

DHS 120.14(1)(c)2.j. j. Data regarding insureds other than the patient, other than the payer category code under par. (b) 5.

DHS 120.14(1)(c)2.k. k. The patient’s employer’s name or school name.

DHS 120.14(1)(c)2.L. L. The patient’s relationship to the insured.

DHS 120.14(1)(c)2.m. m. The insured’s identification number.

DHS 120.14(1)(c)2.n. n. The insured’s policy or group number.

DHS 120.14(1)(c)2.o. o. The insured’s date of birth or gender.

DHS 120.14(1)(c)2.p. p. The patient’s marital, employment or student status.

DHS 120.14(1)(c)4. 4.

DHS 120.14(1)(c)4.a. 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.

DHS 120.14(1)(c)4.b. 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.

DHS 120.14(1)(c)4m. 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.

DHS 120.14(1)(c)5. 5. The physician or his or her delegated representative shall review the final data profile for accuracy and completeness and shall supply the department within 30 calendar days from the day the data is due to the bureau of health information with the following:

DHS 120.14 Note Note: The bureau of health information was renamed the bureau of health information and policy.

DHS 120.14(1)(c)5.a. a. Any additional corrections or additions to the data.

DHS 120.14(1)(c)5.b. b. A signed affirmation statement. A physician or the physician’s delegated representative submitting affirmation statements to the department electronically shall use a digital signature approved by the department and returned by the physician or the physician’s delegated representative during the timeframes for data submission specified by the department. A physician’s or the physician’s delegated representative’s signature on the electronic data affirmation statement represents the physician’s or the physician’s delegated representative’s acknowledgment that the data is accurate and the data submitter may no longer submit revised data.

DHS 120.14(1)(c)6. 6. If the department discovers data errors after the department’s release of the data or if a physician notifies the department of data errors after the department’s release of the data, the department shall note the data errors as caveats to the completed datasets.

DHS 120.14(1)(c)7. 7. The department shall include a comment file with each of the physician databases. Physicians desiring to comment on data they submit shall submit their comments in a standard electronic word processing format. Comments shall be limited to a maximum of 1000 words. All comments shall be submitted with the electronic data affirmation statement no later than the 15th calendar day following the physician’s receipt of the data profile.