Chapter DHS 120

DHS 120.03(16) (16) “Health care provider” has the meaning given in s. 146.81 (1), Stats., and includes a freestanding ambulatory surgery center.

DHS 120.03(17) (17) “Health care service charge” means the full amount billed for medical services before being reduced by any contractual adjustments or other discounts.

DHS 120.03(18) (18) “Hospital” has the meaning specified in s. 50.33 (2), Stats.

DHS 120.03(19) (19) “Independent review board” or “IRB” means a department board established under s. 15.195 (9), Stats., for the purpose of reviewing requests to release department data on physician office visits that, if inappropriately released, may jeopardize the privacy of individual patients or health care providers.

DHS 120.03 Note Note: Section 15.195 (9), Stats., was repealed by 2005 Wis. Act 228.

DHS 120.03(20) (20) “Individual data elements” means items of information from or derived from a uniform patient billing form or an electronic transaction and code set standard for health care.

DHS 120.03(21) (21) “Medical assistance” means the assistance program operated by the department of health services under ss. 49.43 to 49.497, Stats., and chs. DHS 101 to 108.

DHS 120.03(22) (22) “Medicare” means the health insurance program operated by the U.S. department of health and human services under 42 USC 1395 to 1395 ccc and 42 CFR ch. IV, subch. B.

DHS 120.03(23) (23) “Patient” has the meaning given in s. 153.01 (7), Stats.

DHS 120.03(24) (24) “Payer” means a party responsible for payment of a health care service charge, including an insurer or a federal, state or local government.

DHS 120.03 Note Note: Payers often reimburse health care providers a substantially lesser amount than the full charge.

DHS 120.03(25) (25) “Person” means any individual, partnership, association or corporation, the state or a political subdivision or agency of the state or of a local unit of government.

DHS 120.03(26) (26) “Physician” means a person licensed under ch. 448, Stats., to practice medicine or osteopathy.

DHS 120.03(27) (27) “Public program” means any program funded with government funds.

DHS 120.03 Note Note: Examples of public programs are Medicare under 42 USC 1395 and 42 CFR subchapter B, Badgercare under s. 49.665, Stats., Family Care under ss. 46.2805 to 46.2895, Stats., and Medical Assistance (Medicaid) under ss. 49.43 to 49.497, Stats., and chs. DHS 101 to 108 and CHAMPUS under 10 USC 1071 to 1103.

DHS 120.03(28) (28) “Public use data” means any form of data from the department’s comprehensive discharge database or facility level database that does not allow the identification of an individual from the elements released in the data files.

DHS 120.03(29) (29) “Qualified vendor” means an entity under contract with a health care provider that will submit data to the department according to formats the department specifies in its data submission manual.

DHS 120.03(30) (30) “Raw data elements” means any file, individual record, or any subset thereof, that contains information about an individual health care service provided to a single patient released by the department in public use or custom data files.

DHS 120.03 Note Note: Examples of raw data elements are any of the following:

DHS 120.03 Note a. The data files hospitals and surgery centers submit to the department each quarter.

DHS 120.03 Note b. The public-use data files the department produces.

DHS 120.03 Note c. Any custom data file produced by the department that contains individual records representing hospital discharges or surgical cases. Some customers purchase this kind of data when it is more cost-effective than purchasing the complete statewide public-use data files.

DHS 120.03 Note d. A computer printout of the individual data elements in individual records representing hospital discharges or surgical cases.

DHS 120.03(31) (31) “Reportable price increase” means a change in a hospital’s prices that, by itself or combined with other price increases during the preceding 12 months, causes the percentage increase in the hospital’s total gross revenue from patient services for the 12 months following the change to be greater than the change in the consumer price index.

DHS 120.03(32) (32) “Sign” or “signature” means any combination of words, letters, symbols or characters that is attached to or logically associated with a record and that is used by a person for the purpose of authenticating a document, including one that has been created in or transformed into an electronic format.

DHS 120.03(33) (33) “Subacute care” means goal-oriented, comprehensive, inpatient care designed for an individual who has had an acute illness, injury or exacerbation of a disease process. It is rendered immediately after, or instead of, acute hospitalization to treat one or more specific, active, complex medical conditions or to administer one or more technically complex treatments in the context of a person’s underlying long-term conditions and overall situation. Subacute care is generally more intensive than traditional nursing facility care and less intensive than acute inpatient care.

DHS 120.03(34) (34) “Trading partner agreement” means a signed, formal arrangement between a health care provider and a qualified vendor providing the transfer of data under this chapter. The agreement specifies the acceptable data formats, the edit review and verification requirements, including procedures for processing confidential patient data and the authorized signatory for the affirmation statement.

DHS 120.03(35) (35) “Uncompensated health care services” means charity care and bad debts.

DHS 120.03(36) (36) “Uniform patient billing form” means forms consistent with federal data standards for health care payment transactions.

DHS 120.03 History History: Cr. Register, December, 2000, No. 540, eff. 1-1-01; CR 01-051: cr. (9m), Register September 2001 No. 549 eff. 10-1-01; CR 03-033: am. (13), (20) and (34) Register December 2003 No. 576, eff. 1-1-04; corrections in (9) and (21) made under s. 13.92 (4) (b) 6. and 7., Stats., Register January 2009 No. 637.

subch. II of ch. DHS 120 Subchapter II — Administration

DHS 120.04 DHS 120.04 Assessments to fund the ch. 153, Stats., operations of the department and the board.

DHS 120.04(1) (1) Definitions. In this section:

DHS 120.04(1)(a) (a) “Net expenditure” means the excess of revenues over expenses.

DHS 120.04(1)(b) (b) “State fiscal year” means the 12-month period beginning July 1 and ending the following June 30.

DHS 120.04(2) (2) Estimate of expenditures. By October 1 of each year, the department shall estimate the total expenditures for the ch. 153, Stats., operations of the department and the board for the current state fiscal year from which it shall deduct all of the following:

DHS 120.04(2)(a) (a) The estimated total amount of monies related to this chapter the department will receive from user fees, gifts, grants, bequests, devises and federal funds for that state fiscal year.

DHS 120.04(2)(b) (b) The unencumbered remaining balances of the total amount of monies received through assessments, user fees, gifts, grants, bequests, devises and federal funds from the prior state fiscal year related to this chapter.

DHS 120.04(2)(c) (c) The estimated total amount to be received for purposes of administration of this chapter under s. 20.435 (1) (hi), Stats., during the fiscal year and the unencumbered remaining balance of the amount received for purposes of administration of this chapter under s. 20.435 (1) (hg), Stats., for the fiscal year.

DHS 120.04(3) (3) Calculation of assessments.

DHS 120.04(3)(a) (a) Health care providers.

DHS 120.04(3)(a)1. 1. The department shall annually assess health care providers a fee in order to fund the operations of the department and the board as authorized in s. 153.60, Stats. The department shall calculate net expenditures and resulting assessments separately for hospitals, as a group, freestanding ambulatory surgery centers, as a group, and each type of health care provider, as a group, based on the collection, analysis and dissemination of information related to each group.

DHS 120.04(3)(a)2. 2. The assessment for an individual hospital shall be based on the hospital’s proportion of the reported gross private-pay patient revenue for all hospitals for its most recently concluded fiscal year, which is that year ending at least 120 days prior to July 1.

DHS 120.04(3)(a)2m. 2m. The assessment for a hospital emergency department shall be based on the hospital’s proportion of the reported total number of emergency visits for general medical surgical and critical access hospitals. The assessment period shall cover the hospital’s most recently concluded fiscal year, which is that year ending at least 120 days prior to July 1.

DHS 120.04(3)(a)3. 3. The assessment for an individual freestanding ambulatory surgery center shall be based on the freestanding ambulatory surgery center’s proportion of the number of reported surgical procedures for all freestanding ambulatory surgery centers for the most recently concluded calendar year.

DHS 120.04(3)(a)4. 4. The board shall approve assessment amounts for health care provider classes other than hospitals and freestanding ambulatory surgery centers prior to assessment. The amounts shall equal the quotient of the total amount to be paid by the provider group divided by the number of providers licensed by and practicing in Wisconsin.

DHS 120.04(3)(a)5. 5. No health care provider that is not a facility may be assessed under this section an amount exceeding $75 per year.

DHS 120.04(3)(b) (b) Health care plans.

DHS 120.04(3)(b)1. 1. The department shall, by October 1 of each year, estimate the total amount of expenditures related to the collection, database development and maintenance and generation of public data files and standard reports for health care plans that voluntarily agree to supply data to the department.

DHS 120.04(3)(b)2. 2. The department shall divide the expenditure estimate derived in subd. 1. by the total number of enrollees in health care plans that have, by October 1 of each year, notified the department that the health care plan is going to voluntarily supply data to the department under s. DHS 120.15.

DHS 120.04(3)(b)3. 3. The department shall annually assess each health care plan that has voluntarily agreed to supply data to the department a fee proportionate to the amount estimated in subd. 1. equivalent to the health care plan’s contribution to the total number of enrollees determined under subd. 2.

DHS 120.04(4) (4) Payment of assessments.

DHS 120.04(4)(a) (a) Definitions. In this subsection:

DHS 120.04(4)(a)1. 1. “Evidence of being fully retired” means a completed department survey on which the physician certifies that he or she is fully retired and is signed by the physician.

DHS 120.04(4)(a)2. 2. “Additional evidence” means a letter from the entity through which medical care was provided by the physician.

DHS 120.04(4)(b) (b) Hospitals and freestanding ambulatory surgery centers. Each hospital and freestanding ambulatory surgical center shall pay the amount it has been assessed on or before December 1 of each year by check or money order payable as specified in the assessment notice. Payment of the assessment is timely if the assessment is mailed to the address specified in the assessment notice, is postmarked before midnight of December 1 of the year in which the assessment is due, with postage prepaid, and is received not more than 5 days after the prescribed date for making the payment. A payment that fails to satisfy these requirements solely because of a delay or administrative error of the U.S. postal service shall be considered to be timely.

DHS 120.04(4)(c) (c) Individual health care provider classes.

DHS 120.04(4)(c)1. 1. ‘All individual health care provider classes.’ Each health care provider class other than hospitals and freestanding ambulatory surgical centers shall pay the annual or biennial amount assessed.

DHS 120.04(4)(c)2. 2. ‘Physicians.’

DHS 120.04(4)(c)2.a. a. A physician providing evidence of being fully retired shall be exempt from paying the assessment of the collection of claims data specified in subd. 1. The department shall consider physicians providing all medical care free of charge during retirement to be fully retired. The department shall consider physicians who are retired under the patient compensation fund to be fully retired.

DHS 120.04(4)(c)2.b. b. The department may audit its inpatient and ambulatory surgery databases to corroborate the evidence submitted by physicians. If the department audit indicates that a physician who has submitted evidence of being fully retired is actively practicing in the previous calendar quarter, the physician shall submit the claims data assessment, unless the physician can provide additional evidence that the physician’s care was provided at no charge. If the physician claims to be providing medical care at no charge, the physician shall submit additional evidence.

DHS 120.04(4)(d) (d) Health care plans. Each health care plan voluntarily submitting health care plan data shall pay the amount it has been assessed on or before December 1 of each year by check or money order payable as specified in the assessment notice. Payment of the assessment is timely if the assessment is mailed to the address specified in the assessment notice, is postmarked before midnight of December 1 of the year in which due, with postage prepaid, and is received not more than 5 days after the prescribed date for making the payment. A payment that fails to satisfy these requirements solely because of a delay or administrative error of the U.S. postal service shall be considered to be timely.

DHS 120.04 History History: Cr. Register, December, 2000, No. 540, eff. 1-1-01; CR 01-051: am. (2) (intro.), cr. (3) (a) 2m., Register September 2001 No. 549 eff. 10-1-01; correction in (2) (c) made under s. 13.93 (2m) (b) 7., Stats., Register December 2003 No. 576; corrections in (2) (c) made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637.

DHS 120.05 DHS 120.05 Communications addressed to the department.

DHS 120.05(1) (1) Format. Individual health care professionals or the chief executive officer of the facility or the designee of the individual health care professional or the chief executive officer of the facility shall sign all written information or communications submitted by or on behalf of a health care provider to the department.

DHS 120.05(2) (2) Timing. All written communications, including documents, reports and information required to be submitted to the department shall be submitted by 1st class registered mail, by delivery in person or in an electronic format specified by the department. The date of submission is the date the written communication is postmarked, the date delivery in person is made, or the date on the electronic communication.

DHS 120.05 Note Note: Send all communications, except the actual payment of assessments under s. DHS 120.04 (4), to the following address: Bureau of Health Information and Policy, P. O. Box 2659, Madison, WI 53701-2659, or deliver them to Room 372, 1 West Wilson Street, Madison, Wisconsin.

DHS 120.05 History History: Cr. Register, December, 2000, No. 540, eff. 1-1-01; CR 03-033: am. (2) Register December 2003 No. 576, eff. 1-1-04.

DHS 120.06 DHS 120.06 Selection of a contractor.

DHS 120.06(1) (1) Definitions. In this section:

DHS 120.06(1)(a) (a) “Contractor” means a person under contract to the department to collect, process, analyze or store data for any of the purposes of this chapter.

DHS 120.06(1)(b) (b) “Major purchaser, payer or provider of health care services” means any of the following:

DHS 120.06(1)(b)1. 1. A person, a trust, a multiple employer trust, a multiple employer welfare association, an employee benefit plan administrator or a labor organization that purchases health benefits, which provides health care benefits or services for more than 500 of its full-time equivalent employees, or members in the case of a labor organization, either through an insurer or by means of a self-funded program of benefits.

DHS 120.06(1)(b)2. 2. An insurer that writes accident and health insurance and is among the 20 leading insurers for either group or individual accident and health insurance, as specified in the market shares table of the most recent annual Wisconsin insurance report of the state commissioner of insurance. “Major purchaser, payer or provider of health care services” does not include an insurer that writes only disability income insurance.

DHS 120.06(1)(b)3. 3. A trust, a multiple employer trust, a multiple employer welfare association or an employee benefit plan administrator, including an insurer, that administers health benefits for more than 29,000 individuals.

DHS 120.06(1)(b)4. 4. A person that provides health care services and has 100 or more full-time equivalent employees.

DHS 120.06(2) (2) Eligible contractors. If the department designates a contractor for the provision of data processing services for this chapter, including the collection, analysis and dissemination of health care information, the contractor may not be one of the following types of public or private organizations:

DHS 120.06(2)(a) (a) A major purchaser, payer or provider of health care services in this state.

DHS 120.06(2)(b) (b) A subcontractor of an organization in par. (a).

DHS 120.06(2)(c) (c) A subsidiary or affiliate of an organization in par. (a) in which a controlling interest is held and may be exercised by that organization either independently or in concert with any other organization in par. (a).

DHS 120.06(2)(d) (d) An association of any of the entities in pars. (a) to (c).

DHS 120.06(3) (3) Confidentiality. The department may grant the contractor authority to examine confidential materials and perform other specified functions. The contractor shall comply with all confidentiality requirements established under this chapter. The release of confidential information by the contractor without the department’s written consent shall constitute grounds for the department to terminate the contract and subjects the contractor to all pertinent penalties and liabilities described in this chapter.

DHS 120.06 History History: Cr. Register, December, 2000, No. 540, eff. 1-1-01.

DHS 120.07 DHS 120.07 Training.

DHS 120.07(1) (1) General. The department shall conduct throughout the state a series of training sessions for data submitters to explain its policies and procedures and to provide assistance in implementing the requirements of ch. 153, Stats., and this chapter.

DHS 120.07(2) (2) Data submission training associated with ss. DHS 120.12 (5), (5m) and (6), 120.13 and 120.14 (1).

DHS 120.07(2)(a) (a) The department shall sponsor data submission training each time the department establishes a major change in the data submission process.

DHS 120.07(2)(b) (b) Each data submitting entity shall authorize appropriate staff to attend the department’s data submission training.

DHS 120.07(2)(c) (c) If a data submitting entity replaces its department-trained data submission designee, the data submitting entity shall either transfer the knowledge required to submit data to another designee or make arrangements with the department for the replacement designee to obtain department training.