N.H. Admin. Code § Ins 4202.04
Current through Register No. 50, December 12, 2024
Hospitals and community health centers shall submit header and trailer records and uninsured patient encounter data set records using the following specifications in submitting their healthcare uninsured patient encounter data set:
Table 4200.1 File Header Record Layout
| Data Element # | Element | Type | Maximum Length | Description/Codes/Sources |
| HD001 | Record Type | Text | 2 | HD |
| HD002 | Type of File | Text | 2 | UP |
| HD003 | Period Beginning Date | Integer | 6 | CCYYMM |
| HD004 | Period Ending Date | Integer | 6 | CCYYMM |
| HD005 | Record Count | Integer | 10 | Total number of records submitted in this file |
| HD006 | Comments | Text | 80 | Submitter may use this code according to their own option |
Table 4200.2 Trailer Record Layout
| Data Element # | Element | Type | Maximum Length | Description/Codes/Sources |
| TR001 | Record Type | Text | 2 | TR |
| TR002 | Type of File | Text | 2 | UP |
| TR003 | Period Beginning Date | Integer | 6 | CCYYMM |
| TR004 | Period Ending Date | Integer | 6 | CCYYMM |
| TR005 | Date Processed | Date | 8 | CCYYMMDD |
Table 4200.3 Facility Type
| Code | Facility |
| 18 | Unassigned |
| 19 | Unassigned |
| 20 | Urgent Care Facility Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention |
| 21 | Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic; therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. |
| 22 | Outpatient Hospital A portion of a hospital which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization |
| 23 | Emergency Room - Hospital A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided |
| 24 | Ambulatory Surgical Center A freestanding facility, other than a physician's office, where surgical and diagnostic services are provided on an ambulatory basis |
| 25 | Birthing Center A facility, other than a hospital's maternity facilities or a physician's office, which provides a setting for labor, delivery, and immediate postpartum care as well as immediate care of newborn infants |
| 26 | Military Treatment Facility A medical facility operated by one or more of the Uniformed Services, Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Service (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF) |
| 27 | Unassigned |
| 28 | Unassigned |
| 29 | Unassigned |
| 30 | Unassigned |
| 31 | Skilled Nursing Facility A facility which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital |
| 32 | Nursing Facility A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals |
| 33 | Custodial Care Facility A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component |
| 34 | Hospice A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided |
| 35 | Unassigned |
| 36 | Unassigned |
| 37 | Unassigned |
| 38 | Unassigned |
| 39 | Unassigned |
| 40 | Unassigned |
| 41 | Ambulance - Land A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured |
| 42 | Ambulance - Air or Water An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured |
| 43 | Unassigned |
| 44 | Unassigned |
| 45 | Unassigned |
| 46 | Unassigned |
| 47 | Unassigned |
| 48 | Unassigned |
| 49 | Independent Clinic A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only |
| 50 | Federally Qualified Health Center A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician |
| 51 | Inpatient Psychiatric Facility A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician |
| 52 | Psychiatric Facility-Partial Hospitalization A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-based or hospital-affiliated facility |
| 53 | Community Mental Health Center A facility that provides the following services: outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC's mental health services area who have been discharged from inpatient treatment at a mental health facility; 24 hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services, screening for patients being considered for admission to State mental health facilities to determine the appropriateness of such admission; and consultation and education services |
| 54 | Intermediate Care Facility/Mentally Retarded A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF |
| 55 | Residential Substance Abuse Treatment Facility A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board |
| 56 | Psychiatric Residential Treatment Center A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professional staffed group living and learning environment |
| 57 | Non-residential Substance Abuse Treatment Facility A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing |
| 58 | Unassigned |
| 59 | Unassigned |
| 60 | Mass Immunization Center A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting such as, a public health center, pharmacy, or mall but may include a physician office setting |
| 61 | Comprehensive Inpatient Rehabilitation Facility A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech pathology, social or psychological services, and orthotics and prosthetics services |
| 62 | Comprehensive Outpatient Rehabilitation Facility A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services |
| 63 | Unassigned |
| 64 | Unassigned |
| 65 | End-State Renal Disease Treatment Facility A facility other than a hospital, which provides dialysis treatment, maintenance, and/or training to patients or caregivers on an ambulatory or home-care basis |
| 66 | Unassigned |
| 67 | Unassigned |
| 68 | Unassigned |
| 69 | Unassigned |
| 70 | Unassigned |
| 71 | State or Local Public Health Clinic A facility maintained by either State of local health departments that provides ambulatory primary medical care under the general direction of a physician |
| 72 | Rural Health Clinic A certified facility which is located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician |
| 73 | Unassigned |
| 74 | Unassigned |
| 75 | Unassigned |
| 76 | Unassigned |
| 77 | Unassigned |
| 78 | Unassigned |
| 79 | Unassigned |
| 80 | Unassigned |
| 81 | Independent Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office |
| 82 | Unassigned |
| 83 | Unassigned |
| 84 | Unassigned |
| 85 | Unassigned |
| 86 | Unassigned |
| 87 | Unassigned |
| 88 | Unassigned |
| 89 | Unassigned |
| 90 | Unassigned |
| 91 | Unassigned |
| 92 | Unassigned |
| 93 | Unassigned |
| 94 | Unassigned |
Table 4200.4 Data Elements
| Data Element # | Data Element Name | Type | Maximum Length | Description/Codes/Sources |
| UP001 | Record Type | Text | 2 | UP |
| UP002 | Insurance Type | Text | 2 | "12" Uninsured |
| UP003 | Encrypted Patient Last Name | Text | 128 | Encrypted patient last name |
| UP004 | Encrypted Patient First Name | Text | 128 | Encrypted patient first name |
| UP005 | Encrypted Patient Middle Initial | Text | 1 | Encrypted patient middle initial |
| UP006 | Unique Member Identification Code | Text | 100 | Unique member identification code |
| UP007 | Medical Record Number | Text | 100 | Medical record number |
| UP008 | Gender | Text | 1 | M = Male F = Female U = Unknown |
| UP009 | Uninsured Person Year & Month of Birth | Text | 6 | CCYYMM |
| UP010 | Uninsured Person City Name | Text | 30 | City location |
| UP011 | Uninsured Person State or Province | Text | 2 | US Postal Service code |
| UP012 | Uninsured Person Zip Code | Text | 11 | ZIP Code |
| UP013 | Race 1 | Text | 20 | Based on respective codes; or: R1 = American Indian/Alaskan Native R2 = Asian R3 = Black/African American R4 = Native Hawaiian or other Pacific Islander R5 = White R7 = Refused/declined to provide R8 = Unknown R9 = Other Race |
| UP014 | Race 2 | Text | 20 | Same codes as UP013 |
| UP015 | Hispanic Indicator | Text | 1 | Y = Yes Patient is Hispanic/Latino/Spanish N = No Patient is not Hispanic/Latino/Spanish U = Unknown |
| UP016 | Date Service Received | Date | 8 | CCYYMMDD |
| UP017 | Service Provider Tax ID Number | Text | 10 | Federal taxpayer ID number |
| UP018 | National Service Provider ID | Text | 20 | Federal national provider ID number |
| UP019 | Service Provider Location Name | Text | 100 | |
| UP020 | Service Provider Street Address | Text | 100 | Street address |
| UP021 | Service Provider City Name | Text | 128 | |
| UP022 | Service Provider State | Text | 2 | US Postal Service Code |
| UP023 | Service Provider ZIP Code | Text | 11 | |
| UP024 | Service Provider Organization Name | Text | 100 | |
| UP025 | Service Healthcare Provider Specialty | Text | 10 | Specialty Code |
| UP026 | Facility Type Professional | Text | 2 | CMS-1500 Data Set (Table 4100.3 Facility Type) |
| UP027 | E-code | Text | 5 | ICD-9-CM |
| UP028 | Principal Diagnosis | Text | 6 | ICD-9-CM |
| UP029 | Other Diagnosis - 1 | Text | 5 | ICD-9-CM |
| UP030 | Other Diagnosis - 2 | Text | 5 | ICD-9-CM |
| UP031 | Other Diagnosis - 3 | Text | 5 | ICD-9-CM |
| UP032 | Other Diagnosis - 4 | Text | 5 | ICD-9-CM |
| UP033 | Other Diagnosis - 5 | Text | 5 | ICD-9-CM |
| UP034 | Revenue Code | Text | 4 | National uniform billing committee codes |
| UP035 | Procedure Code | Text | 5 | Health Care Common Procedural Coding System (HCPCS); CPT Codes - American Medical Association |
| UP036 | Procedure Modifier - 1 | Text | 2 | |
| UP037 | Procedure Modifier - 2 | Text | 2 | |
| UP038 | Quantity | Text | 3 | |
| UP039 | Charge Amount | Decimal | 10 | |
| UP040 | Paid Amount | Decimal | 10 | |
| UP041 | Record Type | Text | 2 | UP |
| UP042 | Uninsured Identification Code | Text | 128 | Encrypted social security number |
N.H. Admin. Code § Ins 4202.04
#9806, eff 11-1-10