Section 120.03. Definitions.

  Unless otherwise indicated, in this chapter:

(1)  "Affirmation statement" means a department document that when signed by a health care provider or an authorized representative of a health care provider submitting data to the department affirms, to the best of the signer's knowledge, all of the following:

(a) Any necessary corrections to data submitted to the department have been made.

(b) The data submitted are complete and accurate.

(2)  "Bad debts" means claims arising from rendering patient care services that the hospital, using a sound credit and collection policy, determines are uncollectible, but does not include charity care.

(3)  "Board" means the board on health care information established under s. 15.195 (6) , Stats.

(4)  "Charity care" means health care a hospital provides to a patient who, after an investigation of the circumstances surrounding the patient's ability to pay, including nonqualification for a public program, is determined by the hospital to be unable to pay all or a portion of the hospital's normal billed charges. "Charity care" does not include any of the following:

(a) Care provided to patients for which a public program or public or private grant funds pay for any of the charges for the care.

(b) Contractual adjustments in the provision of health care services below normal billed charges.

(c) Differences between a hospital's charges and payments received for health care services provided to the hospital's employees, to public employees or to prisoners.

(d) Hospital charges associated with health care services for which a hospital reduces normal billed charges as a courtesy.

(e) Bad debts.

(5)  "Contractual adjustment" means the difference between a hospital's full amount billed for medical services for patient services and the discounted charge or payment received by the hospital from the payer.

(6)  "Data profile" means a summary of all submitted data and a summary of the number of records received by the department from a health care provider.

(7)  "Data submission manual" means the department's document specifying the procedures for submitting data, including data formats, coding specifications and instructions for editing incorrect data.

(8)  "Data summary" means a report summarizing what the health care provider submitted, including number of records, and a listing of all questionable data records.

(9)  "Department" means the department of health services.

(9m)  "Emergency department" means a distinct, dedicated area within a hospital with the staffing and resources to provide continuously available assessment, stabilization and initial management of patients presenting with conditions throughout the spectrum of acute illness and injury.

(10)  "Employer coalition" means an organization of employers formed for negotiating terms for the purchase of health care coverage or services as a group.

(11)  "Facility" means a hospital, freestanding ambulatory surgery center, inpatient health care facility as defined in s. 50.135 (1) , Stats., hospice, community-based residential facility or rural medical center.

(12)  "Facility level database" means a database pertaining to a facility, including aggregated utilization, staffing or fiscal data for the facility but not including data on an individual patient or data on an individual health care professional.

(13)  "Freestanding ambulatory surgery center" or "center" means any distinct entity that is operated exclusively for the purpose of providing surgical services to patients not requiring hospitalization, that has an agreement with the federal centers for medicare and medicaid services under 42 CFR 416.25 and 416.30 to participate as an ambulatory surgery center, and that meets the conditions set forth in 42 CFR 416.25 to 416.49 .

(14)  "Gross revenue" means the total charges generated by hospitals to inpatients and outpatients for services provided regardless of the amount a hospital actually expects to collect.

(15)  "Health care plan" means any insured or self-insured plan providing coverage of health care expenses.

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

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

(18)  "Hospital" has the meaning specified in s. 50.33 (2) , Stats.

(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.

(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.

(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 .

(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.

(23)  "Patient" has the meaning given in s. 153.01 (7) , Stats.

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

(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.

(26)  "Physician" means a person licensed under ch. 448 , Stats. , to practice medicine or osteopathy.

(27)  "Public program" means any program funded with government funds.

(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.

(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.

(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.

(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.

(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.

(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.

(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.

(35)  "Uncompensated health care services" means charity care and bad debts.

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

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 .

Note

Section 15.195 (6), Stats., was repealed by 2005 Wis. Act 228 . Microsoft Windows NT 6.1.7601 Service Pack 1 Section 15.195 (9), Stats., was repealed by 2005 Wis. Act 228 . Microsoft Windows NT 6.1.7601 Service Pack 1 Payers often reimburse health care providers a substantially lesser amount than the full charge. Microsoft Windows NT 6.1.7601 Service Pack 1 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 . Microsoft Windows NT 6.1.7601 Service Pack 1 Examples of raw data elements are any of the following: Microsoft Windows NT 6.1.7601 Service Pack 1 a. The data files hospitals and surgery centers submit to the department each quarter. Microsoft Windows NT 6.1.7601 Service Pack 1 b. The public-use data files the department produces. Microsoft Windows NT 6.1.7601 Service Pack 1 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. Microsoft Windows NT 6.1.7601 Service Pack 1 d. A computer printout of the individual data elements in individual records representing hospital discharges or surgical cases. Microsoft Windows NT 6.1.7601 Service Pack 1