Section 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.

4.

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.

(c) Data verification, review and comment procedures .

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.

4.

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.

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:

a. Any additional corrections or additions to the data.

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.

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.

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.

8. The department may randomly or for cause audit physician-submitted data to verify the reliability and validity of the data.

9. The department may grant an extension for up to 15 calendar days beyond the 15 calendar days specified in subd. 4. b. if 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.

(d) Data adjustment methods . The department may use any of the following factors for adjusting the physician office data: age; gender; physician specialty; patient zip code; patient diagnosis; procedure; payer category, as appropriate; and other factors, as appropriate. The number and selection of factors the department uses to adjust the data shall depend on the topic under study. The department shall publish in all public reports of the outpatient data the factors used in risk adjustment or the questions and analysis criteria posed to a vendor utilizing proprietary software for a risk adjustment tool. The department shall seek the expertise of technical advisory panels that include physician members, in the regular review of risk adjustment methods and tools. The department shall report at least annually to the board on health care information on the evaluation of risk adjustment tools and the state-of-the-art.

(e) Waiver from data submission requirements .

1. Physicians practicing anytime during calendar year 1998 and submitting claims electronically to any payer shall continue to submit their practice data to the department electronically.

2. Physicians beginning practice in Wisconsin after calendar year 1998 who have the capacity to submit claims data electronically as evidenced by electronic submission to payers shall submit data to the department electronically.

3.

a. The department may grant up to four 6-month exceptions to the requirements in subd. 1. or 2. to physician practices that request an exception to the submission requirements and submit an affidavit as evidence of lost capacity to submit data electronically.

b. The department shall cancel the exception to the submission requirements after 6 months unless the physician requests another exception in writing.

c. If the department discovers evidence of electronic submission of health care claims data within the exception period, the department shall not grant additional exceptions.

4. The department shall report all exceptions granted by the department under subd. 3. to the board.

5. The department may grant an exception to the requirements in subd. 1. or 2. to a physician who submits an affidavit of financial hardship and supporting evidence demonstrating financial inability to comply with the requirements.

(2)   Physician self-report.

(a) Data to be collected .

1. `Health care plan affiliation and updates.' Physicians shall report new affiliations with health care plans and terminations with health care plans to the department within 30 calendar days of the change.

2. `Hospital privileges update.' Physicians shall report hospital privilege changes to the department within 30 days of the hospital's granting of the privileges or the discontinuance of the privileges.

(b) Data submission procedures . Physicians shall report the information in par. (a) to the department through the department's internet submission system. Physicians without access to the internet shall fax or mail their changes to the department.

(c) Data verification, review and comment procedures . The department shall, within 15 working days, send an acknowledgement to the reporting physician verifying the self-report and inviting the physician to submit corrected data within 10 working days.

(d) Data adjustment methods . There shall be no adjustment methods for data submitted under this subsection.

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

(3)   Physician survey.

(a) Data to be collected . The department shall collect all of the following types of workforce and practice information:

1. Name of the physician and address or addresses of main practice or employment.

2. Active status information.

3. License or certification status, including date of initial licensure or certification, credential suspensions or revocations.

4. Medical education and training information.

5. Specialty, board certification and recertification information.

6. Teaching focus information, if applicable.

7. Practice information, including practice name, location, phone number, hours spent at location and provision of obstetrical, pediatric or prenatal care.

8. Whether the physician renders services to medicare and medical assistance patients and, if applicable, whether the physician has signed a medicare participation agreement indicating that she or he accepts assignment on all medicare patients.

9. Whether the physician participates in a voluntary partnercare program specified under s. 71.55 (10) , Stats., under which assignment is accepted for low-income elderly.

10. Date, state and county of most recent residency.

11. Current names and addresses of facilities at which the physician has been granted privileges.

12. The usual and customary charges for office visits, routine tests and diagnostic workups, preventive measures and frequently occurring procedures, as specified by the department.

13. Health plan affiliations.

(b) Data submission procedures .

1. Physicians shall return the survey to the department within 30 days of receiving it. Receipt of data is presumed within 5 days of the date the notice was mailed.

2. The department may grant an extension of a deadline specified in subd. 1. for submission of information 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 labor 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. Physicians who have been granted an extension by the department shall submit their data directly to the department.

(c) Data verification, review and comment procedures . Physicians shall verify or correct information contained on their survey. The department shall verify questionable information by contacting the applicable physician.

(d) Data adjustment methods. There shall be no adjustment methods for data submitted under this subsection.

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

History: Cr. Register, December, 2000, No. 540 , eff. 1-1-01; CR 01-051 : am. (1) (b) 4. a., Register September 2001 No. 549 eff. 10-1-01; CR 03-033 : am. (1) (b) 1., 2., 4. b., 5. and 6. (intro.), (c) 2. (intro.), 4. b., 5. (intro.) and b., (e) 1. and 4., renum. (1) (c) 3. to be (1) (c) 4m. and am., r. (1) (c) 4. c. Register December 2003 No. 576 , eff. 1-1-04.

Note

The bureau of health information was renamed the the bureau of health information and policy. Microsoft Windows NT 6.1.7601 Service Pack 1 For the purposes of par. (b), the Department's address is Bureau of Health Information and Policy, P. O. Box 2659, Madison, Wisconsin 53701-2659, or deliver the communications to Room 372, 1 W. Wilson Street, Madison, Wisconsin. The Bureau of Health Information and Policy's fax number is 608-264-9881. Microsoft Windows NT 6.1.7601 Service Pack 1 Section 71.55 (10), Stats., was repealed by 2003 Wis. Act 33 . Microsoft Windows NT 6.1.7601 Service Pack 1 Physicians who are required to send their information directly to the department should use the following address: Bureau of Health Information and Policy, P. O. Box 2659, Madison, Wisconsin 53701-2659, or deliver the communications to Room 372, 1 W. Wilson Street, Madison, Wisconsin. Microsoft Windows NT 6.1.7601 Service Pack 1