10A NCAC 13C .0206 REPORTING REQUIREMENTS
(a) The Department shall establish the lists of the statewide 20 most common outpatient imaging procedures and 20 most common outpatient surgical procedures performed in the ambulatory surgical facility setting to be used for reporting the data required in Paragraphs (c) and (d) of this Rule. The lists shall be determined annually based upon data provided by the certified statewide data processor. The Department shall make the lists available on its website. The methodology to be used by the certified statewide data processor for determining the lists shall be based on the data collected from all licensed facilities in the State in accordance with G.S. 131E-214.2 as follows:
(1) the 20 most common imaging procedures shall be based upon all outpatient data for ambulatory surgical facilities and represent all occurrences of the diagnostic radiology imaging codes section of the CPT codes, then selecting the top 20 to be provided to the Department; and
(2) the 20 most common outpatient surgical procedures shall be based upon the primary procedure code from the ambulatory surgical facilities and represent all occurrences of the surgical codes section of the CPT codes, then selecting the top 20 to be provided to the Department.
(c) In accordance with G.S. 131E-214.13, all licensed ambulatory surgical facilities shall report the data required in Paragraph (d) of this Rule related to the statewide 20 most common outpatient imaging procedures and the statewide 20 most common outpatient surgical procedures to the certified statewide data processor in a format provided by the certified statewide processor. This report shall include the related primary CPT and HCPCS codes. Commencing with the reporting period ending September 30, 2015, an annual data report shall be submitted. Each annual report shall be submitted by January 1.
(d) The report as described in Paragraph (c) of this Rule shall be specific to each reporting ambulatory surgical facility and shall include:
(1) the average gross charge for each CPT code or procedure without a public or private third party payer source;
(2) the average negotiated settlement on the amount that will be charged for each CPT code or procedure as required for patients defined in Subparagraph (d)(1) of this Rule. The average negotiated settlement shall be calculated using the average amount charged all patients eligible for the facility's financial assistance policy, including self-pay patients;
(3) the amount of Medicaid reimbursement for each CPT code or procedure, including all supplemental payments to and from the ambulatory surgical facility;
(4) the amount of Medicare reimbursement for each CPT code or procedure; and
(5) on behalf of patients who are covered by a Department of Insurance licensed third-party and teachers and State employees, the lowest, average, and highest amount of payments made for each CPT code or procedure by each of the facility's top five largest health insurers.
(A) each ambulatory surgical facility shall determine its five largest health insurers based on the dollar volume of payments received from those insurers;
(B) the lowest amount of payment shall be reported as the lowest payment from each of the five insurers on the CPT code or procedure;
(C) the average amount of payment shall be reported as the arithmetic average of each of the five health insurers payment amounts;
(D) the highest amount of payment shall be reported as the highest payment from each of the five insurers on the CPT code or procedure; and
(E) the identity of the top five largest health insurers shall be redacted prior to submission.
(e) The data reported, as defined in Paragraphs (c) and (d) of this Rule, shall reflect the payments received from patients and health insurers for all closed accounts. For the purpose of this Rule, "closed accounts" are patient accounts with a zero balance at the end of the data reporting period.
(f) A minimum of three data elements shall be required for reporting under Paragraph (c) of this Rule.
(g) The information submitted in the report shall be in compliance with the federal Health Insurance Portability and Accountability Act of 45 CFR Part 164.
(h) The Department shall provide all specific ambulatory surgical facility data reported pursuant to this Rule on its website.
History Note: Authority G.S. 131E-147.1; 131E-214.4; 131E-214.13;
Temporary Adoption Eff. December 31, 2014;
Eff. September 30, 2015;
Temporary Amendment Eff. March 31, 2016;
Amended Eff. January 31, 2017.