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Chapter 3. Uniform Billing Format of California Health And Safety Code >> Division 107. >> Part 2. >> Chapter 3.
For purposes of this chapter, the following definitions
shall apply:
(a) "Carrier" means any of the following:
(1) Any insurer, including, but not limited to, disability insurers, nonprofit hospital service plans, fraternal benefit societies, and firemen's, policemen's, or peace officers' benefit and relief associations.
(2) A health care service plan other than a specialized health care service plan.
(3) A self-funded employer sponsored plan, multiple employer trust, or Taft-Hartley Trust as defined by federal law, authorized to pay for health care services in this state.
(4) The State Compensation Insurance Fund.
(5) The health insurance offered to certain employees of this state by the Public Employees' Retirement System known as "PERS Care."
(a) "Carrier" means any of the following:
(1) Any insurer, including, but not limited to, disability insurers, nonprofit hospital service plans, fraternal benefit societies, and firemen's, policemen's, or peace officers' benefit and relief associations.
(2) A health care service plan other than a specialized health care service plan.
(3) A self-funded employer sponsored plan, multiple employer trust, or Taft-Hartley Trust as defined by federal law, authorized to pay for health care services in this state.
(4) The State Compensation Insurance Fund.
(5) The health insurance offered to certain employees of this state by the Public Employees' Retirement System known as "PERS Care."
(b) "Department" means the State Department of Health Services.
(c) "Office" means the Office of Statewide Health Planning and Development.
(d) "Professional health care services" means any diagnostic or treatment services provided in California directly to a patient by a person licensed or practicing pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code who is eligible to directly bill for their services. "Professional health care services" does not include services provided by a person licensed pursuant to a chapter of Division 2 that the director of the office has determined, pursuant to Section 127590, should be exempted.
(e) "Institutional provider services" means any services, equipment, and supplies, other than professional health care services that are provided by an institution, site, or facility through which professional health care services are provided. "Institutional provider services" includes any component of an episode of health care for which there will be charges, other than professional health care services. "Institutional provider services" does not include diagnostic or treatment services that would be considered "professional health care services" but for the fact that the provider is licensed under a chapter of Division 2 of the Business and Professions Code that the director of the office has exempted pursuant to Section 127590.
(f) "California uniform billing form for professional health care services" and "California uniform billing form for institutional provider services" means billing forms in the formats developed by the office pursuant to Section 127580.
(c) "Office" means the Office of Statewide Health Planning and Development.
(d) "Professional health care services" means any diagnostic or treatment services provided in California directly to a patient by a person licensed or practicing pursuant to Division 2 (commencing with Section 500) of the Business and Professions Code who is eligible to directly bill for their services. "Professional health care services" does not include services provided by a person licensed pursuant to a chapter of Division 2 that the director of the office has determined, pursuant to Section 127590, should be exempted.
(e) "Institutional provider services" means any services, equipment, and supplies, other than professional health care services that are provided by an institution, site, or facility through which professional health care services are provided. "Institutional provider services" includes any component of an episode of health care for which there will be charges, other than professional health care services. "Institutional provider services" does not include diagnostic or treatment services that would be considered "professional health care services" but for the fact that the provider is licensed under a chapter of Division 2 of the Business and Professions Code that the director of the office has exempted pursuant to Section 127590.
(f) "California uniform billing form for professional health care services" and "California uniform billing form for institutional provider services" means billing forms in the formats developed by the office pursuant to Section 127580.
The office, after consultation with the Insurance
Commissioner, the Director of the Department of Managed Health Care,
the State Director of Health Services, and the Director of Industrial
Relations, shall adopt a California uniform billing form format for
professional health care services and a California uniform billing
form format for institutional provider services. The format for
professional health care services shall be the format developed by
the National Uniform Claim Form Task Force. The format for
institutional provider services shall be the format developed by the
National Uniform Billing Committee. The formats shall be acceptable
for billing in federal Medicare and medicaid programs. The office
shall specify a single uniform system for coding diagnoses,
treatments, and procedures to be used as part of the uniform billing
form formats. The system shall be acceptable for billing in federal
Medicare and medicaid programs.
(a) Carriers shall accept, and providers shall use, a
completed California uniform billing form, or the electronic
equivalent, for each instance when a carrier provides coverage for
professional health care services and for each instance when a
carrier provides coverage for institutional provider services.
(b) Carriers that are health care service plans licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), and providers of professional health care services or institutional provider services covered by those plans shall be exempt from the requirement of subdivision (a) except in instances when the provider of the professional health care services bills the plan for the specific services provided and in instances when the provider of the institutional provider services bills the plan for the specific services provided.
(c) Nothing in the forms shall be construed to prohibit a carrier from requiring that its insured or enrollee, or a person acting on behalf of the insured or enrollee, submit other information to the carrier as necessary to determine that the professional health care services or institutional provider services are covered under the terms of the carrier's health benefits plan.
(b) Carriers that are health care service plans licensed under the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code), and providers of professional health care services or institutional provider services covered by those plans shall be exempt from the requirement of subdivision (a) except in instances when the provider of the professional health care services bills the plan for the specific services provided and in instances when the provider of the institutional provider services bills the plan for the specific services provided.
(c) Nothing in the forms shall be construed to prohibit a carrier from requiring that its insured or enrollee, or a person acting on behalf of the insured or enrollee, submit other information to the carrier as necessary to determine that the professional health care services or institutional provider services are covered under the terms of the carrier's health benefits plan.
The Director of the Office of Statewide Health Planning and
Development may determine that the definition of "professional
health care services" in subdivision (d) of Section 127575 does not
include services provided by persons licensed under certain chapters
of Division 2 of the Business and Professions Code and shall have the
authority to determine the chapters that shall be exempt.
The department shall adopt the California uniform billing
form formats for use in all health care payment programs it
administers, including, but not limited to, Medi-Cal, county health
services programs, and other health care payment programs, for each
instance when a program provides coverage for professional health
care services and for each instance when a program provides coverage
for institutional provider services. The department may adapt the
billing format for institutional provider services only to the extent
necessary for the forms to be optically scanned and automatically
microfilmed. The department shall provide exemptions from this
requirement as necessary and appropriate to the efficient operation
of health care service plans that do not reimburse providers on a
fee-for-service basis, except that the plans shall use the formats in
instances when the professional or institutional provider bills a
plan for the specific services provided. The department shall
implement this requirement in any Medi-Cal contract for fiscal
intermediary services entered into on or after January 1, 1993.
(a) The department, in consultation with the office and the
California Health Policy and Data Advisory Commission, may develop a
uniform core dataset for public health programs to do all of the
following:
(1) Reduce administrative complexity.
(2) Eliminate unnecessary duplication in the collection and reporting of data.
(3) Facilitate integration, consistency, and transfer of data among public health and health services programs.
(4) Promote monitoring of health status, planning, policy development and service coordination, quality assurance, and program evaluation for all public health programs.
(b) The department, in consultation with the office and the California Health Policy and Data Advisory Commission, shall develop proposed policies and procedures to ensure privacy and confidentiality of data and appropriate use and access to data.
(c) This section shall not be construed to require any physician and surgeon or other health care provider to provide any additional items of information to these public health care programs.
(1) Reduce administrative complexity.
(2) Eliminate unnecessary duplication in the collection and reporting of data.
(3) Facilitate integration, consistency, and transfer of data among public health and health services programs.
(4) Promote monitoring of health status, planning, policy development and service coordination, quality assurance, and program evaluation for all public health programs.
(b) The department, in consultation with the office and the California Health Policy and Data Advisory Commission, shall develop proposed policies and procedures to ensure privacy and confidentiality of data and appropriate use and access to data.
(c) This section shall not be construed to require any physician and surgeon or other health care provider to provide any additional items of information to these public health care programs.
