N.H. Code Admin. R. Ins 4202.04
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:
(a) The file header record layout shall be submitted using the following data elements:
(b) The file header record layout shall conform to the following:
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
(c) The trailer header record layout shall be submitted using the following data elements:
(d) The trailer record layout shall conform to the following:
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
(f) The uninsured patient encounter data set record layout shall be submitted using the following general specifications:
(g) The uninsured patient encounter data set shall be submitted using the following data elements for each service provided during a unique encounter (multiple lines per encounter as needed to describe all services provided during the encounter).
(8) UP008. This element is named "gender". The data type of this element is text. Its length is one. Hospitals and community health centers shall code according to:
(13) UP013. This element is named "Race 1". The data type of this element is text. Its length is 20. Coding for this element shall:
d. Hospitals and community health centers may alternatively code as follows:
(15) UP015. This element is named "Hispanic indicator". The data type of this element is text. Its length is one. Hospitals and community health centers shall code according to:
(26) UP026. This element is named "facility type professional". The data type of this element is text. Its length is 2. Hospitals and community health centers shall code facility type according to the Medicare Claims Processing Manual Form, CMS-1500 data set;
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
(h) The uninsured patient encounter data elements shall conform to the following:
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
Source. #9806, eff 11-1-10