Effective Date: 03/28/2007
Title: Section 400.18 - Information policy and other reporting requirements

400.18 Information policy and other reporting requirements. The department's collection, use and disclosure of data obtained by the New York State Statewide Planning and Research Cooperative System from medical facilities shall be governed by the provisions of this Section. This section shall also govern the functioning of the Data Protection Review Board and the Council on Hospital Information Policy and establish provisions for hospital accounting and reporting.

(a) Definitions. For the purposes of this section, the following terms shall have the following meanings:

(1) New York State Statewide Planning and Research Cooperative System (SPARCS) shall mean a statewide centralized health care system which incorporates data submitted to the department by hospitals pursuant to Universal Data Set Specifications and subdivision (b) of this section, the patient review instrument data submitted by residential health care facilities pursuant to section 86-2.30 of this Title, ambulatory surgery data submitted by hospital-based and freestanding centers pursuant to subdivision (d) of this section, and emergency services data submitted by hospitals pursuant to subdivision (h) of this section.

(2) Deniable individual stay or visit data, except as provided in paragraph (3) of this subdivision, shall mean data pertaining to a particular individual's facility stay or visit that contain one or more of the following deniable data elements, which, if disclosed, would constitute an unwarranted invasion of personal privacy: medical record number, admit number, admit or visit date, discharge date, date(s) of surgery, third-party payor identification numbers, address, birthdate, physician identification, accident date, facility identification, and Patient Review Instrument data elements referred to in paragraph (11) of this subdivision.

(3) Individual stay or visit data shall mean data pertaining to six or more facility patients which do not include any of the deniable data elements referred to in paragraph (2) of this subdivision. The following shall not constitute deniable data elements: month and year of admission or visit, month and year of discharge, length of stay, number of pre-operative days, number of post-operative days, class of payor, census tract location of patient, age of patient at one-year intervals for patients one-year old or older, age of patient at one-week intervals for patients less than one-year old, physician speciality, number of attending physicians, presence or absence of an accident, facility reimbursement peer group, chief complaint, both textual and coded, and gender. Any data pertaining to fewer than six facility patients shall be deemed to constitute deniable individual stay or visit data.

(4) Facility stay or visit data shall mean individual stay or visit data and, in addition, the deniable data element of facility identification.

(5) Aggregated data shall mean a statistical tabulation of facility patient records, with no single grouping or tabulation to be based upon fewer than six facility patient records. Where groupings are based upon fewer than six records, such groupings will be eliminated or combined with other groupings.

(6) Deniable aggregated data shall mean aggregated data which include one or more of the deniable data elements referred to in paragraph (2) of this subdivision.

(7) SPARCS shall mean a unit within the New York State Department of Health whose functions and responsibilities are elaborated in paragraph (e)(3) of this section.

(8) Data protection review board (DPRB) shall mean a board whose members are appointed by the commissioner and whose functions and responsibilities are elaborated in paragraph (e)(4) of this section.

(9) Patient review instrument (PRI) shall mean the reporting form developed, by the Department of Health, pursuant to section 86-2.30 of this Title.

(10) PRI data shall mean the data submitted on PRI forms by residential health care facilities.

(11) Deniable individual PRI data shall mean data pertaining to a particular individual that contain one or more of the following deniable data elements which, if disclosed, would constitute an unwarranted invasion of personal privacy: operating certificate number, social security number, official facility name, patient name, medical record number, room number, unit number, date of birth, date of initial admission, Medicaid number, and Medicare number.

(12) Aggregated PRI data shall mean a statistical tabulation of residential health care facility patient records, with no single grouping or tabulation to be based on fewer than six residential health care facility patient records; however, it shall be noted by SPARCS on the requested data, if approved, where the tabulation would result in fewer than six residential health care facility patient records.

(13) Deniable aggregated PRI data shall mean aggregated data which include one or more of the deniable data elements referred to in paragraph (11) of this subdivision.

(14) Ambulatory Surgery Data Abstract Project (ASDAP) shall mean the data format used by hospital based and free-standing ambulatory surgery centers to report to the Department of Health pursuant to subdivision (d) of this section.

(15) ASDAP data shall mean the data submitted by hospital-based and free-standing ambulatory surgery centers.

(16) Emergency service data (ESD) shall mean data submitted by hospitals which related to visits by patients to the hospital's emergency service, whether or not such patients are admitted to the inpatient level of care for treatment or observation.

(b) Uniform bill. (1) All hospitals shall file for each patient such uniform bill elements for patient health services rendered by a hospital as part of the UDS, such uniform bill elements as are set forth in Appendixc C-2, infra and such additional elements as are approved by the Commissioner upon finding that they are recommended by the National Uniform Billing Committee and the National Committee on Vital Health Statistics or are necessary for permitted uses of SPARCS data. Facilities shall submit or cause to have submitted the data in computer-readable format according to specifications provided by the Commissioner. Such data shall be provided for all patients discharged. The commissioner may waive the requirement that a facility submit ancillary charge data if a hospital can show that it is presently without an ancillary charge structure. The commissioner shall be responsible for protecting the confidentiality and privacy in accordance with subdivision (e) of this section.

(2) All data describing the patient's age, sex, birthweight or admission weight for neonates, principal and other diagnoses and principal and other procedures shall be supported by the patient's medical record.

(c) Uniform discharge abstract. (1) All hospitals shall file for each patient discharged as part of the UDS such uniform discharge abstract elements as are set forth in Appendix C-3, infra, and such additional elements as are approved by the commissioner upon finding that they are recommended by the National Uniform Billing Committee and the National Committee on Vital Health Statistics or are necessary for permitted uses of SPARCS data. Facilities shall submit or cause to be submitted such data in computer-readable format according to specifications provided by the commissioner. Such data shall be provided for all inpatients discharged. The commissioner shall be responsible for protecting the confidentiality and privacy of data in accordance with subdivision (e) of this section.

(2) Data provided on the uniform discharge abstract that describe the patient's age, sex, birthweight or admission weight for neonates, principal diagnosis, other diagnoses, principal procedure, and other procedures shall be identical to the data included in the patient's discharge uniform bill and shall be supported by the patient's medical record.

(d) Ambulatory surgery data. (1) All facilities licensed under article 28 of the Public Health Law that provide ambulatory surgery services shall submit in an electronic format for each patient surgical visit that requires a stay of less than 24 hours any procedure listed in the American Medical Association Current Procedural Terminology (CPT) as prescribed by the commissioner to be maintained on an annual basis, including but not limited to all procedures in the Surgery Section of CPT.

(2) Facilities shall submit or cause to be submitted such correct or corrected data in computer-readable format according to specifications provided by the Commissioner. Any hospital-owned magnetic media will be returned to the hospital subsequent to receipt by the department.

(3) Facilities certified by the department to provide hospital-based ambulatory surgery services shall submit such data within 30 days of the end of each calendar quarter.

(4) Facilities which do not submit data or corrected data within 30 days of receipt of the department's error report concerning such data will not be reimbursed under section 86-1.41 of this Title until compliance with this section is certified in writing by the commissioner or his or her designee.

(5) Request for deniable individual or aggregate data or data reports based on data submitted pursuant to this section shall be processed pursuant to subdivision (e) of this section.

(6) Nothing in this section shall be construed to authorize the performance of procedures for which appropriate approval has not been obtained under part 709 and part 710 of this Title.

(e) Disclosure of data contained in the Uniform Data Set, patient review instrument as contained on section 86-2.30 of this Title, ambulatory surgery data abstract project (ASDAP) and emergency service data (ESD) to prevent unwarranted invasions of personal privacy.

(1) Purposes of SPARCS, the PRI, ESD and ASDAP.

(i) SPARCS, ESD and ASDAP are designed to contribute to the goal of providing high quality medical care at reasonable cost to the inhabitants of the State by serving as an information source for organizations and agencies seeking to promote the efficient delivery of health care services.

(ii) The PRI is designed to classify patients for the purposes of determining appropriate levels of reimbursement in residential health care facilities.

(iii) Consistent with subparagraphs (i) and (ii) of this paragraph, the purposes for which data from SPARCS, the PRI, ESD or ASDAP may be used to include the following:

(a) financial studies--investigation of alternate means of paying for hospital, ambulatory surgery, emergency department services, and/or residential health care facilities care to bring about a more cost-effective system of hospital, ambulatory surgery, emergency department services, and/or residential health care facility financing;

(b) rate setting--modeling of rate policies and calculating of reimbursement rates for hospitals, ambulatory surgery, emergency departments, and/or residential health care facilities;

(c) surveillance--surveillance of hospitals, ambulatory surgery, emergency departments, and/or residential health care facilities including investigation of fraud and abuse, medical audit, utilization review, and outbreak detection;

(d) health planning and resource allocation studies--the rational allocation of limited resources to health care, provision of adequate health care and article 28 approval processes;

(e) epidemiological studies -- epidemiology identification of exceptional morbidity or mortality patterns for more in-depth study. Studies of prevalence and incidence of diseases can be indicated by these data;

(f) research studies--investigation into a number of health care research studies, including utilization, variations of length of stay, disease dynamics and health economics, for patient use patterns;

(g) identification of emergency service patterns of utilization to assist in resource or intervention planning; or

(h) review of hospital, ambulatory surgery, emergency department, and/or residential health care facility to assess quality of care.

(2) Access to data by the Department of Health, the Centers for Medicare and Medicaid Services (CMS) of the United States Department of Health and Human Services, the National Center for Health Statistics and the New York State Health Systems Agencies (HSA's).

(i) Notwithstanding any other provisions of this section, all requests from CMS or any such succeeding agency for deniable individual stay or visit data or deniable aggregated data shall be approved and processed by the SPARCS bureau when federal law requires disclosure of such data pertaining to patients covered by Titles V, XVIII, or XIX of the Social Security Act.

(ii) Notwithstanding any other provision of this section, all requests for individual stay or visit data, aggregated data and facility stay or visit data from the Department of Health, CMS or any such succeeding agency, the National Center for Health Statistics or the New York State HSA's shall be approved and processed by the SPARCS bureau.

(iii) The SPARCS Bureau shall notify the DPRB of all requests processed in accordance with subparagraphs (i), and (ii) of this paragraph.

(3) SPARCS. (i) Functions.

(a) All requests for data from SPARCS, ESD, PRI data and ASDAP data shall be submitted to SPARCS.

(b) SPARCS shall review all requests for data in order to ensure that the request is technically feasible in terms of the ability of SPARCS, ESD, the PRI data bank or ASDAP to produce the required data.

(c) All requests for data which are not technically feasible shall be returned to the applicant with a statement containing the reason why the request is being returned.

(d) All requests for individual stay or visit data, aggregated data, ESD, PRI data or ASDAP data which do not constitute deniable individual stay or visit data, facility stay or visit data, deniable aggregated data or deniable PRI data and which are technically feasible shall be processed within a reasonable time.

(e) All requests for PRI and ASDAP data which do not constitute deniable PRI data or deniable ASDAP data and which are technically feasible shall be processed pursuant to Part 50 of this Title.

(f) SPARCS shall review all requests for deniable individual stay or visit data, facility stay or visit data, deniable aggregated data, deniable ESD, deniable PRI data amd deniable ASDAP data in order to determine:

(1) whether the purpose of the request is consistent with the purpose for which data from SPARCS, ESD, the PRI data bank or the ASDAP bank may be used. In making its review, SPARCS shall not be limited to a review of the ostensible purpose of the request, as stated in the applicant's formal request for data;

(2) whether the applicant is qualified to undertake the intended study; and

(3) the utility of each study for which data is requested.

(g) SPARCS shall not recommend for approval requests for deniable individual stay or visit data, facility stay or visit data, deniable aggregated data,deniable ESD, deniable PRI data, or deniable ASDAP data unless it is satisfied that:

(1) the request is technically feasible in terms of the ability of the SPARCS bureau to produce the requested data;

(2) the purpose of the request is consistent with the purposes for which data from SPARCS, ESD, PRI data or ASDAP data may be used;

(3) the applicant is qualified to undertake the intended study; and

(4) the applicant requires such data and is able to ensure that patient privacy is protected.

(h) After completing its review, SPARCS shall forward all requests for deniable aggregated data, facility stay or visit data, deniable individual stay or visit data, deniable PRI data, deniable ESD and deniable ASDAP data together with its recommendations, the results of its review and all supporting data to the Data Protection Review Board.

(ii) SPARCS shall publish monthly or cause to be published monthly in the State Register and may publish or cause to be published, in such trade, industry or professional publication as the bureau may select, a listing of all recipients of deniable individual stay or visit data, facility stay or visit data, deniable aggregated data, deniable ESD, deniable PRI data or deniable ASDAP data and the purposes for which the data has been utilized.

(4) Data Protection Review Board (DPRB). (i) Membership.

(a) The DPRB shall consist of 17 members to be appointed by the commissioner for terms of three years.

(b) In making appointments to the DPRB, the commissioner shall consider recommendations submitted by the statewide constituencies represented in clause (ii)(b) of this paragraph.

(c) Members shall serve without remuneration.

(ii) Functions. (a) The DPRB, by a majority vote of its members, shall approve or disapprove requests for deniable individual and/or aggregated facility stay data, deniable individual and/or aggregated PRI data, deniable ESD or deniable ASDAP data, subject to ratification by the commissioner.

(b) The DPRB shall be representative of the following groups:

(1) Federal government (one member);

(2) State government (one member);

(3) private third-party payors which are corporations organized in accordance with article 43 of the Insurance Law (one member);

(4) commercial insurers (one member);

(5) hospital providers (two members);

(6) health systems agencies (one member);

(7) professional review organizations (PRO) or utilization review organization (one member);

(8) consumers (three members);

(9) medical societies (one member);

(10) bar associations (one member);

(11) medical record associations (one member);

(12) health care academic researchers (one member); and

(13) residential health care facility providers (two members).

(c) The DPRB shall not approve any request for deniable individual stay or visit data, hospital stay or visit data, deniable aggregated data, deniable ESD, deniable PRI data or deniable ASDAP data unless it determines that the criteria for approval as established in clause (3)(i)(g) of this subdivision has been satisified.

(d) The DPRB may approve an application requesting that data from SPARCS, ESD, PRI data or ASDAP data be supplied on a periodic basis for a predetermined time not to exceed three years. Notwithstanding any prior appoval given to an applicant to receive data on a periodic basis, the DPRB may at any time require an applicant to submit a new application to be approved or disapproved pursuant to this regulation.

(iii) Procedures. (a) All requests for data to be reviewed by the DPRB shall be entered into a log to be maintained by SPARCS.

(b) The DPRB shall meet monthly or as necessary. Prior to each meeting, DPRB members shall receive a summary description of each request on that meeting's agenda, along with copies of all previous reviews and recommendations pertaining to that request.

(c) No later than 21 days prior to the date of its monthly meeting, the DPRB shall notify or cause to be notified any person or agency filing a written request, such request to be renewed yearly in December, for summary descriptions of each request for data on that meeting's agenda. The DPRB may charge, for such summary descriptions, a fee which shall consist of the cost of preparation, handling and postage for the summary.

(d) At its monthly meeting, the DPRB shall vote on all requests for data which have been sumbitted to DPRB members more than 21 days prior to the date of its meeting. Notwithstanding the above, the DPRB may vote to defer a request for data for one month. The DPRB may defer a request for data only once.

(e) After each meeting of the DPRB, each request for SPARCS data which has not been deferred shall be forwarded to the commissioner for his or her ratification or disapproval. Any request which has not been deferred and which has not been approved by a majority of the members of the DPRB shall be deemed to have been disapproved by the DPRB.

(f) After completing its review, the DPRB shall forward all requests it receives for deniable hospital data, deniable ESD, deniable PRI data and/or deniable ASDAP data together with its recommendations, the results of its review, and all supporting data, to the commissioner.

(5) The commissioner shall not ratify any request for deniable individual stay or visit data, facility stay or visit data or deniable aggregated data, deniable ESD, deniable PRI data or deniable ASDAP data unless he or she determines that the criteria for approval as established in clause (3)(i)(g) of this subdivision has been satisfied.

(6) The commissioner shall make his or her decision whether to ratify or disapprove the determination of the DPRB within 10 business days after receiving from the DPRB the request for data.

(7) If the decision of the commissioner is to disapprove the DPRB determination, he or she shall return the request for data to the DPRB which shall reconsider the request at its next meeting. If, after such reconsideration, two thirds of the members of the DPRB vote to overturn the commissioner's decision, the request shall be processed in accordance with the DPRB's determination notwithstanding the objection of the commissioner. If two thirds of the members of the DPRB do not vote to overturn the commissioner's decision, the request shall be processed in accordance with the commissioner's decision.

(8) Access to and purging of data. (i) Examples of entities which may receive SPARCS data, ESD, PRI data and ASDAP data pursuant to this section include the following:

(a) State Departments of Health, Social Services and Insurance;

(b) third-party payors;

(c) health systems agencies;

(d) professional review organizations (PRO) or utilization review organizations;

(e) hospitals;

(f) State and local hospital associations;

(g) the Federal Department of Health and Human Services;

(h) medical societies;

(i) local departments of health and social services;

(j) residential health care facilities;

(k) hospital-based or free-standing ambulatory surgery centers;

(l) State and local residential health care facility associations; and

(m) consumers.

(ii) Notwithstanding anything contained in this section to the contrary, a facility has the right to receive or inspect all data pertaining to its own patients for the period of time they visited or remained patients at that facility and a health care practioner has the right to receive or inspect all data pertaining to patients where the health care practioner has been identified as being the attending, operating or other physician of the patient.

(iii) Notwithstanding anything contained in this section to the contrary, a residential health care facility has the right to receive or inspect all PRI data pertaining to its own patients for the period of time they remained patients at that residential health care facility.

(iv) Notwithstanding anything contained in this section to the contrary, hospital-based and free-standing ambulatory surgery facilities have the right to receive or inspect all ASDAP data pertaining to their own patients for the period of time they remained patients in those facilities.

(v) All source material received by the department and used to enter data into SPARCS shall be subject to these regulations. All such source material shall be destroyed in accordance with State law within one month of tape or other source material acceptance.

(vi) All contracts or agreements entered into between the department and any person or entity who supplies data to SPARCS, ESD, PRI data, or ASDAP data shall ensure that any such data which has been collected solely for submission to SPARCS, ESD, the PRI data bank or ASDAP is to be destroyed 30 days after acceptance by the department.

(9) Requests for data. (i) Requests for data may be submitted on a standard form to be supplied by SPARCS. All requests for data shall contain the following information:

(a) the specific nature of data requested;

(b) the particular tape format or report format desired;

(c) the time period within which the data are desired; and

(d) for data to be supplied more than once, the frequency with which data are to be supplied.

(ii) Requests for deniable or non-deniable PRI data, ESD or ASDAP data, individual stay or visit data or aggrevated data which do not constitute deniable PRI data, ESD or ASDAP data, deniable individual stay or visit data, facility stay or visit data or deniable aggregated data shall contain an ssurance that no attempt will be made to identify any specific individuals, physicians or providers of services about whom data are supplied.

(iii) For all requests for deniable individual stay or visit data, facility stay or visit data, deniable aggregated data, deniable PRI data, deniable ESD or deniable ASDAP data, the following additional information shall be provided:

(a) the nature of the study for which the data is requested;

(b) a general description of any research leading up to the request;

(c) the qualifications of the applicant to undertake the study;

(d) the measures the applicant proposes to take to ensure that patient privacy is protected; and

(e) specific citations to any applicable law which should be considered as part of this application.

(iv) All requests for deniable individual stay or visit data, facility stay or visit data, deniable aggregated data, deniable PRI data, deniable ESD or deniable ASDAP data shall contain the following assurances and promises:

(a) only those persons named in the request will have access to the data;

(b) the data will be used only for the purposes stated in the request;

(c) no deniable individual stay or visit data, deniable aggregated data, facility stay or visit data or deniable PRI data, deniable ESD or ASDAP data will be released to any other person or entity without prior written authorization pursuant to this regulation; and

(d) no attempt will be made to use any data supplied to identify any specific patients unless the data supplied are to be used only for legally authorized surveillance of providers of health services or utilization review and specific authorization for such use has been given pursuant to this section.

(v) Any applicant who provides specific provider identification numbers in his request for data shall furnish, as part of his application, proof of notification to all such providers of his request. Any provider so notified shall have the right to submit comments to SPARCS. Such comments shall be included with any data pertaining to the provider which is disclosed to the applicant.

(vi) In addition to any other sanction or penalty as provided by law, any person who violates any provision of this regulation or any promise or provision contained therein, shall be liable pursuant to the provisions of the Public Health Law.

(10) Security. (i) The director of SPARCS shall designate, in writing, to the Department of Health security officer, those department employees and SPARCS staff authorized to have access to the data bank. Steps shall be taken by the department security officer in cooperation with SPARCS to control access to the data bank through the use of systems software and security procedures designed to protect data against unauthorized access. The Department of Health security officer shall appoint certain employees of the SPARCS staff and the department to be data security officers. These data security officers shall recommend data security rules and procedures to the security officer who, after review by the commissioner, shall publish the rules and procedures.

(ii) In addition to any other sanction or penalty as provided by law, any employee of the department who willfully violates this regulation or any other rule or procedure pertaining to the disclosure of any material collected pursuant to subdivisions (b)-(d) and (h) of this section shall be deemed to have committed an act of misconduct and shall be disciplined in accordance with the provisions of the Civil Service Law.

(11) Charges for data. (i) The commissioner shall charge a fee to all persons and organizations receiving either hard copy or electronic files produced from SPARCS, ESD, PRI data or ASDAP data. Said fees will be derived by totaling the actual systems analysis, program development and computer production costs incurred in the production of the requested reports. These fees shall be waived in the following instances:

(a) reports to hospitals, residential health care or ambulatory surgery facilities which enable such facilities to verify that the data they submitted to SPARCS or the department is the same data resident in the SPARCS data bank, shall be furnished by the Department of Health, SPARCS at no cost to such facilities. This data will be supplied to facilities requesting their own data in a standard format. Hard copy or computer tape standard reports will be available for both uniform bill elements and uniform discharge abstract data elements; and

(b) when the requestor is a general hospital, residential health care or ambulatory surgery facility, or its designee, as approved by the commissioner, seeking SPARCS UDS data, ESD, PRI data or ASDAP data relating to reimbursement rate determinations and/or rate appeals, the data will be supplied at no cost to the requestor.

(ii) A series of reports to be known collectively as the SPARCS publication series, which are determined by the commissioner with the advice of the State Hospital Review and Planning Council, to be of statewide value and promoting the provision of quality medical care at a reasonable cost and the efficient delivery of health care services will be provided to the health care community at the actual cost of printing. The SPARCS publication series will contain reports aggregated at either the State or regional levels. Should an organization, other than a general hospital, residential health care facility, ambulatory surgery program or third-party payor, request more detailed report, i.e., aggregated by county, facility or ZIP code, they will be provided at the lesser of the actual cost of photocopying or the rates prescribed by Freedom of Information Law, providing this detailed data is available. If the requested data is not available, it will be necessary for the requestor to submit a special request, and the requested report will be provided at the actual cost of production.

(iii) The commissioner may waive the cost of reports requested by a third-party payor, a general hospital, a residential health care or ambulatory surgery facility or its designee, and such other entities as may be authorized by law, when the provision of such reports is consistent with the established uses of SPARCS data, will promote the efficient delivery of health care services and will not negatively impact on the ability of SPARCS to produce other reports. For the purpose of this paragraph, third-party payor is defined as follows:

(a) Centers for Medicare and Medicaid Services (CMS) and the Office of CHAMPUS or succeeding agencies;

(b) agencies or entities organized under the laws of the State of New York which appropriate, receive or administer Titles V, XVIII or XIX of the Federal Social Security Act monies;

(c) agencies or entities organized under the laws of the State of New York which incur costs for the purchase of inpatient hospital services, residential health care facility services, emergency department services, or ambulatory surgery services on behalf of their clients who are admitted to New York State general hospitals, or are patients in residential health care facilities, emergency departments, or ambulatory surgery centers; and

(d) corporations and organizations duly authorized and certified by the New York State Insurance Department to provide health insurance benefits to their subscribers as inpatients in New York State general hospitals, or are patients in residential health care facilities, or ambulatory surgery programs;

(f) Council on Hospital Information Policy. (1) For the purpose of this subdivision, the term Council on Hospital Information Policy (CHIP) shall mean a council consisting of representatives of the major hospital data producers, collectors and users whose purpose is to advise the department on matters relating to hospital health care data. The council shall meet at least four times in each full calendar year.

(2) Membership.

(i) The CHIP shall consist of 14 members, to be appointed by the commissioner for terms of three years.

(ii) The CHIP shall be representatives of the following groups, which may recommend individuals to be appointed by the commissioner; such appointments shall not be unreasonably withheld:

(a) the hospital industry (three members);

(b) private third-party payors and commercial insurers (three members);

(c) quality assurance or UR organizations (three members);

(d) health systems agencies (three members); and

(e) hospital care academic researchers (two members).

(iii) A majority vote of the total membership of the CHIP shall be required in order to take any council action.

(iv) Members shall serve without remuneration.

(3) Functions.

(i) The CHIP shall advise the commissioner on matters relating to the hospital health care data policy including the following:

(a) the establishment of new hospital data collection systems, including the formulation of regulations governing such systems, and the development of efficient and effective data collection methodologies.

(b) the maintenance and/or modification of SPARCS; and

(c) the preparation of general purpose reports which address the common information requirements of data users.

(ii) The CHIP shall review annually the requests that have been made for SPARCS data and shall make recommendations to the commissioner with respect to:

(a) the need to modify, add or delete specific data and information items based upon consideration of the actual operational needs of SPARCS; and

(b) changes that would make the system for processing requests more efficient.

(iii) Consistent with subdivision (e) of this section, the CHIP shall advise and assist the SPARCS bureau and the DPRB:

(a) by providing advice and guidance relating to:

(1) policy issues of concern to the commissioner involving SPARCS or the DPRB; and

(2) proposed regulation changes involving SPARCS or the DPRB; and

(b) by providing advice, with respect to specific requests for SPARCS data.

(g) Accounting and reporting. (1) Effective for all fiscal years beginning on or after January 1, 1975, hospitals shall maintain their accounts and records in accordance with the American Hospital Association manual, Chart of Accounts for Hospitals. Such accounts and records are to be maintained on an accrual basis except where an alternate system is mandated by law.

(2) For fiscal years beginning on or after January 1, 1975, hospitals shall submit to the New York State Department of Health or its authorized agent a certified uniform financial report and a uniform statistical report of hospitals within 120 days after the close of each fiscal year. The data shall be reported as follows:

(i) In accordance with the policies and instructions in the following:

(a) American Hospital Association manual, Cost Findings and Rate Setting for Hospitals;

(b) American Hospital Association manual, Uniform Hospital Definition;

(c) Blue Cross/Blue Shield of Greater New York's manual, Recommended Bases for Cost Allocation;

(d) American Institute of Certified Public Accountants manual, Hospital Audit Guide; and

(e) Part 86 of the Commissioner of Health's administrative rules and regulations (10 NYCRR Part 86).

(ii) All government subsidies shall be reported on the income statement of the uniform financial report on the line provided and such amounts shall be itemized on the notes to financial statements by payor and purpose. Such grants are not to be used to reduce allowances as indicated in the American Institute of Certified Public Accountants manual, Hospital Audit Guide.

(iii) Investments, other than donations, shall be reported on the balance sheet of the uniform financial report at cost. The notes to the financial statements shall describe the assets and indicate the quoted market value and cost for each category of investment.

(iv) Fixed assets, other than donations, shall be reported on the balance sheet of the uniform financial report at cost.

(v) Discounts, allowances and bad debts shall be reported and broken out on the Blue Cross and New York State supplement to the institutional cost report by hospital service.

(h) Emergency Service Data (ESD)

(1) All hospitals shall file for each emergency service patient such emergency service data elements as are set forth in Appendix C-5 infra and such additional elements as may be approved by the commissioner upon finding that they are recommended by the National Uniform Billing Committee and the National Committee on Vital Health Statistics or are necessary for permitted uses of SPARCS data. Facilities shall submit or cause to have submitted the data in computer-readable format according to specifications provided by the commissioner. Such data shall be provided for all patient visits. The hospital inpatient data abstract shall include those patients receiving emergency services who are subsequently admitted as inpatients to the same hospital. In these cases, the hospital is to identify that emergency services were performed prior to the inpatient admission. The commissioner shall be responsible for protecting confidentiality and privacy in accordance with subdivision (e) of this section.

(2) Facilities shall submit or cause to be submitted such correct or corrected data in computer-readable format according to specifications provided by the commissioner. Any hospital-owned magnetic media will be returned to the hospital subsequent to receipt by the department.

(3) Facilities that are licensed to provide emergency services shall submit or cause to be submitted such data within 30 days following the month of patient discharge.

(4) Facilities which do not submit data or corrected data within 30 days of receipt of the department's error report concerning such data shall not be reimbursed under section 86-1.41 of this Title until compliance with this section is certified in writing by the commissioner or his or her designee.

(5) Request for deniable individual or aggregate data or data reports based on data submitted pursuant to this section shall be processed pursuant to subdivision (e) of this section.


Volume: C