95R003

3. New Schedule 7

3.1 Add at the end of the Regulations:

SCHEDULE 7 Regulation 49A

HOSPITAL CASEMIX PROTOCOL

Part 1—Explanatory Notes

Hospital Casemix Protocol: object

1. The object of the Hospital Casemix Protocol is to specify the financial, clinical and demographic data that funds must give to the Department in respect of every episode of hospital treatment for which a charge is billed to a fund.

Hospital Casemix Protocol: definitions

2. In this Protocol:

“blank filled” means that where blank filling is a valid entry, the field is filled with blanks;

“CCU” means the Coronary Care Unit of a hospital;

“CMBS” means Commonwealth Medicare Benefits Schedule;

“contracted doctor” means a doctor who has entered into a medical purchaser-provider agreement under section 73BDA of the National Health Act 1953;

“contracted hospital” means a hospital that has entered into a purchaser-provider agreement under section 73BD of the National Health Act 1953;

“DRG” means Diagnosis Related Group;

“episode” means the period between admission and separation that a person spends in one hospital, and includes leave periods not exceeding 7 days;

[NOTE: This definition of “episode” differs from the definition set out in the NHDD.]

“fund” means a health benefits fund conducted by a registered organization;

“ICD-9-CM” means The International Classification of Diseases 9th Revision Clinical Modification (Australian Version);

“MAA” means mandatory for all, and fields identified with this flag must contain a valid entry regardless of whether the episode occurred in a contracted hospital or a non contracted hospital;

“MAC” means mandatory for contracted hospitals, and fields identified with this flag must contain a valid entry. Where the episode occurred in a non contracted hospital, the field becomes optional;

“NHDD” means version 3 of the National Health Data Dictionary, published in May 1994;

“OPA” means that fields identified with this flag are optional for all hospitals;

“OPH” means optional for public hospitals, and fields identified with this flag are optional for public hospitals, whether contracted or not, and mandatory for private hospitals;

“OPO” means optional for public hospitals overnight, and fields identified with this flag are optional for public hospitals, whether contracted or not, where the patient stayed overnight;

“overnight-stay patient” means a person who is admitted to, and who separates from, a hospital on different dates;

“sameday patient” means a person who is admitted to, and who separates from, a hospital on the same date;

“valid arrangement” means an arrangement made under section 4C of the National Health Act 1953.

[NOTE: “NHTP” (nursing home type patient) is defined in subsection 3 (1) of the Health Insurance Act 1973.]

How to use the Protocol: the Parts of the Protocol

3. The medical record supplied to the Department by a fund must comply with the specification set out in the File Structure: Medical Record in Part 2, and with the contents set out in Record Content: Medical Record in Part 4.

4. The hospital episode record supplied to the Department by a fund must comply with the specification set out in the File Structure: Hospital Episode Record in Part 3, and with the contents set out in Record Content: Hospital Episode Record in Part 5.

How to use the Protocol: format specifications and how the details must be sent

5. All fields are to be initialised to blanks.

6. Blanks are not a valid entry for some fields. These fields are identified in Column 5.

7. Where identified in Column 5, blanks are a valid entry under the following conditions:

(a) the data item is optional; or

(b) specific conditions apply and these are noted in Column 5.

8. A record will be rejected by the Department if any of the following data items is coded as blank:

(a) Fund identifier in either Part 4 or 5;

(b) Link Identifier in either Part 4 or 5;

(d) Total charge in Part 5;

(e) Total benefit in Part 5;

(f) Date of birth in Part 5;

(g) Postcode in Part 5;

(h) Gender in Part 5;

(i) Date admitted in Part 5;

(j) Date separated in Part 5;

(k) Separation mode in Part 5;

(l) Principal Diagnosis Code in Part 5.

9. Records not containing valid entries for items in item 8 will be rejected.

10. If 10% of records in any transmission batch are rejected all records in that transmission batch will be returned to the fund. The fund will resubmit the rejected transmission within 4 weeks from the date of receipt of rejected records.

11. Where a hospital is required to provide data to a fund, the hospital episode record must comply with the specifications set out in the File Structure: Hospital Episode Record in Part 3. The hospital must reach an agreement with the fund as to the medium on which the data must be sent.

12. Where a fund gives data to the Department, the fund must give the data to the Department using:

(a) DOS formatted floppy disks; or

(b) magnetic tapes; or

(d) other electronic media as agreed with the Department in writing.

How to use the Protocol: data structure and specifications

13. A fund must give data to the Department in ASCII format with a record length as stated in Parts 2 and 3 of the Protocol.

14. For the purpose of the field size column (Column 3 in Parts 4 and 5):

(a) D is a date field. Legal values are 0-9 and blanks. The format is DDMMCCYY;

(b) N is a numeric field. N fields must be right justified and left blank filled. Legal characters are 0-9 and blanks;

(c) C is a character field. C fields must be right justified and left blank filled. Legal characters are alpha, 0-9 and blanks;

(d) I is for ICD-9-CM codes. I fields must be left justified and right blank filled and should not include decimal points.

15. Data items requiring rounding are noted in Column 5 in Parts 4 and 5. Rounding takes fractions to the nearest whole number. If the fraction is 0.5 acceptable rounding is up for an odd number and down for an even number.

16. All data items should reflect the completed discharge data set.

How to use the Protocol: how will the data transfer work

17. A fund has the primary responsibility for giving the information set out in Column 2-Data item of Parts 4 and 5.

18. Where the fund gives data to the Department, the data must include all episodes, whether or not the episodes took place in a contracted hospital.

19. Where the hospital gives data to the fund:

(a) the data set out in items 27-56 in Part 5, Record Content: Hospital Episode Record must be sent; and

(b) the data sent in accordance with paragraph (a) must be sent using the structure set out in items 27-56 in Part 3, File Structure: Hospital Episode Record.

[NOTE: The NHDD is published by the Australian Institute of Health and Welfare and aims to set out uniform definitions and data items to be used in the collection of health and welfare data. The definitions set out in the NHDD are endorsed by the National Health Information Management Group through the National Health Information Agreement.]

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Part 2—File structure: medical record

Column 1 Item No.	Column 2 Data Item	Column 3 Start Position	Column 4 Field size	Column 5 Repetitions
1	Fund identifier	1	3	1
2	Link identifier	4	24	1
3	CMBS item	28	5	1
4	Medical charge	33	5	1
5	CMBS benefit	38	5	1
6	Fund benefit	43	5	1
7	CMBS date of service	48	8	1
8	Contracted doctor	56	1	1
9	Total record length	56

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Part 3—File structure: hospital episode record

Column 1 Item No.	Column 2 Data Item	Column 3 Start Position	Column 4 Field size	Column 5 Repetitions
1	Fund identifier	1	3	1
2	Link identifier	4	24	1
3	Provider (hospital) code	28	8	1
4	Product code	36	8	1
5	Hospital contract status	44	1	1
6	Total days paid	45	4	1
7	Accommodation charge	49	6	1
8	Accommodation benefit	55	6	1
9	Theatre charge	61	5	1
10	Theatre benefit	66	5	1
11	Labour ward charge	71	5	1
12	Labour ward benefit	76	5	1
13	Intensive Care Unit charge	81	5	1
14	Intensive Care Unit benefit	86	5	1
15	Prosthesis charge	91	5	1
16	Prosthesis benefit	96	5	1
17	Pharmacy charge	101	5	1
18	Pharmacy benefit	106	5	1
19	Total charge	111	6	1
20	Total benefit	117	6	1
21	Front End Deductible	123	5	1
22	Ancillary cover status	128	1	1
23	Ancillary charges	129	5	1
24	Ancillary benefits	134	5	1
25	Medical charges	139	6	1
26	Medical benefits	145	6	1
27	Date of birth	151	8	1
28	Postcode	159	4	1
29	Gender	163	1	1
30	Date admitted	164	8	1
31	Date separated	172	8	1
32	Hospital type	180	1	1
33	ICU days	181	3	1
34	DRG code	184	3	1
35	DRG version	187	2	1
36	Admission time	189	4	1
37	Admission transfer type	193	1	1
38	Age in years	194	3	1
39	Age in days	197	3	1
40	Neonatal admission weight	200	4	1
41	Hours of mechanical ventilation	204	4	1
42	Separation mode	208	2	1
43	Separation time	210	4	1
44	Separation transfer type	214	1	1
45	Acute days of stay	215	4	1
46	Total leave days	219	4	1
47	Non-acute days of stay	223	4	1
48	Principal diagnosis code	227	5	1
49	Secondary diagnoses codes	232	5	14
50	Principal procedure code	302	4	1
51	Secondary procedure codes	306	4	14
52	Sameday status	362	1	1
53	Principal CMBS item number	363	5	1
54	Principal CMBS date	368	8	1
55	Time in operating theatre (Principal CMBS)	376	4	1
56	Secondary CMBS item numbers	380	5	14
57	Total record length	449

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Part 5—Record content: hospital episode record

Column 1 Item No.	Column 2 Data item	Column 3 Field size	Column 4 Required	Column 5 Coding Description
1	Fund identifier	C(3)	MAA	See fund codes
2	Link identifier	C(24)	MAA	A unique identifier of an episode that links data items from this Part (Part 5) to the medical record (Part 4). The fund may encrypt membership identifier for this purpose
3	Provider (hospital) code	C(8)	MAA	The hospital provider number
4	Product code	C(8)	MAA	The product code for patient’s insurance cover at separation. The fund must supply documentation of cover field values
5	Hospital contract status	C(1)	MAA	Y means a hospital with which a fund has a contract N means a hospital with which the fund does not have a contract
6	Total days paid	N(4)	MAA	The total number of days for which benefits were paid by the fund, including days for which benefits were paid as an NHTP
7	Accommodation charge	N(6)	MAA	Accommodation charges rounded to the nearest dollar. An entry of 0 dollars means that no accommodation charges were billed Blanks are only valid where an accommodation charge was not separately identified but was billed under another charge item
8	Accommodation benefit	N(6)	MAA	Accommodation benefit rounded to the nearest dollar. An entry of 0 dollars means that no accommodation benefits were paid Blanks are only valid where an accommodation benefit was not separately identified but was paid under another benefit item
9	Theatre charge	N(5)	MAA	Theatre charges rounded to the nearest dollar. An entry of 0 dollars means that no theatre charges were billed Blanks are only valid where a theatre charge was not separately identified but was billed under another charge item
10	Theatre benefit	N(5)	MAA	Theatre benefit rounded to the nearest dollar. An entry of 0 dollars means that no theatre benefits were paid Blanks are only valid where a theatre benefit was not separately identified but was paid under another benefit item
11	Labour ward charge	N(5)	MAA	Labour ward charges rounded to the nearest dollar. An entry of 0 dollars means that no labour ward charges were billed Blanks are only valid where a labour ward charge was not separately identified but was billed under another charge item
12	Labour ward benefit	N(5)	MAA	Labour ward benefit rounded to the nearest dollar. An entry of 0 dollars means that no labour ward benefits were paid Blanks are only valid where a labour ward benefit was not separately identified but was paid under another benefit item
13	Intensive Care Unit (ICU) charge	N(5)	MAA	ICU charge rounded to the nearest dollar. An entry of 0 dollars means that no ICU charges were billed. Blanks are only valid where an ICU charge was not separately identified but was billed under another charge item
14	Intensive care unit (ICU) benefit	N(5)	MAA	ICU benefit rounded to the nearest dollar. An entry of 0 dollars means that no ICU benefits were paid Blanks are only valid where an ICU benefit was not separately identified but was paid under another benefit item
15	Prosthesis charge	N(5)	MAA	Prosthesis charge rounded to the nearest dollar. An entry of 0 dollars means that no prosthesis charge was billed Blanks are only valid where a prosthesis charge was not separately identified but was billed under another charge item
16	Prosthesis benefit	N(5)	MAA	Prosthesis benefit rounded to the nearest dollar. An entry of 0 dollars means that no prosthesis benefit was paid Blanks are only valid where a prothesis benefit was not separately identified but was paid under another benefit item
17	Pharmacy charge	N(5)	MAA	Pharmacy charge rounded to the nearest dollar. An entry of 0 dollars means that no pharmacy charges were billed Blanks are only valid where a pharmacy charge was not separately identified but was billed under another charge item
18	Pharmacy benefit	N(5)	MAA	Pharmacy benefit rounded to the nearest dollar. An entry of 0 dollars means that no pharmacy benefits were paid Blanks are only valid where a pharmacy benefit was not separately identified but was paid under another benefit item
19	Total charge	N(6)	MAA	The total charge field must contain the actual total charge billed by the hospital Total charges rounded to the nearest dollar. An entry of 0 dollars means that no charges were billed A blank entry is not valid in this field
20	Total benefit	N(6)	MAA	The total benefits field should contain the actual total benefits paid to the hospital by the fund Total benefits rounded to the nearest dollar. An entry of 0 dollars means that no benefits were paid A blank entry is not valid in this field
21	Front end deductible	N(5)	MAA	The amount of FED deducted from the benefit otherwise payable by the fund to the patient Blank means there is an FED but the amount is unknown 0 means there was no FED applicable
22	Ancillary cover status	C(1)	MAA	Y means that the patient has ancillary cover N means that the patient does not have ancillary cover
23	Ancillary charges	N(5)	OPA	The ancillary charges incurred during the episode and billed against an ancillary table
24	Ancillary benefits	N(5)	OPA	The ancillary benefits paid for charges billed as occurring during the episode
25	Medical charges	N(6)	MAA	The total Medical charges as set out in Part 4
26	Medical benefits	N(6)	MAA	The total CMBS and Fund benefits as set out in Part 4
27	Date of birth	D(8)	MAA	DDMMCCYY
28	Postcode	C(4)	MAA	The patient’s residential postcode
29	Gender	C(1)	MAA	1 = Male; 2 = Female; 0 = Unknown
30	Date admitted	D(8)	MAA	DDMMCCYY
31	Date separated	D(8)	MAA	DDMMCCYY
32	Hospital type	C(1)	MAA	1 = public; 2 = private; 3 = private day facility; 4 = public day facility; 9 = other
33	ICU days	N(3)	OPH	The number of days spent by the patient in: ICU; and/or CCU; and/or neonatal intensive care; and/or paediatric intensive care. This data item does not include days spent in High Dependency Units.
34	DRG code	C(3)	OPA	Blank filled if not known
35	DRG version	C(2)	OPA	10 = version 1; 20 = version 2; 21 = version 2.1; 30 = version 3
36	Admission time	N(4)	MAA (sameday patients only)	The admission hour is based on a 24-hour clock. For example, 6:35AM is entered as 0635.
37	Admission transfer type [to this hospital]	C(1)	MAC	If the patient transferred in from another hospital, the data item must indicate whether the care in the admitting hospital was more or less resource intensive per day than the care provided in the hospital from which the patient was transferred. The data item must be entered using the following codes: Blank means there was no transfer. U means Up Transfer: this hospital stay was more resource intensive per day. D means Down Transfer: this hospital stay was less resource intensive per day. L means Lateral Transfer: this hospital stay was of similar resource intensity per day. X means transfer type unknown.
38	Age in years	N(3)	MAA	The age of the patient at admission. The data item must be entered using a valid range of 0 - 124. If the patient’s age was 365 days or less, then enter zeros.
39	Age in days	N(3)	MAC	The age of the patient at admission if less than 1 year of age. The data item must be entered using a valid range of 0 - 365.
40	Neonatal admission weight	N(4)	MAC	The admission weight rounded to the nearest gram for Neonates (patient age less than 29 days old).
41	Hours of mechanical ventilation	N(4)	MAC	The number of hours (rounded) for which the patient received mechanical ventilation during the episode.
42	Separation mode	C(2)	MAC	01 means separation or transfer of the patient to an acute hospital 02 means separation or transfer of the patient to a nursing home 03 means separation or transfer of the patient to a psychiatric hospital 04 means separation or transfer of the patient to another health facility 05 means statistical separation-type change 06 means the patient left the hospital against medical advice 07 means a statistical separation from leave 08 means the patient died 09 means the patient went home / other
43	Separation time	N(4)	MAA (sameday patients only)	This separation time is based on a 24-hour clock. For example, 10:35PM is entered as 2235.
44	Separation transfer type [Separation from this hospital]	C(1)	MAC	If the patient was transferred to another hospital, the data item must indicate whether the care in the separating hospital was more or less resource intensive per day than the care expected to be required by the patient in the hospital to which the patient was transferred. The data item must be entered using the following codes: Blank means there was no separation transfer U means Up Transfer: this hospital stay expected to be less resource intensive per day D means Down Transfer: this hospital stay expected to be more resource intensive per day L means Lateral Transfer: this hospital stay expected to be of similar resource intensity per day X means transfer type unknown
45	Acute days of stay	N(4)	MAA	Acute days of stay are calculated: as 1 for sameday patients; or by subtracting the date of admission from the date of separation, and excluding any leave days.
46	Total leave days	N(4)	MAA	This data item is calculated as the sum of leave days for all leave periods during the episode. If there are no leave days, enter 0. Leave days exclude one-day leave periods for acute and private psychiatric hospital patients, and are subject to the following conditions:
				Patients in acute hospitals and private psychiatric hospitals who do not require treatment over a weekend or other short period may leave the hospital temporarily with the approval of the hospital or treating medical practitioner. If there is a decision that the patient will return to the same hospital within a short time to resume treatment, this absence is defined as “leave”. A patient of a public psychiatric hospital who leaves the hospital for a short period without a formal discharge is defined as being on leave from the hospital. [NOTE: See NHDD P27a and P4-62.]
47	Non-acute days of stay	N(4)	MAA	This data item refers to the number of days in the hospital that exceeded 35 days without certification.
48	Principal diagnosis code	I(5)	MAC	The ICD-9-CM code for the diagnosis or condition chiefly responsible for occasioning the hospital admission. A blank entry is not valid for this field.
49	Secondary diagnosis codes	I(5) 14 times	MAC	Additional ICD-9-CM diagnosis codes for conditions other than the principal diagnosis: that arose during the patient’s stay in hospital; that affected the patient’s treatment and/or length of stay in hospital by greater than one day; that existed at the time of the patient’s admission to hospital and for which treatment was given. [NOTE: See NHDD P36 and ICD-9-CM under the entry Additional Diagnoses.]
50	Principal procedure code	I(4)	MAC	The ICD-9-CM procedure code for the procedure which consumed the greatest amount of hospital resources. Blank means no ICD-9-CM procedure code was applicable [NOTE: See NHDD P37 and ICD-9-CM.]
51	Secondary procedure codes	I(4) 14 times	MAC	Additional ICD-9-CM procedure codes for other procedures performed during the episode. [NOTE: See NHDD P38 and ICD-9-CM.]
52	Sameday status	C(1)	MAC	0 means patient with a valid arrangement allowing overnight stay for procedure normally performed on a sameday basis. 1 means sameday patient. 2 means overnight patient (other than type 0 above).
53	Principal CMBS item number	C(5)	OPH	Principal CMBS item related to the Principal Procedure Code referred to in Item 50 in this Part. Blank means there was no applicable CMBS item.
54	Principal CMBS date	D(8)	OPH	The date on which the principal CMBS procedure was carried out. (DDMMCCYY) Blank means there was no Principal CMBS date.
55	Time in operating theatre (Principal CMBS)	N(4)	MAA (sameday patients only)	The time in minutes that the patient spent in the operating theatre, from the time the patient entered the operating theatre until the time the patient left the operating theatre. Zero means no time was spent in the operating theatre. Blank means there was no applicable CMBS item.
56	Secondary CMBS item numbers	C(5) 14 times	OPH	Additional CMBS item numbers related to the Secondary Procedure Codes referred to in item 51 in this Part. Blank means there was no applicable CMBS item.

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Part 6—Registered Health Benefits Organizations

Column 1 Item No.	Column 2 Name	Column 3 Identifier
1	A.C.A. Health Benefits Fund	ACA
2	A.M.A Health Fund Limited	AMA
3	Army Health Benefits Society	AHB
4	Australian Health Management Pty Ltd	AHM
5	Australian Unity Friendly Society**	AUF
6	C.D.H. Benefits Fund	CDH
7	Commonwealth Bank Health Society (Friendly Society)	CBH
8	C.P.S. Health Benefits Society	CPS
9	CUA Members’ Benefits Friendly Society	CUA
10	FAI Health Benefits Limited	FAI
11	Geelong Medical and Hospital Benefits Association Limited	GMH
12	Goldfields Medical Fund (Inc.)	GMF
13	Government Employees Health Fund Limited	GEH
14	Grand United Friendly Society	GUF
15	Health Care Insurance Ltd	HCI
16	Healthguard Health Benefits Fund Limited	HHB
17	Health Insurance Fund of WA	HIF
18	Hospital Benefits Association Limited*	HBA
19	Hospital Benefits Fund of Western Australia (Inc.), The	HBF
20	Hospitals Contribution Fund of Australia, Limited, The	HCF
21	Independent Order of Odd Fellows of Victoria	IOF
22	I.O.R. Australia Pty Ltd	IOR
23	Latrobe Health Services, Inc.	LHS
24	Lysaght Hospital and Medical Club, The	LHM
25	Manchester Unity Independent Order of Oddfellows Friendly Society in New South Wales	MUI
26	Medibank Private (Health Insurance Commission)	MBP
27	Medical Benefits Fund of Australia Ltd	MBF
28	Mildura District Hospital Fund	MDH
29	MIM Employees Health Fund	MIM
30	Mutual Community Ltd*	MCL
31	National Mutual Health Insurance Pty Ltd*	NMH
32	Naval Health Benefits Society	NHB
33	New South Wales Teacher’s Federation Health Society	NTF
34	N.I.B. Health Funds Limited	NIB
35	Over 50’s Friendly Society, The	OFF
36	Phoenix Welfare Association Limited, The	PWA
37	Queensland Teachers Union Health Society	QTU
38	Queenstown Medical Union Health Benefits	QMU
39	Railway & Transport Employees’ Friendly Society Health Fund	RTE
40	Reserve Bank Health Society	RBH
41	S.G.I.C. Health Pty Limited	SGI
42	South Australian Police Employees’ Health Fund Incorporated	SPE
43	South Australian Public Servants	SPS
44	St Luke’s Medical & Hospital Benefits Association	SLM
45	“The Sydney Morning Herald” Hospital Fund	SMH
46	Transport Friendly Society	TFS
47	United Ancient Order of Druids	UAD
48	United Ancient Order of Druids Registered Friendly Society Grand Lodge of New South Wales, The	UAF
49	Eastern District Health Fund Ltd	WDH
50	Yallourn Medical and Hospital Society, The	YMH

[NOTES:

* Mutual Community is owned and operated by National Mutual. In Victoria, Mutual Community trades as HBA.

** Australian Natives’ Association and Manchester Unity Independent Order of Oddfellows Friendly Society in Victoria now trade as Australian Unity Friendly Society.]

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NOTES

1. Notified in the Commonwealth of Australia Gazette on 30 May 1995.

2. Statutory Rules 1954 No. 35 as amended by 1957 No. 71; 1958 No. 63; 1962 Nos. 55, 70 and 113; 1965 Nos. 17, 94 and 185; 1966 No. 99; 1967 No. 86; 1969 Nos. 91 and 220; 1970 Nos. 70 and 166; 1971 Nos. 28, 76, 103 and 138; 1972 No. 79; 1973 Nos. 17, 75, 111, 221, 225 and 267; 1974 Nos. 52, 104, 105, 113 and 263; 1975 Nos. 14, 49, 66, 100, 124, 165 and 207; 1976 Nos. 113, 217 and 227; 1977 Nos. 11, 34, 51 and 112; 1978 Nos. 66, 178, 208 and 266; 1979 Nos. 59, 107, 208 and 231; 1980 Nos. 84, 292 and 309; 1981 Nos. 43, 97, 115, 232 and 318; 1982 Nos. 38, 82, 84, 250 and 284; 1983 Nos. 45, 247 and 267; 1984 Nos. 66, 161, 200, 308, 322 and 427; 1985 Nos. 86, 136, 186, 187, 206 and 288; 1986 Nos. 47, 53, 208, 330, 353 and 360; 1987 Nos. 50, 76, 100 and 310; 1989 Nos. 291, 292 and 334; 1990 Nos. 24, 86, 114, 292, 335 and 396; 1991 Nos. 40, 41, 232, 262, 263, 310 and 339; 1992 Nos. 136 and 187; 1993 Nos. 48, 85, 153, 260, 261, 273, 280 and 284; 1994 Nos. 2, 9, 106, 139, 201, 253, 256, 296, 349 and 451; 1995 Nos. 1, 14, 34 and 52.