Alabama Administrative Code Chapter 420-12-1 — Hospital Discharge Data System

420 Alabama Department of Public Health

Ala. Admin. Code r. 420-12-1-.01 Definitions

(1) "Aggregate Data" is a set of multiple data records that are tabulated, combined, or otherwise summarized for the purpose of describing characteristics of a group of patient discharges. No individualized patient data is identifiable in Aggregate Data.

(2) "AlaHA" means the administrative offices and staff of the Alabama Hospital Association.

(3) "Advisory Council" refers to the Hospital Discharge Data Advisory Council established under Code of Ala. 1975, §22-21-410.

(4) "Department" is the Alabama Department of Public Health. References to the "Department" in these rules may include any vendor contracted by the Department pursuant to Code of Ala. 1975, §22-21-411(d), to perform activities concerning Hospital Discharge Data on behalf of the Department.

(5) "Delinquent Discharge Data Report" includes:

(a) Any Discharge Data Report not received by the Department within 60 calendar days after the end of the quarter for which the discharge data is required to be reported.

(b) Any Discharge Data Report that remains uncorrected or incomplete after 15 calendar days following notification by the Department of receipt of an incomplete Discharge Data Report.

(6) "Discharge" is defined as the formal release of a patient from a hospital in either an inpatient or outpatient situation.

(7) "Discharge Data" means data regarding a patient's discharge as an inpatient or outpatient from a hospital, as required on the UB-04 Uniform Hospital Billing Form, or any successor form established by the National Uniform Billing Committee, and on other forms that include services provided for covered inpatient and outpatient discharges.

(8) "Discharge Data Report" means a report to the Department of all discharge records for patients receiving inpatient or outpatient services at a particular hospital during the 3 months immediately preceding the date of the discharge data, as described in this Chapter and the Hospital Discharge Data System Procedure Manual.

(9) "Discharge Record" means a record of an individual inpatient or outpatient discharge required to be reported under Code of Ala. 1975, §22-21-410, et seq., this Chapter, and the Hospital Discharge Data System Procedure Manual.

(10) "Error" means discharge data or Discharge Data Reports that are incomplete or inconsistent with the specifications set forth in this Chapter or the Hospital Discharge Data System Procedure Manual.

(11) "HIPAA" means the Health Insurance Portability and Accountability Act, Pub. L. 104- 191.

(12) "Hospital" means general acute care, critical access and specialized hospitals, as well as any freestanding emergency department that is separately licensed by the Department as a provider-based division of a hospital, as defined by rules of the Department and licensed pursuant to Article 2 of Chapter 21 of Title 22, Code of Ala. 1975, and that are located in this state.

(13) "Hospital Discharge Data Procedure Manual" means the procedure manual prepared and maintained by AlaHA that provides the data elements for each hospital discharge record to be included in the Discharge Data Report submitted to the Department, their descriptions and reporting formats, and any additional information required to be included in the Discharge Data Report.

(14) "Inpatient Discharge" includes persons who received reception and care in a hospital for a continuous period of 24 hours or more for the purpose of giving advice, diagnosis, nursing service, or treatment bearing on the physical health of the person, including persons receiving maternity care involving labor and delivery for any period of time.

(15) “Limited Data Set” is protected health information that excludes the following direct identifiers of the individual or of relatives, employers, or household members of the individual:

(a) Names.

(b) Postal address information, other than town or city, state, and zip code.

(c) Telephone numbers.

(d) Fax numbers.

(e) Electronic mail addresses.

(f) Social security numbers.

(g) Medical record numbers.

(h) Health plan beneficiary numbers.

(i)Account numbers.

(j) Certificate/license numbers.

(k) Vehicle identifiers and serial numbers, including license plate numbers.

(l) Device identifiers and serial numbers.

(m) Web universal resource locators (URLs).

(n) Internet protocol (IP) address numbers.

(o) Biometric identifiers, including finger and voice prints.

(p) Full face photographic images and any comparable images.

The Department may use or disclose a limited data set as defined herein only for the purposes of research, public health, or health care operations after having entered into a data use agreement with the limited data set recipient, if required, in compliance with 45 C.F.R. §§ 164.514(e)(1)-(3).

(16)“Line Level Data” means data at the individual patient level, e.g., where each line of information may represent the information for a single patient or hospitalization event. Line level data may include protected health information on individual patients. It is not aggregated or summarized data. Line level data is anonymized to protect patient privacy when included in a limited data set.

(17)"Outpatient Discharge" includes persons receiving reception and care in a hospital for a continuous period of less than 24 hours for the purpose of giving advice, diagnosis, nursing service, or treatment bearing on the physical health of the person, excluding persons receiving maternity care involving labor and delivery. Emergency room discharges are included in outpatient discharges for purposes of these rules.

(18) "Patient Identifiers" is defined as information that reasonably could be expected to reveal the identity of a patient, including those items contained in 45 C.F.R. §l64.5l 4(b)(2)(i).

(19) "Processed Data" is defined as data that has been reviewed by the Department for the purpose of detecting errors in the data set.

(20) "Verified Data" is defined as data that has been processed by the Department, reviewed and corrected by the hospital, and accepted by the Department.

History

• Author: Sherri L. Davidson, Ph.D., M.P.H.; Dana H. Billingsley
• Authority: Code of Ala. 1975, §22-21-410, et seq.
• New Rule: Published January 31, 2022; effective March 17, 2022. Amended: Published June 30, 2026; effective August 14, 2026.

Ala. Admin. Code r. 420-12-1-.02 Required Elements

(1) The minimum data set for each discharge record to be included in the Discharge Data Report includes all of the elements set forth on the UB-04 Form or any successor form that complies with these rules.

(2) All inpatient and outpatient discharges are required to be reported.

(3) All data elements reported by the hospital should be the actual values used by the hospital. No reported data elements should be encrypted, calculated, or otherwise altered.

(4) The disclosure of protected health information by a hospital pursuant to Code of Ala. 1975, §22-21-410, et seq. and this Chapter shall be recognized as a disclosure to a public health authority as required by law, pursuant to HIPAA and the Privacy Rules promulgated thereunder at 45 C.F.R. §§164.514(a) and (b).

History

• Author: Sherri L. Davidson, Ph.D., M.P.H.; Dana H. Billingsley
• Authority: Code of Ala. 1975, §22-21-410, et seq.
• New Rule: Published January 31, 2022; effective March 17, 2022. Amended: Published June 30, 2026; effective August 14, 2026.

Ala. Admin. Code r. 420-12-1-.03 Submission Timelines

(1) Submission of Discharge Data Reports is required every 3 months for the 3 months included in that reporting period, according to the schedule set forth in paragraph (2) below.

(2) All required Discharge Data Reports must be received by the Department every calendar quarter according to the following schedule:

(3) All Discharge Data Reports must be submitted via secured electronic means, as specified by the Department.

History

• Author: Sherri L. Davidson, Ph.D., M.P.H.; Dana H. Billingsley
• Authority: Code of Ala. 1975, §22-21-410, et seq.
• New Rule: Published January 31, 2022; effective March 17, 2022. Amended: Published June 30, 2026; effective August 14, 2026.

Ala. Admin. Code r. 420-12-1-.04 Processing And Verification

(1) If errors are identified by the Department in a submitted Discharge Data Report, the Department will provide the hospital’s Chief Executive Officer or designee with a written and electronic notice of the identified errors. The submitting hospital will investigate and supply the Department with complete discharge data to correct the identified errors within 15 calendar days of the date of the hospital's receipt of the notice.

(2) Discharge Data Reports with identified errors must be corrected and resubmitted within the 15-day period specified in paragraph (1) above, or they will be considered delinquent and subject to the penalties prescribed in Code of Ala. 1975, §22-21-417 and this Chapter.

(3) After the quarterly data have been computerized, edited, updated, and determined by the Department to be the final data set for that quarter, the quarterly data is considered verified. Hospitals may continue to correct their submitted quarterly data and reduce their error rates until the close of that calendar year, at which time the final data set is verified and available for use by the public and for the release of limited data sets by the Department. No additional changes can be made by a hospital to any quarterly data set once the annual data is verified as final.

(4) Upon verification of the final data set at the close of each year, AlaHA or its contractual agent shall submit to the State Health Planning and Development Agency (SHPDA) such annual patient origin data as is required to be submitted to SHPDA under existing law.

History

• Author: Sherri L. Davidson, Ph.D., M.P.H.; Dana H. Billingsley
• Authority: Code of Ala. 1975, §22-21-410, et seq.
• New Rule: Published January 31, 2022; effective March 17, 2022. Amended: Published June 30, 2026; effective August 14, 2026.

Ala. Admin. Code r. 420-12-1-.05 Penalty Assessment

(1) The Department will assess a civil penalty of five cents per discharge record per day for each day the discharge data required to be reported is delinquent.

(2) The maximum civil penalty for a Delinquent Discharge Data Report is $10 for each discharge record. The Department will issue a written notice of assessment of the civil penalty to any hospital that has a pending Delinquent Discharge Data Report.

(3) For hospitals failing to submit any Discharge Data Reports by the submission deadline:

(a) The number of inpatient hospital discharge records for a particular hospital's Delinquent Discharge Data Report per quarter will be estimated by dividing the number of total inpatient discharges in the most recent annual report on file for that hospital by four.

(b) The number of outpatient discharge records for a particular hospital's Delinquent Discharge Data Report per quarter will likewise be estimated using data from the hospital's most recent annual report on file with the Department by dividing the number of total outpatient discharges by four.

(c) The sum of the estimates of inpatient discharge records and outpatient discharge records from (a) and (b) above will be used to calculate the penalty assessed for a Delinquent Discharge Data Report. Any positive or negative adjustments to the final estimate, up to a maximum of 10 percent, will be made once the actual Discharge Data Reports are received by the Department.

(4) Hospitals not submitting any Discharge Data Reports by the submission deadline will begin accruing penalties for Delinquent Discharge Data Reports on the day immediately following the date of the submission deadline and will cease accruing penalties on the day when the actual Discharge Data Reports are received by the Department or the maximum penalty $10 per discharge record is reached, whichever occurs first.

(5) Hospitals which do not submit corrected Discharge Data Reports within the additional 15 days allocated for error correction will accrue Delinquent Discharge Data Report penalties beginning the sixteenth day after the date of the Department's written error notification to the hospital and will cease accruing penalties on the day when the actual corrected Discharge Data Reports are received by the Department or the maximum penalty of $10 per discharge record is reached, whichever occurs first. The State Health Officer has the authority to delay, modify, or waive any penalty imposed for failure to correct any particular data element if the failure to correct is due to force majeure or other extraordinary circumstances beyond the control of the hospital.

(6) The allowable error rate for Discharge Data Reports is no more than 3 percent. Discharge Data Reports that fall within the acceptable error rate will not be subject to any Delinquent Discharge Data Report penalties. Hospitals that exceed the acceptable error rate will be penalized based on total errors, unless corrected within the time period provided in paragraph (5) of this rule.

(7) A notice of civil penalty assessment issued by the Department to the hospital’s Chief Executive Officer or designee will estimate the approximate penalty per day to be assessed, based on the estimated number of discharge records to be contained in the Discharge Data Report, as set forth in paragraph (3) above, or the number of discharge records submitted in excess of the 3 percent allowable error rate. The notice of assessment will also state that penalties will accrue until the date that actual or corrected Discharge Data Reports are received or the maximum penalty of $10 per discharge record is reached.

(8) Upon receipt of a notice of civil penalty assessment from the Department for any Delinquent Discharge Data Report, the hospital has the right to an informal conference with the State Health Officer.

(a) A written request for an informal conference must be received by the State Health Officer within 30 calendar days of the hospital's receipt of the notice of civil penalty assessment.

(b) In its request for an informal conference, the hospital may request that the Department waive the civil penalty assessment. The State Health Officer may waive the penalty in cases of an act of God or other acts beyond the control of the hospital, at the discretion of the State Health Officer, or for other reasons reasonably related to compliance with Code of Ala. 1975, §22-21-410, et seq. Waiver of the penalty is in the sole discretion of the State Health Officer.

(c) Based on the information provided during the informal conference, the State Health Officer may, in his discretion, when granting a hospital's request for waiver of the civil penalty assessment, impose a further deadline for receipt of the Delinquent Discharge Data Reports. Failure to provide any Discharge Data Reports by this deadline or to provide acceptable Discharge Data Reports within the allowable error rate by this deadline subjects the hospital once again to the penalty provisions of paragraph (6) of this section and following.

(9) Penalties will cease to accrue for hospitals requesting an informal conference with the State Health Officer until the date the conference is held. An informal conference will be held within 30 days of the date of the State Health Officer's receipt of the request for an informal conference. After the informal conference or, if no conference is requested, after the time for requesting the informal conference has expired, the Department may proceed to collect any applicable civil penalty assessment.

(10) If the hospital wishes to appeal the decision of the State Health Officer following the informal conference, a written request for a hearing before an Administrative Law Judge must be sent to the State Health Officer within 15 calendar days of the State Health Officer's written decision. Such hearing is to be conducted in accordance with the requirements for contested case hearings under the Alabama Administrative Procedure Act and the Department's rules for contested cases pursuant to Chapter 420- 1-3.

(11) A hospital with unpaid civil penalties levied more than 30 calendar days prior to the expiration of such hospital's license shall not be eligible to renew its license until all unpaid penalties, except for penalties subject to appeal and penalties for which payment arrangements have been made that are satisfactory to the Department, have been paid in full.

History

• Author: Sherri L. Davidson, Ph.D., M.P.H.; Dana H. Billingsley
• Authority: Code of Ala. 1975, §22-21-410, et seq.
• New Rule: Published January 31, 2022; effective March 17, 2022. Amended: Published June 30, 2026; effective August 14, 2026.

Ala. Admin. Code r. 420-12-1-.06 Hospital Discharge Data Advisory Council

(1) General

(a) The Advisory Council shall assist in developing rules and standards necessary to implement the requirements of Code of Ala. 1975, §22-21-410, et seq., to review and serve as consultants to the Department on all matters related to any reports, studies, or publications authorized thereunder, and to serve as consultants to the Department on matters relating to discharge data.

1. The Department, upon consultation and approval of the Council, shall establish and maintain processes and systems necessary for the protection, collection, and dissemination of the discharge data.

2. The Department, after consultation and with the approval of the Council, shall adopt all rules necessary to implement the provisions of Code of Ala. 1975, §22-21-410, et seq.

(b) The Advisory Council shall review and approve any amendments to the rules and regulations, or policies and procedures, governing hospital discharge data reporting.

(c) All meetings of the Advisory Council shall be announced in advance and conducted pursuant to the provisions of the Open Meetings Act,·Code of Ala. 1975, §36-25A-1, et seq.

(d) A quorum for purposes of conducting Advisory Council business shall be seven of the appointed members of the Advisory Council.

(e) All meetings shall require personal attendance of the members of the Advisory Council for purposes of determining whether a quorum is present and conducting business.

(f) The Advisory Council may appoint a technical advisory committee, which may or may not be comprised of members of the Advisory Council.

(g) The Advisory Council shall meet at least annually, but may meet more often as needed to carry on the business of the Council.

(2) Composition and Term

(a) The Advisory Council shall be composed of the following members:

1. Seven hospital representatives appointed by AlaHA, including at least one representative of a rural hospital, one representative of an urban hospital, one representative of a governmental hospital, one representative of a not-for-profit hospital, one representative of a pediatric hospital, and one representative of a for-profit hospital.

2. Two physicians appointed by the Medical Association of the State of Alabama.

3. One member appointed by Blue Cross Blue Shield of Alabama.

4. One consumer appointed by the Governor.

5. The Commissioner of the Alabama Medicaid Agency, or his or her designee.

6. The Executive Director of SHPDA, or his or her designee.

7. The State Health Officer, or his or her designee, who shall serve as chair of the Advisory Council, without a vote, except where there is a tie vote of the voting members of the Council.

(b) The Council shall reflect the diversity of gender, race, and geographical areas of the state.

(c) The term of office of each member shall be for 4 years.

(d) A member may serve two consecutive terms and shall serve until a successor is appointed. If a vacancy occurs, the original appointing authority shall fill the vacancy for the remainder of the unexpired term.

(e) Members shall not receive a salary or per diem allowance for serving as members of the Council.

History

• Author: Sherri L. Davidson, Ph.D., M.P.H.; Dana H. Billingsley
• Authority: Code of Ala. 1975, §22-21-410, et seq.
• New Rule: Published January 31, 2022; effective March 17, 2022. Amended: Published June 30, 2026; effective August 14, 2026.

Ala. Admin. Code r. 420-12-1-.07 Data Availability

(1) The State Health Officer has the authority to delay the release of any particular data element(s) to the public if it is determined that the quality or completeness of the information received by the Department is not acceptable.

(2) The Department may release limited data sets and create reports for public release using any available processed and verified de-identified line level discharge data. For purposes of this rule, processed and verified aggregate Discharge Data is intended to mean de-identified line level data. The Department may also conduct studies and publish information based upon the discharge data received, provided the studies and published information do not include information in a form which could be used to identify any patient or violate HIPAA. All properly processed and verified discharge data and information released by the Department must satisfy the requirements for public disclosure under Code of Ala. 1975, §22-21-410, et seq., this Chapter, and applicable federal law.

(3) A contractual agent of the Department or of AlaHA may receive any record necessary, together with any needed patient identifiers, to carry out its contractual duties. This includes any organization contracted with the Department or AlaHA to provide editing, quality control, database management services, or research for the Department or AlaHA. Any such contractual agent must agree in writing to establish and maintain appropriate controls to protect the confidentiality of the data or records received and must agree to return or destroy any such data or records at the termination of the contract.

(4) Limited data sets will be made available for public release by the Department upon receipt of an application for such data and a signed data use agreement binding the requester to the terms of use and confidentiality provisions of Code of Ala. 1975, §22-21-410, et seq. and this Chapter; provided, however, that a bureau or division of the Department requesting a limited data set for the purpose of fulfilling its responsibilities to the Department may receive a limited data set upon execution of an internal confidentiality agreement, in lieu of a data use agreement. All requesters will utilize an application form and data use agreement developed by the Department, with the assistance of the Council.

(5) The Department maintains a proprietary interest in all data files it provides to the public, and such files are made available solely for use by the requester and may not be given or sold to another entity. No data files will be made available for public release until 12 months following the close of the applicable calendar year.

(6) Any requests respecting the release of discharge data limited data sets shall be addressed by the Council.

History

• Author: Sherri L. Davidson, Ph.D., M.P.H.; Dana H. Billingsley
• Authority: Code of Ala. 1975, §22-21-410, et seq.
• New Rule: Published January 31, 2022; effective March 17, 2022. Amended: Published June 30, 2026; effective August 14, 2026.

Ala. Admin. Code r. 420-12-1-.08 Confidential Information

(1) All information reported to the Department pursuant to Code of Ala. 1975, §22-21-410, et seq., and this Chapter is not available for release until it has been processed and verified by the Department.

(2) Discharge data that has been processed and verified may be released by the Department pursuant to the provisions of 45 C.F.R. §§164.514(b) or (e), as applicable, provided, also, that such data satisfies the requirements for public disclosure under Code of Ala. 1975, §22-21-410, et seq., this Chapter, and any other applicable federal law.

(3) In no event may patient identifiers be released to the public at any time. The Department shall not publicly release discharge data or other information in any form which could reasonably be expected to reveal the identity of any patient. Reports and studies prepared and released by the Department based upon discharge data shall not include any specific information or combination of information which could be used to identify any patient.

(a) To maintain patient confidentiality, data files and/or reports released to the public must meet the requirements for a limited data set.

(b) Information that reasonably could be expected to reveal the identity of a patient, including those items contained in 45 C.F.R. §164.514(b)(2)(i), must be deleted. Limited data sets must exclude the direct identifiers of the individual patient or of relatives, employers, or household members of the individual patient, as enumerated in 45 C.F.R. §164.514(e)(2).

(4) The Department may conduct studies and publish information based upon the de-identified line level discharge data, provided the studies and published information do not include information in a form which could be used to reidentify any patient or violate HIPAA.

(5) Individual patient data submitted to the Department by a hospital shall not constitute a public record and shall at all times remain confidential and privileged from discovery. The release of identifiable patient health information may be made only to the hospital that initially reported the identifiable information, upon the written request of the hospital.

(6) Any agency of the state of Alabama receiving confidential hospital discharge data or Discharge Data Reports containing such confidential information shall agree in writing to follow all confidentiality restrictions of the Department concerning use of such data.

(7) Discovery of patient specific information from original sources is not precluded where the information is otherwise non privileged and discoverable under applicable law.

(8) The State Health Officer may use or authorize use of this data for purposes that are necessary to provide for or protect the health of the population and as permitted by law.

History

• Author: Sherri L. Davidson, Ph.D., M.P.H.; Dana H. Billingsley
• Authority: Code of Ala. 1975, §22-21-410, et seq.
• New Rule: Published January 31, 2022; effective March 17, 2022. Amended: Published June 30, 2026; effective August 14, 2026.