(a) Within five months after the end of each reporting quarter, DSHS shall compile one or more electronic data files for each reporting hospital using all discharge claims received from each hospital. The file shall have one record for each patient discharged during the reporting quarter and one record for any patient discharged during one prior reporting quarter for whom additional discharge claims have been received. This file will include all data submitted by the hospital, which DSHS intends to use in the creation of the public use data file. The data files, including reports and any additional information returned to the hospital, allows the hospital to provide physicians and other health professionals the opportunity to review, request correction of, and comment on records of discharged patients for whom they are shown as "attending" or "operating or other." DSHS shall determine the format and medium in which the quarterly file will be delivered to hospitals.
(b) The chief executive officer or chief executive officer's designated agent of each hospital shall indicate whether the hospital is certifying or not certifying the discharge encounter data specified in subsection (a) of this section, sign and return the form corresponding to the discharge report for each quarter using forms supplied by DSHS. The certification form may be signed by a person designated by the chief executive officer and acting as the officer's agent. Designation of an agent does not relieve the chief executive officer of personal responsibility for the certification. If the chief executive officer or chief executive officer's designated agent does not believe the quarterly file is accurate, the officer shall provide DSHS with detailed comments regarding the errors or submit a written request (on a form supplied by DSHS) and provide the data necessary to correct any inaccuracy and certify the file subject to those corrections being made prior to the deadlines specified in this subsection. Corrections to certification discharge data shall be submitted on or prior to the following schedule: Quarter 1- October 1; Quarter 2- January 1; Quarter 3- April 1; and Quarter 4- July 1. Chief Executive Officers or designees that elect not to certify shall submit a reasoned justification explaining their decision to not certify their discharge encounter data and attach the justification to the certification form. Election to not certify data does not prevent data from appearing in the public use data file. Data that is not corrected and submitted by the deadline may appear in the public use data file.
(c) The signed certification form shall represent that:
  (1) policies and procedures are in place within the hospital's processes to validate and assure the accuracy of the discharge encounter data and any corrections submitted; and
  (2) all errors and omissions known to the hospital have been corrected or the hospital has submitted comments describing the errors and the reasons why they could not be corrected; and
  (3) to the best of their knowledge and belief, the data submitted accurately represents the hospital's administrative status of discharged inpatients for the reporting quarter; and
  (4) the hospital has provided physicians and other health professionals a reasonable opportunity to review and comment on the discharge data of patients for which they were reported in one of the available physician number and name fields provided on the acceptable formats specified in §421.9 of this title (relating to Discharge Reports--Records, Data Fields and Codes) (for example, "attending physician" or "operating or other physician" as applicable). The physicians or other health professionals may write comments and have errors brought to the attention of the chief executive officer or the chief executive officer's designated agent and the chief executive officer or the chief executive officer's designated agent, shall address any comments by the physicians or other health professionals.
  (5) if the chief executive officer or the officer's designee elects not to certify the discharge encounter data for a specific quarter, a written justification of any unresolved data issues concerning the accuracy and completeness of the data at the time of the certification shall be included on the certification form. Discharge data that has been edited, returned to hospital and is not certified may be released and published in the public use data file.
(d) Each hospital shall submit its certification form for each quarter's data to DSHS by the fifteenth day of the seventh month (Quarter 1- October 15; Quarter 2- January 15; Quarter 3- April 15; and Quarter 4- July 15) following the last day of the reporting quarter as specified in §421.3(a)(1) - (4) of this title (relating to Schedule for Filing Discharge Reports). Individual hospital requests for an extension to these deadlines will not be granted. DSHS may extend the deadline for all hospitals when deemed necessary.
(e) Hospitals, physicians or other health professionals may submit concise written comments regarding any data submitted by them or relating to services, they have delivered which may be released as public use data. Comments shall be submitted to DSHS on or before the dates specified in subsection (d) of this section, regarding the submission of the certification form. Commenters are responsible for assuring that the comments contain no patient or physician identifying information. Comments shall be submitted electronically using the method described in §421.4(a) and (b) of this title (relating to Instructions for Filing Discharge Reports).
(f) Failure to either correct a discharge report which has been submitted and contains errors or omissions known to the hospital on or prior to the dates specified in subsection (b) of this section or to address in the comments the errors known to the hospital contained in the data and return the comments on or prior to the dates specified in subsection (d) of this section is punishable by a civil penalty pursuant to Health and Safety Code, §108.014(b).

Source Note: The provisions of this §421.7 adopted to be effective August 19, 1997, 22 TexReg 7490; amended to be effective December 29, 1997, 22 TexReg 12494; amended to be effective July 26, 1998, 23 TexReg 7365; amended to be effective July 29, 2001, 26 TexReg 5408; amended to be effective April 21, 2002, 27 TexReg 3183; amended to be effective July 6, 2003, 28 TexReg 4915; transferred effective September 1, 2004, as published in the Texas Register September 10, 2004, 29 TexReg 8842; amended to be effective December 27, 2007, 32 TexReg 9683; amended to be effective July 5, 2017, 42 TexReg 3373; amended to be effectiveJanuary 30, 2019, 44 TexReg 429