INSTRUCTIONS FOR COMPLETING THE OPPC SELF-REPORTING FORM Please complete the OPPC Self-Reporting Form any time that an Other Provider-Preventable Condition occurs. NOTE: A separate form must be completed for each procedure. ACN - Enter the Attachment Control Number (ACN) if this is an attachment for an electronically submitted institutional claim. Provider PROMISe Number - Enter the facility's 9-digit provider number. Service Location Number - Enter the facility's 4-digit service location number. Recipient Name - Enter the recipient's full name. Recipient ID - Enter the recipient's 10-digit identification number. Date of Birth - Enter the recipient's date of birth (MMDDCCYY). Admission Date - Enter the date of admission (MMDDCCYY). Discharge Date - Enter the date of discharge (MMDDCCYY). Was this an operation/invasive procedure - Enter an X for yes or no for line a), b), and c). ICD-PCS Procedure Code, Description and Date - Enter the ICD-PCS procedure code, description and date. NOTE: A separate form must be completed for each procedure. Were any of the following involved - Enter an X for each provider type. Name, Position, Title and License/Certification/NPI Number - Enter the name, position, title and License/ Certification/ NPI Number as applicable for each provider type. If more space is needed, see Attachments described below. Details - Enter the specifics pertaining to this procedure. If more space is needed, see Attachments described below. Charges Related to the OPPC - Use this section to identify any charges that are being reported for non-payment. Attachments - If more space is needed, attach an 8 �" x 11" sheet of paper. Include all of the following at the top of each page: the ACN, Provider PROMISe Number, Service Location, Recipient Name, Recipient ID, Admission Date and Discharge Date. www.dpw.state.pa.us American LegalNet, Inc. www.FormsWorkFlow.com OPPC Self-Reporting Form ACN: _______________________________________ Provider PROMISe Number: _______________________________________________ Recipient Name: __________________________________________________ Service Location Number: ________________________________________ DOB: _________________ Provider Name: __________________________________________________________________________________________________________________________ Recipient ID: _______________________________ Admission Date: _________________________________________________________ Was this: Discharge Date: ________________________________________________ a) the wrong operation/invasive procedure on correct patient (Y65.51)? b) operation/invasive procedure on patient not scheduled (Y65.52)? c) the correct operation/invasive procedure on wrong side/body part (Y65.53)? Yes Yes Yes No No No Date: ______________________ ICD-PCS Procedure Code: _________________________ Description: _____________________________________________ Were any of the following involved: Anesthesiologist Assistant surgeon Physician/surgeon Dentist Position Nurse (RN or LPN) OR Technician Radiologist Podiatrist Title Certified Registered Nurse Anesthetist (CRNA) Physician Assistant (PA) Certified Registered Nurse Practitioner (CRNP) Other (Specify) ________________________________________ Name License/Cert./NPI Number Details: _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________ Charges Related to the OPPC: Revenue Code Description Service Date(s) Service Units Charges American LegalNet, Inc. www.FormsWorkFlow.com MA 551 10/15