DAR File No. 38568

Health, Center for Health Data, Health Care Statistics

Rule R428-15

Health Data Authority Health Insurance Claims Reporting

Notice of Proposed Rule

(Amendment)

DAR File No.: 38568
Filed: 06/02/2014 10:08:52 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment is in response to a review of Title R428 that identified inconsistencies in the writing of the rule.

Summary of the rule or change:

This amendment removes definitions of terms, exemption and extension procedures, and penalties contained in Rule R428-2. It also makes technical and conforming amendments.

State statutory or constitutional authorization for this rule:

• Title 26, Chapter 33a

Anticipated cost or savings to:

the state budget:

This amendment makes technical changes that improve consistency and clarity of Rule R428-15. The Utah Department of Health (UDOH) determines that these changes will not create any cost or savings impact to the state budget or UDOH's budget, since the changes will not increase workload and can be carried out with existing budget.

local governments:

This filing does not create any direct cost or savings impact to local governments since they are not directly affected by the rule; nor are local governments indirectly impacted because the rule does not create a situation requiring services from local governments.

small businesses:

None--Small businesses are not impacted by this rule change, with all potentially impacted having more than 50 employees. As a result, the rule will have no effect on small business budgets for costs or savings.

persons other than small businesses, businesses, or local governmental entities:

Minor technical changes in Rule R428-15 will not create any cost or savings to businesses, individuals, local governments or persons that are not small businesses.

Compliance costs for affected persons:

There are no compliance costs for persons affected by these changes to Rule R428-15. Although there are several modifications within this amendment, they will not impact affected persons.

Comments by the department head on the fiscal impact the rule may have on businesses:

No effect on business because it makes no material change in current practices.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Center for Health Data, Health Care Statistics
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Mike Martin at the above address, by phone at 801-538-9205, by FAX at 801-538-9916, or by Internet E-mail at [email protected]
• Rex Olsen at the above address, by phone at 801-538-9498, by FAX at 801-536-0940, or by Internet E-mail at [email protected]
• Norman Thurston at the above address, by phone at 801-538-7052, by FAX at 801-237-0787, or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/15/2014

This rule may become effective on:

07/22/2014

Authorized by:

David Patton, Executive Director

R428. Health, Center for Health Data, Health Care Statistics.

R428-15. Health Data Authority Health Insurance Claims Reporting.

R428-15-1. Legal Authority.

This rule is promulgated under authority granted in Utah Code Title 26, Chapter 33a and in accordance with the Utah Health Data Plan as adopted in Rule R428-1.

 

R428-15-2. Purpose.

This rule establishes requirements for certain entities that pay for health care to submit data to the Utah Department of Health.

 

[R428-15-3. Definitions.

These definitions apply to rule R428-15, in addition:

(1) "Committee" means the Utah Health Data Committee as defined in 26-33a-102.

(2) "Office" means the Office of Health Care Statistics within the Utah Department of Health, which serves as staff to the Utah Health Data Committee.

(3) "Carrier" means:

(a) a commercial insurance company engaged in the business of health care insurance in the state of Utah, as defined in 31A-1-301, including a business under an administrative services organization or administrative services contract arrangement;

(b) a third party administrator, as defined in 31A-1-301, licensed by the state of Utah that collects premiums or settles claims of residents of the state, for health care insurance policies or health benefit plans, as defined in 31A-1-301;

(c) a governmental plan as defined in Section 414 (d), Internal Revenue Code;

(d) a non-electing church plan as described in Section 410 (d), Internal Revenue Code;

(e) a licensed professional employer organization acting as an administrator of a health care insurance policy;

(f) a health benefit plan funded by a self-insurance arrangement; or

(g) a dental stand-alone company as defined in 31A-8-101.

(4) "Claim" means a request or demand on a carrier for payment of a benefit.

(5) "Health care claims data" means information consisting of, or derived directly from, member enrollment, medical claims, and pharmacy claims that this rule requires a carrier to report.

(6) "Adjudicated claim" means a claim submitted to a carrier for payment where the carrier has made a determination whether the services provided fall under the carrier's benefit.

(7) "Health Insurance" has the same meaning as found in Subsection 31A-1-301.

(8) "Technical specifications" means the Technical Specifications and Data Submission Procedures for the State of Utah All Payer Database Version 1.3 for data submissions required prior to May 15, 2014 and the Utah All-Payer Claims Database Data Submission Guide Version 2 for data submissions beginning May 15, 2014. Both documents are adopted and incorporated by reference.

 

]R428-15-[4]3. Reporting Requirements.

(1) Each carrier shall submit health care claims data described in the [technical specifications]Data Submission Guide for Claims Data for each covered person where Utah is the covered person's primary residence, regardless of where the services are provided.

(2) Each carrier shall submit data for all fields contained in the [technical specifications]Data Submission Guide for Claims Data if the data are available to the carrier. Each carrier shall notify the Office or its designee of any data elements that are required to be reported under this rule, but that are not available to the carrier.

(3) Each carrier shall submit the health care claims data on a monthly basis.

(4) Each monthly submission is due no later than the last day of the month following the month in which the carrier adjudicated the claim.

 

[R428-15-5. Reporting Process.

(1) Submission procedures and guidelines are described in detail in the technical specifications.

 

R428-15-6. Extensions and Exemptions.

(1) A carrier that covers fewer than 2,500 individual Utah residents is exempt from all requirements of this rule.

(2) The committee may grant exemptions when the carrier demonstrates that compliance imposes an unreasonable cost to the carrier. The committee may grant extensions when the carrier documents that technical or unforeseen difficulties prevent compliance.

(a) A carrier may request an extension for any deadline required in this rule. For each deadline for which the carrier requests an extension, the carrier must submit its request no less than 15 calendar days before the deadline in question.

(b) A carrier may request an exemption from any particular requirement or set of requirements of this rule. The carrier must submit a request for exemption no less than 30 calendar days before the date the carrier would have to comply with the requirement.

(3) The carrier requesting an extension or exemption shall include:

(a) The carrier's name, mailing address, telephone number, and contact person;

(b) the dates the exemption or extension is to start and end;

(c) a description of the relief sought, including reference to specific sections or language of the requirement;

(d) a statement of facts, reasons, or legal authority in support of the request; and

(e) a proposed alternative to the requirement or deadline.

(4) The committee may grant an extension for a maximum of 30 calendar days. A carrier wishing an additional extension must submit an additional, separate request.

(5) The committee may grant an exemption for a maximum of one calendar year. A carrier wishing an additional exemption must submit an additional, separate request.

 

R428-15-7. Third-party Contractors.

The Office may contract with a third party to collect and process the health care claims data and will prohibit it from using the data in any way but those specifically designated in the scope of work.

 

]R428-15-[8]4. Carrier Registration.

Each carrier required to submit health care claims data shall register by September 1 of each year. Each carrier newly required to submit health care claims data under this rule, either by a change to the rule or because it no longer qualifies for an exemption, shall register with the Office [by completing the registration on line at: http://health.utah.gov/hda/apd/ ]within 30 days of being required to submit.

 

R428-15-[9]5. Testing of Files.

(1) Prior to February 14, 2014, each carrier required to report under this rule shall meet with the Office or its designee to establish a data submission testing plan and time line. Each carrier shall contact the Office to arrange this meeting by January 15, 2014.

(2) Each carrier shall, according to its data submission testing plan, submit to the Office or its designee a test dataset for determining compliance with the standards for data submission and participate in testing. This test dataset must be in the same format as required by the [technical specifications]Data Submission Guide for Claims Data as of May 15, 2014.

(3) Carriers that become subject to this rule after January 15, 2014 shall submit to the Office a dataset for determining compliance with the standards for data submission no later than 90 days after the first date of becoming subject to the rule.

 

R428-15-[10]6. Rejection of Files.

The Office or its designee may reject and return any data submission that fails to conform to the submission requirements. A carrier whose submission is rejected shall resubmit the data in the appropriate, corrected format to the Office, or its designee within 10 state business days of notice that the data does not meet the submission requirements.

 

R428-15-[11]7. Replacement of Data Files.

A carrier may replace a complete dataset submission if no more than one year has passed since the end of the month in which the file was submitted. However, the Office may allow a later submission if the carrier can establish exceptional circumstances for the replacement.

 

R428-15-[12]8. Limitation of Liability.

As provided in [Utah Code ]Section 26-25-1, [a carrier]any data supplier that submits data pursuant to this rule[, including third-party administrators that submit employee data, is not] cannot be held liable for [providing]having provided the required information to the Department.

 

[R428-15-13. Penalties.

Pursuant to Section 26-23-6, a carrier that violates any provision of this rule may be assessed an administrative civil money penalty for each day of non-compliance. Fines may be imposed as follows:

(1) Not to exceed the sum of $10,000 per violation

(2) Each day of violation is a separate violation.

 

]KEY: APCD, payers, claims, transparency

Date of Enactment or Last Substantive Amendment: [January 7, ]2014

Authorizing, and Implemented or Interpreted Law: 26-33a; 26-25