Insurance, Administration

Rule R590-262

Health Data Authority Health Insurance Claims Reporting

Change in Proposed Rule

DAR File No.: 35201
Filed: 11/23/2011 04:28:01 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This change is a result of comments received during the initial comment period.

Summary of the rule or change:

Changes to the rule include corrections in punctuation, grammar, and numbering. More substantive changes include the addition of (c) to Subsection R590-262-2(2) that allows health data to be used for the enrollment data elements identified in Rule R428-15, Health Data Authority Health Insurance Claims Reporting; deletion of Section R590-262-4, Reporting Requirements, since this information is already found in the code; the addition of a new Subsection R590-262-4(4), Reporting Process, requires an insurer to submit medical claims, enrollment and pharmacy data files for all Utah residents; in Section R590-262-7, Insurer Registration, adds the latest date possible to register online with the Office of Health Care Statistics; and in Section R590-262-11, Provider Notification, has been added requiring notification to those receiving shared data. (DAR NOTE: This change in proposed rule has been filed to make additional changes to a proposed new rule that was published in the September 15, 2011, issue of the Utah State Bulletin, on page 41. Underlining in the rule below indicates text that has been added since the publication of the proposed rule mentioned above; strike-out indicates text that has been deleted. You must view the change in proposed rule and the proposed new rule together to understand all of the changes that will be enforceable should the agency make this rule effective.)

State statutory or constitutional authorization for this rule:

• Section 31A-22-614.5

Anticipated cost or savings to:

the state budget:

The changes to this rule will have no fiscal impact on the department's costs, revenues, or workload. No filings will need to be made to the department. The only change in procedure is the requirement to provide an electronic notification with those to whom data is being shared.

local governments:

This rule will have no fiscal impact on local government. The rule requires certain entities that pay health care claims to submit data to the Utah Department of Health.

small businesses:

Small businesses that would be affected by this rule are the Clinical Health Information Exchange (cHIE), and any small business they share their data with. There will be no fiscal impact on these entities as a result of these changes. There is a procedural change that requires those like cHIE that share this data, to, at the same time, provide an electronic notification.

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

There will be no fiscal impact as a result of this rule. The only procedural change is that of providing an electronic notice to anyone that the data is shared with.

Compliance costs for affected persons:

There will be no fiscal impact as a result of this rule. The only procedural change is that of providing an electronic notice to anyone that the data is shared with.

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

The changes to this rule will have no fiscal impact on businesses. The changes are to clean-up grammar, punctuation and outlining, plus it adds online notification requirements to those with whom the data is shared.

Neal T. Gooch, Commissioner

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

Insurance
Administration
Room 3110 STATE OFFICE BLDG
450 N MAIN ST
SALT LAKE CITY, UT 84114-1201

Direct questions regarding this rule to:

• Jilene Whitby at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at jwhitby@utah.gov

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:

01/17/2012

This rule may become effective on:

01/24/2012

Authorized by:

Jilene Whitby, Information Specialist

R590[ ]. Insurance, Administration.

R590-262. Health Data Authority Health Insurance Claims Reporting.

R590-262-1. Authority.

This rule is promulgated pursuant to Subsection 31A-22-614.5(3)(a) to coordinate with the provision of Subsection 26-1-37(2)(b) and Utah Department of Health rules R428-1 and R428-15.

 

R590-262-2. Purpose and Scope.

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

(2) This rule[and] allows the data to be shared with the state's designated secure health information master index person index, Clinical Health Information Exchange (cHIE), to be used:

(a) in compliance with data security standards established by:

(i) the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, 110 Stat. 1936: and

(ii) the electronic commerce agreements established in a business associate agreement; and

(b) for the purpose of coordination of health benefit plans , and;

(c) for the enrollment data elements identified in Utah Administrative Rule R428-15, Health Data Authority Health Insurance Claims Reporting.

[(2)](3) An insurer that covers fewer than 2500 individual Utah residents is exempt from all requirements of this rule.

 

R590-262-3. Definitions.

In addition to the definitions in Section 31A-1-301, the following definitions shall apply for the purpose of this rule:

(1) "Claim" means a request or demand on an insurer for payment of a benefit.

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

(3) "Health Insurance" has the same meaning as found in Subsection 31A-1-301(76).

(4) "Insurer" means:

(a) a commercial insurance company engaged in the business of health care insurance in the state of Utah, as defined in Subsection 31A-1-301[ ](92), including a business under an administrative services organization or administrative services contract arrangement;

(b) a third party administrator, as defined in Subsection 31A-1-301[ ](161), licensed by the Utah Insurance Department, and that collects premiums or settles claims of residents of the state, for health care insurance policies or health benefit plans, as defined in Subsection 31A-1- 301[ ](74) ;

(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; or

(e) a licensed professional employer organization acting as an administrator of a health care insurance policy under Title 31A, Chapter 40 or health benefit plan funded by a self-insurance arrangement.

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

(6) "Technical specifications" means the technical specifications document published by the Health Data Committee describing the variables and formats of the data that are to be submitted as well as submission directions and guidelines.

 

R590-262-4. [Reporting Requirements.

Each insurer shall submit enrollment, medical claims, and pharmacy data described in R590-262-5 where Utah is the patient's primary residence and enrollment, medical claims, and pharmacy data for services provided in or out of state to Utah residents.

 

R590-262-5. ]Reporting Process.

(1) Submission procedures and guidelines are described in detail in the technical specifications published by the Health Data Committee. The health care claims data shall be either X12 format, or flat text files formatted according to the technical specifications.

(2) All medical claims shall be submitted to the Office through the Utah Health Information Network (UHIN) in X12 format.

(3) All enrollment and pharmacy data files shall be submitted to the Office in flat text files using either UHIN or FTP Secure.

(4) An insurer shall submit the information in Subsections (2) and (3) for all Utah residents.

 

R590-262-[6]5. Required Data Elements.

(1) The enrollment, medical claims, and pharmacy data elements are described in detail in the technical specifications published by the Health Data Committee. Each insurer shall submit data for all fields contained in the submission specifications if the data are available to the insurer.

(a) Each insurer must submit enrollment files as a flat file.

(b) Each insurer must submit medical claims as X12 messages as modified by this rule. All X12 format messages must contain all the necessary segments for processing through UHIN. This includes ISA/IEA segments, GS and GE segments, Segment Qualifier codes, etc., as specified in the X12 implementation guides. If a segment or qualifier is required for X12 format, it is required for all submissions under this rule. If a segment or qualifier is not required for X12 format, but is required by this rule, it must be submitted as required by this rule. Submitted files must be in the ASC X12 4010A1 x098 for a Professional Claim and in the ASC X12 4010A1 x096 for an Institutional Claim.

(c) Each insurer must submit pharmacy claims as a flat file.

(2) Each insurer must submit the enrollment files data elements as required in R428-15.

 

R590-262-[7]6. 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.

 

R590-262-[8]7. Insurer Registration.

Each insurer shall register with the Office by completing the registration online at[:] http://health.utah.gov/hda/apd/ no later than February 1, 2012, and annually thereafter [by] no later than September 1[ of each year].

 

R590-262-[9]8. Testing of Files.

Insurers that become subject to this rule 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.

 

R489-262-[10]9. Rejection of Files.

The Office or its designee may reject and return any data submission that fails to conform to the submission requirements. Paramount among submission requirements are: First Name, Last Name, Member ID, Relationship to Subscriber, Date of Birth, Address, City, State, Zip Code, Sex, which are key data fields that the insurer must submit for each enrolled member and claim. An insurer whose submission is rejected shall resubmit the data in the appropriate, corrected format to the Office, or its designee within [10]ten state business days of notice that the data does not meet the submission requirements[,].

 

R590-262-[11]10. Replacement of Data Files.

An insurer 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 insurer can establish exceptional circumstances for the replacement.

 

R590-262-[12]11. Provider Notification.

(1) The following notification must be provided to a person that receives shared data, "This shared data is provided for informational purposes only. Contact the insurer for current, specific eligibility, or benefits coverage determination."

(2) The notification in this section shall be provided in coordination with provider participation in the master index patient index and the cHIE programs.

 

R590-262-12. Limitation of Liability.

A person furnishing information of the kind described in this rule is immune from liability and civil action if the information is furnished to or received from:

(a) the commissioner of insurance or the executive director of the Department of Health or [the] their employees or representatives;

(b) federal, state, or local law enforcement or regulatory officials or their employees or representatives; or

(c) the insurer that issued the policy connected with the data set.

 

R590-262-13. Penalties.

A person found to be in violation of this rule shall be subject to penalties as provided in Section 31A-2-308.

 

R590-262-14. Enforcement Date.

The commissioner will begin enforcing this rule upon the rule's effective date.

 

R590-262-15. Severability.

If any provision of this rule or its application to any person or situation is held to be invalid, that invalidity shall not affect any other provision or application of this rule which can be given effect without the invalid provision or application, and to this end the provisions of this rule are declared to be severable.

 

KEY: health insurance claims reporting

Date of Enactment or Last Substantive Amendment: [2011]2012

Authorizing, and Implemented or Interpreted Law: 31A-22-614.5(3)(a)