Insurance, Administration

Rule R590-262

Health Data Authority Health Insurance Claims Reporting

Notice of Proposed Rule

(Amendment)

DAR File No.: 36418
Filed: 06/27/2012 04:28:21 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The changes to this rule are to clarify and clean-up unnecessary wording and definitions.

Summary of the rule or change:

The changes made are to clarify that long-term care insurance and income replacement policies are exempt from the rule; to remove redundant definitions; require insurers to permit the Health Department to re-disclose specified information; and to clarify a date when submissions are due.

State statutory or constitutional authorization for this rule:

• Section 31A-22-614.5
• Section 26-1-37

Anticipated cost or savings to:

the state budget:

The changes are cleanup in nature and for clarification purposes. They will have no fiscal impact on the department or the state's budget. No additional filings or other work will be required of the department and no changes will result in department expenses or revenues.

local governments:

This rule has no fiscal impact on local governments. It deals solely with the relationship between the department, its licensees and the State Health Department.

small businesses:

This rule impacts large businesses: insurers and employers of 2,500 or more individuals.

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

The changes to this rule are for clarification purposes only and will have no fiscal impact on insurers or their insureds.

Compliance costs for affected persons:

The changes to this rule are for clarification purposes only and will have no fiscal impact on those regulated by it.

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

This rule will have no fiscal impact on Utah businesses.

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:

08/14/2012

This rule may become effective on:

08/21/2012

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 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.

(3) (a) This rule applies to an insurer offering a health benefit plan.

(b) This rule does not apply to:

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

(ii) a long-term care insurance policy; or

(iii) an income replacement policy.

 

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]a person engaged in the business of offering a health benefit plan[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 that is acting as an administrator of a health care insurance policy [under Title 31A, Chapter 40] or a 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.

(1) Each insurer shall submit enrollment, medical claims, and pharmacy data described in R428-15-5 and R590-262-5, where Utah is the patient's primary residence, for services provided in or out of the state of Utah.

(2) Each insurer shall permit the Utah Department of Health to redisclose the enrollment and eligibility information with the state designated entity for the purpose of coordination of benefits.

(3) Each insurer shall submit monthly health care claims data. Each monthly submission is due no later than the last day of the following month.

 

R590-262-[4]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-[5]6. 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, professional medical claims, institutional medical claims, and pharmacy claims data elements as required in R428-15.

 

R590-262-[6]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.

 

R590-262-[7]8. 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,]30 days after becoming subject to this rule and annually thereafter by no later than September 1.

 

R590-262-[8]9. 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-[9]10. 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 ten state business days of notice that the data does not meet the submission requirements.

 

R590-262-[10]11. 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-[11]12. 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]13. 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 Insurance Department, the executive director of the Department of Health , or 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]14. 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]15. Enforcement Date.

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

 

R590-262-[15]16. 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: [March 7, ]2012

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