DAR File No. 38568
This rule was published in the June 15, 2014, issue (Vol. 2014, No. 12) of the Utah State Bulletin.
Health, Center for Health Data, Health Care Statistics
Health Data Authority Health Insurance Claims Reporting
Notice of Proposed Rule
DAR File No.: 38568
Filed: 06/02/2014 10:08:52 AM
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.
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.
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@example.com
- Rex Olsen at the above address, by phone at 801-538-9498, by FAX at 801-536-0940, or by Internet E-mail at firstname.lastname@example.org
- 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@example.com
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:
This rule may become effective on:
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 R428-1.
This rule establishes requirements for certain entities that pay for health care to submit data to the Utah Department of Health.
These definitions apply to rule R428-15, in
(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
(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
(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
(g) a dental stand-alone company as defined in
(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
(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.
4]. Reporting Requirements.
(1) Each carrier shall submit health care
claims data described in the [
technical specifications] 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] 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
(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
(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
(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
(a) The carrier's name, mailing address, telephone
number, and contact person;
(b) the dates the exemption or extension is to start and
(c) a description of the relief sought, including
reference to specific sections or language of the
(d) a statement of facts, reasons, or legal authority in
support of the request; and
(e) a proposed alternative to the requirement or
(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.
8]. 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.
9]. 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] as of May 15,
(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.
10]. 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.
11]. 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.
12]. Limitation of Liability.
As provided in [
Utah Code ]Section 26-25-1, [ a carrier] that submits data pursuant to this rule[ , including third-party administrators that submit employee
data, is not] liable for [ providing] the
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
(2) Each day of violation is a separate
]KEY: APCD, payers, claims, transparency
Date of Enactment or Last Substantive Amendment: [
Authorizing, and Implemented or Interpreted Law: 26-33a; 26-25
More information about a Notice of Proposed Rule is available online.
The Portable Document Format (PDF) version of the Bulletin is the official version. The PDF version of this issue is available at https://rules.utah.gov/publicat/bull-pdf/2014/b20140615.pdf. The HTML edition of the Bulletin is a convenience copy. Any discrepancy between the PDF version and HTML version is resolved in favor of the PDF version.
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For questions regarding the content or application of this rule, please contact Mike Martin at the above address, by phone at 801-538-9205, by FAX at 801-538-9916, or by Internet E-mail at firstname.lastname@example.org; 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@example.com; Norman Thurston at the above address, by phone at 801-538-7052, by FAX at 801-237-0787, or by Internet E-mail at firstname.lastname@example.org. For questions about the rulemaking process, please contact the Division of Administrative Rules.