DAR File No. 40891
This rule was published in the November 1, 2016, issue (Vol. 2016, No. 21) of the Utah State Bulletin.
Health Data Authority Health Insurance Claims Reporting
Notice of Proposed Rule
DAR File No.: 40891
Filed: 10/14/2016 03:29:07 PM
Purpose of the rule or reason for the change:
The proposed rule changes adopt a process to allow a self-funded employer plan to affirmatively select to provide healthcare claim data to Utah's All Payer Claim Database (APCD).
Summary of the rule or change:
Prior to the Supreme Court's decision in Gobeille v. Liberty Mutual Ins. Co. issued this last March, insurers and third-party administrators were required to submit healthcare claim data for all fully insured and employer self-funded plans to Utah's APCD. After the Court's decision, Utah's rule was revised to remove the mandatory reporting requirements for the employer self-funded plans, see Subsection R590-262-2(3)(c). To be able to continue to collect self-funded employer data, the proposed rule changes require an insurer and third-party administrator to provide an employer of a self-funded health plan a form that allows an employer to instruct the plan administrator to continue to submit data to the APCD.
Statutory or constitutional authorization for this rule:
- Subsection 31A-22-614.5(3)(a)
Anticipated cost or savings to:
the state budget:
Because the proposed amendments apply to health insurers and third-party administrators, the changes to this rule do not have an anticipated cost or savings to the state budget.
Because the proposed amendments only apply to health insurers and third-party administrators, there is no cost impact to local governments.
The proposed amendments apply to health insurers and third-party administrators, and some third-party administrators may be a small business. The impact will be minimal. The rule changes require a health insurer or third-party administrator to provide a document to a self-funded employer client. If the client chooses to submit their data to the APCD, the health insurer, or third-party administrator would then be required to submit the data. The applicable data is currently being submitted for all fully insured commercial health insurance. It was also being submitted for self-funded employer plans up until March 2016 when the Supreme Court decided such entities were not required to provide the data. However, the decision did not bar an employer from voluntarily providing such data to the APCD. This rule sets forth a process for self-funded employers to voluntarily provide data.
persons other than small businesses, businesses, or local governmental entities:
The proposed amendments apply to health insurers and third-party administrators. The impact will be minimal. The rule changes require a health insurer or third-party administrator to provide a document to a self-funded employer client. If the client chooses to submit their data to the APCD, the health insurer, or third-party administrator would then be required to submit the data. The applicable data is currently being submitted for all fully insured commercial health insurance. It was also being submitted for self-funded employer plans up until May 2016 when the Supreme Court decided such entities were not required to provide the data. However, the decision did not bar an employer from voluntarily providing such data to the APCD. This rule sets forth a process for self-funded employers to voluntarily provide data.
Compliance costs for affected persons:
There should only be minimal costs due to the requirement to provide a client a single-page opt-in form for an affirmative election. There should not be any additional compliance costs for the submission of data because the information had been required to be submitted until March 2016.
Comments by the department head on the fiscal impact the rule may have on businesses:
There are no anticipated costs or savings to any businesses. Other than providing a client an opt-in form, the updates are already an industry standard, so the requirements are already in force with affected entities.
Todd E. Kiser, Commissioner
The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:Insurance
Room 3110 STATE OFFICE BLDG
450 N MAIN ST
SALT LAKE CITY, UT 84114-1201
Direct questions regarding this rule to:
- Steve Gooch at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at firstname.lastname@example.org
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:
Interested persons may attend a public hearing regarding this rule:
- 11/09/2016 01:00 PM, State Office Bldg, 450 N State St., Room 3112, Salt Lake City, UT
This rule may become effective on:
Steve Gooch, Information Specialist
R590. Insurance, Administration.
R590-262. Health Data Authority Health Insurance Claims Reporting.
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;
(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 insurer that covers fewer than 2500 individual Utah residents:
(ii) a long-term care insurance policy; or
(iii) an income replacement policy.
This] rule does not
require a person to provide information concerning a self-funded
employee [ welfare benefit ]plan[ as defined in 29 U.S.C. Section 1002(1)].
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) "Insurer" means:
(a) a person engaged in the business of offering a health benefit plan , including a business under an administrative services organization or administrative services contract arrangement;
(b) a third party administrator that collects premiums or settles claims for health care insurance policies;
(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.
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.
"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
(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.
R590-262-5. 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
R590-262-6. 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
(2) Each insurer must submit the enrollment files, professional medical claims, institutional medical claims, and pharmacy claims data elements as required in R428-15.
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.
. Insurer Registration.
Each insurer shall register with the Office by completing the registration online at http://health.utah.gov/hda/apd/ no later than 30 days after becoming subject to this rule and annually thereafter by no later than September 1.
. 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.
. 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.
. 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.
. 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
. 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 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.
A person found to be in violation of this rule shall be subject to penalties as provided in Section 31A-2-308.
. Enforcement Date.
The commissioner will begin enforcing this rule upon the rule's effective date.
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: [
May 23], 2016
Authorizing, Implemented or Interpreted Law: 31A-22-614.5(3)(a)
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/2016/b20161101.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 Steve Gooch at the above address, by phone at 801-538-3803, by FAX at 801-538-3829, or by Internet E-mail at email@example.com. For questions about the rulemaking process, please contact the Office of Administrative Rules.