Utah Administrative Code

The Utah Administrative Code is the body of all effective administrative rules as compiled and organized by the Division of Administrative Rules (see Subsection 63G-3-102(5); see also Sections 63G-3-701 and 702).

NOTE: For a list of rules that have been made effective since January 1, 2020, please see the codification segue page.

NOTE TO RULEFILING AGENCIES: Use the RTF version for submitting rule changes.

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

Rule R428-13. Health Data Authority. Audit and Reporting of Health Plan Performance Measures.

As in effect on January 1, 2020

Table of Contents

R428-13-1. Legal Authority.

This rule is promulgated under authority granted by Title 26, Chapter 33a, Utah Code, and in accordance with the Utah Health Care Performance Measurement Plan.

R428-13-2. Purpose.

This rule establishes the process for the collection of HEDIS data from Utah carriers that are needed to promote informed consumer choice in plan selection and measure the quality of care provided to enrollees of Utah carriers.

R428-13-3. Submission of Performance Measures.

(1) Each carrier shall compile and submit HEDIS data for the preceding calendar year to the Office by July 1 of each year.

(2) By January 1 of each year, each carrier shall submit to the Office a plan for creating and providing HEDIS data for the preceding calendar year.

(3) Each carrier shall contract with an independent audit agency certified by the NCQA to verify the HEDIS data using NCQA HEDIS specifications prior to submitting data to the Office.

(4) Each carrier may employ the rotation strategy for HEDIS measures developed and updated by NCQA.

(5) If a carrier presents "Not Reported (NR)" for required measures, it must document why it did not report the required measure.

(6) Each carrier shall cause its contracted audit agency to submit a copy of the audit agency's final report by August 15 of the submission year to the Office. The final report shall incorporate the carrier's comments.

R428-13-4. Exemptions.

(1) Notwithstanding the requirements in Subsection R428-2-11(2), a carrier that cannot comply with the requirements of this rule must request an exemption by January 1 of the relevant submission year.

(2) A carrier may request an exemption from this rule if the carrier did not operate in Utah for the reporting year, if the number of covered lives is too low for HEDIS standards, or for other similarly prohibitive circumstances beyond the carrier's control.


health, health planning, health policy

Date of Enactment or Last Substantive Amendment

March 25, 2016

Notice of Continuation

September 19, 2017

Authorizing, Implemented, or Interpreted Law


Additional Information


For questions regarding the content or application of rules under Title R428, please contact the promulgating agency (Health, Center for Health Data, Health Care Statistics). A list of agencies with links to their homepages is available at http://www.utah.gov/government/agencylist.html or from http://www.rules.utah.gov/contact/agencycontacts.htm.