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 August 1, 2019, 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 R428-15. Health Data Authority Health Insurance Claims Reporting.

As in effect on August 1, 2019

Table of Contents

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 Rule R428-1.

R428-15-2. Purpose.

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

R428-15-3. Reporting Requirements.

(1) Each carrier shall submit health care claims data described in the Data Submission Guide for Claims Data 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 Data Submission Guide for Claims Data 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.

R428-15-4. 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 Data Submission Guide for Claims Data as of May 15, 2014.

(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.

R428-15-5. 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.

R428-15-6. Limitation of Liability.

As provided in Section 26-25-1, any data supplier that submits data pursuant to this rule cannot be held liable for having provided the required information to the Department.

KEY

data, payers, claims, transparency

Date of Enactment or Last Substantive Amendment

March 25, 2016

Notice of Continuation

October 10, 2014

Authorizing, Implemented, or Interpreted Law

26-33a; 26-25


Additional Information

Contact

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.