No. 40179 (Amendment): Rule R428-15. Health Data Authority Health Insurance Claims Reporting

(Amendment)

DAR File No.: 40179
Filed: 02/01/2016 09:45:39 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This amendment is in response to several reviews of Rule R428-15 that identified inconsistencies in the writing of the rule.

Summary of the rule or change:

This amendment removes Section R428-15-4, "Carrier Registration", as similar reference resides in Rule R428-2; removes Section R428-15-7, "Replacement of Data Files", to reflect current practice; and renumbers sections where needed.

State statutory or constitutional authorization for this rule:

• Title 26, Chapter 33a

Anticipated cost or savings to:

the state budget:

This amendment makes changes that improve the consistency and clarity of Rule R428-15. The Utah Department of Health (UDOH) determines enactment of the amended version does create any cost or savings impact to the state budget or UDOH's budget, since the change does not increase workload and can be carried out with existing budget.

local governments:

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.

small businesses:

None--Small businesses are not impacted by this rule change since all potentially impacted businesses have 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:

Proposed rule changes 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 do not impact affected persons.

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

There is no fiscal impact on business because technical changes do not add compliance costs to affected businesses.

Joseph Miner, MD, 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 [e-mail]
• Stephanie Saperstein at the above address, by phone at 801-538-6430, by FAX at , or by Internet E-mail at [e-mail]

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:

03/16/2016

This rule may become effective on:

03/23/2016

Authorized by:

Joseph Miner, Executive Director

RULE TEXT

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 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. 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 within 30 days of being required to submit.]

 

R428-15- 4 [5]. 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 [6]. 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.

 

[R428-15-7. 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.]

 

R428-15- 6 [8]. 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: [August 5, 2014]2016

Notice of Continuation: October 10, 2014

Authorizing, and Implemented or Interpreted Law: 26-33a; 26-25

 

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