No. 38144 (Amendment): Rule R428-15. Health Data Authority Health Insurance Claims Reporting

(Amendment)

DAR File No.: 38144
Filed: 11/15/2013 11:15:28 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this amendment is to incorporate by reference the technical specification documents (current and revised) and simplify applicable sections where necessary. Procedures outlining how carriers can submit exemptions and extensions have been added. Several references to statutes have been updated for accuracy purposes. New deadlines have been added to the "Testing of Files" section.

Summary of the rule or change:

New rule sections and corrections provide more clarity to Rule R428-15. Edits reflect a change in business practice for the All Payer Claims Database. Technical specifications are now incorporated by reference.

State statutory or constitutional authorization for this rule:

• Title 26, Chapter 33a

This rule or change incorporates by reference the following material:

• Adds Technical Specifications and Data Submission Procedures for the State of Utah All Payer Database Version 1.3, published by Utah Department of Health, Health Data Committee, 09/13/2009
• Adds Utah All-Payer Claims Database Data Submission Guide Version 2.0, published by Utah Department of Health, Health Data Committee, 11/12/2013

Anticipated cost or savings to:

the state budget:

This rule amendment clarifies the extension and extension process, incorporates by reference both data submittal manuals (current and revised), as well as makes technical changes for consistency. 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.

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, 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:

Moving away from the required 837 submissions for medical claims may reduce processing burden on data submitters and thereby achieve cost savings. These changes to Rule R428-15 are needed to support important health care reform initiatives in Utah. Overall cost to the health carrier industry, specifically to those currently required to comply with Rule R428-15, will total approximately $2,376,000 (24 carriers x $99,000). See individual information in the "Compliance costs for affected persons.

Compliance costs for affected persons:

This rule amendment includes the addition of a new Data Submittal Guide enforced as of 05/15/2014. Data submitters will need to comply with this Guide by developing and implementing changes to their data systems. This will increase the submitter's budget and workload, depending on how many modifications need to be made for compliance. One-time costs are estimated to be between $74,250 to $123,750 per data submitter to comply with changes to Rule R428-15, which may not include all necessary staff. This range is based on an estimated amount of $99,000 per submitter for two and 3/4 FTEs at $132,000, working approximately six months per Utah DTS guidelines. Once the submitter makes these changes, there should be no additional ongoing costs above those incurred before the transition.

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

I approve of Rule R432-15 for publication. The impact on the affected businesses is substantial but necessary for the successful operation of the All Payer Claims Database and will benefit those businesses over time.

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 [e-mail]
• Rex Olsen at the above address, by phone at 801-538-9498, by FAX at 801-536-0940, 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:

12/31/2013

Interested persons may attend a public hearing regarding this rule:

• 12/09/2013 09:30 AM, Utah Department of Health, Cannon Health Building, 288 N 1460 W, Room 125, Salt Lake City, UT

This rule may become effective on:

01/07/2014

Authorized by:

David Patton, 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 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. Definitions.

These definitions apply to rule R428-15, in addition:

(1) "Committee" means the Utah Health Data Committee as defined in 26-33a-102.

([1]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.

([2]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[(74)], including a business under an administrative services organization or administrative services contract arrangement;

(b) a third party administrator, as defined in 31A-1-301[(159)], 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 31A-1-301; [(148)]

(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[ or health benefit plan funded by a self-insurance arrangement];[ or]

(f) a health benefit plan funded by a self-insurance arrangement; or

([f]g) a dental stand-alone company as defined in 31A-8-101[(6)].

([3]4) "Claim" means a request or demand on a carrier for payment of a benefit.

([4]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 carrier's benefit.

([5]7) "Health Insurance" has the same meaning as found in Subsection 31A-1-301.

([6]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[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].

 

R428-15-4. Reporting Requirements.

(1) Each carrier shall submit health care claims data described in the technical specifications for each covered person[enrollment, medical claims, and pharmacy data described in R428-15-6] where Utah is the covered person's[patient's] primary residence, regardless of where the services are provided[ and enrollment, medical claims, and pharmacy data for services provided out of state to Utah residents].

(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[begin submitting the required data to the office no later than October 17, 2009. The initial data submission must be completed by November 15, 2009. The initial data submission shall be for claims incurred from January 1, 2007 through December 31, 2008 and which are paid through September 30, 2009. Thereafter, each carrier shall submit monthly health care claims data. Each] monthly basis[submission is due no later than the last day of the following month].

(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[ 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 Secure].

 

R428-15-6. [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 carrier shall submit data for all fields contained in the submission specifications if the data are available to the carrier.

(a) Each carrier must submit enrollment files as a flat file.

(b) Each carrier 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 carrier must submit pharmacy claims as a flat file.

(2) Enrollment Files. Each carrier must submit the following data elements for each enrollment file:

(a) Record Type

(b) Transaction Code

(c) File Create Date

(d) Member ID

(e) Social Security Number

(f) Member's Relationship to Subscriber

(g) Last Name

(h) First Name

(i) Middle Name

(j) Sex

(k) Street

(l) City

(m) State

(n) Zip Code

(o) Primary Phone

(p) Birth date

(q) Race

(r) Ethnicity

(s) Primary/Secondary

(t) Designated Primary Care Physician

(u) PCP ID

(v) Healthplan Code

(w) Benefit Option Code

(x) Option Effective Date

(y) HP Termination Date

(z) Employer Group Code

(aa) Patient ID

(bb) Health Plan Description

(cc) Orig. HP Effective Date

(dd) Member Status.

(3) Professional Medical Claims. Each carrier must submit the following data elements for each professional medical claim:

(a) Data Element - Data Element Description

(b) BHT06 - BHT Beginning of Hierarchical Trans

(c) GS08 - Functional Group Header

(d) GS07 - Functional Group Header

(e) Submitter Information

(i) 1000A NM103 - Submitter Name

(ii) 1000A NM109 - Submitter Identifier

(iii) 1000A PER01-05 - Submitter EDI Contact Information

(f) 1000B NM103 - Receiver Name

(g) 1000B NM109 - Receiver Identifier

(h) Billing Provider

(i) 2010AA NM103 - Billing Provider Name

(ii) 2010AA NM109 - Billing Provider ID

(iii) 2010AA REF02 - Billing Provider Secondary ID

(i) 2000B SBR02 - Individual Relationship Code

(j) 2000B SBR03 - Insured Group or Policy Number

(k) 2010BB NM103 - Payer Name

(l) Subscriber Information

(i) 2010BA NM103 - Subscriber Lname

(ii) 2010BA NM104 - Subscriber Fname

(iii) 2010BA NM105 - Subscriber Middle Name

(iv) 2010BA NM109 - Subscriber Primary Identifier

(v) 2010BA N301 - Subscriber Address1

(vi) 2010BA N302 - Subscriber Address2

(vii) 2010BA N401 - Subscriber City Name

(viii) 2010BA N402 - Subscriber State

(ix) 2010BA N403 - Subscriber Zip Code

(x) 2010BA DMG20 - Subscriber Date of Birth

(xi) 2010BA DMG03 - Subscriber Sex

(xii) 2010BA REF01 - Subscriber Secondary ID Qualifier

(xiii) 2010BA REF02 - Subscriber Secondary ID

(m) Patient Information

(i) 2000C PAT01 - Patients Relationship to Insured

(ii) 2010CA NM103 - Patient Lname

(iii) 2010CA NM104 - Patient Fname

(iv) 2010CA NM105 - Patient Middle Name

(v) 2010CA NM109 - Patient Primary Identifier

(vi) 2010BA/2010CA N301 - Patient Address1

(vii) 2010CA N302 - Patient Address2

(viii) 2010CA N401 - Patient City Name

(ix) 2010CA N402 - Patient State

(x) 2010CA N403 - Patient Zip Code

(xi) 2010CA DMG02 - Patient Date of Birth

(xii) 2010CA DMG03 - Patient Sex

(xiii) 2010CA REF01 - Patient Secondary ID Qualifier

(xiv) 2010CA REF02 - Patient Secondary ID

(n) 2300 CLM05-1 - Facility Type Code

(o) 2300 CLM05-3 - Claim Frequency Type Code

(p) 2300 REF02 When REF01 = F8 - Original Reference Number

(q) 2300 CLM01 - Patient Account Number

(r) 2300 REF02 When REF01 = EA - Medical Record Number

(s) 2300 CLM02 - Total Claim Charge Amount

(t) 2300 AMT02 When AMT01 = F5 - Patient Paid Amount

(u) 2320 AMT02 When AMT01 = D - COB Payer Paid Amount

(v) 2310D NM103 - Service Facility Name

(w) 2310D NM109 - Service Facility ID Code

(x) 2330B DTP03 When DTP01 = 573 - Claim Adjudication Date

(y) 2320 AMT02 When AMT01 = B6 - COB Allowed Amount

(z) Claim Adjustment Information

(i) 2320 CAS01 - Claim Adjustment Group Code

(ii) 2320 CAS02 - Claim Adjustment Reason Code

(iii) 2320 CAS03 - Claim Level Adjustment Amount

(aa) 2310D NM109 - Laboratory or Facility Primary Identifier

(bb) Diagnosis Information

(i) 2300 HI01 -2 - Principal Diagnosis

(ii) 2300 HI02 -2

(iii) 2300 HI03 -2

(iv) 2300 HI04 -2

(v) 2300 HI05

(vi) 2300 HI06 -2

(vii) 2300 HI07 -2

(viii) 2300 HI08 -2

(ix) 2300 HI09 -2

(x) 2300 HI10

(xi) 2300 HI11 -2

(xii) 2300 HI12 -2

(cc) 2310B PRV03 or 2000A - Rendering Provider Specialty

(dd) Rendering Provider Information

(i) 2310B NM103 - Rendering Provider LName

(ii) 2310B NM104 - Rendering Provider FName

(iii) 2310B NM105 - Rendering Provider Name Middle

(iv) 2310B NM107 - Rendering Provider Name Suffix

(v) 2310B NM109 - Rendering Provider Primary Identifier

(vi) 2310B REF02 - Rendering Provider Secondary ID

(ee) 2400 LX01 - Line Counter

(ff) 2400 DTP03 WHEN DTP01 = 472 - Date(s) of Service

(gg) Provider Modifiers

(i) 2400 SV101-2

(ii) 2400 SV101-3

(iii) 2400 SV101-4

(iv) 2400 SV101-5

(v) 2400 SV101-6

(hh) 2400 SV104 - Days or Units

(ii) 2400 SV102 - Line Item Charge Amount

(jj) 2400 AMT02 - Allowed Amount

(kk) 2410 LIN03 - Drug Identification

(ll) 2410 REF02 When REF01 = XZ - Prescription Number

(mm) Drug Information

(i) 2410 CTP05-1 - Drug Units Qualifier

(ii) 2410 CTP04 - Drug Number of Units

(iii) 2410 CTP03 - Drug Cost or Unit Price

(nn) Line Adjustment Codes

(i) 2430 CAS01 - Line Adjustment Group Code

(ii) 2430 CAS02 - Line Adjustment Reason Code

(iii) 2430 CAS03 - Line Level Adjustment Amount.

(4) Institutional Medical Claims. Each carrier must submit the following data elements for each institutional medical claim:

(a) BHT01 BHT06 - Hierarchical Structure Code

(b) GS08 - Functional Group Header

(c) GS01 - Functional Group Header

(d) Submitter Information

(i) 1000A NM103 - Submitter Name

(ii) 1000A NM109 - Submitter Identifier

(iii) 1000A PER01-05 - Submitter EDI Contact Information

(e) 1000B NM103 - Receiver Name

(f) 1000B NM109 - Receiver Identifier

(g) Billing Provider Information

(i) 2010AA NM103 - Billing Provider Name

(ii) 2010AA NM109 - Billing Provider ID

(iii) 2010AA REF02 - Billing Provider Secondary ID

(h) 2000B SBR02 - Individual Relationship Code

(i) 2000B SBR03 - Insured Group or Policy Number

(j) 2010BC NM103 - Payer Name

(k) Subscriber Information

(i) 2010BA NM103 - Subscriber Lname

(ii) 2010BA NM104 - Subscriber Fname

(iii) 2010BA NM105 - Subscriber Middle Name

(iv) 2010BA NM109 - Subscriber Primary Identifier

(v) 2010BA N301 - Subscriber Address1

(vi) 2010BA N302 - Subscriber Address2

(vii) 2010BA N401 - Subscriber City Name

(viii) 2010BA N402 - Subscriber State

(ix) 2010BA N403 - Subscriber Zip Code

(x) 2010BA DMG02 - Subscriber Date of Birth

(xi) 2010BA DMG03 - Subscriber Sex

(xii) 2010BA REF01 - Subscriber Secondary ID Qualifier

(xiii) 2010BA REF02 - Subscriber Secondary Identification

(l) Patient Information

(i) 2000C PAT01 - Patients Relationship to Insured

(ii) 2010CA NM103 - Patient Lname

(iii) 2010CA NM104 - Patient Fname

(iv) 2010CA NM105 - Patient Middle Name

(v) 2010CA NM109 - Patient Primary Identifier

(vi) 2010BA/2010CA N301 - Patient Address1

(vii) 2010CA N302 - Patient Address2

(viii) 2010CA N401 - Patient City Name

(ix) 2010CA N402 - Patient State

(x) 2010CA N403 - Patient Zip Code

(xi) 2010CA DMG02 - Patient Date of Birth

(xii) 2010CA DMG03 - Patient Sex

(xiii) 2010CA REF01 - Patient Secondary ID Qualifier

(xiv) 2010CA REF02 - Patient Secondary Identification

(m) 2300 CLM05-1 - Facility Type Code

(n) 2300 CLM05-3 - Claim Frequency Type Code

(o) 2300 REF02 When REF01 = F8 - Original Reference Number

(p) 2300 DTP03 When DTP01 = 435 - Admission Date/Hour

(q) Institutional Claim Code Information

(i) 2300 CL101 - Institutional Claim Code Admit Type

(ii) 2300 CL102 -Institutional Claim Code Admit Source

(iii) 2300 CL103 - Institutional Claim Code Pt Status

(r) 2300 HI01-2 When HI01-1 = DR - Diagnosis Related Group (DRG)

(s) 2300 DTP03 when DTP01 = 434 - Statement Date

(t) 2300 DTP03 WHEN DTP01 = 096 - Discharge Date

(u) 2300 DTP03 When DTP01 = 096 - Discharge Hour

(v) 2300 CLM01 - Patient Account Number

(w) 2300 REF02 When REF01 = EA - Medical Record Number

(x) 2300 CLM02 - Total Claim Charge Amount

(y) 2300 AMT02 When AMT01 = F5 - Patient Paid Amount

(z) 2320 AMT02 WHEN AMT01 = C4 - Payer Prior Payment

(aa) 2310E NM103 - Service Facility Name

(bb) 2310E NM109 - Service Facility ID Code

(cc) 2330B DTP03 WHEN DTP01 = 573 - Claim Adjudication Date

(dd) 2320 AMT02 When AMT01 = B6 - COB Total Allowed Amount

(ee) Claim Adjustment Information

(i) 2320 CAS01 - Claim Adjustment Group Code

(ii) 2320 CAS02 - Claim Adjustment Reason Code

(iii) 2320 CAS03 - Claim Level Adjustment Amount

(ff) 2310E NM109 - Laboratory or Facility Primary ID

(gg) Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information PAT

(i) 2300 HI02-2 When HI02-1-ZZ - Reason for Visit 1

(ii) 2300 HI02-2 When HI02-1-ZZ - Reason for Visit 2

(iii) 2300 HI02-2 When HI02-1-ZZ - Reason for Visit 3

(hh) 2300 K3 - Present on Admission Indicator

(ii) Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information Admitting DX

(i) 2300 HI02-2 When HI02-1 = BJ

(ii) 2300 HI01-2 When HI01-1 = BK

(jj) Other Diagnosis Information

(i) 2300 HI01-2 When HI01-1 = BF

(ii) 2300 HI02-2 When HI02-1 = BF

(iii) 2300 HI03-2 When HI03-1 = BF

(iv) 2300 HI04-2 When HI04-1 = BF

(v) 2300 HI05-2 When HI05-1 = BF

(vi) 2300 HI06-2 When HI06-1 = BF

(vii) 2300 HI07-2 When HI07-1 = BF

(viii) 2300 HI08-2 When HI08-1 = BF

(ix) 2300 HI09-2 When HI09-1 = BF

(x) 2300 HI10-2 When HI10-1 = BF

(xi) 2300 HI11-2 When HI11-1 = BF

(xii) 2300 HI12-2 When HI12-1 = BF

(kk) Principal, Admitting, E-Code and Patient Reason for Visit Diagnosis Information

(i) 2300 HI03-2 When HI03-1 = BN E-Code 1

(ii) 2300 HI03-2 When HI03-1 = BN E-Code 2

(iii) 2300 HI03-2 When HI03-1 = BN E-Code 3

(ll) 2300 HI01-2 When HI01-1 = BR Principal Procedure Code Principal Procedure

(mm) 2300 HI01-4 When HI01-1 = BR Principal Procedure Date

(nn) Other Procedure Codes and Dates

(i) 2300 HI01-2 When HI01-1 = BQ Other Procedure Code

(ii) 2300 HI01-4 When HI01-1 = BQ Other Procedure Date

(iii) 2300 HI02-2 When HI02-1 = BQ Other Procedure Code

(iv) 2300 HI02-4 When HI02-1 = BQ Other Procedure Date

(v) 2300 HI03-2 When HI03-1 = BQ Other Procedure Code

(vi) 2300 HI03-4 When HI03-1 = BQ Other Procedure Date

(vii) 2300 HI04-2 When HI04-1 = BQ Other Procedure Code

(viii) 2300 HI04-4 When HI04-1 = BQ Other Procedure Date

(ix) 2300 HI05-2 When HI05-1 = BQ Other Procedure Code

(x) 2300 HI05-4 When HI05-1 = BQ Other Procedure Date

(oo) Attending Physician Information

(i) 2000A or 2310A PRV03 - Attending Physician Specialty Information

(ii) 2310A NM103 - Attending Physician LName

(iii) 2310A NM104 - Attending Physician FName

(iv) 2310A NM105 - Attending Physician Name Middle

(v) 2310A NM107 - Attending Physician Name Suffix

(vi) 2310A NM109 - Attending Physician Primary ID

(vii) 2310A REF02 - Attending Physician Secondary ID

(pp) 2400 LX01 - Line Counter

(qq) 2400 DTP03 When DTP01 = 472 Date(s) of Service

(rr) Institutional Service Line Codes

(i) 2400 SV202-2 - Institutional Service Line Product/Service ID

(ii) 2400 SV202-3 - Institutional Service Line Procedure Modifier - 1

(iii) 2400 SV202-4 - Institutional Service Line Procedure Modifier - 2

(iv) 2400 SV202-5 - Institutional Service Line Procedure Modifier - 3

(v) 2400 SV202-6 - Institutional Service Line Procedure Modifier - 4

(vi) 2400 SV201 - Institutional Service Line (Revenue Codes)

(ss) 2400 SV205 - Service Units

(tt) 2400 SV203 - Line Item Charge Amount

(uu) Drug Information

(i) 2410 LIN03 - Drug Identification

(ii) 2410 REF02 when REF01 = XZ - Prescription Number

(iii) 2410 CTP05-1 - Drug Units Qualifier

(iv) 2410 CTP04 - Drug Number of Units

(v) 2410 CTP03 - Drug Cost or Unit Price

(vv) Line Adjustment Codes

(i) 2430 CAS01 - Line Adjustment Group Code

(ii) 2430 CAS02 - Line Level Adjustment Reason Code

(iii) 2430 CAS03 - Line Level Adjustment Amount.

(5) Pharmacy claims. Each carrier must submit the following data elements for each pharmacy claim:

(a) Payer Name

(b) Insured Group or Policy Number

(c) Subscriber Information

(i) Subscriber Last Name

(ii) Subscriber First Name

(iii) Subscriber Middle Name

(iv) Subscriber Primary Identifier

(v) Subscriber Address

(vi) Subscriber Address 2

(vii) Subscriber City

(viii) Subscriber State

(ix) Subscriber Zipcode

(x) Subscriber Phone

(xi) Subscriber Date of Birth

(xii) Subscriber Sex

(xiii) Subscriber Secondary Identification Qualifier

(xiv) Subscriber Secondary Identification

(d) Patient Information

(i) Patients Relationship to Insured

(ii) Patient Last name

(iii) Patient First name

(iv) Patient Middle Name

(v) Patient Primary Identifier

(vi) Patient Address

(vii) Patient Address 2

(viii) Patient City

(ix) Patient State

(x) Patient ZipCode

(xi) Patient Phone

(xii) Patient Date of Birth

(xiii) Patient Sex

(xiv) Patient Secondary Identification Qualifier

(xv) Patient Secondary Identification

(e) RxClaimNo

(f) RxClaimNoCrossRef

(g) RxNo

(h) PBMMebID

(i) RXClaimTxnType

(j) RxType

(k) RxClaimXrefNo

(l) RxAdjType

(m) SubscriberSfx

(n) Prescriber Information

(i) RxPrescriberID

(ii) RxPrescriberNoType

(iii) RxPrescriberName

(o) RxPharmacyNo

(p) MembMcareSTatus

(q) RxWrittenDt

(r) RxFilledDt

(s) Reject Codes

(i) Reject Code 1

(ii) Reject Code 2

(iii) Reject Code 3

(iv) Reject Code 4

(v) Reject Code 5

(t) RxPaidDt

(u) RxTotalPdAmt

(v) PatientPaidAmount

(w) RxQualifier

(x) RxID

(y) RxNDC

(z) RxTradeNm

(aa) RxGenericNm

(bb) GCNNumber

(cc) GPINumber

(dd) UnitsOfMeasure

(ee) UnitDoseIndicator

(ff) DispensingStatus

(gg) QuantityIntended

(hh) RxMtrcFilQty

(ii) RxDaysSupplyNo

(jj) DrugStrength

(kk) DosageDescription

(ll) CompoundIndicator

(mm) RxNoRefills

(nn) RxRefillNo

(oo) RxDAWCode

(pp) Therapeutic ClassCode - AHFS

(qq) USC Code

(rr) DEA Class of Drug

(ss) Drug Class

(tt) Drug Category Code

(uu) RxBrandInd

(vv) RecordDateTimeStamp.

 

R428-15-7.] Extensions and Exemptions.

[A carrier that covers fewer than 2,500 individual Utah residents is exempt from all requirements of this rule.

](1) A carrier that covers fewer than 2,500 individual Utah residents is exempt from all requirements of this rule.

(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 compliance.

(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 question.

(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 shall include:

(a) The carrier's name, mailing address, telephone number, and contact person;

(b) the dates the exemption or extension is to start and end;

(c) a description of the relief sought, including reference to specific sections or language of the requirement;

(d) a statement of facts, reasons, or legal authority in support of the request; and

(e) a proposed alternative to the requirement or deadline.

(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-[8]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.

 

R428-15-[9]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.[ Each carrier shall register by September 21, 2009 and annually thereafter by September 1 of each year.]

 

R428-15-[10]9. Testing of Files.

(1) Prior to February[October] 14[5], 20 14[09], each carrier required to report under this rule shall meet with[submit to] the Office or its designee to establish a data submission testing plan and time line[a dataset for determining compliance with the standards for data submission]. Each carrier shall contact the Office to arrange this meeting by January 15, 2014[This test dataset must be in the same format as required by the technical specifications document and shall contain data for any month within 2007 or 2008].

(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, 2014.[Each carrier must meet with the Office prior to the carrier's initial data submission to review individual submission formatting. The carrier must contact the Office to arrange this meeting by September 30, 2009.]

(3) Carriers that become subject to this rule after January 15[September 21], 2014[09] 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.

 

R428-15-1[1]0. 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 carrier must submit for each enrolled member and claim.] 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.

 

R428-15-1[2]1. 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.

 

R428-15-1[3]2. 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.

 

R428-15-1[4]3. 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 violation

(2) Each day of violation is a separate violation.

 

KEY: APCD, [all] payers[database], claims [health care quality], transparency

Date of Enactment or Last Substantive Amendment: [March 16, 2012]2014

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

 

---