R428-2-3. Definitions

  (1) The terms used in this rule are defined in Section 26-33a-102.

  (2) In addition, the following definitions apply to all of Title R428:

  (a) "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.

  (b) "Ambulatory surgery data" means the consolidation of complete billing, medical, and personal information describing a patient, the services received, and charges billed for a surgical or diagnostic procedure treatment in an outpatient setting into a data record.

  (c) "Ambulatory surgical facility" is defined in Section 26-21-2.

  (d) "Carrier" means any of the following Third Party Payors as defined in 26-33a-102(16):

  (i) an insurer engaged in the business of health care or dental insurance in the state of Utah, as defined in Section 31A-1-301;

  (ii) a business under an administrative services organization or administrative services contract arrangement;

  (iii) a third party administrator, as defined in Section 31A-1-301, 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 Section 31A-1-301;

  (iv) a governmental plan, as defined in Section 414 (d), Internal Revenue Code, that provides health care benefits;

  (v) a program funded or administered by Utah for the provision of health care services, including Medicaid, the Utah Children's Health Insurance Program created under Section 26-40-103, and the medical assistance programs described in Title 26, Chapter 18 or any entity under a contract with the Utah Department of Health to serve clients under such a program;

  (vi) a non-electing church plan, as described in Section 410 (d), Internal Revenue Code, that provides health care benefits;

  (vii) a licensed professional employer organization as defined in Section 31a-40-102 acting as an administrator of a health care insurance plan;

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

  (ix) the Public Employees' Benefit and Insurance Program created in Section 49-20-103;

  (x) a pharmacy benefit manager, defined to be a person that provides pharmacy benefit management services as defined in Section 49-20-502 on behalf of any other carrier defined in subsection R428-2-3.

  (e) "Claim" means a request or demand on a carrier for payment of a benefit.

  (f) "Covered period" means the calendar year on which the data used for calculation of HEDIS measures is based.

  (g) "Data element" means the specific information collected and recorded for the purpose of health care and health service delivery. Data elements include information to identify the individual, health care provider, data supplier, service provided, charge for service, payer source, medical diagnosis, and medical treatment.

  (h) "Discharge data" means the consolidation of complete billing, medical, and personal information describing a patient, the services received, and charges billed for a single inpatient hospital stay into a discharge data record.

  (i) "Electronic media" means a compact disc, digital video disc, external hard drive, or other media where data is stored in digital form.

  (j) "Electronic transaction" means to submit data directly via electronic connection from a hospital or ambulatory surgery facility to the Office according to Electronic Data Interchange standards established by the American National Standards Institute's Accredited Standards Committee, known as the Health Care Transaction Set (837) ASC X 12N.

  (k) "Eligible Enrollee" means an enrollee who meets the criteria outlined in the NCQA survey specifications.

  (l) "Emergency Room Data" means the consolidation of complete billing, medical, and personal information describing a patient, the services received, and charges billed for a single visit and treatment of a patient in an emergency room into an emergency room data record.

  (m) "Enrollee" means any individual who has entered into a contract with a carrier for health care or on whose behalf such an arrangement has been made.

  (n) "Health Insurance" has the same meaning as found in Section 31A-1-301.

  (o) "Healthcare 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.

  (p) "Healthcare Facility" means a hospital or ambulatory surgical facility.

  (q) "Healthcare Facility Data" means ambulatory surgery data, discharge data, or emergency room data.

  (r) "HEDIS" means the Healthcare Effectiveness Data and Information Set, a set of standardized performance measures developed by the NCQA.

  (s) "HEDIS data" means the complete set of HEDIS measures calculated by the carriers according to NCQA specifications, including a set of required measures and voluntary measures defined by the department, in consultation with the carriers.

  (t) "Hospital" means a general acute hospital or specialty hospital as defined in Section 21-21-2 that is licensed under Rule R432.

  (u) "Level 1 data element" means a required reportable data element.

  (v) "Level 2 data element" means a data element that is reported when the information is available from the patient's hospital record.

  (w) "NCQA" means the National Committee for Quality Assurance, a not-for-profit organization committed to evaluating and reporting on the quality of managed care plans.

  (x) "Office" means the Office of Health Care Statistics within the Utah Department of Health.

  (y) "Order" means an action of the committee that determines the legal rights, duties, privileges, immunities, or other interests of one or more specific persons, but not a class of persons.

  (z) "Patient Social Security number" is the social security number of a person receiving health care.

  (aa) "Performance Measure" means the quantitative, numerical measure of an aspect of the carrier, or its membership in part or in its entirety, or qualitative, descriptive information on the carrier in its entirety as described in HEDIS.

  (bb) "Public Use Data Set" means a data extract or a subset of a database that is deemed by the Office to not include identifiable data or where the probability of identifying individuals is minimal.

  (cc) "Report" means a disclosure of data or information collected or produced by the committee or Office, including but not limited to a compilation, study, or analysis designed to meet the needs of specific audiences.

  (dd) "Research and Statistical Purposes" means having the objective of creating knowledge or answering questions, including a systematic investigation that includes development, testing, and evaluation; the description, estimation, projection, or analysis of the characteristics of individuals, groups, or organizations; an analysis of the relationships between or among these characteristics; the identification or creation of sampling frames and the selection of samples; the preparation and publication of reports describing these matters; and the development, implementation, and maintenance of methods, procedures, or resources to support the efficient use or management of the data.

  (ee) "Research Data Set" means a data extract or subset of a database intended for use by investigators or researchers for bona fide research purposes that may include identifiable information or where there is more than a minimal probability that the data could be used to identify individuals.

  (ff) "Record linkage number" is an irreversible, unique, encrypted number that will replace patient social security number.

  (gg) "Sample file" means the data file containing records of selected eligible enrollees drawn by the survey agency from the carrier's sampling frame.

  (hh) "Sampling Frame" means the carrier enrollment file as described criteria outlined by the NCQA survey specifications.

  (ii) "Submission year" means the year immediately following the covered period.

  (jj) "Survey agency" means an independent contractor on contract with the Office of Health Care Statistics.

  (kk) "Utah Health Care Performance Measurement Plan" means the plan for data collection and public reporting of health-related measures, adopted by the Utah Health Data Committee to establish a statewide health performance reporting system.

  (ll) "Uniform billing form" means the uniform billing form recommended for use by the National Uniform Billing Committee.

  (mm) "Utah Healthcare Facility Data Submission Guide" means the document referenced in Subsection R428-1-4(1).

  (nn) "NCQA Survey Specifications" means the document referenced in Subsection R428-1-4(2)

  (oo) "NCQA HEDIS Specifications" means the document referenced in Subsection R428-1-4(3)

  (pp) "Data Submission Guide for Claims Data" means the document referenced in Subsection R428-1-4(4).