R590-262-2. Purpose and Scope

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

  (2) This rule allows the data to be shared with the state's designated secure health information master index person index, Clinical Health Information Exchange (cHIE), to be used:

  (a) in compliance with data security standards established by:

  (i) the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, 110 Stat. 1936: and

  (ii) the electronic commerce agreements established in a business associate agreement;

  (b) for the purpose of coordination of health benefit plans; and

  (c) for the enrollment data elements identified in Utah Administrative Rule R428-15, Health Data Authority Health Insurance Claims Reporting.

  (3)(a) This rule applies to an insurer offering:

  (i) a health benefit plan; or

  (ii) a dental plan.

  (b) This rule does not apply to:

  (i) an insurer that as of the first day of the reporting period:

  (A) covers fewer than 2,500 individual Utah residents; or

  (B) provides administrative services for fewer than 2,500 individual Utah residents covered under self-funded employee plans;

  (ii) a fully insured employer group or self-funded employee plan whose primary place of business is outside the state of Utah and no more than 25% of the employees are residents of Utah;

  (iii) a long-term care insurance policy; or

  (iv) an income replacement policy.

  (c) Except as provided in Subsection (4), this rule does not require a person to provide information concerning a self-funded employee plan.

  (4)(a) The submission of health care claims data by an insurer on behalf of a self-funded employee plan is considered mandatory if and only if the self-funded employee plan opts-in under R590-262-7.

  (b) An insurer is not obligated to submit data on behalf of a self-funded employee plan that fails to respond to opt-in requests required in R590-262-7.