Arkansas Administrative Code › Agency 054 - Arkansas Insurance Department › Rule 054.00.15-002 - Rule 100: Arkansas Healthcare Transparency Initiative Standards

Current through Register Vol. 49, No. 6, June, 2024
Section 1.
Authority
This Rule is issued pursuant to Act 1233 of 2015 of the Arkansas
			 90 General Assembly, also known as the "Arkansas Healthcare Transparency
			 Initiative Act of 2015" (hereafter "Healthcare Transparency Initiative Act" or
			 "Act"). Pursuant to Act 1233 of 2015, which became effective upon signature by
			 the Governor of the State of Arkansas on April 8, 2015, the Arkansas Insurance
			 Department ("AID") is authorized to issue Rules to implement provisions of the
			 Healthcare Transparency Initiative Act. In addition, this Rule is issued
			 pursuant to Ark. Code Ann. §
								23-61-108(b)(1)
			 which states that the Arkansas Insurance Commissioner ("Commissioner") has
			 authority to promulgate rules and regulations necessary for the effective
			 regulation of the business of insurance.
Section 2.
Purpose
The purpose of the this Rule is to establish the guidelines for
			 submission of medical, dental, and pharmaceutical claims, unique identifiers
			 and geographic and demographic information for covered individuals, and
			 provider files to the Arkansas Healthcare Transparency Initiative for the
			 purpose of creating and maintaining a multi-payer claims database as a source
			 of healthcare information to support consumers, researchers, and policy makers
			 in healthcare decisions within the state. The Rule is intended to create and
			 maintain an informative source of healthcare information to support consumers,
			 researchers and policymakers in healthcare decisions within the state and
			 empower Arkansans to drive, deliver, and seek out value in the healthcare
			 system.
Section 3.
Applicability & Scope
This Rule applies to all submitting entities as defined in
			 Section 4 of this Rule unless otherwise exempted pursuant to Section 5.C of
			 this Rule.
Section 4.
Definitions
The following definitions shall apply in this Rule:
(1) "Administrator" means the Arkansas Center
		  for Health Improvement;
(2) "AID"
		  means the Arkansas Insurance Department;
(3) "All-payer claims database" or "APCD"
		  means the database created and maintained by the Arkansas Healthcare
		  Transparency Initiative, including the ongoing all-payer claims database
		  project funded through the Arkansas Insurance Department, that receives and
		  stores data from submitting entities;
(4) "APCD Council" means a federation of
		  government, private, non-profit, and academic organizations focused on
		  improving the development and deployment of state-based APCDs;
(5) "Arkansas Healthcare Transparency
		  Initiative" or "Initiative" means the initiative established pursuant to Act
		  1233 of 2015 to create and maintain a database, including the ongoing all-payer
		  claims database project funded through the Arkansas Insurance Department, that
		  receives and stores data from submitting entities;
(6) "Arkansas Healthcare Transparency
		  Initiative Board" or "Initiative Board" means the advisory board established
		  under Act 1233 of 2015;
(7)
		  "Arkansas resident" means an individual for whom a submitting entity has
		  identified an Arkansas address as the individual's primary place of residence.
		  For individuals covered by a student health plan, Arkansas resident" means any
		  student enrolled in a student plan for an Arkansas college or university
		  regardless of his or her address of record;
(8) "Commissioner" means the person in charge
		  of the Arkansas Insurance Department;
(9) "Covered individual" means a natural
		  person who is an Arkansas resident and is eligible to receive medical, dental,
		  or pharmaceutical benefits under any policy, contract, certificate, evidence of
		  coverage, rider, binder, or endorsement that provides for or describes
		  coverage;
(10) "Data" means
		  information consisting of, or derived directly from enrollment files, medical
		  claims files, dental claims files, pharmacy claims files, provider files and
		  validation reports;
(11) "Data set"
		  means a collection of individual data records and data elements that comprises
		  the file types for an enrollment file, medical claims file, dental claims
		  files, pharmacy claims file, and a provider file submitted quarterly, and in
		  the format outlined in the DSG.
(12) "Data Submission Guide" or "DSG" means a
		  document approved by the Commissioner in consultation with the Initiative
		  Board, that sets forth the required data file format, data elements, code
		  tables, edit specifications, thresholds required for a submission to be deemed
		  complete, methods for submitting data, validation reports, exception processes,
		  adjustment files, and other information associated with the submitting
		  entities' reporting duties;
(13)
		  "Dental claims file" means, as further defined in the DSG, a data file that
		  contains service level remittance information for all paid and denied claims
		  for each billed dental service for covered individuals including without
		  limitation unique identifiers, geographic and demographic information but not
		  direct personal identifiers; provider information and services rendered to a
		  covered individual; charge/payment information; and clinical
		  diagnosis/procedure codes. Claims and benefits not subject to this Rule will
		  not be included in a dental claims file. The term may exclude certain data that
		  is prohibited to release according to state or federal law;
(14) "Direct personal identifiers" means
		  information relating to a covered individual that contains primary or obvious
		  identifiers, such as the individual's name, street address, e-mail address,
		  telephone number, and Social Security number. "Direct personal identifiers"
		  does not include geographic or demographic information that would not allow the
		  identification of a covered individual;
(15) "Enrollment file" means unique
		  identifiers, demographic and geographic information relating to covered
		  individuals;
(16) "HIPAA" means the
		  Health Insurance Portability and Accountability Act,
		  42
		  U.S.C. Section 1320d-
		  1320d-8
		  and its implementing regulations, 45 C.F.R. Parts 160, 162 and 164, as may be
		  amended;
(17) "Historical data"
		  means a one-time data submission following submission of a test file and for a
		  period commencing on January 1, 2013 and ending according to the data
		  submission schedule in this Rule;
(18) "Medical claims file" means, as further
		  defined in the DSG, a data file that contains service level remittance
		  information for all paid and denied claims for each billed medical service for
		  covered individuals including without limitation unique identifiers, geographic
		  and demographic information but not personal identifiers; provider information
		  and services rendered to a covered individual; charge/payment information; and
		  clinical diagnosis/procedure codes. Claims and benefits not subject to this
		  Rule will not be included in a medical claims file. The term may exclude
		  certain data that is prohibited to release according to state or federal
		  law;
(19) "Pharmacy claims file"
		  means a data file containing service level remittance information from all paid
		  and denied claims for each prescription for covered individuals including
		  without limitation unique identifiers, geographic and demographic information
		  but not personal identifiers; provider information; charge/payment information;
		  and national drug codes. The term may exclude certain data that is prohibited
		  to release according to state or federal law;
(20) "Provider file" means a data file that
		  includes additional information as set forth in the DSG about the providers
		  that are included in a medical claims file, dental claims file, or pharmacy
		  claims file;
(21) "Submitting
		  entity" means an entity that is subject to this Rule and its data reporting
		  requirements;
a. "Submitting entity" includes
		  the following entities:
i. an entity that
		  provides health or dental insurance or a health or dental benefit plan in the
		  state, including without limitation an insurance company, medical services
		  plan, hospital plan, hospital medical service corporation, health maintenance
		  organization, or fraternal benefits society, provided that the entity has
		  covered individuals and the entity had at least two thousand (2,000) covered
		  individuals as of December 31 in the previous calendar year;
ii. a health benefit plan offered or
		  administered by or on behalf of the state or an agency or instrumentality of
		  the state;
iii. a health benefit
		  plan offered or administered by or on behalf of the federal government with the
		  agreement of the federal government;
iv. the Arkansas Workers' Compensation
		  Commission;
v. any other entity
		  providing a plan of health insurance or medical, dental, or pharmaceutical
		  benefits subject to state insurance regulation, a third-party administrator, or
		  a pharmacy benefits manager, provided that the entity has covered individuals
		  and the entity had at least two thousand (2,000) covered individuals as of
		  December 31 in the previous calendar year; and
vi. an entity that contracts with
		  institutions of the Department of Correction or Department of Community
		  Correction to provide medical, dental, or pharmaceutical care to inmates;
vii. A health benefit plan subject
		  to the Employee Retirement Income Security Act of 1974,
		  Pub. L. No.
		  93-406 ("ERISA");
b. "Submitting entity" does not include an
		  entity that provides health insurance or a health benefit plan that is
		  accident-only, specified disease, hospital indemnity and other fixed indemnity,
		  long-term care, disability income, Medicare supplement, or other supplemental
		  benefit coverage from which benefit payments are directly to the covered
		  individual;
c. In instances where
		  more than one submitting entity is involved in the administration of a policy,
		  the payer shall be responsible for submitting the claims data on policies that
		  it has written or sold as a bundle, provided however that in instances where
		  more than one submitting entity is involved in the administration of a policy,
		  those entities will work together to use the same unique identifier for a
		  covered individual across separate feeds for medical, prescription, and other
		  claims; and
d. If a "submitting
		  entity" contracts with another entity to provide subcontracted claims
		  processing services, the entity which contracts directly with the customer
		  shall be the submitting entity for purposes of this Rule;
(22) "Test file" means a data file, as
		  further defined by the DSG, that includes a sample of service level remittance
		  information for billed medical or dental services or prescriptions for covered
		  individuals;
(23) "Unique
		  identifier" means, as further defined in the DSG, an identifier that is
		  guaranteed to be unique among all identifiers for covered individuals but does
		  not include direct personal identifiers;
(24) "Validation report" means, as further
		  defined in the DSG, a report from the submitting entity that provides
		  aggregated information about a quarterly data submission to provide control
		  totals and record counts.