Hawaii Administrative Rules › Title 11 - DEPARTMENT OF HEALTH › Subtitle 1 - GENERAL DEPARTMENTAL PROVISIONS › Chapter 188 - SUBMISSION OF ADMINISTRATIVE DATA TO THE STATE HEALTH PLANNING AND DEVELOPMENT AGENCY › Subchapter 1 - GENERAL PROVISIONS › Section 11-188-2 - Definitions

Current through June, 2024
As used in this chapter, unless a different meaning clearly
					 appears in the context:
"Administrative data" or "data" means:
(1) Statistical and financial reports of
				  information;
(2) Provider invoices
				  or similar patient encounter data;
(3) Records of services used for or resulting
				  from administering delivery of health care, pharmacy benefits, or dental care,
				  including health care claims data, records of services provided under health
				  benefits plans as defined in section
				  87A-1, HRS;
				  and
(4) Any other records as
				  established pursuant to administrative rules adopted pursuant to chapter
				  91, HRS.
"Administrator" means the administrator of the state health
					 planning and development agency.
"Agency" means the state health planning and development
					 agency as established in section
					 323D-11,
					 HRS.
"Annual plan" means the plan developed by the agency
					 pursuant to section
					 323D-18.5,
					 HRS. "Carrier" means any of the following:
(1) An insurer engaged in the business of
				  health care or dental insurance in the State;
(2) A business under an administrative
				  services organization or administrative services contract
				  arrangement;
(3) A third party
				  administrator, licensed by the State, that collects premiums or settles claims
				  of residents of the State, for health care insurance policies or health benefit
				  plans;
(4) A governmental plan, as
				  defined in section 414(d), Internal Revenue Code, that provides health care
				  benefits;
(5) A program funded or
				  administered by the State for the provision of health care services, including
				  medicaid;
(6) A licensed
				  professional employer organization acting as an administrator of a health care
				  insurance plan;
(7) A health
				  benefit plan funded by a self-insurance arrangement;
(8) The public employees' benefit and
				  insurance program or EUTF; or
(9) A
				  pharmacy benefit manager, defined to be a person that provides pharmacy benefit
				  management services on behalf of any other carrier.
"Cell size" means the count of persons that share a set of
					 characteristics contained in a statistical cell or table.
"Data element" means the specific information collected and
					 recorded for the purpose of health care and health service delivery. Data
					 elements include, but are not limited to information to identify the
					 individual, health care provider, data supplier, service provided, charge for
					 service, payer source, medical diagnosis, and medical treatment.
"Data sharing agreement" means an agreement between a data
					 submitter and the agency that governs the- provision and use of data by the
					 agency.
"Data submission guide" means the document referenced in
					 section 11-188-11 for data submissions to the agency or the agency's
					 designee.
"De-identified test database" means the database composed
					 of de-identified test data for use by authorized individuals to test analytic
					 algorithms and statistical methods.
"Dental claims file" means a data file composed of dental
					 service level remittance information for all non-denied adjudicated claims for
					 each billed dental service, including but not limited to member demographics,
					 provider information, care and payment information, and clinical diagnosis and
					 procedure codes.
"Designee" or "designees" means a governmental or nonprofit
					 entity with which the agency has entered into an agreement pursuant to section
					 323D-18.5,
					 HRS, to perform, on behalf of the agency, data collection and management, data
					 analysis, reporting, and administrative functions. The pacific health
					 informatics and data center is the agency's designee.
"Direct personal identifiers" means health care claims data
					 relating to an individual patient, member, or enrollee that contains primary,
					 distinct, or recognizable identifiers, including but not limited to: names;
					 date of birth; business names when that name would serve to identify a person;
					 postal address information other than town or city, state, and five-digit zip
					 code; specific latitude and longitude or other geographic information that
					 would be used to derive a postal address; telephone and fax numbers; electronic
					 mail addresses; social security numbers; vehicle identifiers and serial
					 numbers, including but not limited to license plate numbers; medical record
					 numbers; health plan beneficiary numbers; certificate and license numbers;
					 internet protocol addresses and uniform resource locators that identify a
					 business that would serve to identify a person; and personal photographic
					 images.
"Disclosure" or "disclose" means the release, transfer,
					 provision of access to, or divulging in any other manner of information outside
					 the entity holding the information.
"Employer-union health benefits trust fund" or "EUTF" means
					 the Hawaii employer-union health benefits trust fund established under chapter
					 87A, HRS.
"Encrypted record identifier" means a code or other means
					 of record identification to allow patients, members, or enrollees to be tracked
					 across the data without revealing their identity or personal health. Encrypted
					 identifiers are not direct personal identifiers.
"Encryption" or "encrypted" means the use of an algorithmic
					 process to transform data into a form in which the data is rendered unreadable
					 or unusable without the use of a confidential process or key as defined in
					 section
					 487N-1, HRS.
"Health benefit plan" or "health benefits plan" means a
					 policy, contract, certificate, or agreement entered into or offered by a
					 provider of health insurance to provide, deliver, arrange for, pay for, or
					 reimburse any of the costs of health care services, as defined in section
					 87A-1, HRS.
"Health care claims data" means any information consisting
					 of, or derived directly from, member eligibility data, medical claims, pharmacy
					 claims, dental claims, vision claims, and other data submitted by reporters to
					 the agency or the agency's designee.
"Health care provider" means a health care facility,
					 physician licensed under chapter
					 453,HRS, dentist licensed under
					 chapter
					 448,HRS, chiropractor licensed under
					 chapter
					 442,HRS, optometrist licensed under
					 chapter 459,HRS, podiatrist licensed under chapter
					 463E,HRS, psychologist licensed
					 under chapter
					 465,HRS, occupational therapist
					 subject to chapter 457G,HRS, physical therapist licensed under chapter
					 461J,HRS, or any person,
					 partnership, corporation, facility, or institution licensed, certified, or
					 authorized by law to provide professional health care services in the State to
					 an individual during that individual's medical care, treatment, or
					 confinement.
"Health insurance" means insurance against bodily injury,
					 disablement, or death by accident, or accidental means, or the expense thereof;
					 against disablement or expense resulting from sickness; and every insurance
					 appertaining thereto.
"Individually identifiable health information" means
					 information that is a subset of health information, including demographic
					 information collected from an individual; and that:
(1) Is created or received by a health care
				  provider, health plan, employer, or health care clearinghouse; and
(2) Relates to the past, present, or future
				  physical or mental health or condition of an individual; the provision of
				  health care to an individual; or the past, present, or future payment for the
				  provision of health care to an individual; and:
(A) That identifies an individual;
				  or
(B) With respect to which there
				  is a reasonable basis to believe that the information can be used to identify
				  the individual.
"Mandatory reporter" means providers of health insurance
					 that provide health benefit plans funded by the Hawaii employer-union health
					 benefits trust fund and the state medicaid agency, which are required under
					 section
					 323D-18.5,
					 HRS, to submit data to the agency or the agency's designee.
"Medical claims file" means a data file composed of medical
					 service level remittance information for all non-denied adjudicated claims for
					 each billed service including but not limited to member demographics, provider
					 information, care and payment information, and clinical diagnosis and procedure
					 codes, and shall include all claims related to medical, vision, and behavioral
					 health.
"Med-QUEST" means the Hawaii state medicaid agency
					 established to administer the medicaid program.
"Member" means the insured subscriber and any spouse or
					 dependent covered by the subscriber's policy. The member is the subject of the
					 activities of the claim or claim line performed by the health care
					 provider.
"Member eligibility file" means a data file containing
					 demographic information for each individual member eligible for medical,
					 vision, dental,-or pharmacy benefits for one or more days of coverage at any
					 time during the reporting period.
"Pacific health informatics and data center" means the data
					 center program of the University of Hawaii telecommunications and social
					 informatics research program of the social science research institute of the
					 college of social sciences of the University of Hawaii at Manoa.
"Personally identifiable information" means information
					 relating to an individual that contains direct or indirect identifiers for
					 which a reasonable basis exists to believe that the information can be used to
					 identify an individual.
"Pharmacy benefit manager" means any person, business, or
					 entity that performs pharmacy benefit management, including but not limited to
					 a person or entity under contract with a pharmacy benefit manager to perform
					 pharmacy benefit management on behalf of a managed care company, nonprofit
					 hospital or medical service organization, insurance company, third-party payer,
					 or health program administered by the State, pursuant to section
					 431R-1, HRS.
"Pharmacy claims file" means a data file containing service
					 level remittance information from all non-denied adjudicated claims for each
					 prescription, including but not limited to member demographics, provider
					 information, charge and payment information, and national drug codes.
"Protected health information" means individually
					 identifiable health information: