Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS › Section 590-243-1 - Definitions

Current through 2024-29, July 17, 2024
Unless the context indicates otherwise, the following words
				  and phrases shall have the following meanings:
A.
Billing Provider
. "Billing
				provider" means a provider or other entity that submits claims to health care
				claims processors for health care services directly performed or provided to a
				subscriber or member by a service provider.
B.
Capitated Services
.
				"Capitated services" means services rendered by a provider through a contract
				where payments are based upon a fixed dollar amount for each member
				monthly.
C.
Carrier
.
				"Carrier" means an insurance company licensed in accordance with 24-A M.R.S.,
				including a health maintenance organization, a multiple employer welfare
				arrangement licensed pursuant to Title 24-A, Chapter 81, a preferred provider
				organization, a fraternal benefit society, or a nonprofit hospital or medical
				service organization or health plan licensed pursuant to 24 M.R.S. An employer
				exempted from the applicability of 24-A M.R.S., Chapter 56-A under the federal
Employee Retirement Income Security Act of 1974
, 29
United States Code
, Sections 1001 to 1461 (1988) ("ERISA") is
				not considered a carrier.
D.
Co-Insurance
. "Co-insurance" means the dollar amount a member pays
				as a pre-determined percentage of the cost of a covered service after the
				deductible has been paid.
E.
Co-Payment
. "Co-payment" means the fixed dollar amount a member
				pays to a health care provider at the time a covered service is provided or the
				full cost of a service when that is less than the fixed dollar
				amount.
F.
Deductible
.
				"Deductible" means the total dollar amount a member pays towards the cost of
				covered services over an established period before any payments are made by the
				contracted third-party payor.
G.
Dental Claims File
. "Dental claims file" means a data file
				composed of service level remittance information including, but not limited to,
				member demographics, provider information, charge/payment information, and
				current dental terminology codes from all non-denied adjudicated claims for
				each billed service.
H.
Designee.
"Designee" means an entity with which the MHDO has
				entered into an arrangement under which the entity performs data collection,
				validation and management functions for the MHDO and is strictly prohibited
				from releasing information obtained in such a capacity.
I.
Health Care Claims Processor.
"Health care claims processor" means a third-party payor, third-party
				administrator, Medicare health plan sponsor, or pharmacy benefits
				manager.
J.
Hospital
.
				"Hospital" means any acute care institution required to be licensed pursuant to
			 	22 M.R.S., Chapter 405.
K.
MBI
. "MBI" means the Center for Medicare and Medicaid Services
				Medicare Beneficiary Identifier.
L.
Medical Claims File
. "Medical claims file" means a data file
				composed of service level remittance information including, but not limited to,
				member demographics, provider information, charge/payment information, and
				clinical diagnosis/procedure codes from all nondenied adjudicated claims for
				each billed service.
M.
Medicare Health Plan Sponsor
. "Medicare health plan sponsor" means
				a health insurance carrier or other private company authorized by the United
				States Department of Health and Human Services, Centers for Medicare and
				Medicaid Services to administer Medicare Part C and Part D benefits under a
				health plan or prescription drug plan.
N.
Member
. "Member" includes the
				subscriber and any spouse or dependent who is covered by the subscriber's
				policy.
O.
Member Eligibility
				File
. "Member eligibility file" means a data file composed of
				demographic information for each individual member eligible for medical,
				pharmacy, or dental insurance benefits for one or more days of coverage any
				time during the reporting month.
P.
MHDO
. "MHDO" means the Maine Health Data Organization.
Q.
M.R.S.
"M.R.S." means
Maine Revised Statutes
.
R.
Non-hospital Provider
.
				"Non-hospital provider" means any provider of health care services other than a
				hospital.
S.
Pharmacy
.
				"Pharmacy" means a drug outlet licensed under 32 M.R.S., Chapter 117.
T.
Pharmacy Benefits Manager
.
				"Pharmacy benefits manager" means an entity that performs pharmacy benefits
				management as defined in  24-A M.R.S. §4347, sub-section 17.
U.
Pharmacy Benefits Manager
				Compensation.
"Pharmacy benefits manager compensation" means the
				difference between:
i. the value of payments
				made by a carrier to its pharmacy benefits manager; and
ii. the value of payments made by the
				pharmacy benefits manager to dispensing pharmacies for the provision of
				prescription drugs or pharmacy services with regard to pharmacy benefits
				covered by the carrier.