New Mexico Administrative Code › Title 7 - HEALTH › Chapter 1 - HEALTH GENERAL PROVISIONS › Part 31 - STATEWIDE HEALTH CARE CLAIMS DATABASE › Section 7.1.31.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
"Allowed
				amount"
means the negotiated amount eligible for payment for a health
				care service or item rendered by a provider.
B.
"Billed amount"
means the
				amount billed by a provider requesting payment for health care services or
				items rendered.
C.
"Claim"
means a financial accounting of or a request for payment
				for health care items or services rendered by a provider.
D.
"Data"
means the data
				required by this rule to be submitted to this database, including data on the
				following health factors: mortality and natality, including accidental causes
				of death; morbidity; health behavior; disability; health system costs,
				availability, utilization and revenues; environmental factors; health
				personnel; demographic factors; social, cultural and economic conditions
				affecting health, including language preference; family status; medical and
				practice outcomes as measured by nationally accepted standards and quality of
				care; and participation in clinical research trials.
E.
"Data provider"
means a
				person that possesses health information, including any public or private
				sector licensed health care practitioner, primary care clinic, ambulatory
				surgery center, ambulatory urgent care center, ambulatory dialysis unit, home
				health agency, long-term care facility, hospital, pharmacy, third-party payer
				and any public entity that has health information.
F.
"Database"
means the
				statewide all-payer health care claims database established in this
				rule.
G.
"Department"
means the department of health.
H.
"Direct patient identifier"
means a data variable that identifies
				an individual, including: names; telephone numbers; fax numbers; social
				security number; medical record numbers; health plan beneficiary numbers;
				account numbers; certificate or license numbers; vehicle identifiers and serial
				numbers, including license plate numbers; device identifiers and serial
				numbers; web universal resource locators; internet protocol address numbers;
				biometric identifiers, including finger and voice prints; elements of dates
				more granular than a year; un-aggregated ages over 89; geographic subdivisions
				smaller than the state, except the first three digits of ZIP, full face
				photographic images and any comparable images; and any other unique identifying
				number, characteristic, or code, except as permitted by
				45
				C.F.R 164.514(c).
I.
"ERISA plan"
means an
				employee welfare benefit plan to the extent that the plan provides medical care
				to employees or their dependents under the Employee Retirement Income Security
				Act of 1974 directly or through insurance, reimbursement or other
				means.
J.
"Health
				information"
or
"health data"
means any data relating to
				health care; health status, including environmental, social and economic
				factors; a health system or provider; health costs, financing, and including
				data that would customarily be collected in the ordinary course of business for
				the data provider; annual audited financial statements customarily prepared by
				a data provider; information on major capital expenditures; data established by
				regulation to be collected to carry out the requirements of the Health
				Information System Act; data required to be collected by other state or federal
				laws; and annual surveys or collection of data may be used as an alternative to
				collection of health data from some health service providers to the extent it
				can be shown that the information collected will meet validity and quality
				standards.
K.
"Health
				information system"
or
"HIS"
means the health information
				system established by the Health Information System Act, Sections
				24-14A-1
				to
				24-14A-10,
				NMSA 1978.
L.
"Health
				insurance carrier"
means any entity that offers the following:
(1) group health and dental coverage governed
				by the provisions of the Health Care Purchasing Act;
(2) individual health and dental insurance
				policies, health benefits plans and certificates of insurance governed by the
				provisions of Chapter 59A, Article 22 NMSA 1978;
(3) health and dental multiple-employer
				welfare arrangements governed by the provisions of Section
				59A-15-20
				NMSA 1978;
(4) group and blanket
				health and dental insurance policies, health benefits plans and certificates of
				insurance governed by the provisions of Chapter 59A, Article 23 NMSA
				1978;
(5) individual and group
				health and dental health maintenance organization contracts governed by the
				provisions of the Health Maintenance Organization Law Chapter 59A, Article 46
				NMSA 1978; and
(6) individual and
				group health and dental nonprofit health benefits plans governed by the
				provisions of the Nonprofit Health Care Plan Law Chapter 59A, Article 47 NMSA
				1978.