New Mexico Administrative Code › Title 7 - HEALTH › Chapter 1 - HEALTH GENERAL PROVISIONS › Part 21 - DATA REPORTING REQUIREMENTS FOR HEALTH PLANS › Section 7.1.21.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
In addition to the definitions in the health information
				  system Act, Section
				  24-14A-1
				  et seq. NMSA 1978, the following definitions apply for purposes of this
				  rule:
A.
Consumer health
				information report
means a report that provides the public with
				information on which to base health care purchasing decisions, published by the
				commission pursuant to Sections
				24-14A-3
				D(11) and
				24-14A-3.1D(2)
				of the Health Information System Act, Section
				24-14A-1
				et seq. NMSA 1978, and 7 NMAC 1.22 [now 7.1.22 NMAC].
B.
Director
means the director
				of the commission
C.
Health
				care
means any care, treatment, service or procedure to maintain,
				diagnose or otherwise affect an individual's physical or mental
				condition.
D.
Health care
				professional
means any individual licensed, certified or otherwise
				authorized or permitted by law to provide health care in the practice of a
				profession.
E.
Health care
				provider
means any individual, corporation, partnership, organization,
				facility, institution or other entity licensed, certified or otherwise
				authorized or permitted by law to provide health care in the ordinary course of
				business or practice of a profession.
F.
Health information system
or
HIS
means the health information system established by the Health
				Information System Act, Section
				24-14A-1
				et seq. NMSA 1978.
G.
Health
				plan report
means the document or electronic submission required by this
				rule to be submitted annually to the commission, containing the HEDIS®
				reporting set and additional core performance measures required by the
				commission. ®NCQA registered trademark.
H.
Health plan reporting period
means the calendar year in which a reporting health plan delivers the services
				included in the health plan report. To illustrate, the 1996 reporting period is
				for services delivered in 1996.
I.
HEDIS
means the Health Plan Employer Data and Information set
				published by the national committee for quality assurance (NCQA).
J.
HEDIS data elements
means the
				rate, numerator, denominator, size of the eligible population and data
				collection methodology for non-tabular measures that are reported as
				percentages and are contained in HEDIS.
K.
HEDIS reporting set
means the
				full set of measures designated by the national committee for Quality Assurance
				as reporting measures in the current version of HEDIS.
L.
HEDIS reporting version
means
				the version of HEDIS published by the national committee for quality assurance
				applicable to the same reporting period designated by the national committee
				for quality assurance as the health plan reporting period defined in this
				rule.
M.
HEDIS
				specifications
means the specifications contained in the latest version
				or technical update of HEDIS applicable to the health plan reporting period,
				which may include separate reports for service populations and product types,
				such as health maintenance organization products, point of service products,
				preferred provider organization products, medicare risk products, and medicaid
				managed care products.
N.
HIS
				advisory committee
means the committee the commission establishes
				pursuant to Section
				24-14A-3.1
				of the Health Information System Act, Section
				24-14A-1
				et seq. NMSA 1978.
O.
Managed
				health care plan
means a health benefit plan offered by a health care
				insurer that provides for the delivery of comprehensive basic health care
				services and medically necessary services to individuals enrolled in such plans
				through its own employed health care professionals or by contracting with
				selected or participating health care providers that conform to explicit
				selection standards, or both, and which either requires a covered person to
				use, or creates incentives, including financial incentives, for a covered
				person to use, health care providers managed, employed by, or under contract
				with the managed health care plan or health care insurer.
P.
Outcome measures
means
				changes in patient health status and satisfaction resulting from specific
				medical and health interventions, as distinguished from the effects of other
				factors that influence patient health and satisfaction.
Q.
Patient
means a person for
				whom health information is contained in the health information
				system.
R.
Performance
				measures
include, but are not limited to, quality indicators, outcome
				measures and health care service information.
S.
Proprietary information
means
				confidential technical information, administrative information, and/or business
				methods that are the property of the reporting health plan and are perceived to
				confer a competitive position in the health care market by not being openly
				known by competitors.
T.
Quality compassSM
means a national
				database maintained and disseminated by the NCQA which includes plan-specific
				comparative and descriptive information on managed health care plan
				performance.
U.
Quality
				indicator
means a standardized and nationally or professionally
				recognized measure of a discrete element or aspect of health care useful for
				the purpose of monitoring quality of care.
V.
Quality of care
means the
				degree to which health services for individuals and populations increase the
				likelihood of desired health outcomes or are consistent with current
				professional knowledge. The provision of health services should reflect
				appropriate use of the most current knowledge about scientific, clinical,
				technical, interpersonal, manual, cognitive, and organizational and management
				elements of health care.
W.
Reporting health plan
means a health care insurer that:
(1) is required to obtain a certificate of
				authority or licensure in New Mexico;
(2) has a total premium volume in excess of
				$5,000,000 in the year prior to the health plan reporting period; and
(3) offered one or more managed health care
				plans in New Mexico during the health plan reporting period.