Oregon Administrative Rules › Chapter 409 - OREGON HEALTH AUTHORITY, HEALTH POLICY AND ANALYTICS › Division 25 - ALL PAYER ALL CLAIMS DATA REPORTING PROGRAM › Section 409-025-0100 - Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
The following definitions apply to OAR 409-025-0100  to
				409-025-0190:
(1) "Accident policy"
			 means an insurance policy that provides benefits only for a loss due to
			 accidental bodily injury.
(2)
			 "Allowed amount" means the actual amount of charges for healthcare services,
			 equipment, or supplies that are covered expenses under the terms of an
			 insurance policy or health benefits plan.
(3) "APAC" means all payer all
			 claims.
(4) "Association" means any
			 organization, including a labor union, that has an active existence for at
			 least one year, that has a constitution and bylaws and that has been organized
			 and is maintained in good faith primarily for purposes other than that of
			 obtaining insurance.
(5) "Attending
			 provider" means the individual health care provider who delivered the health
			 care services, equipment, or supplies specified on a health care
			 claim.
(6) "Authority" means the
			 Oregon Health Authority.
(7)
			 "Billing provider" means the individual or entity that submits claims for
			 health care services, equipment, or supplies delivered by an attending
			 provider.
(8) "Capitated services"
			 means services rendered by a provider through a contract in which payments are
			 based upon a fixed monthly dollar amount for each enrollee.
(9) "Carrier" shall have the meaning given
			 that term in ORS 743B.005.
(10)
			 "Certificate of authority" shall have the meaning given that term in ORS
			 731.072.
(11) "Charges" means the
			 actual dollar amount charged on the claim.
(12) "Claim" means an encounter or request
			 for payment under the terms of an insurance policy, health benefits plan,
			 Medicare, or Medicaid.
(13)
			 "Coinsurance" means the percentage an enrollee pays toward the cost of a
			 covered service.
(14) "Control
			 totals file" means a data set containing summary information on medical,
			 pharmacy and dental claims, members, providers, and premiums used to validate
			 the detailed files submitted.
(15)
			 "Coordinated Care Organization (CCO)" shall have the meaning given that term in
			 ORS 414.025.
(16) "Copayment" means
			 the fixed dollar amount an enrollee 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.
(17)
			 "Data file" means electronic health information including medical claims files,
			 enrollment files, medical provider files, pharmacy claims files, dental claims
			 files, control totals files, subscriber-billed premiums files, payment
			 arrangement files and any other related information specified in these
			 rules.
(18) "Data set" means a
			 collection of individual data records, whether in electronic or manual
			 files.
(19) "Data vendor" means the
			 entity under contract with the Authority to administer in whole or in part the
			 all payer all claims database and related functions.
(20) "DCBS" means the Oregon Department of
			 Consumer and Business Services.
(21) "Deductible" means the total dollar
			 amount an enrollee pays toward the cost of covered services over an established
			 period before the carrier or third-party administrator makes any payments under
			 an insurance policy or health benefit plan.
(22) "De-identified health information" means
			 health information that does not identify an individual and with respect to
			 which there is no reasonable basis to believe that the information can be used
			 to identify an individual.
(23)
			 "Dental claims file" means a data set comprised of dental health care service
			 level remittance information for all adjudicated claims for each billed service
			 including but not limited to provider information, charge and payment
			 information, and clinical diagnosis and procedure codes for an Oregon resident
			 as defined in ORS 803.355 or a non-resident who is a member of a PEBB or OEBB
			 group health insurance plan.
(24)
			 "Direct personal identifier" means information relating to an individual
			 patient or enrollee that contains primary or obvious identifiers, including:
(a) Names;
(b) Business names when that name would serve
			 to identify a person;
(c) Postal
			 address information other than town or city, state, and 5-digit zip
			 code;
(d) Specific latitude and
			 longitude or other geographic information that would be used to derive postal
			 address;
(e) Telephone and fax
			 numbers;
(f) Electronic mail
			 addresses;
(g) Social security
			 numbers;
(h) Vehicle identifiers
			 and serial numbers, including license plate numbers;
(i) Medical record numbers;
(j) Health plan beneficiary
			 numbers;
(k) Certificate and
			 license numbers;
(l) Internet
			 protocol (IP) addresses and uniform resource locators (URL) that identify a
			 business that would serve to identify a person;
(m) Biometric identifiers, including finger
			 and voice prints; and
(n) Personal
			 photographic images.