Rhode Island Code of Regulations › Title 216 - Department of health › Chapter 10 - Public Health Administration › Subchapter 10 - Registries › Part 5 - Rhode Island All-Payer Claims Database › Section 216-RICR-10-10-5.2 - Definitions

Current through June 14, 2024
A. Wherever used in this Part, the following
				  terms shall be construed as follows:
1.
				  "Alternative payment model (APM) file" means a data file composed of payments
				  made to providers outside of the traditional fee-for-service (FFS) model. For
				  example, alternative payment models may include, but are not limited to, pay
				  for performance/penalty, shared savings/shared risk, global budget, limited
				  budget, and capitation. Alternative payment models may also include FFS
				  payments which are settled or reconciled under a certain alternative payment
				  model category. The APM file also includes all payments made to providers under
				  the traditional FFS model. In accordance with R.I. Gen. Laws §
											23-17.17-9(e),
				  the APM file shall not include trade secrets as defined in R.I. Gen. Laws
				  §
											6-41-1(4).
2. "Applicant" means an individual or
				  organization that requests health care claims data set and information in
				  accordance with the procedures and requirements instituted by the Department
				  pursuant to this Part.
3. "Data
				  aggregator" means a vendor selected by the Director that has a contract to act
				  on behalf of the Department to collect and process health care claims data on
				  behalf of the Director.
4.
				  "Department" means the Rhode Island Department of Health.
5. "Dental claims file" means a data file
				  composed of service-level remittance information for all submitted and
				  non-denied adjudicated claims for each billed dental service, including but not
				  limited to Member Encrypted Unique Identifier, provider information,
				  charge/payment information, and dental procedure codes.
6. "Director" means the Director of the
				  Department of Health or his or her duly authorized designee.
7. "Direct personal identifier" means any
				  information, as to a Member, other than case or code numbers used to create
				  anonymous or encrypted data, that plainly discloses the identity of an
				  individual, including:
a. Names;
b. Street addresses (other than town or city,
				  State and five (5) digit ZIP code);
c. Telephone numbers;
d. Fax numbers;
e. Electronic mail addresses;
f. Social Security numbers;
g. Medical record numbers;
h. Health plan beneficiary numbers;
i. Patient account numbers;
j. Certificate license numbers;
k. Vehicle identifiers and serial numbers,
				  including license plate numbers;
l.
				  Device identifiers and serial numbers;
m. Uniform resource locators (URL);
n. Personal Internet protocol (IP)
				  addresses;
o. Biometric
				  identifiers, including finger and voice prints; and
p. Full face photographs (or comparable
				  images).
8. "Disclosure"
				  means the release, transfer, provision of access to, or divulging in any other
				  manner of information outside the entity holding the information.
9. "Encrypted unique identifier" means a code
				  or other means of record identification to allow each Patient, Member or
				  enrollee to be tracked across the data set, including across payers and over
				  time, without revealing Direct Personal Identifiers. Encrypted Unique
				  Identifiers are assigned to each Patient, Member or enrollee in order that all
				  Direct Personal Identifiers can be removed from the data when data is
				  submitted. Using the Encrypted Unique Identifier, all records relating to a
				  Patient, Member or enrollee can be linked for analytical, public reporting and
				  research purposes without identifying the Patient, Member or
				  enrollee.
10. "Encrypted unique
				  identifier vendor" means a vendor selected and approved by the Director to
				  collect demographic data only from Insurers, assign an Encrypted Unique
				  Identifier to each Patient, Member, or enrollee, and transmit that identifier
				  to the Insurer.
11. "Hashing" means
				  a one (1) way method by which the true value of data has been transformed
				  (through the conversion of the information into an unrecognizable string of
				  characters) in order to prevent the identification of persons or groups. True
				  value of hashed elements is deliberately non-recoverable by any recipient,
				  including the Data Aggregator.
12.
				  "Health benefit plan" means a policy, contract, certificate or agreement
				  entered into, or offered by an Insurer to provide, deliver, arrange for, pay
				  for or reimburse any of the costs of health care services.
13. "Health care claims data set" means a
				  collection of individual claims-based data files, including Dental Claims File,
				  Medical Claims Files, Pharmacy Claims Files, Member Eligibility Files and
				  Provider Files, whether in electronic or manual form.
14. "Health care facility" means the same
				  meaning as contained in R.I. Gen. Laws Chapter 23-17 and the Regulations
				  promulgated pursuant to that Chapter.
15. "Health care provider" means any person
				  or entity licensed to provide or lawfully providing health care services,
				  including, but not limited to, a physician, hospital, intermediate care
				  facility or other Health Care Facility, dentist, nurse, optometrist,
				  podiatrist, physical therapist, psychiatric social worker, pharmacist or
				  psychologist, and any officer, employee, or agent of that provider acting in
				  the course and scope of his or her employment or agency related to or
				  supportive of health care services.
16. "HIPAA" means the Health Insurance
				  Portability and Accountability Act of 1996, as amended, and its implementing
				  Regulations (45 C.F.R. Parts 160 through 164).
17. "Insurer" means any entity subject to the
				  insurance laws and Regulations of Rhode Island, that contracts or offers to
				  contract to provide, deliver, arrange for, pay for, or reimburse any of the
				  costs of health care services and/or dental services, including, without
				  limitation, an insurance company offering accident and sickness insurance, a
				  health maintenance organization, as defined by R.I. Gen. Laws §
											27-41-1, a
				  nonprofit hospital or medical service corporation, as defined by R.I. Gen. Laws
				  Chapters 27-19 and 27-20, or any other entity providing a plan of health
				  insurance or health benefits. For the purpose of this Part, a third
				  (3rd) party Payer, third
				  (3rd) party Administrator, Pharmacy Benefits Manager
				  or Medicare or Medicaid health plan sponsor is also deemed to be an
				  Insurer.
18. "Medical claims file"
				  means all submitted and non-denied adjudicated claims for each billed service
				  paid by an Insurer as defined in §
											5.2(A)(16)
				    of this Part on behalf of a Member as defined in §
											5.2(A)(18)
				    of this Part regardless of where the service was provided. This data file
				  includes but is not limited to service level remittance information including,
				  but not limited to, Member Encrypted Unique Identifier, provider information,
				  charge/payment information, and clinical diagnosis/procedure codes as described
				  further in the RIAPCD Technical Specification Manual.
19. "Member" means a Rhode Island resident
				  who is a Subscriber and any spouse or dependent who is covered by the
				  Subscriber's policy under contract with an Insurer. The term also includes
				  Members of a small employer health insurance plan as defined by R.I. Gen Laws
				  §
											27-50-3 regardless of the State of residency of the Member.
20. "Member eligibility file" means a data
				  file composed of demographic information for each individual Member eligible
				  for medical or pharmacy benefits as specified in the RIAPCD Technical
				  Specification Manual, for one (1) or more days of coverage at any time during
				  the reporting month.
21. "Patient"
				  means any person in the data set that is the subject of the activities of the
				  claim submitted to and/or paid by the Insurer or covered by the health benefits
				  plan.
22. "Personal health
				  information" means information, as to a Member, about health status or
				  provision of healthcare, including demographic information, medical history,
				  test and laboratory results, insurance information and other data that a
				  healthcare professional collects to identify an individual and determine
				  appropriate care.
23. "Pharmacy
				  benefits manager" or "PBM" means any person or entity that develops or manages
				  pharmacy benefits, pharmacy network contracts, or the pharmacy benefit bid
				  process pursuant to a contract held with an Insurer for the provision of such
				  services.
24. "Pharmacy 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 national drug codes from all submitted and
				  non-denied adjudicated claims for each prescription filled.
25. "Provider file" means a data file
				  composed of provider information for each provider included on a medical,
				  pharmacy or dental claim submitted during the reporting period, regardless of
				  the type of provider or location where the services were provided, as specified
				  in the RIAPCD Technical Specification Manual.
26. "Rhode Island all-payer claims database"
				  or "RIAPCD" means a health care quality and value database for the collection,
				  management and reporting of eligibility, claims and provider data submitted
				  pursuant to R.I. Gen. Laws Chapter 23-17.17.
27. "RIAPCD technical specification manual"
				  means the document entitled RIAPCD Technical Specification Manual Version 1.6
				  issued by the Department, or its contracted agent, that sets forth the required
				  data file format, record specifications, data elements, definitions, code
				  tables and edit specifications.
28.
				  "Subscriber" means the individual responsible for payment of premiums to an
				  Insurer or whose employment is the basis for eligibility for Membership in a
				  Health Benefit Plan.
29.
				  "Third-party administrator" or "TPA" means any person with a certificate of
				  authority, issued pursuant to R.I. Gen Laws §
											27-20.7-12,
				  who directly or indirectly solicits or effects coverage of, underwrites,
				  collects charges or premiums from, or adjusts or settles claims on Members,
				  pursuant to R.I. Gen. Laws §
											27-20.7-2(1).
30. "Third-party payer" means a State agency
				  that pays for health care services, or an insurer, carrier, including a carrier
				  that provides only administrative services for plan sponsors, nonprofit
				  hospital, medical services organization, or managed care organization licensed
				  in Rhode Island.
31. "User" means
				  any person who the Department has authorized to access and use data from the
				  Rhode Island All-Payer Claims Database.