Texas Administrative Code › Title 28 - INSURANCE › Part 1 - TEXAS DEPARTMENT OF INSURANCE › Chapter 21 - TRADE PRACTICES › Subchapter TT - ALL-PAYOR CLAIMS DATABASE › Section 21.5402 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
					 subchapter, have the following meanings unless the context clearly indicates
					 otherwise.
(1) Allowed amount--Has the
				  meaning assigned by Insurance Code §
										38.402, concerning
				  Definitions.
(2) Center--The Center
				  for Health Care Data at The University of Texas Health Science Center at
				  Houston.
(3) Data--Has the meaning
				  assigned by Insurance Code §
										38.402.
(4) Data files--Files submitted under this
				  subchapter, including dental claims data files, enrollment and eligibility data
				  files, medical claims data files, pharmacy claims data files, and provider
				  files.
(5) Database--Has the
				  meaning assigned by Insurance Code §
										38.402.
(6) Dental claims data file--A file that
				  includes data as specified in the Texas APCD CDL about any dental claim or
				  encounter for which some action has been taken on the claim during the
				  reporting period, including payment, denial, adjustment, or other
				  modification.
(7) Enrollment and
				  eligibility data file--A file that provides identifying data as specified in
				  the Texas APCD CDL about a person who is enrolled and eligible to receive
				  health care coverage from a payor, whether or not the member used services
				  during the reporting period, with one record per member, per month, per
				  plan.
(8) Medical claims data
				  file--A file that includes data as specified in the Texas APCD CDL about
				  medical claims and other encounter information for which some action has been
				  taken on the claim during the reporting period, including payment, denial,
				  adjustment, or other modification.
(9) Payor--Has the meaning assigned by
				  Insurance Code §
										38.402.
(10) Pharmacy claims data file--A file that
				  includes data as specified in the Texas APCD CDL about all claims filed by
				  pharmacies, including mail order and retail dispensaries, for prescriptions
				  that were dispensed, processed, and paid during the reporting period.
(11) Provider file--A file that includes
				  information as specified in the Texas APCD CDL about all providers (regardless
				  of network status) that submitted claims that are included in the medical
				  claims data file, dental claims data file, or pharmacy claims data file, with a
				  separate record provided for each unique physical location for a provider who
				  practices in multiple locations.
(12) Qualified research entity--Has the
				  meaning assigned by Insurance Code §
										38.402.
(13) Stakeholder advisory group--Has the
				  meaning assigned by Insurance Code §
										38.402.
(14) Submission guide--The document entitled
				  "The Texas All-Payor Claims Database Data Submission Guide," created by the
				  Center, that outlines administrative procedures and provides technical guidance
				  for submitting data files.
(15)
				  Texas APCD CDL--The standardized format, or common data layout (CDL), for
				  All-Payor Claims Database (APCD) data files published by the Center and based
				  on the "All-Payer Claims Database Common Data Layout" established by the
				  National Association of Health Data Organizations and used with
				  permission.
(16) Texas resident
				  member--Any policyholder or certificate holder (subscriber) of a plan issued in
				  Texas whose residence is within the state of Texas and all covered dependents,
				  regardless of where the dependent resides.