Code of Vermont Rules › Agency 21 - DEPARTMENT OF FINANCIAL REGULATION › Sub-Agency 040 - DIVISION OF HEALTH CARE ADMINISTRATION › Chapter 021 - REGULATION H-2008-01 - VERMONT HEALTHCARE CLAIMS UNIFORM REPORTING AND EVALUATION SYSTEM ("VHCURES") › Section 21 040 021 - REGULATION H-2008-01 - VERMONT HEALTHCARE CLAIMS UNIFORM REPORTING AND EVALUATION SYSTEM ("VHCURES")

Current through June, 2024
Section 1 Purpose
The purpose of this rule is to set forth the requirements for
				  the submission of health care claims data, member eligibility data, and other
				  information relating to health care provided to Vermont residents or by Vermont
				  health care providers and facilities by health insurers, managed care
				  organizations, third party administrators, pharmacy benefit managers and others
				  to the Department of Banking, Insurance, Securities and Health Care
				  Administration and conditions for the use and dissemination of such claims
				  data, all as required by and consistent with the purposes of
				  18 V.S.A. §
											9410.
Section 2 Authority
This rule is issued pursuant to the authority vested in the
				  Commissioner of the Department of Banking, Insurance, Securities and Health
				  Care Administration by
				  18 V.S.A. §
											9410, as well as
				  8 V.S.A. §
											15 and other applicable portions of Chapter
				  221 of Title 18.
Section 3
				Definitions
As used in this Rule
A. "BISHCA" or "Department" means the Vermont
				Department of Banking, Insurance, Securities and Health Care
				Administration.
B. "Capitated
				services" means services rendered by a provider through a contract in which
				payment are based upon a fixed dollar amount for each member on a monthly
				basis.
C. "Cell size" means the
				count of persons that share a set of characteristics contained in a statistical
				table.
D. "Charge" means the actual
				dollar amount charged on the claim.
E. "Co-insurance" means the percentage a
				member pays toward the cost of a covered service.
F. "Commissioner" means the commissioner of
				the Department of Banking, Insurance, Securities and Health Care Administration
				or his or her designee.
G.
				"Co-payment" means the fixed dollar amount a member 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.
H. "Current Procedural Terminology (CPT)"
				means a medical code set of physician and other services, maintained and
				copyrighted by the American Medical Association (AMA), and adopted by the U.S.
				Secretary of Health and Human Services as the standard for reporting physician
				and other services on standard transactions.
I. "Data set" means a collection of
				individual data records, whether in electronic or manual files.
J. "Deductible" means the total dollar amount
				a member pays towards the cost of covered services over an established period
				of time before the contracted third-party payer makes any payments.
K. "De-identified health information" means
				information that does not identify an individual patient, member or enrollee
				and with respect to which no reasonable basis exists to believe that the
				information can be used to identify an individual patient, member or enrollee.
				De-identification means that health information is not individually
				identifiable and requires the removal of Direct Personal Identifiers associated
				with patients, members or enrollees.
L. "Direct personal identifiers" is
				information relating to an individual patient, member or enrollee that contains
				primary or obvious identifiers, including:
(1) Names;
(2) Business names when that name would serve
				to identify a person;
(3) Postal
				address information other than town or city, state, and 5-digit zip
				code;
(4) Specific latitude and
				longitude or other geographic information that would be used to derive postal
				address;
(5) Telephone and fax
				numbers;
(6) Electronic mail
				addresses;
(7) Social security
				numbers;
(8) Vehicle Identifiers
				and serial numbers, including license plate numbers;
(9) Medical record numbers;
(10) Health plan beneficiary
				numbers;
(11) Certificate and
				license numbers;
(12) Internet
				protocol (IP) addresses and uniform resource locators (URL) that identify a
				business that would serve to identify a person;
(13) Biometric identifiers, including finger
				and voice prints; and
(14) Personal
				photographic images.
M.
				"Disclosure" means the release, transfer, provision of access to, or divulging
				in any other manner of information outside the entity holding the
				information.
N. "Encrypted
				identifier" is a code or other means of record identification to allow
				patients, members or enrollees to be tracked across the data set without
				revealing their identity. Encrypted identifiers are not direct
				identifiers.
O. "Encryption" means
				a method by which the true value of data has been disguised in order to prevent
				the identification of persons or groups, and which does not provide the means
				for recovering the true value of the data.
P. "Health benefit plan" means a policy,
				contract, certificate or agreement entered into, or offered by a health insurer
				to provide, deliver, arrange for, pay for or reimburse any of the costs of
				health care services.
Q.
				"Healthcare claims data" means information consisting of or derived directly
				from member eligibility files, medical claims files, pharmacy claims files and
				other related data pursuant to the Vermont Healthcare Claims Uniform Reporting
				and Evaluation System (VHCURES) in effect at the time of the data submission.
				"Healthcare claims data" does not include analysis, reports, or studies
				containing information from health care claims data sets if those analyses,
				reports, or studies have already been released in response to another request
				for information or as part of a general distribution of public information by
				BISHCA.
R. "Healthcare premium"
				means the dollar amount charged for any policies offered by health insurers
				which partially or fully cover the cost of health care services.
S. "Healthcare Common Procedure Coding System
				(HCPCS)" means a medical code set that identifies health care procedures,
				equipment, and supplies for claim submission purposes. These are often known as
				"local codes".
T. "Health care"
				means care, services, or supplies related to the health of an individual. It
				includes but is not limited to (1) preventive, diagnostic, therapeutic,
				rehabilitative, maintenance, or palliative care, and counseling, service,
				assessment, or procedure with respect to the physical or mental condition, or
				functional status, of an individual or that affects the structure or function
				of the body; and (2) sale or dispensing of a drug, device, equipment, or other
				item in accordance with a prescription [
				45
				CFR §
											160.103 ].
U. "Health care facility" shall be defined as
				per
				18 V.S.A §
											9432, as amended from time to time.
V. "Health care provider" means a person,
				partnership, corporation, facility or institution, licensed or certified or
				authorized by law to provide professional health care service in this state to
				an individual during that individual's medical care, treatment or confinement,
				as per
				18 V.S.A. §
											9432.
W. "Health information" means any
				information, whether oral or recorded in any form or medium, that 1) is created
				or received by a health-care provider, health plan, public health authority,
				employer, life insurer, school or university, or health-care clearinghouse; and
				2) relates to the past, present, or future physical or mental health or
				condition of an individual, the provision of health care to an individual, or
				the past, present, or future payment for the provision of health care to an
				individual shall be as defined in
				45
				CFR §
											160.103.
X. "Health insurer" means those entities
				defined in
				18 V.S.A. §§
											9402 and
				9410(j)(1),
				and includes any health insurance company, nonprofit hospital and medical
				service corporation, managed care organization, third party administrator,
				pharmacy benefit manager, and any entity conducting administrative services for
				business or possessing claims data, eligibility data, provider files, and other
				information relating to health care provided to Vermont residents or by Vermont
				health care providers and facilities. The term may also include, to the extent
				permitted under federal law, any administrator of an insured, self-insured, or
				publicly funded health care benefit plan offered by public and private
				entities.
Y. "HIPAA" means the
				federal Health Insurance Portability and Accountability Act of 1996,
				Public Law
				104-191.
Z. "Indirect personal identifiers" means
				information relating to an individual patient, member or enrollee that a person
				with appropriate knowledge of and experience with generally accepted
				statistical and scientific principles and methods could apply to render such
				information individually identifiable by using such information alone or in
				combination with other reasonably available information.
Aa. "International Classification of
				Diseases" or "ICD" shall mean that medical code set maintained by the World
				Health Organization..
Ab. "Mandated
				Reporter" means a health insurer as defined herein and at
				18 V.S.A. §
												9410(j)(1) with two hundred
				(200) or more enrolled or covered members in each month during a calendar year,
				including both Vermont residents and any non-residents receiving covered
				services provided by Vermont health care providers and facilities.
Ac. "Medical claims file" means a data file
				composed of service level remittance information for all non-denied adjudicated
				claims for each billed service including, but not limited to member
				demographics, provider information, charge/payment information, and clinical
				diagnosis and procedure codes, and shall include all claims related to
				behavioral or mental health.
Ad.
				"Member" means the insured subscriber and any spouse and/or dependent covered
				by the subscriber's policy.
Ae.
				"Member eligibility file" means a data file containing demographic information
				for each individual member eligible for medical or pharmacy benefits for one or
				more days of coverage at any time during the reporting month.
Af. "Patient" means any person in the data
				set that is the subject of the activities of the claim performed by the health
				care provider.
Ag. "Payer" means a
				third-party payer or third-party administrator.
Ah. "Payment" means the actual dollar amount
				paid for a claim by a health insurer.
Ai. "Personal identifiers" means information
				relating to an individual that contains direct or indirect identifiers to which
				a reasonable basis exists to believe that the information can be used to
				identify an individual.
Aj.
				"Pharmacy Benefit Manager" or "PBM" means a person or entity that performs
				pharmacy benefit management as that term is defined at
				18 V.S.A. §
												9471(4). The term includes a
				person or entity in a contractual or employment relationship with an entity
				performing pharmacy benefit management for a health plan.
Ak. "Pharmacy claims file" means a data file
				containing service level remittance information from all non-denied adjudicated
				claims for each prescription including, but not limited to: member
				demographics; provider information; charge/payment information; and national
				drug codes.
Al. "Prepaid amount"
				means the fee for the service equivalent that would have been paid for a
				specific service if the service had not been capitated.
Am. "Principal Investigator" means the person
				in charge of a project that makes use of limited use research health care
				claims data sets. The principal investigator is the custodian of the data and
				is responsible for compliance with all restrictions, limitations and conditions
				of use associated with the data release.
An. "Public Use Data Set" means a publicly
				available data set containing only the public use data elements specified in
				this Rule as unrestricted data elements in Appendix J.
Ao. "Reporter" means a health insurer as
				defined herein and at 18 V.S.A. § 94100(j)(1), and shall include Voluntary
				Reporters as defined herein.
Ap.
				"Subscriber" means the individual responsible for payment of premiums or whose
				employment is the basis for eligibility for membership in a health benefit
				plan.
Aq. "Third-party
				Administrator" means any person who, on behalf of a health insurer or purchaser
				of health benefits, receives or collects charges, contributions or premiums
				for, or adjusts or settles claims on or for residents of this State or Vermont
				health care providers and facilities.
Ar. "Vermont Healthcare Claims Uniform
				Reporting and Evaluation System" or "VHCURES" means the Department's system for
				the collection, management and reporting of eligibility, claims and related
				data submitted pursuant to
				18 V.S.A. §
												9410.
As. "Voluntary Reporter" includes any entity
				other than a mandated reporter, including any health benefit plan offered or
				administered by or on behalf of the federal government where such plan, with
				the agreement of the federal government, voluntarily submits data to the BISHCA
				commissioner for inclusion in the database on such terms as may be
				appropriate.