Washington Administrative Code › Title 182 - Health Care Authority › ALL PAYER HEALTH CARE CLAIMS DATABASE › Chapter 182-70 - All payer health care claims database › ALL PAYER HEALTH CARE CLAIMS DATABASE › Section 182-70-020 - Definitions required by chapter 43.371 RCW

Current through Register Vol. 24-14, July 15, 2024
The following definitions apply throughout this chapter
					 unless the context clearly indicates another meaning.
"Allowed amount" means the maximum dollar amount
					 contractually agreed to for an eligible health care service covered under the
					 terms of an insurance policy, health benefits plan or state labor and
					 industries program.
"Billed amount" means the dollar amount charged for a
					 health care service rendered.
"Claim file" means a data set composed of health care
					 service level remittance information for all nondenied adjudicated claims under
					 the terms of an insurance policy, health benefits plan or state labor and
					 industries program including, but not limited to, covered medical services
					 files, pharmacy files and dental files.
"Covered medical services file" means a data set composed
					 of service level remittance information for all nondenied adjudicated claims
					 for Washington covered persons that are authorized under the terms of an
					 insurance policy, health benefits plan or state labor and industries program
					 including, but not limited to, member demographics, provider information,
					 charge and payment information including facility fees, clinical diagnosis
					 codes and procedure codes.
"Data file" means a data set composed of member or provider
					 information including, but not limited to, member eligibility and enrollment
					 data and provider data with necessary identifiers.
"Dental claims file" means a data set composed of service
					 level remittance information for all nondenied adjudicated claims for dental
					 services for Washington covered persons including, but not limited to, member
					 demographics, provider information, charge and payment information including
					 facility fees, and current dental terminology codes as defined by the American
					 Dental Association.
"Member eligibility and enrollment data file" means a data
					 set containing data about Washington covered persons who receive health care
					 coverage from a payer for one or more days of coverage during the reporting
					 period including, but not limited to, subscriber and member identifiers, member
					 demographics, plan type, benefit codes, and enrollment start and end
					 dates.
"Paid amount" means the dollar amount paid for a health
					 care service rendered under the terms of an insurance policy, health benefits
					 plan or state labor and industries program for covered services, excluding
					 member copayments, coinsurance, deductibles and other sources of third-party
					 payment. This dollar amount includes incentive payments that are captured in
					 the claims financial fields in the
WA-APCD Data Submission
					 Guide
; such incentive payments include, but are not limited to,
					 withholds, shared savings payments, case or episode payments, and
					 pay-for-performance amounts. For capitated services the fee-for-service
					 equivalent is to be reported as the paid amount.
"Pharmacy claims file" means a data set containing service
					 level remittance information for all nondenied adjudicated claims for pharmacy
					 services for Washington covered persons including, but not limited to, enrolled
					 member demographics, provider information, charge and payment information
					 including dispensing fees, and national drug codes.
"Provider data with necessary identifiers" means a data
					 file containing information about health care providers that submitted claims
					 for providing health care services, equipment or supplies, to subscribers or
					 members and such other data as required by the data submission
					 guide.
Statutory Authority:
						RCW
						43.371.050(6) and chapter
						43.371 RCW. WSR 17-22-121, §
												82-75-020,
						filed 10/31/17, effective 12/1/17. Statutory Authority: Chapter 43.371 RCW. WSR
						16-04-068, §
												82-75-020,
						filed 1/29/16, effective 2/29/16.