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 182-70-030 - Additional definitions authorized by chapter 43371 RCW

Current through Register Vol. 24-14, July 15, 2024
The following additional definitions apply throughout this
					 chapter unless the context clearly indicates another meaning.
"Authority" means the Washington state health care
					 authority.
"Capitation payment" means a payment model where providers
					 receive a payment on a per "covered person" basis, for specified calendar
					 periods, for the coverage of specified health care services regardless of
					 whether the patient obtains care. Capitation payments include, but are not
					 limited to, global capitation arrangements that cover a comprehensive set of
					 health care services, partial capitation arrangements for subsets of services,
					 and care management payments.
"Claim" means a request or demand on a carrier, third-party
					 administrator, or the state labor and industries program for payment of a
					 benefit.
"Claimant" means a person who files a workers compensation
					 claim with the Washington state department of labor and industries.
"Coinsurance" means the percentage or amount an enrolled
					 member pays towards the cost of a covered service.
"Copayment" 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.
"Data management plan" or "DMP" means a formal document
					 that outlines how a data requestor will handle the WA-APCD data to ensure
					 privacy and security both during and after the project.
"Data policy committee" or "DPC" is the advisory committee
					 required by
					 RCW
					 43.371.020(5)(h) to provide
					 advice related to data policy development.
"Data release committee" or "DRC" is the advisory committee
					 required by
					 RCW
					 43.371.020(5)(h) to
					 establish a data release process and to provide advice regarding formal data
					 release requests.
"Data submission guide" means the document that contains
					 data submission requirements including, but not limited to, required fields,
					 file layouts, file components, edit specifications, instructions and other
					 technical specifications.
"Data use agreement" or "DUA" means the legally binding
					 document signed by either the lead organization and the data requestor, or the
					 authority and the data requestor, or the authority and a Washington state
					 agency, that defines the terms and conditions under which access to and use of
					 the WA-APCD data is authorized, how the data will be secured and protected, and
					 how the data will be destroyed at the end of the agreement term.
"Days" means calendar days.
"Deductible" means the total dollar amount an enrolled
					 member pays on an incurred claim toward the cost of specified covered services
					 designated by the policy or plan over an established period of time before the
					 carrier or third-party administrator makes any payments under an insurance
					 policy or health benefit plan.
"Director" means the director of the health care
					 authority.
"Fee-for-service equivalent" means the amount that would
					 have been paid by the payer for a specified service if the service had not been
					 capitated or paid under an alternative payment formula like treatment episodes,
					 or the fee amount reflected in the payer's internal fee schedule(s) for
					 services that are not paid on a fee-for-service basis.
"Fee-for-service payment" means a payment model where
					 providers receive a negotiated or payer-specified rate for a specific health
					 care service provided to a patient.
"Health benefits plan" or "health plan" has the same
					 meaning as in
					 RCW
					 48.43.005.
"Health care" means care, services, or supplies related to
					 the prevention, cure or treatment of illness, injury or disease of an
					 individual, which includes medical, pharmaceutical or dental care. Health care
					 includes, but is not limited to:
(a)
				  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
(b)Sale or dispensing of a drug, device,
				  equipment, or other item in accordance with a prescription.
"Lead organization" means the entity selected by the health
					 care authority to coordinate and manage the database as provided in chapter
					 43.371 RCW.
"Malicious intent" means the person acted willfully or
					 intentionally to cause harm, without legal justification.
"Member" means a person covered by a health plan including
					 an enrollee, subscriber, policyholder, beneficiary of a group plan, or
					 individual covered by any other health plan.
"Person" means an individual; group of individuals however
					 organized; public or private corporation, including profit and nonprofit
					 corporations; a partnership; joint venture; public and private institution of
					 higher education; a state, local, and federal agency; and a local or tribal
					 government.
"PFI" means the proprietary financial information as
					 defined in
					 RCW
					 43.371.010(12).
"PHI" means protected health information as defined in the
					 Health Insurance Portability and Accountability Act (HIPAA). Incorporating this
					 definition from HIPAA, does not, in any manner, intend or incorporate any other
					 HIPAA rule not otherwise applicable to the WA-APCD.
"Subscriber" means the insured individual who pays the
					 premium or whose employment makes him or her eligible for coverage under an
					 insurance policy or member of a health benefit plan.
"WA-APCD" means the statewide all payer health care claims
					 database authorized in chapter 43.371 RCW.
"WA-APCD program director" means the individual designated
					 by the authority as responsible for the oversight and management of the
					 operations of the statewide all payer health care claims database authorized in
					 chapter 43.371 RCW.
"Washington covered person" means any eligible member and
					 all covered dependents where the covered person is a Washington state resident,
					 or the state of Washington has primary jurisdiction, and whose laws, rules and
					 regulations govern the members' and dependents' insurance policy or health
					 benefit plan.
Statutory Authority:
						RCW
						43.371.010(3) and
						43.371.070. WSR
						19-05-054, §
												82-75-030,
						filed 2/15/19, effective 3/18/19; WSR 18-19-056, §
												82-75-030,
						filed 9/15/18, effective 10/16/18. Statutory Authority:
						RCW
						43.371.070(1)(h). WSR
						18-15-002, §
												82-75-030,
						filed 7/5/18, effective 8/5/18. Statutory Authority:
						RCW
						43.371.050(6) and chapter
						43.371 RCW. WSR 17-22-121, §
												82-75-030,
						filed 10/31/17, effective 12/1/17. Statutory Authority: Chapter 43.371 RCW. WSR
						17-08-079, §
												82-75-030,
						filed 4/4/17, effective 5/5/17; WSR 16-22-062, §
												82-75-030,
						filed 11/1/16, effective 12/2/16; WSR 16-04-068, §
												82-75-030,
						filed 1/29/16, effective 2/29/16.