West Virginia Code of State Rules › Agency 114A - Secretary Of DHHR; Insurance Commissioner; And Chair Of The Health Care Authority › Title 114A - LEGISLATIVE RULE DEPARTMENT OF HEALTH AND HUMAN RESOURCES AND OFFICES OF THE INSURANCE COMMISSIONER › Series 114A-01 - All-Payer Claims Database - Data Submission Requirements › Section 114A-1-2 - Definitions

Current through Register Vol. XLI, No. 28, July 12, 2024
As used in this rule:
2.1. "All-payer claims database" or "APCD" or
				"Act" means the program established pursuant to W. Va. Code §
									33-4A-1
et seq
. for the collection, management and release of medical
				claims data submitted by health care payers.
2.2. "Accredited Standards Committee (ASC)
				X12" means the standards development organization accredited by the American
				National Standards Institute (ANSI) that develops and maintains electronic data
				interchange (EDI) standards and related documents for national and global
				markets, including standards for insurance claims transactions, or any
				successor organization.
2.3.
				"American National Standards Institute" or "ANSI" means the nonprofit
				membership organization that acts as an administrator and coordinator of the
				United States private sector voluntary standardization system consisting of
				public agencies and private organizations.
2.4. "APCD Council" means the collaborative
				effort convened and coordinated by the University of New Hampshire (UNH) and
				the National Association of Health Data Organizations (NAHDO) that is focused
				on improving the development and deployment of state-based all-payer claims
				database programs, including the development of a common data layout for use by
				such programs.
2.5. "Commissioner"
				means the West Virginia Insurance Commissioner.
2.6. "Data" means the data elements from
				enrollment and eligibility files, specified types of claims, and reference
				files for data elements not maintained in formats consistent with national
				coding standards.
2.7. "Data set"
				means a collection of individual data records and data elements, whether in
				electronic or manual files.
2.8.
				"Data submitter" means a health care payer that the Commissioner has determined
				is subject to the submission and reporting requirements of this rule for a
				given calendar year because it meets the threshold of having paid or
				administered the payment of health insurance claims in this state for policies
				for 500 or more covered lives in the prior calendar year and has not been
				exempted for cause from such requirements.
2.9. "Data processor" means any entity that
				performs data collection and data management functions pursuant to a contract
				for purposes of the state's all-payer claims database.
2.10. "Health care payer" means any insurer
				or health maintenance organization licensed in this state that pays medical
				benefits pursuant to a policy, certificate, or contract of health; any state
				and federal government payers of such benefits; any workers' compensation
				insurer; or any third-party administrator that administers a self-funded health
				insurance plan.
2.11. "Health care
				provider" or "provider" means any physician, hospital or other person or
				organization that is licensed or otherwise authorized in this state to furnish
				health care services.
2.12.
				"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/procedure codes. The term
				includes data related to behavioral, mental health, or substance abuse
				treatment.
2.13. "Member" means a
				subscriber and the spouse, dependent or other persons covered by the
				subscriber's policy.
2.14. "Member
				Eligibility file" means a data file that contains 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 period.
2.15. "National Council for Prescription Drug
				Programs" or "NCPDP" means the standards development organization accredited by
				the American National Standards Institute (ANSI) that develops and maintains
				national standards for pharmacy payers and providers, including standards for
				the pharmacy claim transaction, or any successor organization.
2.16. "Personal identifiers" means
				information relating to an individual member or insured that identifies, or can
				be used to identify, locate, or contact a particular individual member or
				insured.
2.17. "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.
2.18. "Secretary" means the Secretary of the
				West Virginia Department of Health and Human Resources.
2.19. "Standards Development Organization" or
				"SDO" means an entity accredited by the American National Standards Institute
				(ANSI), such as ASC X-12, National Council for Prescription Drug Programs
				(NCPDP) and Health Level Seven (HL-7), that is responsible for maintaining the
				structure and control elements of transactions, or any of its
				successors.
2.20. "Submission
				Manual" or "Manual" means the legislative rule promulgated pursuant to
				subsection 4.2. of this rule that sets forth the required data file format,
				data elements, code tables, edit specifications, thresholds required for a
				submission to be deemed complete, methods for submitting data, submission
				schedules, and other information associated with the data submitters'
				submission and reporting duties.
2.21. "TPA" means a third-party administrator
				licensed by the Commissioner under W. Va. Code §
									33-46-12
				or §
									33-46-14
				or registered with the Commissioner under W. Va. Code §
									33-46-13.
				A TPA that administers claims for an ERISA plan is not required to submit data
				but may voluntarily submit data.