Or. Admin. R. 409-025-0100 - Definitions
The following definitions apply to OAR 409-025-0100 to 409-025-0190:
(1) "Accident policy "
means an insurance policy that provides benefits only for a loss due to
accidental bodily injury.
(2)
"Allowed amount " means the actual amount of charges for healthcare services,
equipment, or supplies that are covered expenses under the terms of an
insurance policy or health benefits plan.
(3) "APAC" means all payer all
claims.
(4) "Association " means any
organization, including a labor union, that has an active existence for at
least one year, that has a constitution and bylaws and that has been organized
and is maintained in good faith primarily for purposes other than that of
obtaining insurance.
(5) "Attending
provider " means the individual health care provider who delivered the health
care services, equipment, or supplies specified on a health care
claim.
(6) "Authority" means the
Oregon Health Authority.
(7)
"Billing provider " means the individual or entity that submits claims for
health care services, equipment, or supplies delivered by an attending
provider .
(8) "Capitated services "
means services rendered by a provider through a contract in which payments are
based upon a fixed monthly dollar amount for each enrollee.
(9) "Carrier " shall have the meaning given
that term in ORS 743B.005.
(10) "Certificate of authority " shall have
the meaning given that term in ORS
731.072.
(11) "Charges " means the actual dollar amount
charged on the claim.
(12) "Claim "
means an encounter or request for payment under the terms of an insurance
policy, health benefits plan, Medicare, or Medicaid.
(13) "Coinsurance " means the percentage an
enrollee pays toward the cost of a covered service.
(14) "Control totals file " means a data set
containing summary information on medical, pharmacy and dental claims, members,
providers, and premiums used to validate the detailed files
submitted.
(15) "Coordinated Care
Organization (CCO) " shall have the meaning given that term in ORS
414.025.
(16) "Copayment " means the fixed dollar
amount an enrollee 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.
(17) "Data file "
means electronic health information including medical claims files, enrollment
files, medical provider files, pharmacy claims files, dental claims files,
control totals files, subscriber-billed premiums files, payment arrangement
files and any other related information specified in these rules.
(18) "Data set " means a collection of
individual data records, whether in electronic or manual files.
(19) "Data vendor " means the entity under
contract with the Authority to administer in whole or in part the all payer all
claims database and related functions.
(20) "DCBS " means the Oregon Department of
Consumer and Business Services.
(21) "Deductible " means the total dollar
amount an enrollee pays toward the cost of covered services over an established
period before the carrier or third-party administrator makes any payments under
an insurance policy or health benefit plan.
(22) "De-identified health information " means
health information that does not identify an individual and with respect to
which there is no reasonable basis to believe that the information can be used
to identify an individual.
(23)
"Dental claims file " means a data set comprised of dental health care service
level remittance information for all adjudicated claims for each billed service
including but not limited to provider information, charge and payment
information, and clinical diagnosis and procedure codes for an Oregon resident
as defined in ORS 803.355 or a non-resident who is
a member of a PEBB or OEBB group health insurance plan.
(24) "Direct personal identifier " means
information relating to an individual patient or enrollee that contains primary
or obvious identifiers, including:
(a)
Names;
(b) Business names when that
name would serve to identify a person ;
(c) Postal address information other than
town or city, state, and 5-digit zip code;
(d) Specific latitude and longitude or other
geographic information that would be used to derive postal address;
(e) Telephone and fax numbers;
(f) Electronic mail addresses;
(g) Social security numbers;
(h) Vehicle identifiers and serial numbers,
including license plate numbers;
(i) Medical record numbers;
(j) Health plan beneficiary
numbers;
(k) Certificate and
license numbers;
(l) Internet
protocol (IP) addresses and uniform resource locators (URL) that identify a
business that would serve to identify a person ;
(m) Biometric identifiers, including finger
and voice prints; and
(n) Personal
photographic images.
(25) "Disability policy " means an insurance
policy that provides benefits for losses due to a covered illness or
disability.
(26) "Disclosure " means
the release, transfer, provision of access to, or divulging in any other manner
of information outside the entity holding the information.
(27) "DRC" means Data Review
Committee.
(28) "Dual eligible
special needs plan " means a special needs plan that enrolls beneficiaries
entitled to both Medicare and Medicaid.
(29) "Enrollment file " means a data set
containing demographic information for each individual enrollee eligible for
medical benefits for one or more days of coverage at any time during a calendar
month for an Oregon resident as defined in ORS
803.355 or a non-Oregon resident
who is a member of a PEBB or OEBB group health insurance plan.
(30) "Eligible employee " shall have the
meaning given that term in ORS
743B.005.
(31) "Employee " shall have the meaning given
that term in ORS 654.005.
(32) "Employer " shall have the meaning given
that term in ORS 654.005.
(33) "Encrypted identifier " means a code or
other means of identification to allow individual patients or enrollees to be
tracked across data sets without revealing their identity.
(34) "Encryption " means a method by which the
true value of data has been disguised to prevent the identification of
individual patients or enrollees and does not provide the means for recovering
the true value of the data.
(35)
"Enrollee " means enrollee as defined in ORS
743B.005.
(37) "Exemption " means a requested variance
from a validation rule on data format or quality threshold.
(38) "Extension " means a requested variance
from the Data Submission schedule incorporated by reference under OAR
409-025-0120 and 409-025-0125.
(39)
"Facility " means a health care facility as defined in ORS
442.015.
(40) "Genetic test " shall have the meaning
given that term in ORS
192.531.
(41) "Group health insurance " shall have the
meaning given that term in ORS
731.098.
(42) "Health benefit plan " shall have the
meaning given that term in ORS
743B.005.
(43) "Health care " shall have the meaning
given that term in ORS
192.556.
(44) "Health care operations" means certain
administrative, financial, legal, and quality improvement activities that are
necessary to run programs including, but not limited to, conducting quality
assessment and improvement activities, population-based activities relating to
improving health or reducing health care costs, case management and care
coordination, evaluating practitioner, provider, or health plan performance,
and underwriting, enrollment, premium rating and other activities related to
creation, renewal, or replacement of a health insurance contract.
(45) "Health care provider" shall have the
meaning given that term in ORS
192.556.
(46) "Health information " shall have the
meaning given that term in ORS
192.556.
(47) "Health insurance exchange " shall have
the meaning given that term in ORS
741.300.
(48) "Healthcare Common Procedure Coding
System (HCPCS) " means a medical code set, maintained by the United States
Department of Health and Human Services, that identifies health care
procedures, equipment, and supplies for claim submission purposes.
(49) "HIPAA " means Title II, Subtitle F of
the Health Insurance Portability and Accountability Act of 1996,
42 USC
1320d, et seq. and the federal regulations
adopted to implement the Act.
(50)
"Hospital indemnity policy " means an insurance policy that provides benefits
only for covered hospital stays.
(51) "Indirect personal identifier " means
information relating to an individual patient or enrollees 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.
(52) "Individual", when used in a list of
required lines of business, means individual health benefit plans.
(53) "Individually identifiable health
information " shall have the meaning given that term in ORS
192.556.
(54) "Insurance " shall have the meaning given
that term in ORS 731.102.
(55) "Labor union " means any organization
which is constituted for the purpose, in whole or in part, of collective
bargaining or dealing with employers concerning grievances, terms or conditions
of employment or of other mutual aid or protection in connection with
employees.
(56) "Large group " means
health benefit plans for employers with more than 50 employees.
(57) "Long-term care insurance " shall have
the meaning given that term in ORS
743.652.
(58) "Mandatory reporter " means any reporting
entity defined as a mandatory reporter in OAR 409-025-0110.
(59) "Medicaid " means medical assistance
provided under 42 U.S.C.
section 1396a (section 1902 of the Social
Security Act) or Children's Health Insurance Program (CHIP) medical assistance
provided under 42 U.S.C
section 1397aa -mm (section 2103 of the
Social Security Act), as administered by the Division of Medical Assistance
Programs.
(60) "Medicaid
fee-for-service" (Medicaid FFS) means that portion of Medicaid where a health
care provider is paid a fee for each covered health care service delivered to
an eligible Medicaid patient.
(61)
"Medical claims file " means a data set composed of health care service level
remittance information for all adjudicated claims for each billed service
including but not limited to provider information, charge and payment
information, and clinical diagnosis and procedure codes for an Oregon resident
as defined in ORS 803.355 or a non-Oregon resident
who is a member of a PEBB or OEBB group health insurance plan.
(62) "Medicare " means coverage under Part A,
Part B, Part C, or Part D of Title XVIII of the Social Security Act,
42 U.S.C.
135 et seq., as amended.
(63) "Non-claims based primary care
expenditures " means resources given to a primary care provider or practice for
services and are not otherwise in a fee-for-service arrangement.
(64) "OEBB " means the Oregon Educators
Benefit Board.
(65) "Paid amount "
means the actual dollar amount paid for claims.
(66) "Patient " means any person in the data
set who is the subject of the activities of the claim performed by the health
care provider.
(67)
"Patient -Centered Primary Care Home" or "PCPCH" means a health care team or
clinic as defined in ORS
414.655 that meets the standards
pursuant to OAR 409-055-0040, and has been recognized through the process
pursuant to OAR 409-055-0040.
(68)
"Payment arrangement file " means a data set composed of total and primary
care-related dollars disbursed, by payment arrangement and line of
business.
(69) "PEBB " means the
Oregon Public Employees' Benefit Board.
(70) "Person " shall have the meaning given
that term in ORS 731.116.
(71) "Pharmacy benefit manager (PBM) " means a
person or entity that performs pharmacy benefit management, including a person
or entity in a contractual or employment relationship with a person or entity
performing pharmacy benefit management for a health benefits plan.
(72) "Pharmacy claims file " means a data set
containing service level remittance information from all adjudicated claims
including, but not limited to provider information, charge and payment
information, and national drug codes for an Oregon resident as defined in ORS
803.355 or a non-Oregon resident
who is a member of a PEBB or OEBB group health insurance plan.
(73) "Policy " shall have the meaning given
that term in ORS 731.122.
(74) "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.
(75) "Premium " shall have the meaning given
that term in ORS 743B.005.
(76) "Primary care " means family medicine,
general internal medicine, naturopathic medicine, obstetrics and gynecology,
pediatrics or general psychiatry.
(77) "Primary care provider" means:
(a) A physician, naturopath, nurse
practitioner, physician assistant or other health professional licensed or
certified in this state, whose clinical practice is in the area of primary
care .
(b) A health care team or
clinic certified by the Authority as a PCPCH.
(78) "Principal investigator (PI) " means the
person in charge of a research project that makes use of limited data sets. The
PI is the custodian of the data and shall comply with all state and federal
restrictions, limitations, and conditions of use associated with the data
release.
(79) "Protected health
information " shall have the meaning given that term in ORS
192.556.
(80) "Provider file " means a data set
containing information about health care providers providing health.
(81) "Public health authority " means the
Public Health Division of the Authority or local public health authority as
defined in ORS 431A.005.
(82) "Public health purposes " means the
activities of a public health authority for preventing or controlling disease,
injury, or disability including, but not limited to, the reporting of disease,
injury, vital events such as birth or death, and the conduct of public health
surveillance, investigations, and interventions.
(83) "Registered entity " means any person
required to register with DCBS under ORS
744.714.
(84) "Reporting entity " means:
(a) An insurer as defined in ORS
731.106 or fraternal benefit
society as defined in ORS
748.106 required to have a
certificate of authority to transact health insurance business in
Oregon;
(b) A health care service
contractor as defined in ORS
750.005 that issues medical
insurance in Oregon;
(c) A
third-party administrator required to obtain a license under ORS
744.702;
(d) A pharmacy benefit manager or fiscal
intermediary, or other person that is by statute, contract, or agreement
legally responsible for payment of a claim for a health care item or
service;
(e) A coordinated care
organization as defined in ORS
414.025; and
(f) An insurer providing coverage funded
under Part A, Part B, or Part D of Title XVIII of the Social Security Act,
subject to approval by the United States Department of Health and Human
Services.
(85)
"Research " means a systematic investigation, including research development,
testing and evaluation, designed to develop or contribute to generalized
knowledge.
(86) "Self-insured plan "
means any plan, program, contract, or any other arrangement under which one or
more employers, unions, or other organizations provide health care services or
benefits to their employees or members in this state, either directly or
indirectly through a trust or third-party administrator.
(87) "Small employer health insurance" means
health benefit plans for employers whose workforce consists of at least two but
not more than 50 eligible employees.
(88) "Special Needs Plan " means a Medicare
health benefit plan created by the Medicare Modernization Act that is
specifically designed to provide targeted care to individuals with special
needs.
(89) "Specific disease
policy " means an insurance policy that provides benefits only for a loss due to
a covered disease.
(90)
"Strongly-encrypted " means an encryption method that uses a cryptographic key
with many random keyboard characters.
(91) "Subscriber " means the individual
responsible for payment of premiums or whose employment is the basis for
eligibility for membership in a health benefit plan .
(92) "Subscriber -billed Premium File" means
the data set that includes premium information at the subscriber level for
medical, pharmacy and dental insurance.
(93) "Summarized data " means data aggregated
by one or more categories. Summarized data created from protected health
information may not contain direct or indirect identifiers.
(94) "Third-party administrator (TPA) " means
any person who directly or indirectly solicits or effects coverage of,
underwrites, collects charges or premiums from, or adjusts or settles claims
on, residents of Oregon or residents of another state from offices in Oregon,
in connection with life insurance or health insurance coverage; or any person
or entity who must otherwise be licensed under ORS
744.702.
(95) "Transact insurance " shall have the
meaning given that term in ORS
731.146.
(96) "Trust " means a fund established by two
or more employers in the same or related industry or by one or more labor
unions or by one or more employers and one or more labor unions or by an
association .
(97) "Vision policy "
means a health benefits plan covering only vision health care .
(98) "Voluntary reporter " means any
registered or reporting entity , other than a mandatory reporter , that
voluntarily elects to comply with the reporting requirements in OAR
409-025-0100 to 409-025-0170.
(99)
"Waiver " means an approved variance from the types of files submitted under OAR
409-025-0120 and 409-025-0125.
Notes
Statutory/Other Authority: ORS 443.373
Statutes/Other Implemented: ORS 442.372 & 443.373
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