Tenn. Comp. R. & Regs. 0780-01-79-.06 - COMPLIANCE WITH DATA STANDARDS AND PENALTIES FOR NON-COMPLIANCE

(1) Compliance.

(a) Health insurance issuers shall make every effort to report the data fields as described in the Procedure Manual if the data field is present in any part of their data systems. Health insurance issuers shall submit data fields even in circumstances where the data is integrated from multiple systems. The Procedure Manual shall include minimum thresholds for submissions to be considered complete.

(b) The Department, or its designee, shall evaluate each member eligibility file, medical claims file and pharmacy claims file to determine compliance with the Procedure Manual.

(c) Upon completion of the evaluation, the Department or its designee shall promptly notify each health insurance issuer whether its data submissions satisfy the standards. This notification shall identify the specific file and the data elements that do not satisfy the standards.

(d) Each health insurance issuer notified of a non-compliant data submission shall respond within 10 business days of the notification by making the changes necessary to satisfy the standards.

(2) Penalties for Non-Compliance.

(a) The Department may assess a civil penalty of up to one hundred dollars ($100.00) per day for delinquent claims submissions.

(b) Failure to conform to the requirements for submission shall result in the rejection of the applicable data file(s). All rejected files shall be resubmitted in the appropriate, corrected form to the Department, or their designee, within 10 business days. The Department may assess a civil penalty of up to one hundred dollars ($100.00) per day for rejected files not resubmitted within 10 business days.

(c) The Commissioner has the authority to delay, reduce, or waive any penalty for not correcting any particular data element if:

1. Correcting the failure would be excessively onerous for the health insurance issuer on technical grounds such as: the health insurance issuer does not gather the particular data element or does not store the particular data element;

2. The health insurance issuer is working diligently, in the Commissioner's judgment, to correct the failure; or,

3. The failure to correct is due to force majeure or other events of extraordinary circumstances clearly beyond the control of the health insurance issuer.

Notes

Tenn. Comp. R. & Regs. 0780-01-79-.06

Emergency rule filed March 11, 2010; effective through September 7, 2010. Original rule filed June 10, 2010; effective September 8, 2010.

Authority: 2009 Public Acts, Chapter 611, T.C.A. §§ 56-2-125 and 56-2-301.