Utah Admin. Code R428-2-2 - Definitions
(1) Terms used in this rule are defined in
Section 26B-8-501. Additionally, the
following definitions apply to Title R428:
(2) "Adjudicated claim" means a claim
submitted to a carrier for payment where the carrier has made a determination
whether the services provided fall under the carrier's benefit.
(3) "Ambulatory surgery data" means the
consolidation of complete billing, medical, and personal information describing
a patient, the services received, and charges billed for a surgical or
diagnostic procedure treatment in an outpatient setting into a data
record.
(4) "Ambulatory surgical
facility" means the same as defined in Section
26B-2-201.
(5) "Carrier" means any of the following
third party payors as defined in Subsection
26B-8-501(14):
(a) an insurer engaged in the business of
health care or dental insurance in Utah, as defined in Section
31A-1-301;
(b) a business under an administrative
services organization or administrative services contract
arrangement;
(c) a third party
administrator, as defined in Section
31A-1-301, licensed by Utah that
collects premiums or settles claims of residents of the state, for health care
insurance policies or health benefit plans, as defined in Section
31A-1-301;
(d) a governmental plan,
as defined in Section 414(d), Internal Revenue Code, that provides health care
benefits;
(e) a program funded or
administered by Utah for the provision of health care services, including
Medicaid, the Utah Children's Health Insurance Program created under Section
26B-3-902, and the medical
assistance programs described in Title 26B, Chapter 3, Part 1, Medical
Assistance Act or any entity under a contract with the Utah Department of
Health and Human Services to serve clients under such a program;
(f) a non-electing church plan, as described
in Section 410(d), Internal Revenue Code, that provides health care
benefits;
(g) a licensed
professional employer organization as defined in Section
31a-40-102 acting as an
administrator of a health care insurance plan;
(h) a health benefit plan funded by a
self-insurance arrangement;
(i) the
Public Employees' Benefit and Insurance Program created in Section
49-20-103;
(j) a pharmacy benefit manager, defined to be
a person that provides pharmacy benefit management services as defined in
Section 49-20-502 on behalf of any other
carrier defined in Section
R428-2-3.
(6) "Claim" means a request or demand on a
carrier for payment of a benefit.
(7) "Control number" means a number or other
identifier that:
(a) is assigned by the
department to an individual's health data;
(b) is consistent with the best practices of
data privacy; and
(c) is used to
ensure health data is not able to be readily associated with an individual when
the health data is provided for research or statistical
analysis.
(8) "Covered
period" means the calendar year on which the data used for the calculation of
HEDIS measures is based.
(9) "Data
element" means the specific information collected and recorded for health care
and health service delivery. Data elements include information to identify the
individual, health care provider, data supplier, service provided, charge for
service, payer source, medical diagnosis, and medical treatment.
(10) "Department" means the Utah Department
of Health and Human Services.
(11)
"De-identified data" means data that does not contain the 18 identifiers
itemized in the Health Insurance Portability and Accountability Act (HIPAA) of
1996, Pub. L. No. 104-191 , or
specifically, the Privacy Rule,
45 CFR
164.514 (2024), and does not otherwise
contain information which can be reasonably used to identify and
individual.
(12) "Discharge data"
means the consolidation of complete billing, medical, and personal information
describing a patient, the services received, and charges billed for a single
inpatient hospital stay into a discharge data record.
(13) "Eligible enrollee" means an enrollee
who meets the criteria outlined in survey specifications published by the
NCQA.
(14) "Emergency room data"
means the consolidation of complete billing, medical, and personal information
describing a patient, the services received, and charges billed for a single
visit and treatment of a patient in an emergency room into an emergency room
data record.
(15) "Enrollee" means
any individual who has entered into a contract with a carrier for health care
or on whose behalf such an arrangement has been made.
(16) "Health insurance" means the same as
defined in Section
31A-1-301.
(17) "Healthcare claims data" means
information consisting of, or derived directly from member enrollment, medical
claims, pharmacy claims, and dental claims that this rule requires a carrier to
report.
(18) "Healthcare facility"
means a hospital or ambulatory surgical facility.
(19) "Healthcare facility data" means
ambulatory surgery data, discharge data, or emergency room data.
(20) "HEDIS" means the Healthcare
Effectiveness Data and Information Set, a set of standardized performance
measures developed by the NCQA.
(21) "HEDIS data" means the complete set of
HEDIS measures calculated by the carriers according to NCQA specifications,
including a set of required measures and voluntary measures defined by the
department, in consultation with the carriers.
(22) "Hospital" means a general acute
hospital or specialty hospital as defined in Section
26B-2-201 that is licensed under
Title R432.
(23) "Identifiable
health data" means any item, collection, or grouping of data which makes the
individual supplying it or described in the data identifiable. Identifiable
data may also be referred to as limited data.
(24)
(a)
"Limited data" means data that does not contain 16 of the 18 identifiers
itemized by the HIPAA Privacy Rule for creating de-identified data.
(b) Of the 18 identifiers, limited data shall
only contain:
(i) ages in years, months, or
days or hours, and single category for those ages 89 and older;
(ii) city, state, five digits or more zip
code; and
(iii) dates such as
admission, discharge, service, date of birth, date of death.
(c) Limited data is considered to
be identifiable data and subject to the same restrictions unless an exception
is granted in writing.
(25) "NCQA" means the National Committee for
Quality Assurance, a not-for-profit organization committed to evaluating and
reporting on the quality of managed care plans.
(26) "Patient Social Security number" is the
social security number of a person receiving health care.
(27) "Performance measure" means the
quantitative, numerical measure of an aspect of the carrier, or its membership
in part or in its entirety, or qualitative, descriptive information on the
carrier in its entirety as described in HEDIS.
(28) "Report" means a disclosure of data or
information collected or produced by the department, including a compilation,
study, or analysis designed to meet the needs of specific audiences.
(29) "Research and statistical purposes"
means having the objective of creating knowledge or answering questions,
including a systematic investigation that includes development, testing, and
evaluation; the description, estimation, projection, or analysis of the
characteristics of individuals, groups, or organizations; an analysis of the
relationships between or among these characteristics; the identification or
creation of sampling frames and the selection of samples; the preparation and
publication of reports describing these matters; and the development,
implementation, and maintenance of methods, procedures, or resources to support
the efficient use or management of the data.
(30) "Sample file" means the data file
containing records of selected eligible enrollees drawn by the survey agency
from the carrier's sampling frame.
(31) "Sampling frame" means the carrier
enrollment file as described in the criteria outlined by the NCQA survey
specifications.
(32) "Submission
year" means the year immediately following the covered period.
(33) "Survey agency" means an independent
contractor on contract with the Health Care Statistics Program.
(34) "Utah Health Care Performance
Measurement Plan" means the plan for data collection and public reporting of
health-related measures, adopted by the department to establish a statewide
health performance reporting system.
(35) "Utah Healthcare Facility Data
Submission Guide" means the document referenced in Subsection
R428-1-4(1).
(36) "NCQA Survey Specifications" means the
document referenced in Subsection
R428-1-4(2).
(37) "NCQA HEDIS Specifications" means the
document referenced in Subsection
R428-1-4(3).
(38) "Data Submission Guide for Claims Data"
means the document referenced in Subsection
R428-1-4(4).
(39) "Violation" means a failure to comply
with any requirement found in Title R428 by a person or entity subject to Title
R428.
(40) "Violator" means any
person or entity subject to Title R428 who does not comply with a requirement
in Title R428.
Notes
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