8.100 GENERAL
PROVISIONS
8.101 Authority.
The Board adopts this rule pursuant to
18 V.S.A. §§
9375,
9380,
9404,
9410,
9453, and
9454.
8.102 Purpose.
The Green Mountain Care Board ("Board" or "GMCB") stewards
two data sets (collectively "the health care database"). The Vermont Health
Care Uniform Reporting and Evaluation System ("VHCURES") data set contains
information related to health care utilization, costs, and resources provided
to Vermont residents. The Vermont Uniform Hospital Discharge Data Set
("VUHDDS") contains information related to health care provided to patients at
health care facilities in Vermont and health care provided to Vermont residents
at health care facilities in other states.
Health insurers, health care providers, hospitals and other
health care facilities, and governmental agencies must submit reports, data,
schedules, statistics, and other information specified by the Board for
inclusion in the health care database. This rule sets forth the Board's
requirements for reporting health care claims and eligibility data, inpatient
discharge data, outpatient procedure and service data, emergency department
data, and other information relating to health care provided in Vermont and to
Vermont residents outside the state. Green Mountain Care Board Rule 9.000 sets
forth the processes by which the Board makes data available to support
legitimate and beneficial research and analysis.
8.103 Definitions.
For purposes of this rule:
(1) "Ambulatory surgery center" has the same
meaning as in
18 V.S.A. §
2141(1).
(2) "Board" or "GMCB" means the Green
Mountain Care Board established in Title 18, Chapter 220 of the Vermont
Statutes Annotated, the Board's staff, or other designee of the
Board.
(3) "Claims data" means
service-level remittance and other related administrative information generated
from the interaction of patients and the health care delivery system. Examples
of claims data include provider information; charge and payment information;
clinical diagnosis, procedure, and service codes; and national drug codes.
Claims data also include information intended to represent payments made under
an accountable care organization- based payment reform model.
(4) "Council chair" means the chair of the
Data Governance Council.
(5) "Data
Governance Council" or "Council" means the committee established by the Board
and given responsibilities for the Board's data governance program.
(6) "Data set" means a collection of logical
individual data records, regardless of format.
(7) "Data collection vendor" means a vendor
with whom the Board contracts to manage data collection, cleansing, validation,
integration, and consolidation related to the health care database.
(8) "Days" means calendar days unless
otherwise indicated.
(9)
"Eligibility data" means demographic information for each individual member
enrolled for medical or pharmacy benefits for one or more days of coverage at
any time during a reporting period.
(10) "General hospital" has the same meaning
as in
18 V.S.A. §
1902(1)(A).
(11) "Health care" has the same meaning as in
45
C.F.R. §
160.103.
(12) "Health care database" means the VHCURES
and VUHDDS data sets, collectively.
(13) "Health care facility" has the same
meaning as in
18 V.S.A. §
9432(8).
(14) "Health care provider" has the same
meaning as in
18 V.S.A. §
9432(9).
(15) "Health insurer" has the same meaning as
in
18 V.S.A. §
9410(j)(1).
(16) "Insured" has the same meaning as in
18 V.S.A. §
9418(a)(10).
(17) "Mandatory submitter" means any person
required to submit data for inclusion in the health care database.
(18) "Member" means the insured subscriber
and any other person(s) eligible for health care benefits under the
subscriber's policy, such as the subscriber's spouse or dependent.
(19) "Patient" means any person in a data set
that is the subject of the activities of the claim performed by the health care
provider.
(20) "Person" means any
natural person, business entity, municipality, the State of Vermont or any
department, agency, or subdivision of the State, and any partnership,
unincorporated association, or other legal entity.
(21) "Pharmacy benefit manager" or "PBM" has
the same meaning as in
18 V.S.A. §
9471(5).
(22) "Psychiatric hospital" has the same
meaning as in
18 V.S.A. §
1902(1)(B).
(23) "Reporting manual(s)" means either the
VHCURES Reporting Manual or the VUHDDS Reporting Manual or the two documents
collectively.
(24) "Submitters"
means mandatory submitters and voluntary submitters collectively.
(25) "Subscriber" means the individual
responsible for payment of premiums or whose employment, income, or other
circumstances is the basis for eligibility for membership in a health benefit
plan.
(26) "Third-party
administrator" or "TPA" means any person who receives or collects charges,
contributions, or premiums for, or adjusts or settles claims on or for
residents of Vermont or health insurers.
(27) "Vermont Health Care Uniform Reporting
and Evaluation System" or "VHCURES" means the data set containing information
related to eligibility, health care claims, and related data submitted by
health care insurers to the GMCB.
(28) "Vermont Uniform Hospital Discharge Data
Set" or "VUHDDS" means the data set consisting of inpatient discharge data,
outpatient procedures and services data, and emergency department data
submitted by general hospitals, ambulatory surgery centers, and psychiatric
hospitals that is maintained by the Vermont Department of Health.
(29) "VHCURES members" means members who are
Vermont residents.
(30) "VHCURES
Reporting Manual" means the document created and maintained by the Board or the
Data Governance Council that specifies data submission requirements for the
VHCURES data set, including the required data submission schedule, required
fields, file layouts, file components, edit specifications, instructions, and
other technical information.
(31)
"Voluntary submitter" includes persons other than mandatory submitters,
including any health benefit plan offered or administered by or on behalf of
the federal government or a self-insured employer, that voluntarily submits
data to the Board for inclusion in the health care database.
(32) "VUHDDS Reporting Manual" means the
document created and maintained by the Board or the Data Governance Council
that specifies data submission requirements for the VUHDDS data set, including
the required data submission schedule, required fields, file layouts, file
components, edit specifications, instructions, and other technical
information.
8.200
VHCURES REGISTRATION AND SUBMISSION
8.201 Registration.
(a) Prior to doing business in Vermont and by
each December 31 thereafter, health insurers shall register with the Board on
the form(s) described in subsection (b) of this section. Health insurers that
are VHCURES submitters shall also identify whether they are paying health care
claims for VHCURES members.
(b) The
Board, in conjunction with the data collection vendor, shall issue and maintain
registration forms for health insurers. The forms shall require health insurers
to provide the Board with information on their organization and lines of
business, including whether the health insurer is a VHCURES mandatory submitter
and what data the health insurer will report to the Board.
(c) Health insurers shall notify the Board
when changes are made to any of the health insurer's contact information or the
data being submitted to the Board. The amended registration form shall be
submitted no later than fifteen (15) days after the applicable change goes into
effect.
8.202 VHCURES
Submitters.
(a)
(1)
VHCURES Mandatory
Submitters. VHCURES mandatory submitters are health
insurers with an average of two hundred (200) or more members in each month of
the last calendar year who are VHCURES members.
(2) A VHCURES mandatory submitter, as defined
in subpart (a)(1) of this subsection, must, for each health line of business
(e.g., comprehensive major medical, third-party administrator
(TPA)/administrative services only (ASO), Medicare Part C, and Medicare Part
D), regularly submit to the VHCURES data collection vendor medical claims data,
dental claims data, pharmacy claims data, member eligibility data, provider
data, and other non-claims information for all members who are VHCURES members.
The data must be submitted in the manner and format(s) and at the times
specified in this rule and the VHCURES Reporting Manual.
(3) Each VHCURES mandatory submitter is
responsible for the submission of data relating to all health care claims
processed by a contractor or subcontractor on its behalf unless such contractor
or subcontractor is already submitting identical data as a VHCURES mandatory
submitter in its own right.
(b)
(1)
VHCURES Voluntary Submitters. A VHCURES
voluntary submitter may submit the data specified in subpart (a)(2) of this
subsection to the VHCURES data collection vendor.
(2) The Board encourages VHCURES voluntary
submitters to follow the data submission specifications and schedule outlined
in section 8.203 of this rule and the VHCURES Reporting Manual.
8.203 VHCURES Data
Submission.
(a)
File
Organization. Data shall be submitted in the format(s)
specified in the VHCURES Reporting Manual.
(b)
Submission
Protocol. Files shall be submitted electronically by either
secure sockets layer (SSL) web upload interface or secure file transfer
protocol (FTP), or as specified in the VHCURES Reporting Manual. Email
attachments shall not be accepted.
(c)
Testing of
Files. At least sixty (60) days prior to the initial
submission of files or whenever the data element content of the files as
described in the VHCURES Reporting Manual is subsequently altered, each VHCURES
submitter shall submit data to the data collection vendor in accordance with
the VHCURES Reporting Manual for testing and validation.
(d)
Rejection of
Files. Failure to conform to subsections (a) or (b) of this
section shall result in the rejection and return of the applicable data
file(s). All rejected and returned files shall be resubmitted in the
appropriate corrected form to the VHCURES data collection vendor within ten
(10) days.
(e)
Replacement of Data Files. In the event a
complete data file submission is replaced more than one (1) year after the end
of the month in which the file was submitted, the VHCURES submitter must notify
the Board. Individual adjustment records may be submitted with any data file
submission in accordance with the applicable data submission
schedule.
(f)
Run-Out Period. VHCURES submitters shall
submit data for at least a six (6) month period following the termination of
coverage date for the particular VHCURES member.
(h)
(1)
Reporting Period. The reporting period
for submission for all VHCURES mandatory submitters shall be determined by the
highest total number of VHCURES members for any one month of the calendar year.
Data files are to be submitted in accordance with the schedule contained in the
VHCURES Reporting Manual.
(2) If
data files submitted by an individual VHCURES submitter support or are related
to files submitted by another VHCURES submitter, the Data Governance Council
may establish a different reporting period for the parties involved.
(i)
Data
Collection Vendor's Submission Requirements. The VHCURES
data collection vendor may provide additional guidelines, information, and
instructions regarding the submission of data to VHCURES. Subject to section
8.400 of this rule, VHCURES mandatory submitters shall comply with the
guidelines, information, and instructions the VHCURES data collection vendor
sets.
8.204 GMCB VHCURES
Reporting Manual.
The Board, through its Data Governance Council, shall issue
and maintain a publicly accessible document entitled "VHCURES Reporting Manual"
addressing the following topics:
(a)
The data VHCURES mandatory submitters shall submit;
(b) Technical specifications for the data,
including the member eligibility data, medical claims data, and pharmacy claims
data;
(c) The reporting schedule
for VHCURES mandatory submitters; and
(d) Any other matters the Board deems
appropriate.
8.205 Data
Quality Assurance.
The Board shall work in collaboration with the VHCURES data
collection vendor to ensure that submitted data are accurate and consistent
with the VHCURES Reporting Manual and the data collection vendor's submission
requirements.
8.300 VUHDDS
SUBMISSION
8.301 VUHDDS Submitters.
(a)
(1)
VUHDDS Mandatory Submitters. VUHDDS
mandatory submitters are ambulatory surgery centers, general hospitals, and
psychiatric hospitals in Vermont.
(2) A VUHDDS mandatory submitter, as defined
in subpart (a)(1) of this subsection, must submit including inpatient discharge
data, outpatient procedure and service data, emergency department data, and
other financial, scope- and volume-of-service, and utilization data to the
VUHDDS data collection vendor. The data must be submitted in the manner and
format(s) and at the times specified in the VUHDDS Reporting Manual.
(3) The submissions required under this
section shall be in addition to any submissions required by the uniform
reporting manual described in GMCB Rule 3.000.
(b)
(1)
VUHDDS Voluntary Submitters. A VUHDDS
voluntary submitter may submit the data specified in subsection 8.301(a)(2) to
the VUHDDS data collection vendor.
(2) The Board encourages VUHDDS voluntary
submitters to follow the data submission specifications and schedule outlined
in the VUHDDS Reporting Manual.
(c)
Data Collection
Vendor's Submission Requirements. The VUHDDS data
collection vendor may provide additional guidelines, information, and
instructions regarding the submission of data to VUHDDS. Subject to section
8.400 of this rule, VUHDDS mandatory submitters shall comply with the
guidelines, information, and instructions the VUHDDS data collection vendor
sets.
8.302 GMCB VUHDDS
Reporting Manual.
VUHDDS Reporting Manual. The Board,
through its Data Governance Council, shall issue and maintain a publicly
accessible guidance document, entitled "VUHDDS Reporting Manual," addressing
topics including:
(a) The data VUHDDS
mandatory submitters shall submit;
(b) Technical specifications for the data
submitted to VUHDDS;
(c) The
reporting schedule for VUHDDS mandatory submitters; and
(d) Any other matters the Board deems
appropriate.
8.303 Data
Quality Assurance.
The Board shall work in collaboration with its data
collection vendor to ensure that submitted data are accurate and consistent
with the VUHDDS Reporting Manual and any additional guidelines, information,
and instructions the data collection vendor may issue.
8.400 CHANGES TO A REPORTING MANUAL
8.401 Modifications and Revisions to a
Reporting Manual.
The Data Governance Council may revise or modify reporting
manuals as appropriate. Prior to approving any revisions or modifications, the
Council will send each affected submitter notice and a copy of the proposed
revisions or modifications. The Board will also post the notice and proposed
revisions or modifications on its website. The Council will accept public
comments on the proposed revisions or modifications for thirty (30) days from
the date of posting and will review and consider all comments received before
approving revisions or modifications.
8.402 Public Meeting.
The Data Governance Council may hold a public meeting to
discuss and receive comments on proposed revisions or modifications to
reporting manuals. Such meetings, if held, must be held in accordance with the
Vermont Open Meeting Law,
1 V.S.A. §§
310, et seq.
8.403 Implementation.
Revisions or modifications to reporting manuals shall become
effective one hundred twenty (120) days, or such longer time specified by the
Data Governance Council, after the Data Governance Council votes to approve
them. The Data Governance Council shall review all comments related to the time
required by submitters to comply with any revisions or modifications to the
reporting manuals, and the Council shall consider such comments when
determining whether to specify a time period longer than one hundred twenty
days before revisions or modifications become effective. During that 120-day
period (or longer, if specified by the Data Governance Council), affected
mandatory submitters shall work with the Board and the data collection vendor
to ensure the revisions or modifications can be implemented effectively. For
good cause, an affected submitter may request a reasonable extension to the
120-day (or longer, if specified by the Data Governance Council) implementation
period, which the Council may grant as it deems appropriate. Any such request
shall be submitted to the Council chair in writing and contain the length of
the extension requested and a detailed explanation as to why there is good
cause to grant the extension.
8.404 Appeal Procedure.
A decision by the Data Governance Council to deny a request
for an extension to the 120-day (or longer, if specified by the Data Governance
Council) implementation period may be appealed to the Board by filing a written
request to the Board chair within thirty (30) days of the Council's decision.
If the request does not include a request for a hearing, the Board may decide
the appeal based on the record developed by the Data Governance Council.
8.500 ENFORCEMENT
8.501 Sanctions for Violations.
Violations of data submission requirements, confidentiality
requirements, or any other provisions of
18 V.S.A. §
9410 or this rule, may be subject to sanction
by the Board in accordance with
18 V.S.A. §
9410(g) after written notice
and an opportunity for a hearing. The Board's authority to impose sanctions is
in addition to any other powers granted to the Board to investigate, subpoena,
or seek other legal or equitable remedies, including the power of the Board to
enforce the terms of a governing contract.
8.600 OTHER MATTERS
8.601 Waiver of Rules.
In order to prevent unnecessary hardship, delay, or
injustice, or for other good cause, the Board may waive the application of any
provision of this rule upon such conditions as it may require, unless precluded
by the rule itself or by statute.
8.602 Conflict.
In the event this rule or any section thereof conflicts with
a federal statute, rule, or regulation or a Vermont statute, the federal or
state statute, or the federal rule or regulation shall govern.
8.603 Severability.
If any provision of this rule or the application thereof to
any person or circumstance is for any reason held to be invalid, the remainder
of the rule and the application of such provisions to other persons or
circumstances shall be not affected thereby.
8.604 Effective Date.
This rule shall become effective fifteen (15) days after
adoption and supersedes all previously issued rules and policies related to the
health care database, including Regulation H-2008-01 issued by the Vermont
Department of Banking, Insurance, Securities and Health Care
Administration.
