R590. Insurance, Administration.R590-262. Health Data Authority Health Insurance Claims Reporting.
R590-262-1. Authority.
This rule is promulgated by the commissioner pursuant to Sections 31A-2-201 and 31A-22-614.5.
R590-262-2. Purpose and Scope.
(1) The purpose of this rule is to:
(a) establish the requirements for entities that pay for health care to submit data to the Utah Department of Health and Human Services;
(b) coordinate with:
(i) Sections 26B-8-411 and 26B-85-504; and
(ii) Rules R428-1 and R428-15;
(c) allow the data to be shared with the state's designated secure health information master patient index, Clinical Health Information Exchange (cHIE), to be used:
(i) in compliance with data security standards established by:
(A) the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, 110 Stat. 1936: and
(B) the electronic commerce agreements established in a business associate agreement;
(ii) for coordination of health insurance benefits; and
(iii) for the enrollment data elements identified in Rule R428-15.
(2) This rule applies to an insurer offering or administering health insurance, including a self-funded employee health plan that opts-in under Section R590-262-7.
(3) This rule does not apply to:
(a) an insurer that, as of the first day of the reporting period, covers fewer than 2,500 individual Utah residents;
(b) a long-term care insurance policy;
(c) an income replacement policy; or
(d) except as provided in Subsection (2)(c), a self-funded employee health plan.
(4)(a) The submission of data by an insurer on behalf of a self-funded employee health plan is considered mandatory if the employer sponsoring the self-funded employee health plan opts-in under Section R590-262-7.
(b) An insurer is not obligated to submit data on behalf of a self-funded employee health plan that opts-out or fails to respond to an opt-in request required in Section R590-262-7.
R590-262-3. Definitions.
Terms used in this rule are defined in Sections 31A-1-301 and 26B-8-501. Additional terms are defined as follows:
(1) "Data" means information consisting of, or derived directly from, enrollment, medical claims, dental claims, and pharmacy claims that this rule requires an insurer to report.
(2) "Insurer," for purposes of this rule, means:
(a) a person engaged in the business of offering health insurance;
(b) a third-party administrator that settles claims for:
(i) health insurance policies; or
(ii) a self-funded employee health plan if the employer of the self-funded employee health plan opts-in under Section R590-262-7;
(c) a governmental plan as defined in Section 414(d), Internal Revenue Code;
(d) a non-electing church plan as described in Section 410(d), Internal Revenue Code; or
(e) a licensed professional employer organization that is acting as an administrator of a health insurance policy.
(3) "Office" means the Healthcare Information and Analysis Program within the Utah Department of Health and Human Services Division of Data, Systems, and Evaluation.
(4) "Reporting period" means a calendar year.
(5)(a) "Self-funded employee health plan" means:
(i) an employee welfare benefit plan as defined in 29 U.S.C. Section 1002(1) whose health coverage is provided other than through an insurance policy; and
(ii) the plan has opted-in under Section R590-262-7.
(b) Self-funded employee health plan does not include:
(i) a governmental plan as defined in Section 414(d), Internal Revenue Code;
(ii) a non-electing church plan as described in Section 410(d), Internal Revenue Code; or
(iii) the Public Employees' Benefit and Insurance Program created in Section 49-20-103.
(6) "Technical specifications" means the technical specifications document published by the Health Data Committee describing the variables and formats of the data that are to be submitted as well as submission directions and guidelines.
R590-262-4. Reporting Requirements.
(1) An insurer shall submit the data described in this rule and Section R428-15-3, if Utah is the patient's primary residence, for a service provided in or out of Utah.
