Hawaii Administrative Rules
Title 11 - DEPARTMENT OF HEALTH
Subtitle 1 - GENERAL DEPARTMENTAL PROVISIONS
Chapter 188 - SUBMISSION OF ADMINISTRATIVE DATA TO THE STATE HEALTH PLANNING AND DEVELOPMENT AGENCY
Subchapter 1 - GENERAL PROVISIONS
Section 11-188-2 - Definitions
Current through February, 2024
As used in this chapter, unless a different meaning clearly appears in the context:
"Administrative data" or "data" means:
(1) Statistical and financial reports of information;
(2) Provider invoices or similar patient encounter data;
(3) Records of services used for or resulting from administering delivery of health care, pharmacy benefits, or dental care, including health care claims data, records of services provided under health benefits plans as defined in section 87A-1, HRS; and
(4) Any other records as established pursuant to administrative rules adopted pursuant to chapter 91, HRS.
"Administrator" means the administrator of the state health planning and development agency.
"Agency" means the state health planning and development agency as established in section 323D-11, HRS.
"Annual plan" means the plan developed by the agency pursuant to section 323D-18.5, HRS. "Carrier" means any of the following:
(1) An insurer engaged in the business of health care or dental insurance in the State;
(2) A business under an administrative services organization or administrative services contract arrangement;
(3) A third party administrator, licensed by the State, that collects premiums or settles claims of residents of the State, for health care insurance policies or health benefit plans;
(4) A governmental plan, as defined in section 414(d), Internal Revenue Code, that provides health care benefits;
(5) A program funded or administered by the State for the provision of health care services, including medicaid;
(6) A licensed professional employer organization acting as an administrator of a health care insurance plan;
(7) A health benefit plan funded by a self-insurance arrangement;
(8) The public employees' benefit and insurance program or EUTF; or
(9) A pharmacy benefit manager, defined to be a person that provides pharmacy benefit management services on behalf of any other carrier.
"Cell size" means the count of persons that share a set of characteristics contained in a statistical cell or table.
"Data element" means the specific information collected and recorded for the purpose of health care and health service delivery. Data elements include, but are not limited to information to identify the individual, health care provider, data supplier, service provided, charge for service, payer source, medical diagnosis, and medical treatment.
"Data sharing agreement" means an agreement between a data submitter and the agency that governs the- provision and use of data by the agency.
"Data submission guide" means the document referenced in section 11-188-11 for data submissions to the agency or the agency's designee.
"De-identified test database" means the database composed of de-identified test data for use by authorized individuals to test analytic algorithms and statistical methods.
"Dental claims file" means a data file composed of dental service level remittance information for all non-denied adjudicated claims for each billed dental service, including but not limited to member demographics, provider information, care and payment information, and clinical diagnosis and procedure codes.
"Designee" or "designees" means a governmental or nonprofit entity with which the agency has entered into an agreement pursuant to section 323D-18.5, HRS, to perform, on behalf of the agency, data collection and management, data analysis, reporting, and administrative functions. The pacific health informatics and data center is the agency's designee.
"Direct personal identifiers" means health care claims data relating to an individual patient, member, or enrollee that contains primary, distinct, or recognizable identifiers, including but not limited to: names; date of birth; business names when that name would serve to identify a person; postal address information other than town or city, state, and five-digit zip code; specific latitude and longitude or other geographic information that would be used to derive a postal address; telephone and fax numbers; electronic mail addresses; social security numbers; vehicle identifiers and serial numbers, including but not limited to license plate numbers; medical record numbers; health plan beneficiary numbers; certificate and license numbers; internet protocol addresses and uniform resource locators that identify a business that would serve to identify a person; and personal photographic images.
"Disclosure" or "disclose" means the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information.
"Employer-union health benefits trust fund" or "EUTF" means the Hawaii employer-union health benefits trust fund established under chapter 87A, HRS.
"Encrypted record identifier" means a code or other means of record identification to allow patients, members, or enrollees to be tracked across the data without revealing their identity or personal health. Encrypted identifiers are not direct personal identifiers.
"Encryption" or "encrypted" means the use of an algorithmic process to transform data into a form in which the data is rendered unreadable or unusable without the use of a confidential process or key as defined in section 487N-1, HRS.
"Health benefit plan" or "health benefits plan" means a policy, contract, certificate, or agreement entered into or offered by a provider of health insurance to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, as defined in section 87A-1, HRS.
"Health care claims data" means any information consisting of, or derived directly from, member eligibility data, medical claims, pharmacy claims, dental claims, vision claims, and other data submitted by reporters to the agency or the agency's designee.
"Health care provider" means a health care facility, physician licensed under chapter 453,HRS, dentist licensed under chapter 448,HRS, chiropractor licensed under chapter 442,HRS, optometrist licensed under chapter 459,HRS, podiatrist licensed under chapter 463E,HRS, psychologist licensed under chapter 465,HRS, occupational therapist subject to chapter 457G,HRS, physical therapist licensed under chapter 461J,HRS, or any person, partnership, corporation, facility, or institution licensed, certified, or authorized by law to provide professional health care services in the State to an individual during that individual's medical care, treatment, or confinement.
"Health insurance" means insurance against bodily injury, disablement, or death by accident, or accidental means, or the expense thereof; against disablement or expense resulting from sickness; and every insurance appertaining thereto.
"Individually identifiable health information" means information that is a subset of health information, including demographic information collected from an individual; and that:
(1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
(2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and:
"Mandatory reporter" means providers of health insurance that provide health benefit plans funded by the Hawaii employer-union health benefits trust fund and the state medicaid agency, which are required under section 323D-18.5, HRS, to submit data to the agency or the agency's designee.
"Medical claims file" means a data file composed of medical service level remittance information for all non-denied adjudicated claims for each billed service including but not limited to member demographics, provider information, care and payment information, and clinical diagnosis and procedure codes, and shall include all claims related to medical, vision, and behavioral health.
"Med-QUEST" means the Hawaii state medicaid agency established to administer the medicaid program.
"Member" means the insured subscriber and any spouse or dependent covered by the subscriber's policy. The member is the subject of the activities of the claim or claim line performed by the health care provider.
"Member eligibility file" means a data file containing demographic information for each individual member eligible for medical, vision, dental,-or pharmacy benefits for one or more days of coverage at any time during the reporting period.
"Pacific health informatics and data center" means the data center program of the University of Hawaii telecommunications and social informatics research program of the social science research institute of the college of social sciences of the University of Hawaii at Manoa.
"Personally identifiable information" means information relating to an individual that contains direct or indirect identifiers for which a reasonable basis exists to believe that the information can be used to identify an individual.
"Pharmacy benefit manager" means any person, business, or entity that performs pharmacy benefit management, including but not limited to a person or entity under contract with a pharmacy benefit manager to perform pharmacy benefit management on behalf of a managed care company, nonprofit hospital or medical service organization, insurance company, third-party payer, or health program administered by the State, pursuant to section 431R-1, HRS.
"Pharmacy claims file" means a data file containing service level remittance information from all non-denied adjudicated claims for each prescription, including but not limited to member demographics, provider information, charge and payment information, and national drug codes.
"Protected health information" means individually identifiable health information:
(1) Except as provided in paragraph (2), that is:
(2) Protected health information excludes individually identifiable health information, pursuant to 45 C.F.R. section 160.103:
"Provider file" means a data file containing information on every health care provider contracted by the provider of health insurance during the reporting period.
"Provider of health insurance" means a group health insurance contract or service agreement that may include medical, hospital, surgical, prescription drug, vision, or dental services, in which a carrier agrees to provide, pay for, arrange for, or reimburse the cost of the services, including third party administrators.
"Report" means a combination of data or information collected and produced by the agency or its designee(s), including but not limited to a compilation, study, or analysis designed to meet the needs of specific audiences, without personally identifiable information.
"Social security number" means the social security number of a member or subscriber.
"Subscriber" means the individual responsible for payment of premiums or whose employment is the basis for eligibility for membership in a health benefit plan.
"Third party administrator" means any person who, on behalf of a health insurer or purchaser of health
benefits, receives or collects charges, contributions, or premiums for, or adjusts or settles claims on or for residents of the State of Hawaii, health care providers and facilities.
"Voluntary reporter" means a provider of health insurance or other data source provider that is not required to provide data but agrees to provide data in accordance with a data use agreement.
