Rhode Island Code of Regulations
Title 216 - Department of health
Chapter 10 - Public Health Administration
Subchapter 10 - Registries
Part 5 - Rhode Island All-Payer Claims Database
Section 216-RICR-10-10-5.5 - Submission Requirements

A. Except as specifically exempted pursuant to § 5.3.2 of this Part, each Insurer shall submit to the Director a Health Care Claims Data Set pursuant to § 5.5.3 of this Part and an APM File, pursuant to § 5.5.4 of this Part. The Health Care Claims Data Set shall include claims-line detail for all health care services provided to a Member, whether or not the health care was provided within Rhode Island. Such data shall include, but shall not be limited to, fully-insured and self-funded accounts, all commercial medical products for all individuals and all group sizes and Medicare or Medicaid health plans. Such data shall not include Direct Personal Identifiers. The APM File shall include all payments for Members under contracts sitused in Rhode Island. For contracts issued at the group level, the contract is considered sitused in the State where the contract is sold. For contracts that are issued at the individual level, the contract is considered sitused in the State where the individual resides.

B. The Health Care Claims Data Sets and APM File shall be submitted to the Data Aggregator in the format required in the RIAPCD Technical Specification Manual.

C. Insurers shall transmit the required Health Care Claims Data Sets and APM File by means of a secure file transfer system to the Data Aggregator in a manner that is fully compliant with HIPAA and applicable Rhode Island statutes and Regulations.

A. Each Insurer shall submit to the Director or his or her designee by December 31st of each year, in a format outlined in the RIAPCD Technical Specification Manual, a contact and enrollment update form indicating if health care claims are being paid for Members and, if applicable, the types of coverage and estimated enrollment for the following calendar year.

B. It shall be the responsibility of the Insurer to resubmit or amend the form whenever modifications occur relative to the health care claims data set files, type(s) of business conducted, or contact information.

A. Medical Claims File: Insurers shall submit data files consistent with the definition contained in § 5.2(A)(17) of this Part. As detailed in the RIAPCD Technical Specification Manual, payers shall report information about services provided to Members under all reimbursement arrangements, including but not limited to fee for service, capitated arrangements, and any other claims-based payment methods.

B. Pharmacy Claims File: Insurers shall submit data files consistent with the definition contained in § 5.2(A)(23) of this Part for all pharmacy paid claims for covered pharmacy benefits that were actually dispensed to Members.

C. Dental Claims File: Insurers shall submit data files consistent with the definition contained in § 5.2(A)(4) of this Part for all dental paid claims for covered dental benefits that were actually dispensed to Members.

D. Member Eligibility File: Insurers shall submit data files consistent with the definition contained in § 5.2(A)(19) of this Part. As detailed in the RIAPCD Technical Specification Manual, payers shall report information on every Member enrolled during the reporting month whether or not the Member utilized services during the reporting period. This data submission shall not include the Member's Direct Personal Identifiers. The submission will have a Unique Identifier attached and shall be protected by the removal or Hashing of all Direct Personal Identifiers.

E. Provider File: Insurers shall submit files consistent with the definition contained in § 5.2(A)(24) of this Part. As detailed in the RIAPCD Technical Specification Manual, payers shall report information that will uniquely identify Health Care Providers and allow retrieval of related information from Eligibility, Medical, and Pharmacy Claims Files.

A. The Director may require Insurers to submit and periodically update information about the insurance product covering each Member, including covered services, market sector, plan characteristics, total premiums, deductibles, co-insurance and copayments as set forth in the RIAPCD Technical Specification Manual.

B. Alternative Payment Model File: Insurers shall submit annual APM files. As detailed in the RIAPCD Technical Specification Manual, payers shall report information on all payments made to providers, inclusive of those under the traditional FFS model, and contracts under payment arrangements outside of the traditional FFS model. In accordance with R.I. Gen. Laws § 23-17.17-9(e), the APM File shall not include trade secrets, as defined in R.I. Gen. Laws § 6-41-1(4).