Utah Administrative Code
Topic - Health
Title R428 - Center for Health Data, Health Care Statistics
Rule R428-2 - Health Data Authority Standards for Health Data
Section R428-2-3 - Definitions
Universal Citation: UT Admin Code R 428-2-3
Current through Bulletin 2024-06, March 15, 2024
(1) The terms used in this rule are defined in Section 26-33a-102.
(2) In addition, the following definitions apply to all of Title R428:
(a) "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.
(b) "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.
(c) "Ambulatory
surgical facility" is defined in Section
26-21-2.
(d) "Carrier" means any of the following
Third Party Payors as defined in Subsection
26-33a-102(16):
(i) an insurer engaged in the business of
health care or dental insurance in Utah, as defined in Section
31A-1-301;
(ii) a business under an administrative
services organization or administrative services contract
arrangement;
(iii) 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;
(iv) a governmental
plan, as defined in Section 414 (d), Internal Revenue Code, that provides
health care benefits;
(v) 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
26-40-103,
and the medical assistance programs described in Title 26, Chapter 18, Medical
Assistance Act or any entity under a contract with the Utah Department of
Health to serve clients under such a program;
(vi) a non-electing church plan, as described
in Section 410 (d), Internal Revenue Code, that provides health care
benefits;
(vii) a licensed
professional employer organization as defined in Section
31a-40-102 acting as
an administrator of a health care insurance plan;
(viii) a health benefit plan funded by a
self-insurance arrangement;
(ix)
the Public Employees' Benefit and Insurance Program created in Section
49-20-103;
(x) 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.
(e) "Claim" means a request or demand on a
carrier for payment of a benefit.
(f) "Covered period" means the calendar year
on which the data used for calculation of HEDIS measures is based.
(g) "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.
(h) "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.
(i)
"Electronic media" means a compact disc, digital video disc, external hard
drive, or other media where data is stored in digital form.
(j) "Electronic transaction" means to submit
data directly via electronic connection from a hospital or ambulatory surgery
facility to the Office according to Electronic Data Interchange standards
established by the American National Standards Institute's Accredited Standards
Committee, known as the Health Care Transaction Set (837) ASC X 12N.
(k) "Eligible Enrollee" means an enrollee who
meets the criteria outlined in the NCQA survey specifications.
(l) "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.
(m) "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.
(n) "Health Insurance" has the same meaning
as found in Section
31A-1-301.
(o) "Healthcare claims data" means
information consisting of, or derived directly from, member enrollment, medical
claims, and pharmacy claims that this rule requires a carrier to
report.
(p) "Healthcare Facility"
means a hospital or ambulatory surgical facility.
(q) "Healthcare Facility Data" means
ambulatory surgery data, discharge data, or emergency room data.
(r) "HEDIS" means the Healthcare
Effectiveness Data and Information Set, a set of standardized performance
measures developed by the NCQA.
(s)
"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.
(t) "Hospital" means a
general acute hospital or specialty hospital as defined in Section 21-21-2 that
is licensed under Title R432.
(u)
"Level 1 data element" means a required reportable data element.
(v) "Level 2 data element" means a data
element that is reported when the information is available from the patient's
hospital record.
(w) "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.
(x) "Office" means the
Office of Health Care Statistics within the Utah Department of
Health.
(y) "Order" means an action
of the committee that determines the legal rights, duties, privileges,
immunities, or other interests of one or more specific persons, but not a class
of persons.
(z) "Patient Social
Security number" is the social security number of a person receiving health
care.
(aa) "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.
(bb) "Public Use Data Set" means a data
extract or a subset of a database that is deemed by the Office to not include
identifiable data or where the probability of identifying individuals is
minimal.
(cc) "Report" means a
disclosure of data or information collected or produced by the committee or
Office, including a compilation, study, or analysis designed to meet the needs
of specific audiences.
(dd)
"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.
(ee) "Research Data Set"
means a data extract or subset of a database intended for use by data users for
bona fide research or statistical purposes that may include identifiable
information or where there is more than a minimal probability that the data
could be used to identify individuals.
(ff) "Record linkage number" is an
irreversible, unique, encrypted number that will replace patient social
security number.
(gg) "Sample file"
means the data file containing records of selected eligible enrollees drawn by
the survey agency from the carrier's sampling frame.
(hh) "Sampling Frame" means the carrier
enrollment file as described criteria outlined by the NCQA survey
specifications.
(ii) "Submission
year" means the year immediately following the covered period.
(jj) "Survey agency" means an independent
contractor on contract with the Office of Health Care Statistics.
(kk) "Utah Health Care Performance
Measurement Plan" means the plan for data collection and public reporting of
health-related measures, adopted by the Utah Health Data Committee to establish
a statewide health performance reporting system.
(ll) "Uniform billing form" means the uniform
billing form recommended for use by the National Uniform Billing
Committee.
(mm) "Utah Healthcare
Facility Data Submission Guide" means the document referenced in Subsection
R428-1-4(1).
(nn) "NCQA Survey Specifications" means the
document referenced in Subsection
R428-1-4(2)
(oo) "NCQA HEDIS Specifications"
means the document referenced in Subsection
R428-1-4(3)
(pp) "Data Submission Guide for
Claims Data" means the document referenced in Subsection
R428-1-4(4).
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