90-590-243 Me. Code R. § 1

Current through 2024-51, December 18, 2024

Section 590-243-1 - Definitions

Unless the context indicates otherwise, the following words and phrases shall have the following meanings:

A.Billing Provider. "Billing provider" means a provider or other entity that submits claims to health care claims processors for health care services directly performed or provided to a subscriber or member by a service provider.

B.Capitated Services. "Capitated services" means services rendered by a provider through a contract where payments are based upon a fixed dollar amount for each member monthly.

C.Carrier. "Carrier" means an insurance company licensed in accordance with 24-A M.R.S., including a health maintenance organization, a multiple employer welfare arrangement licensed pursuant to Title 24-A, Chapter 81, a preferred provider organization, a fraternal benefit society, or a nonprofit hospital or medical service organization or health plan licensed pursuant to 24 M.R.S. An employer exempted from the applicability of 24-A M.R.S., Chapter 56-A under the federal Employee Retirement Income Security Act of 1974, 29 United States Code, Sections 1001 to 1461 (1988) ("ERISA") is not considered a carrier.

D.Co-Insurance. "Co-insurance" means the dollar amount a member pays as a pre-determined percentage of the cost of a covered service after the deductible has been paid.

E.Co-Payment. "Co-payment" means the fixed dollar amount a member pays to a health care provider at the time a covered service is provided or the full cost of a service when that is less than the fixed dollar amount.

F.Deductible. "Deductible" means the total dollar amount a member pays towards the cost of covered services over an established period before any payments are made by the contracted third-party payor.

G.Dental Claims File. "Dental claims file" means a data file composed of service level remittance information including, but not limited to, member demographics, provider information, charge/payment information, and current dental terminology codes from all non-denied adjudicated claims for each billed service.

H.Designee. "Designee" means an entity with which the MHDO has entered into an arrangement under which the entity performs data collection, validation and management functions for the MHDO and is strictly prohibited from releasing information obtained in such a capacity.

I.Health Care Claims Processor. "Health care claims processor" means a third-party payor, third-party administrator, Medicare health plan sponsor, or pharmacy benefits manager.

J.Hospital. "Hospital" means any acute care institution required to be licensed pursuant to 22 M.R.S., Chapter 405.

K.MBI. "MBI" means the Center for Medicare and Medicaid Services Medicare Beneficiary Identifier.

L.Medical Claims File. "Medical claims file" means a data file composed of service level remittance information including, but not limited to, member demographics, provider information, charge/payment information, and clinical diagnosis/procedure codes from all nondenied adjudicated claims for each billed service.

M.Medicare Health Plan Sponsor. "Medicare health plan sponsor" means a health insurance carrier or other private company authorized by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services to administer Medicare Part C and Part D benefits under a health plan or prescription drug plan.

N.Member. "Member" includes the subscriber and any spouse or dependent who is covered by the subscriber's policy.

O.Member Eligibility File. "Member eligibility file" means a data file composed of demographic information for each individual member eligible for medical, pharmacy, or dental insurance benefits for one or more days of coverage any time during the reporting month.

P.MHDO. "MHDO" means the Maine Health Data Organization.

Q.M.R.S. "M.R.S." means Maine Revised Statutes.

R.Non-hospital Provider. "Non-hospital provider" means any provider of health care services other than a hospital.

S.Pharmacy. "Pharmacy" means a drug outlet licensed under 32 M.R.S., Chapter 117.

T.Pharmacy Benefits Manager. "Pharmacy benefits manager" means an entity that performs pharmacy benefits management as defined in 24-A M.R.S. §4347, sub-section 17.

U.Pharmacy Benefits Manager Compensation. "Pharmacy benefits manager compensation" means the difference between:

i. the value of payments made by a carrier to its pharmacy benefits manager; and

ii. the value of payments made by the pharmacy benefits manager to dispensing pharmacies for the provision of prescription drugs or pharmacy services with regard to pharmacy benefits covered by the carrier.

V.Pharmacy Claims File. "Pharmacy claims file" means a data file composed of service level remittance information including, but not limited to, member demographics, provider information, charge/payment information, and national drug codes from all non-denied adjudicated claims for each prescription filled.

W.Plan Sponsor. "Plan sponsor" means any person, other than an insurer, who establishes or maintains a plan covering residents of the State of Maine, including, but not limited to, plans established or maintained by two or more employers or jointly by one or more employers and one or more employee organizations, or the association, committee, joint board of trustees or other similar group of representatives of the parties that establish or maintain the plan.

X.POS. "POS" means point of sale.

Y.Provider. "Provider" means a health care facility, health care practitioner, health product manufacturer, health product vendor or pharmacy.

Z.Rebate. "Rebate" means a discount, chargeback, or other price concession that affects the price of a prescription drug product, regardless of whether conferred through regular aggregate payments, on a claim-by-claim basis at the point-of-sale, as part of retrospective financial reconciliations (including reconciliations that also reflect other contractual arrangements), or by any other method. "Rebate" does not mean a "bona fide service fee", as such term is defined in Section 447.502 of Title 42 of the Code of Federal Regulations, published October 1, 2019.

AA.Service Provider. "Service provider" means the provider who directly performed or provided a health care service to a subscriber or member.

BB.Subscriber. "Subscriber" is the insured individual.

CC.Substance Use Disorder (SUD). "SUD" means a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems such as impaired control, social impairment, risky use, and pharmacological tolerance and withdrawal, excluding tobacco/nicotine or caffeine use.

DD.SUD Claims File: "SUD Claims File" means a data file composed of service level remittance information, de-identified in accordance with HIPPA regulations, including member demographics, provider information, charge/payment information, and clinical diagnosis/procedure codes from all non-denied, adjudicated claims and claim lines for each billed service for SUD or SUD related parts of medical and pharmacy claims.

EE.Third-party Administrator. "Third-party administrator" means any person licensed by the Maine Bureau of Insurance under 24-A M.R.S., Chapter 18 who, on behalf of a plan sponsor, health care service plan, nonprofit hospital or medical service organization, health maintenance organization or insurer, receives or collects charges, contributions or premiums for, or adjusts or settles claims on residents of this State.

FF.Third-party Payor. "Third-party payor" means a state agency that pays for health care services or a health insurer, carrier, including a carrier that provides only administrative services for plan sponsors, nonprofit hospital, medical services organization, or managed care organization licensed in the State.

90-590 C.M.R. ch. 243, § 1