N.H. Admin. Code Ins, ch. Ins 4000, app B
The State of New Hampshire Insurance Department 21 South Fruit Street, Suite 14 Concord, NH 03301 (603) 271-2261 Fax (603) 271-1406 TDD Access: Relay NH 1-800-735-2964 |
NHID Opt-In Form
All-Payer Claims Database Indication of Intent for Private Employers Offering Self-Funded Health Coverage in New Hampshire
You are receiving this form under a 2016 New Hampshire law allowing a self-funded private employer to direct its claims administrator to include the health care claims data of its employees and covered dependents in the state's All-Payer Claims Database (APCD) (NH RSA 420-G:11, V).
* In response to rising health care costs, the New Hampshire Insurance Department has, since 2003, collected health care claims data from insurers and third-party administrators in an APCD. To protect privacy, under state law the database "shall not include or disclose any data that contains direct personal identifiers".
(NH RSA 420-G:11-a, I)
* The APCD enhances transparency, providing employers, policymakers, payers, and health care providers with vital information about the factors contributing to rising health care costs in New Hampshire. In addition, the Insurance Department uses the database to provide health cost information to the public, including employers and their employees, through the NH HealthCost website: http://nhhealthcost.nh.gov/.
* New Hampshire's database has always included data from self-funded employers, because the accuracy of information derived from the database increases when more claims are included. In 2016, the U.S. Supreme Court ruled that Vermont could not require self-funded private employers to submit data to the state's APCD. To clarify New Hampshire law after that ruling, the legislature required the creation of this form to allow self-funded private employers to direct their claims administrators to include their data.
If you elect to participate, please indicate your intent below by checking, signing, and providing the requested information; then return this form to your claims administrator. If you have questions about New Hampshire's APCD or the department's efforts to improve health care cost transparency, contact the NH Insurance Department at 603.271.2261 or requests@ins.nh.gov, or visit http://www.nh.gov/insurance/. Thank you.
Please check, sign, and supply information requested below, if electing to participate:
On behalf of the Employer listed below, I elect to participate in claims data submission to the NH APCD. I direct the Third-Party Administrator listed below to submit data to the NH APCD and to disclose this election to the NH Insurance Department.
Authorizing Signature: ___________________________________
Name and Title of Person Authorizing: ___________________________________
Date of Signature: ___________________________________
Employer Name: ___________________________________
Employer Address: ___________________________________
Employer Contact Name: ___________________________________
Employer Contact Phone and Email: ___________________________________
Approximate # of enrolled lives in NH: ___________________________________
Third-Party Administrator: ___________________________________
INSTRUCTIONS FOR COMPLETING "NH Opt-In Form"
Fill in the blank next to the requested information as follows:
Authorizing Signature means the signature of the person authorized to act on behalf of the employer.
Name and Title of Person Authorizing means the printed name and title of the person signing on behalf of the employer.
Date of Signature means the date the form is signed.
Employer Name means the name of the employer being presented the form.
Employer Address means the business address of the employer.
Employer Contact Name means the name of a person, acting on behalf of the employer, that can be contacted with any questions.
Employer Contact Phone and Email means the phone number and email address of the Employer Contact person.
Approximate # of Enrolled Lives in NH means the number of enrollees in the self-funded health coverage, to the best knowledge of the authorizing person.
Third-Party Administrator means the name of the claims administrator for the Employer named on the form.
Fill in the blank next to the requested information as follows:
Authorizing Signature means the signature of the person authorized to act on behalf of the employer.
Name and Title of Person Authorizing means the printed name and title of the person signing on behalf of the employer.
Date of Signature means the date the form is signed.
Employer Name means the name of the employer being presented the form.
Employer Address means the business address of the employer.
Employer Contact Name means the name of a person, acting on behalf of the employer, that can be contacted with any questions.
Employer Contact Phone and Email means the phone number and email address of the Employer Contact person.
Approximate # of Enrolled Lives in NH means the number of enrollees in the self-funded health coverage, to the best knowledge of the authorizing person.
Third-Party Administrator means the name of the claims administrator for the Employer named on the form.
N.H. Admin. Code Ins, ch. Ins 4000, app B