Section 0780-01-79-.02 - DEFINITIONSUnless the context indicates otherwise, the following words and phrases shall have the following meanings:
(1) "Address" means street address, post office box numbers, apartment numbers, e-mail addresses, web universal resource locator (URL) and internet protocol (IP) address number.(2) "Capitated services" means services rendered by a provider through a contract in which payments are based upon a fixed dollar amount for each member on a monthly basis.(3) "Commissioner" means the commissioner of the Tennessee Department of Commerce and Insurance.(4) "Comprehensive medical insurance policy" means an insurance policy covering all that a defined population might reasonably require in order to be in good health, including as a minimum, but not limited to, emergency care, inpatient hospital and physician care, ambulatory physician care and outpatient preventative medical services.(5) "Department" means the Tennessee Department of Commerce and Insurance.(6) "Designee" means an entity with which the Department and/or the department of finance and administration have entered into an arrangement pursuant to which the entity performs data management and collecting functions, and under which the entity is strictly prohibited from using or releasing the information and data obtained in such a capacity for any purposes other than those specified in the agreement.(7) "Direct identifier" means any information, other than case or code numbers used to create anonymous or encrypted data, that plainly discloses the identity of an individual, including:(b) Patient Street addresses other than town or city, state and zip code;(c) All elements of patient birth dates, except year of birth;(d) Patient telephone numbers;(e) Patient facsimile numbers;(f) Patient electronic mail addresses;(g) Patient social security numbers;(h) Medical record numbers;(i) Health Plan beneficiary numbers;(j) Patient account numbers;(k) Patient certificate/license numbers;(l) Vehicle identifiers and serial numbers including license plates;(m) Device identifiers and serial numbers;(n) Web universal resource locators (URLs);(o) Internet protocol (IP) address numbers;(p) Biometric identifiers, including fingerprints, voice prints, and genetic code;(q) Full-face photographic images and any comparable images; or(r) Any other unique patient identifying number, characteristic, or code except encrypted index numbers assigned prior to the transmission by health insurance issuers to the state or designated entity for the purpose of linking procedures by patient, provided a patient's identity cannot be known from the encrypted index number.(8) "Group health plan" means an employee welfare benefit plan, as defined in the Employee Retirement Income Security Act of 1974 ("ERISA") § 3(1), codified in 29 U.S.C. § 1002(1), to the extent that the plan provides medical care to employees or their dependents, as defined under the terms of the plan, or an administrator of such a plan. For purposes of this rule, "group health plan" shall not mean any plan which is offered through a health insurance issuer;(9) "Health care claims data" means information consisting of, or derived directly from, member eligibility files, medical claims files, and pharmacy claims files submitted by health insurance issuers.(10) "Health care practitioner" means physicians and all others certified, registered or licensed in the healing arts, including, but not limited to: (b) Advanced practice nurses(i) Physicians' assistants.(11) "Health insurance issuer" means an entity subject to the insurance laws of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide health insurance coverage, including but not limited to, an insurance company, a health maintenance organization and a nonprofit hospital and medical service corporation. In addition, a "health insurance issuer" also means a pharmacy benefits manager, a third party administrator, and an entity described in § 56-2-121.(12) "Hospital" means a licensed acute or specialty care institution.(13) "Medical claims file" means a data file composed of service level remittance information for all non-denied adjudicated claims for each billed service including, but not limited to:(b) Provider information;(c) Charge/payment information; and(d) Clinical diagnosis/procedure codes.(14) "Member" means the subscriber and any spouse and/or dependent who is covered by the subscriber's policy.(15) "Member eligibility file" means a data file containing demographic information for each individual member eligible for medical or pharmacy benefits for one or more days of coverage at any time during the reporting month.(16) "Pharmacy benefits manager" means a person, business or other entity and any wholly or partially owned subsidiary of the entity, that administers the medication and/or device portion of pharmacy benefits coverage.(17) "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: (b) Provider information;(c) Charge/payment information; and(18) "Plan sponsor" means any person, other than an insurer, who establishes or maintains a plan covering residents of the state of Tennessee, including, but not limited to, plans established or maintained by employers or jointly by one or more employers and one or more employee organizations, committee, joint board of trustees or other similar group of representatives of the parties that establish or maintain the plan.(19) "Provider" means a health care facility, health care practitioner, health product manufacturer, health product vendor or pharmacy.(20) "Sub-contractor" means any entity that contracts with a group health plan or health insurance issuer to provide insurance services.(21) "Subscriber" means the certificate holder.(22) "Third party administrator" means an entity that, on behalf of a health insurance issuer, employer or other entity, provides health benefits coverage or health insurance coverage, as defined in T.C.A. § 56-2-125(a)(5), to individuals in this state, receives or collects charges, contributions or premiums for, or adjudicates, processes or settles claims in connection with, any type of health benefit provided in, or as an alternative to, health insurance coverage.Tenn. Comp. R. & Regs. 0780-01-79-.02
Emergency rule filed March 11, 2010; effective through September 7, 2010. Original rule filed June 10, 2010; effective September 8, 2010.Authority: 2009 Public Acts, Chapter 611 and T.C.A. § 56-2-125.