W. Va. Code R. § 114A-1-2

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114A-1-2 - Definitions

As used in this rule:

2.1. "All-payer claims database" or "APCD" or "Act" means the program established pursuant to W. Va. Code § 33-4A-1et seq. for the collection, management and release of medical claims data submitted by health care payers.

2.2. "Accredited Standards Committee (ASC) X12" means the standards development organization accredited by the American National Standards Institute (ANSI) that develops and maintains electronic data interchange (EDI) standards and related documents for national and global markets, including standards for insurance claims transactions, or any successor organization.

2.3. "American National Standards Institute" or "ANSI" means the nonprofit membership organization that acts as an administrator and coordinator of the United States private sector voluntary standardization system consisting of public agencies and private organizations.

2.4. "APCD Council" means the collaborative effort convened and coordinated by the University of New Hampshire (UNH) and the National Association of Health Data Organizations (NAHDO) that is focused on improving the development and deployment of state-based all-payer claims database programs, including the development of a common data layout for use by such programs.

2.5. "Commissioner" means the West Virginia Insurance Commissioner.

2.6. "Data" means the data elements from enrollment and eligibility files, specified types of claims, and reference files for data elements not maintained in formats consistent with national coding standards.

2.7. "Data set" means a collection of individual data records and data elements, whether in electronic or manual files.

2.8. "Data submitter" means a health care payer that the Commissioner has determined is subject to the submission and reporting requirements of this rule for a given calendar year because it meets the threshold of having paid or administered the payment of health insurance claims in this state for policies for 500 or more covered lives in the prior calendar year and has not been exempted for cause from such requirements.

2.9. "Data processor" means any entity that performs data collection and data management functions pursuant to a contract for purposes of the state's all-payer claims database.

2.10. "Health care payer" means any insurer or health maintenance organization licensed in this state that pays medical benefits pursuant to a policy, certificate, or contract of health; any state and federal government payers of such benefits; any workers' compensation insurer; or any third-party administrator that administers a self-funded health insurance plan.

2.11. "Health care provider" or "provider" means any physician, hospital or other person or organization that is licensed or otherwise authorized in this state to furnish health care services.

2.12. "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, member demographics; provider information; charge/payment information; and clinical diagnosis/procedure codes. The term includes data related to behavioral, mental health, or substance abuse treatment.

2.13. "Member" means a subscriber and the spouse, dependent or other persons covered by the subscriber's policy.

2.14. "Member Eligibility file" means a data file that contains 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 period.

2.15. "National Council for Prescription Drug Programs" or "NCPDP" means the standards development organization accredited by the American National Standards Institute (ANSI) that develops and maintains national standards for pharmacy payers and providers, including standards for the pharmacy claim transaction, or any successor organization.

2.16. "Personal identifiers" means information relating to an individual member or insured that identifies, or can be used to identify, locate, or contact a particular individual member or insured.

2.17. "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 member demographics; provider information; charge/payment information; and national drug codes.

2.18. "Secretary" means the Secretary of the West Virginia Department of Health and Human Resources.

2.19. "Standards Development Organization" or "SDO" means an entity accredited by the American National Standards Institute (ANSI), such as ASC X-12, National Council for Prescription Drug Programs (NCPDP) and Health Level Seven (HL-7), that is responsible for maintaining the structure and control elements of transactions, or any of its successors.

2.20. "Submission Manual" or "Manual" means the legislative rule promulgated pursuant to subsection 4.2. of this rule that sets forth the required data file format, data elements, code tables, edit specifications, thresholds required for a submission to be deemed complete, methods for submitting data, submission schedules, and other information associated with the data submitters' submission and reporting duties.

2.21. "TPA" means a third-party administrator licensed by the Commissioner under W. Va. Code § 33-46-12 or § 33-46-14 or registered with the Commissioner under W. Va. Code § 33-46-13. A TPA that administers claims for an ERISA plan is not required to submit data but may voluntarily submit data.

W. Va. Code R. § 114A-1-2