W. Va. Code R. § 114A-1-3

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

Section 114A-1-3 - Determination of Health Care Payers Subject to Submission and Reporting Requirements; Exemptions

3.1. Presumptive data submitters:

3.1.1. Any health care payer is presumed to be a data submitter for any calendar year if it issued a policy, certificate, or contract under which it paid medical or pharmacy claims, or both, to a provider in this state in the immediately preceding calendar year; and

3.1.2. Any TPA is presumed to be a data submitter for any calendar year if it administered the payment of medical or pharmacy claims, or both, on behalf of a self-funded health plan in the immediately preceding calendar year. Self-funded employer plans governed by ERISA may decide whether or not to submit their data.

3.2. The Commissioner shall maintain and publish on the Office of the Insurance Commissioner's website by April 1 of each year a list of data submitters and the periods with respect to which each must report and submit data in accordance with this rule.

3.2.1. The Commissioner shall exclude from the list presumptive data submitters that, as reflected in Offices of the Insurance Commissioner records, or as otherwise determined by the Commissioner, did not pay or administer the payment of medical claims for 500 or more persons in the preceding calendar year.

3.2.2. Any entity that believes it should not be included on the list for any given year, on the ground that it did not meet the relevant 500-life threshold or that it is not a health care payer covered by this rule, may dispute the Commissioner's determination in accordance with the procedure set forth in W. Va. Code § 33-2-13.

3.2.3. The Secretary may grant an exemption for cause to any presumed data submitter or class of presumed data submitters from all or some of the requirements of this rule. Cause for an exemption includes but is not limited to the increased cost or difficulty in complying with the submission requirements or the marginal value of the data that would be reported by the exempt payers.

3.3. Data related to the following claims and benefits are not subject to this rule:

3.3.1. Claims under policies providing coverage for only accident, disability, or a combination of both; liability insurance or coverage issued as a supplement to liability insurance; credit only insurance; coverage for on-site clinics; similar insurance where medical benefits are secondary or incidental to other insurance benefits;

3.3.2. The following benefits if provided under a separate policy or certificate: limited scope dental or vision; long-term care, nursing home care, home health care, community-based care, or any combination thereof; coverage for only a specified disease or illness; or hospital indemnity or other fixed indemnity insurance and;

3.3.3. Claims under Medicare supplemental policies.

3.4. Any data submitter that has contracted to have its reporting and submission duties under this rule fulfilled by another person (including a TPA that administers that payer's claims) remains responsible for compliance with this rule regardless of the terms of any such contractual arrangement, and such data submitter remains subject to the investigation and enforcement provisions of section 8 of this rule notwithstanding that suspected or demonstrated noncompliance is attributable to the fault of such other person with which the data submitter has an arrangement for submission and reporting.

W. Va. Code R. § 114A-1-3