in-20240417-IR-760240151FNA: ALL PAYER CLAIMS DATA BASE SUBMISSION REQUIREMENTS

Notice of First Public Comment Period LSA Document #24-151 Sec. 1. The definitions in this rule apply throughout this rule. Sec. 2. "Administrator" has the meaning set forth in IC 27-1-44.5-0.2. Sec. 3. "APCD" or "data base" has the meaning set forth in IC 27-1-44.5-1. Sec. 4. "APCD-CDL™" means the common data layout for all payer claims databases, as developed by the University of New Hampshire and the National Association of Health Data Organizations, Version 2.1, released July 1, 2021, and hereby incorporated by reference. For purposes of this rule, a reference to an individual's Social Security number in the APCD-CDL™ means the last four (4) digits of the individual's Social Security number. Sec. 5. "Department" means the Indiana department of insurance. Sec. 6. "Designated submitter" means an entity designated by a health payer or voluntarily participating entity to: Sec.7. "Designated submitter representative" means an individual or the individuals authorized by a designated submitter to: Sec. 8. "Eligibility file" means a file that includes data about each member residing in Indiana, based on the requirements contained in the submission guide. Sec. 9. "ERISA" means the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et seq.). Sec. 10. "ERISA plan" means an employee benefit plan that is subject to ERISA. For purposes of this rule, the term includes a third party administrator of an employee benefit plan. Sec. 11. "Executive director" has the meaning set forth in IC 27-1-44.5-1.2. Sec. 12. "Health payer" has the meaning set forth in IC 27-1-44.5-2. Sec. 13. "Health plan" means health insurance coverage offered to a member by a health payer. Sec. 14. "Historical and catch-up data" means: Sec. 15. "Medical claims file" means a file that includes data about medical claims and other encounter information, based on the requirements contained in the submission guide. Sec. 16. "Member" means an individual covered by, or enrolled in a health plan administered by, a health payer. Sec. 17. "Pharmacy claims file" means a file that includes data about prescription medications and claims filed by pharmacies, based on the requirements contained in the submission guide. Sec. 18. "Plan size submission threshold" means an aggregate total of at least three thousand (3,000) members under a health payer. Sec. 19. "Provider file" means a file that includes additional information about the individuals and entities included in the medical claims file, pharmacy claims file, or eligibility file, and submitted based on the requirements contained in the submission guide. Sec. 20. "Submission guide" or "data submission guide" means the document entitled "Indiana All Payer Claims Database Data Submission Companion Guide", Version 1.1, updated September 2023 and hereby incorporated by reference, developed by the administrator setting forth the required schedules, data file format, record specifications, data elements, and definitions for submitting: Sec. 21. "Submitter" includes the following: Sec. 22. "Third party administrator" has the meaning set forth in IC 27-1-25-1(a). Sec. 23. "Voluntarily participating entity" means an entity: Sec. 24. (a) To request to become a voluntarily participating entity, an entity shall submit a request to the administrator to participate in the APCD through the data portal. (b) A request described in subsection (a) must include the following information related to the voluntarily participating entity: (c) The administrator shall notify the requesting entity of the department's determination. Sec. 25. (a) A health payer not meeting the plan size submission threshold is exempt from the submission requirements set forth in sections 28, 29, and 34 of this rule. The number of Indiana members is calculated by adding together the Indiana members in all the entity's health plans as of December 31 each calendar year. Additional changes in the data submission guide will allow an eighty (80) calendar day window to submit data after the approved and final publications of the data submission guide. (b) A health payer dropping below the plan size submission threshold as of December 31 shall submit data files to the APCD for data through December 31 of that calendar year. The health payer shall notify the APCD of its change in status and may elect to become a voluntarily participating entity. (c) A previously exempt health payer no longer exempt by meeting the plan size submission threshold as of December 31 shall submit data files to the APCD to report the next calendar year's data. (d) A newly created health payer meeting the plan size submission threshold December 31 of the year when it is created shall submit data files to the APCD to report the next calendar year's data. Sec. 26. (a) If a health payer contracts with other entities to administer plan benefits, the health payer has sole responsibility for the timely submission of the data to the APCD. The health payer shall either: (b) A health payer shall identify contracted entities through the registration process. Each contracted entity shall register as set forth in section 27 or 34 of this rule, as applicable. This entity is referred to as a designated submitter. Sec. 27. (a) Health payers shall register in the data portal and review and update, or confirm, the registration information before February 1 each year after the year of its initial registration. (b) When a health payer becomes subject to this rule, it shall register at least sixty (60) calendar days before its first data files are due. (c) A voluntarily participating entity shall register to submit data to the data portal. Before registering, the entity must have been approved to submit data under section 24 of this rule. (d) Submitters shall: Sec. 28. (a) Submitters shall submit data files monthly through the data portal. A monthly file must be submitted by the first business day of the second month after the report month. (b) The following files, as specified in the data submission guide, in conjunction with the APCD-CDL™, must be submitted: (c) Files must exclude data for members only enrolled in the types of coverages set forth in IC 27-1-44.5-2(3)(A) through IC 27-1-44.5-2(3)(H). (d) Data files must comply with file format, technical specifications, and other standards specified in the data submission guide, in conjunction with the APCD-CDL™. (e) If a submitter has identified at least one (1) designated submitter or designated submitter representative to submit information directly to the data portal on their behalf, the data submission is not considered finished until the required files have been received. (f) Submitters shall use the data portal to submit test files to confirm and test their ability to create data files meeting the standards set forth in the data submission guide. Test files will be identified as specified in the data submission guide. Test files will not be considered to have been submitted to the APCD. Sec. 29. (a) A submitter shall use the test function to prepare for submitting historical and catch-up data files. This testing process must be successfully finished before July 1, 2023. (b) Submitters shall submit historical and catch-up data files as set forth in section 28 of this rule for the period beginning January 1, 2020, through July 31, 2023, before September 1, 2023. Additional changes in the data submission guide will be announced with an eighty (80) calendar day window for submitters to prepare, reprogram, test, and submit production data. (c) Submitters shall begin regular monthly reporting with monthly data files for August 2023 before October 3, 2023. Additional changes in the data submission guide will be announced with an eighty (80) calendar day window for submitters to prepare, reprogram, test, and submit production data. Sec. 30. Data files submitted to the data portal but not meeting the file intake specifications detailed in the data submission guide will not be accepted. Submitters will be notified within two (2) business days after submission whether a data file has been accepted or rejected. Sec. 31. If the administrator determines a previously accepted file contains initially unidentified errors, the administrator shall notify the submitter. The submitter shall address the issues identified by the administrator by either: Sec. 32. (a) A submitter unable to submit data files meeting the standards set forth in the data submission guide may request a temporary variance to those requirements. (b) Variance requests may only be submitted through the data portal, and must clearly identify the following with the data submission guide requirements: (c) An administrator shall either approve or disapprove variance requests meeting the requirements of subsection (b) within five (5) calendar days after the date the request was submitted. Sec. 33. (a) If a health payer fails to: (b) If a health payer fails to provide the required information set forth in the written notice described in subsection (a) within thirty (30) calendar days after receiving the notice, the administrator shall give written notice of the failure to report to the health payer by registered or certified mail, return receipt requested and notify the executive director of the health payer's failure to report. (c) The executive director may assess a penalty for uncured violations of up to: (d) If the failure to perform any of the actions set forth in subsection (a) is a result of the action or inaction of a contracted entity identified as a designated submitter or a designated submitter representative, the penalty is assessed to the health payer. (e) The penalties specified in this section do not apply to voluntarily participating entities. (f) Penalties will be deposited into the department of insurance fund created by IC 27-1-3-28. Sec. 34. (a) This section applies only to ERISA plans in effect after June 30, 2023. (b) Section 29 of this rule does not apply to ERISA plans. (c) An ERISA plan must register to submit data to the data portal. An ERISA plan must: (d) A submitter shall use the test function to prepare for submitting historical and catch-up data files. This testing process must be successfully finished before November 1, 2023. (e) Submitters shall submit historical and catch-up data files as set forth in section 28 of this rule for the period beginning January 1, 2020, through December 31, 2023, before April 1, 2024. (f) Submitters shall begin regular monthly reporting with monthly data files for January 2024. Sec. 35. If a section or part of a section of this rule, or its applicability to any person or circumstance, is held invalid by a court, the remainder of the rule or the applicability of the provision to other persons or circumstances is not affected.