TITLE 760 DEPARTMENT OF INSURANCE
Provisional Rule
LSA Document #23-678
DIGEST
Temporarily adds rules to require health payers to submit necessary information to the administrator of the Indiana all payer claims database and to otherwise implement
IC 27-1-44.5. Effective September 23, 2023. Expires March 21, 2024.
SECTION 1. The definitions in this document apply throughout this document.
SECTION 3.
"APCD" or "data base" has the meaning set forth in IC 27-1-44.5-1.
SECTION 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 document, any reference to an individual's Social Security number within the APCD-CDL™ means the last four digits of an individual's Social Security number.
SECTION 5. "Department" means the Indiana department of insurance.
SECTION 6. "Designated submitter" means an entity designated by a health payer or a voluntarily participating entity to:
(1) submit data to the APCD on behalf of the health payer or voluntarily participating entity; and
(2) receive all communications from the administrator and the department regarding the health payer's or voluntarily participating entity's APCD data submissions.
SECTION 7. "Designated submitter representative" means an individual or individuals authorized by a designated submitter to:
(1) submit data to the APCD on behalf of the health payer or voluntarily participating entity; and
(2) receive all communications from the administrator and the department regarding the health payer's or voluntarily participating entity's APCD data submissions.
SECTION 8. "Eligibility file" means a file that includes data about each individual member residing in Indiana, according to the requirements contained in the submission guide.
SECTION 9. "ERISA" means the federal Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et. seq.).
SECTION 10. "ERISA plan" means an employee benefit plan that is subject to ERISA. For purposes of this document, the term includes a third party administrator of an employee benefit plan.
SECTION 12.
"Health payer" has the meaning set forth in IC 27-1-44.5-2.
SECTION 13. "Health plan" means health insurance coverage offered to a member by a health payer.
SECTION 14. "Historical and catch-up data" means:
(1) eligibility files;
(2) medical claims files;
(3) pharmacy claims files; and
(4) provider files;
submitted to the APCD by a submitter for the time period specified in this document.
SECTION 15. "Medical claims file" means a file that includes data about medical claims and other encounter information, according to the requirements contained in the submission guide.
SECTION 16. "Member" means a person who is covered by, or enrolled in a health plan administered by, a health payer.
SECTION 17. "Pharmacy claims file" means a file that includes data about prescription medications and claims filed by pharmacies, according to the requirements contained in the submission guide.
SECTION 18. The "plan size submission threshold" is an aggregate total of 3,000 or more members under a health payer.
SECTION 19. "Provider file" means a file which includes additional information about the individuals and entities that are included in the medical claims file, the pharmacy claims file, or the eligibility file and is submitted according to the requirements contained in the submission guide.
SECTION 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 that sets forth the required schedules, data file format, record specifications, data elements, and definitions for submission of:
(1) eligibility files;
(2) medical claims files;
(3) pharmacy claims files and
(4) provider data files;
SECTION 21. "Submitter" includes the following:
(1) Health payers that meet the plan size submission threshold.
(2) Voluntarily participating entities.
(3) Entities appointed as:
(A) designated submitters; or
(B) designated submitter representatives;
of entities described in subdivisions (1) and (2).
SECTION 22.
"Third party administrator" has the meaning set forth in IC 27-1-25-1(a).
SECTION 23. "Voluntarily participating entity" means an entity that:
(1) is not required to submit data;
(2) chooses to voluntarily submit data; and
(3) has been approved by the department to submit data;
SECTION 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) Each request described in subsection (a) must include the following information related to the voluntarily participating entity:
(1) Business type.
(2) Number of members.
(3) Types of coverage offered.
(4) Contact information.
(c) The administrator shall notify the requesting entity of the department's determination.
SECTION 25. (a) A health payer that does not meet the plan size submission threshold is exempt from the submission requirements set forth in SECTIONs 28, 29, and 34 of this document. The number of Indiana members shall be calculated by adding together the Indiana members in all of the entity's health plans as of December 31 of each calendar year. Any subsequent 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 that drops below the plan size submission threshold as of December 31 must submit data files to the APCD for data through December 31 of that calendar year. The health payer must notify the APCD of its change in status and may elect to become a voluntarily participating entity.
(c) A previously exempt health payer that ceases to be exempt by meeting the plan size submission threshold as of December 31 must submit data files to the APCD to report the next calendar year's data.
(d) A newly created health payer that meets the plan size submission threshold on December 31 of the year in which it is created must submit data files to the APCD to report the next calendar year's data.
SECTION 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 all data to the APCD. The health payer must either:
(1) obtain necessary data from the contracted entity and submit the data to the APCD; or
(2) ensure that the contracted entity submits the data directly to the APCD.
(b) The health payer must identify each contracted entity through the registration process. Each contracted entity must register pursuant to SECTION 27 or SECTION 34 of this document, as applicable. This entity will be referred to as a designated submitter.
SECTION 27. (a) All health payers must register in the data portal. All health payers must review and update, or confirm, all registration information annually by January 31 of each year following the year of its initial registration.
(b) When any health payer becomes subject to this document, it must 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. Prior to registering, the entity must have been approved to submit data pursuant to SECTION 24 of this document.
(d) Submitters must:
(1) register through the data portal;
(2) provide all required information as specified in the data submission guide; and
(3) update registration information;
within fifteen (15) calendar days of any change in the required contact information.
SECTION 28. (a) Submitters must submit data files monthly through the data portal. Each 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:
(1) Eligibility files.
(2) Medical claims files.
(3) Pharmacy claims files.
(4) Provider files.
(c) Files must exclude data for any members who are 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 one (1) or more designated submitters or designated submitter representatives to submit information directly to the data portal on behalf of the entity, the data submission shall not be considered complete until all required files have been received.
(f) Submitters must 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.
SECTION 29. (a) Each submitter must use the test function to prepare for historical and catch-up data file submission. Submitters must successfully complete the testing process by June 30, 2023.
(b) Submitters must submit historical and catch-up data files in accordance with SECTION 28 of this document for the time period from January 1, 2020, through July 31, 2023, no later than August 31, 2023. Any subsequent 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 must begin regular monthly reporting with monthly data files for the month of August 2023 by October 2, 2023. Any subsequent 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.
SECTION 30. Data files that are submitted to the data portal but do not meet the file intake specifications detailed in the data submission guide will not be accepted. Submitters will be notified within two (2) business days of submission whether a data file has been accepted or rejected.
SECTION 31. If the administrator determines that a previously accepted file contains initially unidentified errors, the administrator will notify the submitter. The submitter must address the issues identified by the administrator by either:
(1) explaining to the administrator and providing supporting documentation, as necessary, to show that the file is correct as initially submitted; or
(2) correcting and resubmitting the file within thirty (30) calendar days of notification by the administrator.
SECTION 32. (a) A submitter that is 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:
(1) the nature of the issues;
(2) the plan for correction of the issues; and
(3) the anticipated date of compliance;
with the data submission guide requirements.
(c) The administrator shall either approve or disapprove variance requests meeting the requirements of subsection (b) within five (5) calendar days of the date the request was submitted.
SECTION 33. (a) If any health payer fails to perform any of the following actions:
(1) submit required data to the APCD;
(2) submit required data that passes all data quality validations or variances in accordance with the time periods outlined in this document;
(3) register for the APCD; or
(4) correct submissions rejected because of errors;
the administrator shall provide written notice of the nature of the violation and required steps to cure the violation to the health payer and copy the executive director on the written notice.
(b) If the health payer fails to provide the required information set forth in the written notice described in subsection (a) within thirty (30) calendar days following receipt, the administrator shall provide the health payer with written notice of the failure to report and will 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 the following amounts:
(1) $100 per day per issue for the first thirty (30) days that a health payer fails to provide the required data to the APCD; and
(2) $1,000 for each day thereafter.
In determining whether to impose a penalty, the executive director may consider mitigating factors, including but not limited to, the reasons for the failure to report and the detrimental impact upon the public purpose served by the APCD.
(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 will be assessed to the health payer.
(e) The penalties specified in this SECTION shall not apply to voluntarily participating entities.
(f) Penalties will be deposited into the department of insurance fund created by IC 27-1-3-28.
SECTION 34. (a) This SECTION applies only to ERISA plans in effect on or after July 1, 2023.
(b) SECTION 29 [of this document] does not apply to ERISA plans.
(c) An ERISA plan must register to submit data to the data portal. An ERISA plan must:
(1) complete its initial registration with the APCD by August 31, 2023; and
(2) review and update, or confirm, all registration information annually by January 31 of each subsequent year.
(d) Each submitter must use the test function to prepare for historical and catch-up data file submission. Submitters must successfully complete the testing process by October 31, 2023.
(e) Submitters must submit historical and catch-up data files in accordance with SECTION 28 of this document for the time period from January 1, 2020, through December 31, 2023, no later than March 31, 2024.
(f) Submitters must begin regular monthly reporting with monthly data files for the month of January 2024.
SECTION 35. If any SECTION or portion of a SECTION of this document or its applicability to any person or circumstance is held invalid by a court, the remainder of the document or the applicability of the provision to other persons or circumstances shall not be affected.
SECTION 36. This document expires on March 21, 2024.
Approved by Governor: September 18, 2023
Filed with Publisher: September 22, 2023, 1:20 p.m.
Documents Incorporated by Reference: APCD-CDL™, Version 2.1, released July 1, 2021; Indiana All Payer Claims Database Data Submission Companion Guide, Version 1.1, updated September 2023
Posted: 10/04/2023 by Legislative Services Agency
DIN: 20231004-IR-760230678ERA
Composed: May 19,2024 10:59:33PM EDT
A
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