23 CAR Part 131 — Arkansas Healthcare Transparency Initiative Standards

Chapter I

Subchapter B

Subpart 1

23 CAR § 131-101 Purpose {#sec-23-car-131-101 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-101}

23 CAR § 131-101. Purpose.

(a) The purpose of this part is to establish the guidelines for submission of medical, dental, and pharmaceutical claims, unique identifiers and geographic and demographic information for covered individuals, and provider files to the Arkansas Healthcare Transparency Initiative for the purpose of creating and maintaining a multi­payer claims database as a source of healthcare information to support consumers, researchers, and policymakers in healthcare decisions within the state.

(b) This part is intended to create and maintain an informative source of healthcare information to support consumers, researchers, and policymakers in healthcare decisions within the state and empower Arkansans to drive, deliver, and seek out value in the healthcare system.

23 CAR § 131-102 Applicability and scope {#sec-23-car-131-102 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-102}

23 CAR § 131-102. Applicability and scope.

This part applies to all submitting entities as defined in 23 CAR § 131-103 unless otherwise exempted pursuant to 23 CAR § 131-104(c).

23 CAR § 131-103 Definitions {#sec-23-car-131-103 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-103}

23 CAR § 131-103. Definitions.

The following definitions shall apply in this part:

(1) "Administrator" means the Arkansas Center for Health Improvement;

(2) "AID" means the State Insurance Department;

(3) "All-payer claims database" or "APCD" means the database created and maintained by the Arkansas Healthcare Transparency Initiative, including the ongoing all-payer claims database project funded through the State Insurance Department, that receives and stores data from submitting entities;

(4) "APCD Council" means a federation of government, private, nonprofit, and academic organizations focused on improving the development and deployment of state-based APCDs;

(5) "Arkansas Healthcare Transparency Initiative" or "initiative" means the initiative established pursuant to Acts 2015, No. 1233, to create and maintain a database, including the ongoing all-payer claims database project funded through the State Insurance Department, that receives and stores data from submitting entities;

(6) "Arkansas Healthcare Transparency Initiative Board" or "initiative board" means the advisory board established under Acts 2015, No. 1233;

(7)(A) "Arkansas resident" means an individual for whom a submitting entity has identified an Arkansas address as the individual's primary place of residence.

(B) For individuals covered by a student health plan, “Arkansas resident” means any student enrolled in a student plan for an Arkansas college or university regardless of his or her address of record;

(8) "Commissioner" means the person in charge of the State Insurance Department;

(9) "Covered individual" means a natural person who is an Arkansas resident and is eligible to receive medical, dental, or pharmaceutical benefits under any policy, contract, certificate, evidence of coverage, rider, binder, or endorsement that provides for or describes coverage;

(10) "Data" means information consisting of, or derived directly from:

(A) Enrollment files;

(B) Medical claims files;

(C) Dental claims files;

(D) Pharmacy claims files;

(E) Provider files; and

(F) Validation reports;

(11) "Data set" means a collection of individual data records and data elements that comprises the file types for an enrollment file, medical claims file, dental claims file, pharmacy claims file, and a provider file submitted quarterly and in the format outlined in the DSG;

(12) "Data Submission Guide" or "DSG" means a document approved by the Insurance Commissioner in consultation with the Arkansas Healthcare Transparency Initiative Board 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, validation reports, exception processes, adjustment files, and other information associated with the submitting entities' reporting duties;

(13)(A) "Dental claims file" means, as further defined in the DSG, a data file that contains service-level remittance information for all paid and denied claims for each billed dental service for covered individuals, including without limitation:

(i) Unique identifiers, geographic and demographic information but not direct personal identifiers;

(ii) Provider information and services rendered to a covered individual;

(iii) Charge/payment information; and

(iv) Clinical diagnosis/procedure codes.

(B) Claims and benefits not subject to this part will not be included in a dental claims file.

(C) The term may exclude certain data that is prohibited to release according to state or federal law;

(14)(A) "Direct personal identifiers" means information relating to a covered individual that contains primary or obvious identifiers, such as the individual's:

(i) Name;

(ii) Street address;

(iii) Email address;

(iv) Telephone number; and

(v) Social Security number.

(B) "Direct personal identifiers" does not include geographic or demographic information that would not allow the identification of a covered individual;

(15) "Enrollment file" means unique identifiers, demographic and geographic information relating to covered individuals;

(16) "HIPAA" means the Health Insurance Portability and Accountability Act, 42 U.S.C. §§ 1320d–1320d-8 and its implementing regulations, 45 C.F.R. pts. 160, 162, and 164, as may be amended;

(17) "Historical data" means a one-time data submission following submission of a test file and for a period commencing on January 1, 2013, and ending according to the data submission schedule in this part;

(18)(A) "Medical claims file" means, as further defined in the DSG, a data file that contains service-level remittance information for all paid and denied claims for each billed medical service for covered individuals, including without limitation:

(i) Unique identifiers, geographic and demographic information but not personal identifiers;

(ii) Provider information and services rendered to a covered individual;

(iii) Charge/payment information; and

(iv) Clinical diagnosis/procedure codes.

(B) Claims and benefits not subject to this part will not be included in a medical claims file.

(C) The term may exclude certain data that is prohibited to release according to state or federal law;

(19)(A) "Pharmacy claims file" means a data file containing service-level remittance information from all paid and denied claims for each prescription for covered individuals, including without limitation:

(i) Unique identifiers, geographic and demographic information but not personal identifiers;

(ii) Provider information;

(iii) Charge/payment information; and

(iv) National drug codes.

(B) The term may exclude certain data that is prohibited to release according to state or federal law;

(20) "Provider file" means a data file that includes additional information as set forth in the DSG about the providers that are included in a:

(A) Medical claims file;

(B) Dental claims file; or

(C) Pharmacy claims file;

(21)(A) "Submitting entity" means an entity that is subject to this part and its data reporting requirements.

(B) "Submitting entity" includes the following entities:

(i) An entity that provides health or dental insurance or a health or dental benefit plan in the state, including without limitation an insurance company, medical services plan, hospital plan, hospital medical service corporation, health maintenance organization, or fraternal benefits society, provided that the entity has covered individuals and the entity had at least two thousand (2,000) covered individuals as of December 31 in the previous calendar year;

(ii) A health benefit plan offered or administered by or on behalf of the state or an agency or instrumentality of the state;

(iii) A health benefit plan offered or administered by or on behalf of the federal government with the agreement of the federal government;

(iv) The Arkansas Workers' Compensation Commission;

(v) Any other entity providing a plan of health insurance or medical, dental, or pharmaceutical benefits subject to state insurance regulation, a third-party administrator, or a pharmacy benefits manager, provided that the entity has covered individuals and the entity had at least two thousand (2,000) covered individuals as of December 31 in the previous calendar year;

(vi) An entity that contracts with institutions of the Division of Correction or Division of Community Correction to provide medical, dental, or pharmaceutical care to inmates; and

(vii) A health benefit plan subject to the Employee Retirement Income Security Act of 1974 (ERISA), Pub. L. No. 93-406.

(C) "Submitting entity" does not include an entity that provides health insurance or a health benefit plan that is accident-only, specified disease, hospital indemnity and other fixed indemnity, long-term care, disability income, Medicare supplement, or other supplemental benefit coverage from which benefit payments are directly to the covered individual.

(D) In instances where more than one (1) submitting entity is involved in the administration of a policy, the payer shall be responsible for submitting the claims data on policies that it has written or sold as a bundle, provided, however, that in instances where more than one (1) submitting entity is involved in the administration of a policy, those entities will work together to use the same unique identifier for a covered individual across separate feeds for medical, prescription, and other claims.

(E) If a "submitting entity" contracts with another entity to provide subcontracted claims processing services, the entity which contracts directly with the customer shall be the submitting entity for purposes of this part;

(22) "Test file" means a data file, as further defined by the DSG, that includes a sample of service-level remittance information for billed medical or dental services or prescriptions for covered individuals;

(23) "Unique identifier" means, as further defined in the DSG, an identifier that is guaranteed to be unique among all identifiers for covered individuals but does not include direct personal identifiers; and

(24) "Validation report" means, as further defined in the DSG, a report from the submitting entity that provides aggregated information about a quarterly data submission to provide control totals and record counts.

23 CAR § 131-104 General reporting requirements — Exemptions {#sec-23-car-131-104 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-104}

23 CAR § 131-104. General reporting requirements — Exemptions.

(a) Submitting entity requirements. Unless exempted by the Insurance Commissioner in accordance with subsection (c) of this section or by the explicit language of this part, a submitting entity shall submit to the State Insurance Department through the administrator a completed data set for an enrollment file, a medical claims file, a dental claims file, a pharmacy claims file, a provider file, and a validation report in accordance with:

(1) This section; and

(2) The requirements outlined in the Data Submission Guide.

(b) Data submission timing. Submitting entities shall provide data in accordance with the following schedule:

(1) Test files for submitting entities must be submitted no later than January 1, 2016;

(2)(A) Historical data and regular quarterly submission will commence following submission of test files according to the submission schedule in Appendix A.

(B) For purposes of the submission schedule the following groupings apply:

(i) Group 1 means submitting entities listed in 23 CAR § 131-103(21)(B)(i) with at least one hundred thousand (100,000) covered individuals as of December 31, 2015, and entities listed in 23 CAR § 131-103(21)(B)(ii), (iii), (iv), and (vi);

(ii) Group 2 means submitting entities listed in 23 CAR § 131-103(21)(B)(i) with at least twenty-five thousand (25,000) covered individuals but fewer than one hundred thousand (100,000) covered individuals as of December 31, 2015;

(iii) Group 3 means submitting entities listed in 23 CAR § 131-103(21)(B)(i) with at least ten thousand (10,000) covered individuals but fewer than twenty-five thousand (25,000) covered individuals as of December 31, 2015; and

(iv) Group 4 means submitting entities listed in 23 CAR § 131-103(21)(B)(v) and submitting entities listed in 23 CAR § 131-103(21)(B)(i) with at least two thousand (2,000) covered individuals but fewer than ten thousand (10,000) covered individuals as of December 31, 2015;

(3) Unless otherwise exempted under subsection (c) of this section, submitting entities must submit data according to the established patterns identified in the submission schedule in Appendix A for future years not explicitly listed in the schedule; and

(4) Entities qualifying in more than one (1) group listed in subdivision (b)(2) of this section must submit claims for all covered individuals according to the schedule listed for the first group in which the entity qualifies.

(c) Submitting entity exemptions.

(1)(A) An entity with fewer than two thousand (2,000) covered individuals as of December 31 of the previous calendar year will not be required to submit data in accordance with this part.

(B) For purposes of determining whether an entity is subject to the requirements of this part and for data submission timing in subsection (b) of this section, entities must aggregate the number of covered individuals for all companies at the Group Code level as defined by the National Association of Insurance Commissioners.

(C) Entities that offer medical, dental, and pharmaceutical benefits, or any combination thereof, under separate or combined plans will count all covered individuals, irrespective of the comprehensiveness of the plan, toward the two thousand (2,000) covered individuals threshold.

(2)(A) The Arkansas Workers' Compensation Commission is exempt from submitting a provider file as required by this section.

(B) Until further notice, employer self-funded health plans are exempt from all requirements in this part.

(3)(A) The commissioner may, for good cause, grant an exemption to a submitting entity, or to a class of which the entity is a member, for all or some of the requirements of this part.

(B) "Good cause" includes without limitation pending litigation that may preempt application of Acts 2015, No. 1233, to a submitting entity.

(C) The commissioner will respond in writing within thirty (30) days to any exemption request.

(4) If an entity does not believe it meets the definition of a submitting entity herein or does not believe it meets the two thousand (2,000) covered individuals threshold, that entity may dispute the commissioner’s decision in accordance with the administrative procedures of the State of Arkansas.

23 CAR § 131-105 Submission exclusions — Data Submission Guide {#sec-23-car-131-105 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-105}

23 CAR § 131-105. Submission exclusions — Data Submission Guide.

(a) Extension, variance, or waiver of data submission requirements.

(1) If a submitting entity is temporarily unable to meet the requirements of this part, including the standards in the Data Submission Guide other than those outlined in the exceptions process in the DSG for specific data variables, a submitting entity may submit an exemption request to the Insurance Commissioner including:

(A) The specific requirement to be extended, varied, or waived;

(B) An explanation of the reason or cause;

(C) The methodology proposed to eliminate the necessity of the extension, variance, or waiver, if applicable; and

(D) The time frame required to come into compliance.

(2) The commissioner will respond in writing within thirty (30) days to any exemption request.

(b) Submission exclusions. For purposes of clarity and without limiting the foregoing, the following data are excluded from this part: data related to a health benefit plan that is accident-only, specified disease, hospital indemnity and other fixed indemnity, long-term care, disability income, Medicare supplement, or other supplemental benefit coverage where benefits are paid directly to the covered individual.

23 CAR § 131-106 Data Submission Guide {#sec-23-car-131-106 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-106}

23 CAR § 131-106. Data Submission Guide.

(a) Data Submission Guide standards.

(1) The administrator, in consultation with the Arkansas Healthcare Transparency Initiative Board will develop and make publicly available a Data Submission Guide that will be used to evaluate data submissions, including minimum completion rates (''thresholds") as well as detailed information about criteria tested in automated reviews.

(2) The administrator will provide a periodic update of data submission standards to facilitate submitting entities' creation of files that conform to the DSG.

(3) In developing the DSG the administrator will consult with organizations such as the APCD Council in order to examine appropriate APCD Core Standard provisions.

(b) Revisions to Data Submission Guide.

(1)(A) The administrator may make material DSG revisions no more than once per year.

(B) Material DSG revisions include:

(i) Adding new data elements;

(ii) Adding new codes to existing data elements; or

(iii) Otherwise significantly amending the DSG.

(C) Submitting entities will have thirty (30) days to review and comment on the proposed revisions.

(D) The administrator will review the comments with the initiative board and Insurance Commissioner prior to issuing a revised DSG.

(E) The initiative board shall approve material DSG revisions.

(F) The commissioner will post a final revised version on the State Insurance Department’s website.

(G) The revised DSG will be effective for the files to be submitted not less than one hundred twenty (120) days after the posting date on the department’s website.

(2)(A) The administrator may make technical corrections to the DSG at any time.

(B) Technical corrections are:

(i) Simple revisions to formatting of existing data elements;

(ii) The addition of codes to existing data elements;

(iii) Changes to thresholds that can be accommodated by updated exceptions; and

(iv) Those intended to clarify or otherwise expedite the process of submitting files that conform to the DSG.

(C) Submitting entities will have one hundred twenty (120) days to implement a technical correction.

(3) The administrator will notify submitting entities about all material and technical revisions, including the start and end of comment periods for material revisions.

(c) Manner of data submission.

(1) Submitting entities will submit data in accordance with the manner outlined in the DSG and in compliance with the HIPAA Security Rule or any applicable state law that is more restrictive than the HIPAA Security Rule.

(2) Except as provided in this part, a bulletin, an order, or a directive issued by the commissioner, each submitting entity shall provide data in the form and manner set forth in this part and according to the applicable version of the Data Submission Guide and at such times set forth in any applicable submission schedules.

23 CAR § 131-107 Arkansas Healthcare Transparency Initiative Board — Subcommittees {#sec-23-car-131-107 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-107}

23 CAR § 131-107. Arkansas Healthcare Transparency Initiative Board — Subcommittees.

(a) Arkansas Healthcare Transparency Initiative Board duties and composition.

(1) The Arkansas Healthcare Transparency Initiative Board will serve in an advisory capacity:

(A) Providing input into the various functions of the Arkansas Healthcare Transparency Initiative and its APCD;

(B) Assisting in the development of and revisions to the Data Submission Guide; and

(C) Reviewing recommendations from the Data Oversight Subcommittee and the Scientific Advisory Subcommittee regarding data use and release.

(2) The initiative board will be composed of the following members:

(A) A representative of the Department of Human Services;

(B) A representative of the Department of Health;

(C) A representative of the Office of Health Information Technology or its successor entity;

(D) The Arkansas Surgeon General; and

(E) The following Governor-appointed members:

(i) Two (2) representatives from the health insurance industry, one (1) of whom will be a multi-state representative and one (1) of whom will be a domestic representative;

(ii) A representative from a self-insured employer;

(iii) A representative from an employer of fewer than one hundred (100) full-time employees that provides healthcare coverage to employees through a fully insured product;

(iv) A representative from a healthcare consumer organization;

(v) A representative from the academic research community with expertise in healthcare claims data analysis; and

(vi) A representative with expertise in health data privacy and security.

(3)(A) Governor-appointed members of the initiative board will serve a term of three (3) years.

(B) The initiative board will appoint one (1) member as a chair and determine the qualifications, duties, and term of office for the chair.

(C) Seven (7) members constitute a quorum for a meeting of the initiative board, provided, however, that the lack of a quorum does not preclude action by the Insurance Commissioner with respect to the duties required by Acts 2015, No. 1233, or this part.

(b) Subcommittees.

(1) The Data Oversight Subcommittee of the Arkansas Healthcare Transparency Initiative, which will be composed of three (3) Governor-appointed members and an individual healthcare consumer appointed by the commissioner, will review and make recommendations to the State Insurance Department regarding:

(A) Whether specific data requests are consistent with the purpose and intent of Acts 2015, No. 1233, including without limitation whether the data request contains the minimum required information; and

(B) Reports and publications generated from data requests to ensure compliance with Acts 2015, No. 1233.

(2) The Scientific Advisory Subcommittee of the Arkansas Healthcare Transparency Initiative, which will be composed of the Governor-appointed member of the initiative board from the academic research community and two (2) nonmembers of the initiative board who are academic researchers and appointed by the commissioner, will serve as peer review for academic researchers and provide advice regarding data requests for academic proposals and the scientific rigor of analytic work.

(3) The commissioner may establish and convene as necessary additional subcommittees to carry out the responsibilities of Acts 2015, No. 1233, and this part.

23 CAR § 131-108 Administrator {#sec-23-car-131-108 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-108}

23 CAR § 131-108. Administrator.

(a) The Arkansas Center for Health Improvement will host and administer the APCD and have custody of the data collected by the APCD as part of the Arkansas Healthcare Transparency Initiative.

(b) Except as authorized in state law, the administrator is prohibited from collecting, disclosing, or using data obtained in its capacity as administrator for any purposes other than those specifically authorized in Acts 2015, No. 1233, this part, or any agreement with the State Insurance Department to administer the APCD.

23 CAR § 131-109 Initiative public use and reports {#sec-23-car-131-109 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-109}

23 CAR § 131-109. Initiative public use and reports.

(a)(1) Contingent upon available funding and in consultation with the Arkansas Healthcare Transparency Initiative Board, the State Insurance Department will issue reports from data collected by the Arkansas Healthcare Transparency Initiative, which may include:

(A) Descriptions of patterns of incidence and variation of medical treatment options;

(B) Comparisons of health care quality and performance;

(C) State and regional cost patterns;

(D) Utilization of services;

(E) How healthcare dollars are being spent; and

(F) Healthcare research activities.

(2) Reports generated by the State Insurance Department will be available to the public on a website.

(b)(1) Any and all reports will comply with federal and state privacy laws.

(2) Any and all reports will preserve competition consistent with Statement 6 of the United States Department of Justice and Federal Trade Commission Enforcement Policy and not deprive payers of existing trade secret protections.

(c)(1) After soliciting input from the initiative board, the State Insurance Department will develop a process by which individuals can request data sets to be reviewed by the Data Oversight Subcommittee of the Arkansas Healthcare Initiative Board and the initiative board and approved by the Insurance Commissioner.

(2) Where appropriate, individuals requesting data sets will sign a data use agreement to be approved or denied by the commissioner, upon recommendation of the subcommittee and the initiative board.

(3) The State Insurance Department will not release data sets for solely commercial purposes.

(d) The commissioner may adopt a fee schedule to fulfill data requests under this section.

23 CAR § 131-110 Limited data set requests {#sec-23-car-131-110 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-110}

23 CAR § 131-110. Limited data set requests.

(a)(1) The State Insurance Department, in consultation with the Arkansas Healthcare Transparency Initiative Board, will determine a limited data set of elements to be made available for research projects.

(2) The requester will submit to the Scientific Advisory Subcommittee of the Arkansas Healthcare Initiative Board through the administrator a detailed research scope and purpose to determine if a limited data set can be made available.

(3) The Insurance Commissioner will approve or deny each request for a limited data set, upon recommendation by the subcommittee and the initiative board.

(4) The requester will sign a data use agreement with the commissioner if data is supplied to the requester.

(b) The requester shall protect patient privacy and confidentiality information contained in the limited data set according to:

(1) HIPAA;

(2) Applicable laws of Arkansas; and

(3) The data use agreement.

(c) The commissioner may adopt a fee schedule to fulfill the data requests under this section.

23 CAR § 131-111 Public record {#sec-23-car-131-111 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-111}

23 CAR § 131-111. Public record.

Data submitted by submitting entities to the State Insurance Department through the administrator are:

(1) Confidential;

(2) Exempt from disclosure under the Freedom of Information Act of 1967, Arkansas Code § 25-19-101 et seq.; and

(3) Not subject to subpoena, except to the extent provided in Arkansas Code § 23-61-205.

23 CAR § 131-112 Compliance {#sec-23-car-131-112 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-112}

23 CAR § 131-112. Compliance.

(a) Each time a submitting entity submits a file, the State Insurance Department will evaluate each submitting entity's submissions in accordance with the DSG.

(b)(1) Upon completion of the evaluation, the department will promptly notify each submitting entity in writing whether its submissions satisfy the DSG standards.

(2) This notification shall identify the specific files and the data sets that do not conform to DSG standards.

(c) Each submitting entity notified of a noncompliant data submission shall respond within thirty (30) days of the notification by making the changes necessary to satisfy the DSG standards unless an extension, variance, or waiver has been submitted in accordance with 23 CAR § 131-105(b).

23 CAR § 131-113 Penalties for noncompliance {#sec-23-car-131-113 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-113}

23 CAR § 131-113. Penalties for noncompliance.

(a) Following notice to the submitting entity and the failure to comply during the thirty-day cure period, the Insurance Commissioner may impose a maximum penalty on a submitting entity of one thousand dollars ($1,000) per day, not to exceed thirty thousand dollars ($30,000).

(b) The commissioner may delay, reduce, or waive any penalty.

(c) The commissioner agrees to consider a lower maximum penalty per day than authorized, including a waiver of the penalty, for test data and data receipts due in the 2016 year, based upon the good cause of the submitting entity.

23 CAR § 131-114 Privacy and security {#sec-23-car-131-114 omnilex-key=us-ar-regs-official--title-23-part-131--23 CAR § 131-114}

23 CAR § 131-114. Privacy and security.

(a) The State Insurance Department will institute appropriate administrative, physical, and technical safeguards to ensure that the APCD, its operations, data collection and storage, and reporting disclosures are in compliance with the requirements of applicable federal and state law.

(b) The department will also ensure that the administrator and any vendors comply with applicable federal and state law related to protecting patient privacy and confidentiality.