Title: Section 350.1 - Definitions

Effective Date

09/13/2017

Section 350.1 Definitions. For the purposes of this Part, these terms shall have the following meanings:

(a) “All Payer Database” or “APD” means the health care database maintained by the Department or its contractor that contains APD data.

(b) “APD data” means covered person data, claims data, and any other such data contained within standard transactions for Electronic Data Interchange (EDI) of health care data adopted by the X12 standards organization, the National Council for Prescription Drug Programs (NCPDP) standards organization, any other organizations designated by the federal Department and Human Services to develop and maintain standard transactions for EDI of health care data, as provided in section 1320d-2 of Title 42 of the United States Code (USC) or any other federal law, or any other format designated by the Department for the collection of such data.

(c) “claims data” means:

(1) Benefits and coverage data – data specifying the benefits and coverage available to a covered person, such as cost-sharing provisions and coverage limitations and exceptions;                                   

(2) Health care provider network data – data related to the health care provider and service networks associated with third-party health care payer plans and products, such as the services offered, panel size, licensing/certification, National Provider Identifier(s), demographics, locations, accessibility, office hours, languages spoken, and contact information;

(3) Post-adjudicated claims data – data related to health care claims, including payment data, that has been adjudicated by a third-party health care payer, such as the data included in the X12 Post Adjudicated Claims Data Reporting and the NCPDP Post Adjudication Standard transactions; and

(4) Other health care payment data, such as value based payment information, as determined by the Department.

(d) “covered person” means a person covered under a third-party health care payer contract, agreement, or arrangement that is licensed to operate in New York State by the New York State Department of Financial Services.

(e) “covered person data” means data related to covered persons, such as demographics, member identifiers, coverage periods, policy numbers, plan identifiers, premium amounts, and selected primary care providers.

(f) “data user” means any individual or organization that the Department has granted access to APD data, with or without identifying data elements.

(g) “health care provider” means a provider of “medical and other health services” as defined in 42 USC § 1395x(s), a “provider of services” as defined in 42 USC § 1395x(u), and any other person or organization who furnishes, bills, or is paid for health care in the normal course of business. This includes a clinical laboratory, a pharmacy, an entity that is an integrated organization of health care providers, and an accountable care organization described in 42 USC § 1395jjj. The term also includes atypical providers that furnish nontraditional services that are indirectly health care-related, such as personal care, taxi, home and vehicle modifications, habilitation, and respite services.

(h) “identifying data elements” means those APD data elements that, if disclosed without restrictions on use or re-disclosure, would constitute an unwarranted invasion of personal privacy consistent with federal and state standards for de-identification of protected health information.

(i) “New York State agency” means any New York State department, board, bureau, division, commission, committee, public authority, public benefit corporation, council, office, or other governmental entity performing a governmental or proprietary function for the State of New York.

(j) “submission specifications” means specifications determined by the Department for submitting covered person data and claims data to the APD, such as the data fields, circumstances, format, time, and method of reporting.

(k) “third-party health care payer” means an insurer, organization, or corporation licensed or certified pursuant to article thirty-two, forty-three, or forty-seven of the Insurance Law or article forty-four of the Public Health Law; or an entity, such as a pharmacy benefits manager, fiscal administrator, or administrative services provider that participates in the administration of a third-party health care payer system, including any health plan under 42 USC § 1320d. Unless permitted by federal law, the term does not include self-insured health plans regulated by the Employee Retirement Income Security Act of 1974, 29 USC Chapter 18, although such plans that operate in New York State may choose to participate as a third-party health care payer.

Statutory Authority

Public Health Law, Sections 206(18-a)(d) and 2816

Volume

VOLUME C (Title 10)

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