59E-9.010. Claims Data Collection

(1) Definitions.

(a) “Affiliate” means an entity that exercises control over or is directly or indirectly controlled by the insurer through equity ownership of voting securities; common managerial control; or collusive participation by the management of the insurer and affiliate in the management of the insurer or the affiliate as defined in Section 624.10(1), F.S.

(b) “Agency” means the Florida Agency for Health Care Administration (AHCA) as defined in Section 408.032(1), F.S.

(c) “Claims Data” means complete and accurate eligibility data, medical claims data, and pharmacy claims data of Covered Lives held by Payers as specified in the Submission Guide.

(d) “Covered Lives” means individuals for whom Florida Claims Data is held by the Payer inclusive of insureds, individual policyholders, group certificate-holders, subscribers, members and dependents.

(e) “Facility” means Florida licensed facility pursuant to Chapter 395, F.S.

(f) “HIPAA” means the federal Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 and its implementing regulations (45 C.F.R. Parts 160-164), and any requirements of the Health Information Technology for Economic and Clinical Health Act, as incorporated in the American Recovery and Reinvestment Act of 2009 and its implementing regulations.

(g) “Payer” means health insurers as defined in Chapter 624, F.S., or Health Maintenance Organizations as defined in Chapter 641, F.S., including their Affiliates, that participate in the Florida state group health insurance plan created under Section 110.123, F.S., or Medicaid managed care pursuant to Part IV of Chapter 409, F.S.

(h) “Service or Care Bundle” means a typical treatment plan for a medical condition that consists of one or more procedures, tests and services. Bundles are broken down into treatment steps and those steps may include one or more procedures, tests or services.

(i) “Submission Guide” means the document entitled “Florida Claims Data Submission Guide,” November 2017, that sets forth the required schedules, data file format, record specifications, data elements, definitions, code tables and edit specifications for Payers’ submission of Claims Data to the Agency through its Vendor, hereby incorporated by reference  and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-09235.

(j) “Vendor” means the organization that is under contract with the Agency pursuant to Section 408.05(3)(c), F.S.

(2) Claims Data Collected.

(a) The Vendor shall collect Claims Data from all Payers as specified in Rule 59E-9.010, F.A.C.

(b) Payers shall be exempt from providing Claims Data from health plans covered by the Employee Retirement Income Security Act (ERISA) of 1974 when such employer(s) affirmatively elects not to share these Claims Data.

(c) The Vendor shall not collect Claims Data that reflects the types of coverage referenced in Sections 627.6385(3)(a) through (3)(l) and 641.54 (7)(a) through (7)(l), F.S.

(d) Before delivering Claims Data to the Vendor, each Payer shall remove all information subject to restrictions on use or restrictions of disclosure set forth in 42 C.F.R. Part 2, if applicable.

(3) Claims Data Submission.

(a) Payers shall submit Claims Data for all Covered Lives held by the Payer and its Affiliates to the Agency, through its Vendor, as defined in the Submission Guide.

(b) All Payers submitting their Claims Data shall submit according to the schedule defined in the Submission Guide.

(c) The submission of Claims Data by Payers will be pursuant to a Data Contribution Agreement hereby incorporated by reference as Exhibit B, AHCA Form 4200-0008, November 2017, in the Submission Guide and specified by the Agency and subject to federal and state law and regulation. Payers cannot condition submission on any additional terms, conditions, or restrictions.

(4) Claims Data Audit, Resubmission, and Certification Procedures.

(a) The Submission Guide specifies Claims Data audits, and resubmission policies and procedures.

(b) All Payers submitting data in compliance with this rule shall certify that the data submitted is accurate, complete and verifiable using the Certification of Claims Form hereby incorporated by reference in Exhibit A, AHCA Form 4200-0007, November 2017, in the Submission Guide.

(5) Requirements for Claims Data Publication.

(a) The Agency, as specified in Section 408.05(3)(c), F.S. through its Vendor, shall publish and make available to the public estimated pricing data (de-identified in accordance with HIPAA) based on the Claims Data, on a consumer-friendly website. The website shall allow users to search for the price of health care services by condition or Service Bundles as defined by the Vendor and the Agency.

(b) The Vendor shall calculate an estimated average payment and range of payments for a condition or service bundle to be displayed on the website.

(c) Florida specific state, county and facility-level price estimates will be calculated from the claims dataset based on the location of the provider in the Claims Data.

(d) Price estimates will be reported on the website at the facility or geographic level as directed by the Agency. Price estimates will be derived from historic Claims Data trended forward, and reported using a data suppression methodology such that calculated prices for Service or Care Bundles at a facility or geographic level are based on a designated minimum number of Payers per facility and/or geographic level and a minimum number of claims per Payer needed to disconnect specific prices from any particular Payer.

Rulemaking Authority 408.05(3)(e) FS. Law Implemented 408.05(3) FS. History–New 4-2-18.