Minnesota Legislature
Office of the Revisor of Statutes
Minnesota Administrative Rules
4653.0100 DEFINITIONS.
Subpart 1.
Scope.
The terms used in parts 4653.0200 to 4653.0600 have the meanings given them in this part.
Subp. 3.
Complete submission.
"Complete submission" means data submitted to the data processor by a data submitter that the data processor has determined to contain the required data meeting the required threshold in a format that allows further review and verification of the accuracy of the data.
Subp. 4.
Covered individual.
"Covered individual" means a natural person who is a resident of Minnesota and is eligible to receive health care benefits under any policy, contract, certificate, evidence of coverage, rider, binder, or endorsement that provides for or describes health care coverage with the exception of coverage that is explicitly excluded from the definition of a health plan in Minnesota Statutes, section 62A.011, subdivision 3, clauses (1) to (9) and (11).
Subp. 5.
Data element.
"Data element" means the smallest named unit of information in a transaction.
Subp. 6.
Data element characteristic.
"Data element characteristic" means an attribute of a data element required to be submitted for enrollment data and health care claims data: element number, element name, encrypt, type, max len, description, threshold, and reference standard.
Subp. 7.
Data processor.
"Data processor" means the private entity selected by the commissioner to collect and process health care claims.
Subp. 8.
Data submitter.
"Data submitter" means a health plan company or third-party administrator that has covered individuals and that paid a total of at least $3,000,000 in health care claims for covered individuals during the previous calendar year, or a pharmacy benefit manager that has covered individuals and that paid at least $300,000 in claims for covered individuals during the previous calendar year. In calculating its paid claims, each data submitter must include all health care claims for covered individuals processed by any subcontractor on its behalf.
Subp. 9.
Enrollment data.
"Enrollment data" means demographic information and other information relating to all covered individuals eligible to receive health care benefits.
Subp. 10.
Health care claims data.
"Health care claims data" means information included in an institutional, professional, or pharmacy drug claim or equivalent encounter information transaction for a covered individual that is required under Minnesota Statutes, section 62J.536.
Subp. 11.
Health plan company.
"Health plan company" has the meaning given in Minnesota Statutes, section 62U.01, subdivision 8.
Subp. 12.
Material error.
"Material error" means omission of records or of data within records, or submission of inaccurate information that is of sufficient magnitude to cause the results of analysis performed with the data to be inaccurate or biased.
Subp. 13.
Minnesota resident.
"Minnesota resident" means a natural person for whom the data submitter has identified a Minnesota address as the individual's primary place of residence.
Subp. 14.
Pharmacy benefit manager.
"Pharmacy benefit manager" means a third-party administrator under contract to administer drug benefit programs for self-insurance or health insurance plans.
Subp. 15.
Pricing data.
"Pricing data" means the amount paid by a data submitter to a provider on a claim plus any amount owed by the covered individual, including prepayment, deductible, coinsurance, or co-payment.
Subp. 16.
Provider or health care provider.
"Provider" or "health care provider" has the meaning given in Minnesota Statutes, section 62J.03, subdivision 8.
Subp. 17.
Subcontractor.
"Subcontractor" means an individual or entity that performs on behalf of a health care company or third-party administrator any function or activity involving enrollment data or health care claims data, and is not a part of the health care company's or third party administrator's workforce.
Subp. 18.
Third-party administrator.
"Third-party administrator" means a vendor of risk-management services or an entity administering a self-insurance or health insurance plan as defined in Minnesota Statutes, section 60A.23, subdivision 8.
Subp. 19.
Threshold.
"Threshold" means the required completeness percentage for a particular data element.
History:
34 SR 10
Published Electronically:
July 24, 2009
Official Publication of the State of Minnesota
Revisor of Statutes