Section Ins 4002.01 - DefinitionsUnless the context indicates otherwise, the following words and phrases shall have the following meanings:
(a) "Address" means street addresses, post office box numbers, apartment numbers, e-mail addresses, web universal resource locators (URLs), and internet protocol (IP) address numbers.(b) "Alternative payment arrangements" means those claims considered paid by the carrier or third-party administrator under a capitated services arrangement or a global payment, resulting in zero paid amounts on the claim.(c) "Blanket health insurance" means that form of accident and health insurance defined under RSA 415:18, I-a that is not "health coverage" under RSA 420-G:2, IX, that does not require individual applications from covered persons, and that does not require a carrier or third-party administrator to furnish each person with a certificate of coverage.(d) "Capitated services" means services rendered by a provider through a contract in which payment is based upon a fixed dollar amount for each member on a monthly basis.(e) "Carrier" means any entity subject to the insurance laws and rules of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to provide, deliver, arrange for, pay for, or reimburse any of the costs of health services, or to administer on behalf of a third-party payer, and includes an insurance company, a health maintenance organization, a nonprofit health services corporation, a dental benefits administrator, a third-party administrator, or any other entity arranging for or providing health coverage, Medicare Supplemental, and Medicare Advantage plans.(f) "Commissioner" means the insurance commissioner.(g) "Dental claims file" means a data file composed of service level remittance information for all adjudicated claims for each billed dental service provided to members, including data for services provided under alternative payment arrangements with zero paid amounts.(h) "Department (NHID)" means the New Hampshire insurance department.(i) "Designee" means an entity with which the department or the department of health and human services have entered into an arrangement pursuant to which the entity performs data management and collecting functions and under which the entity is strictly prohibited from using or releasing the information and data obtained in such a capacity for any purposes other than those specified in the agreement.(j) "Department of Health and Human Services (DHHS)" means the New Hampshire department of health and human services.(k) "Direct identifier" means any information, other than case or code numbers used to create anonymous or encrypted data, that plainly discloses the identity of an individual as referenced in 45 CFR Part 164.514 (e)(2).(l) "Encryption" means a method by which the true value of data has been disguised in order to prevent the identification of persons or groups and which does not provide the means for recovering the true value of the data.(m) "Exchange" means a governmental agency or non-profit entity that meets the applicable standards of 42 U.S.C. section 13031 and makes qualified health plans available to qualified individuals and qualified employers in accordance with federal law.(n) "Health care claims data" means the set of data files that are filed by carriers and third-party administrators under this chapter consisting of, or derived directly from, member eligibility, medical claims, pharmacy claims, and dental claims files, including a provider file. "Health care claims data" does not include analysis, reports, or studies containing information from health care claims data sets, if those analyses, reports, or studies have already been released in response to another request for information or as part of a general distribution of public information by the department.(o) "Hospital" means a licensed acute or specialty care institution.(p) "Insured" means an individual in whose name an insurance policy is issued.(q) "Medical claims file" means a data file composed of service level remittance information for all adjudicated claims for each billed medical service provided to members, including data for services provided under alternative payment arrangements with zero paid amounts.(r) "Members" means all individuals, employees, and dependents for which the health carrier or third-party administrator has an obligation to adjudicate, pay, or disburse claim payments. The term includes covered lives. For employer-sponsored group coverage, members include certificate holders and their dependents.(s) "Member eligibility file" means a data file containing demographic information for each individual member eligible for medical, pharmacy, or dental benefits for one or more days of coverage at any time during the reporting month as well as any retrospective updates that correspond to previously submitted eligibility data. The term also includes benefits attributed and associated effective periods.(t) "New Hampshire Comprehensive Health Information System (NHCHIS)" means the system established and operated by the department and the department of health and human services or its designee to collect, store, and analyze health care claims data.(u) "Pharmacy claims file" means a data file composed of service level remittance information from all adjudicated claims for each billed prescription provided to members, including data for services provided under alternative payment arrangements with zero paid amounts.(v) "Plan ID" means the 14-character Health Insurance and Oversight System (HIOS) Plan ID, standard component. The full HIOS ID is unique to each fully insured carrier, product, or plan.(w) "Plan sponsor" means any persons, other than an insurer, who establishes or maintains a plan covering residents of the state of New Hampshire, including plans established or maintained by employers or jointly by one or more employers and one or more employee organizations, committee, joint board of trustees, or other similar group of representatives of the parties that establish or maintain the plan.(x) "Prepaid amount" means the amount that would have been paid by the health care claims processor for a specific service if the service had not been capitated or otherwise did not result in a transfer of funds.(y) "Provider" means a health care facility, medical, dental or behavioral health care practitioner, health product manufacturer, health product vendor, or pharmacy.(z) "Provider file" means a data file listing information about the service providers identified in the medical claims, pharmacy claims, and the dental claims file as servicing billing, prescribing, or primary providers.(aa) "Release" means to make data or information available for inspection and copying to persons other than the data submitter.(ab) "Subcontractor" means a vendor or contractor who manages carved out categories of services, including behavioral health services, pharmacy services, or any other subcontractor that processes claims on behalf of a carrier.(ac) "Subscriber" means the certificate holder who receives coverage from a carrier or third-party administrator as defined in these rules. For employer-sponsored group coverage, the employee or subscriber is considered the certificate holder. For individual coverage, the policyholder is considered the certificate holder. For other types of group coverage, the certificate holder is considered the person who is the principal insured.(ad) "Third party administrator" means any persons licensed by the department that receives or collects charges, contributions, or premiums for, or adjusts or settles claims for, residents of the state on behalf of a plan sponsor, health care services plan, dental services plan, nonprofit hospital or medical service organization, health maintenance organization, or insurer.N.H. Admin. Code § Ins 4002.01
#8279, eff 2-3-05; ss by #9500, eff 7-6-09
Amended by Volume XXXV Number 32, Filed August 13, 2015, Proposed by #10877, Effective 7/10/2015, Expires7/10/2025.Amended by Volume XL Number 50, Filed December 10, 2020, Proposed by #13136, Effective 11/24/2020, Expires 11/24/2030