Section 21.5402 - DefinitionsThe following words and terms, when used in this subchapter, have the following meanings unless the context clearly indicates otherwise.
(1) Allowed amount--Has the meaning assigned by Insurance Code § 38.402, concerning Definitions.(2) Center--The Center for Health Care Data at The University of Texas Health Science Center at Houston.(3) Data--Has the meaning assigned by Insurance Code § 38.402.(4) Data files--Files submitted under this subchapter, including dental claims data files, enrollment and eligibility data files, medical claims data files, pharmacy claims data files, and provider files.(5) Database--Has the meaning assigned by Insurance Code § 38.402.(6) Dental claims data file--A file that includes data as specified in the Texas APCD CDL about any dental claim or encounter for which some action has been taken on the claim during the reporting period, including payment, denial, adjustment, or other modification.(7) Enrollment and eligibility data file--A file that provides identifying data as specified in the Texas APCD CDL about a person who is enrolled and eligible to receive health care coverage from a payor, whether or not the member used services during the reporting period, with one record per member, per month, per plan.(8) Medical claims data file--A file that includes data as specified in the Texas APCD CDL about medical claims and other encounter information for which some action has been taken on the claim during the reporting period, including payment, denial, adjustment, or other modification.(9) Payor--Has the meaning assigned by Insurance Code § 38.402.(10) Pharmacy claims data file--A file that includes data as specified in the Texas APCD CDL about all claims filed by pharmacies, including mail order and retail dispensaries, for prescriptions that were dispensed, processed, and paid during the reporting period.(11) Provider file--A file that includes information as specified in the Texas APCD CDL about all providers (regardless of network status) that submitted claims that are included in the medical claims data file, dental claims data file, or pharmacy claims data file, with a separate record provided for each unique physical location for a provider who practices in multiple locations.(12) Qualified research entity--Has the meaning assigned by Insurance Code § 38.402.(13) Stakeholder advisory group--Has the meaning assigned by Insurance Code § 38.402.(14) Submission guide--The document entitled "The Texas All-Payor Claims Database Data Submission Guide," created by the Center, that outlines administrative procedures and provides technical guidance for submitting data files.(15) Texas APCD CDL--The standardized format, or common data layout (CDL), for All-Payor Claims Database (APCD) data files published by the Center and based on the "All-Payer Claims Database Common Data Layout" established by the National Association of Health Data Organizations and used with permission.(16) Texas resident member--Any policyholder or certificate holder (subscriber) of a plan issued in Texas whose residence is within the state of Texas and all covered dependents, regardless of where the dependent resides.28 Tex. Admin. Code § 21.5402
Adopted by Texas Register, Volume 47, Number 23, June 10, 2022, TexReg 3475, eff. 6/16/2022