8.101 Authority. The Board adopts this rule pursuant to 18 V.S.A. §§ 9375, 9380, 9404, 9410, 9453, and 9454.
8.102 Purpose. The Green Mountain Care Board ("Board" or "GMCB") stewards two data sets (collectively "the health care database"). The Vermont Health Care Uniform Reporting and Evaluation System ("VHCURES") data set contains information related to health care utilization, costs, and resources provided to Vermont residents. The Vermont Uniform Hospital Discharge Data Set ("VUHDDS") contains information related to health care provided to patients at health care facilities in Vermont and health care provided to Vermont residents at health care facilities in other states.
Health insurers, health care providers, hospitals and other health care facilities, and governmental agencies must submit reports, data, schedules, statistics, and other information specified by the Board for inclusion in the health care database. This rule sets forth the Board's requirements for reporting health care claims and eligibility data, inpatient discharge data, outpatient procedure and service data, emergency department data, and other information relating to health care provided in Vermont and to Vermont residents outside the state. Green Mountain Care Board Rule 9.000 sets forth the processes by which the Board makes data available to support legitimate and beneficial research and analysis.
8.103 Definitions. For purposes of this rule:
(1) "Ambulatory surgery center" has the same meaning as in 18 V.S.A. § 2141(1).(2) "Board" or "GMCB" means the Green Mountain Care Board established in Title 18, Chapter 220 of the Vermont Statutes Annotated, the Board's staff, or other designee of the Board.(3) "Claims data" means service-level remittance and other related administrative information generated from the interaction of patients and the health care delivery system. Examples of claims data include provider information; charge and payment information; clinical diagnosis, procedure, and service codes; and national drug codes. Claims data also include information intended to represent payments made under an accountable care organization- based payment reform model.(4) "Council chair" means the chair of the Data Governance Council.(5) "Data Governance Council" or "Council" means the committee established by the Board and given responsibilities for the Board's data governance program.(6) "Data set" means a collection of logical individual data records, regardless of format.(7) "Data collection vendor" means a vendor with whom the Board contracts to manage data collection, cleansing, validation, integration, and consolidation related to the health care database.(8) "Days" means calendar days unless otherwise indicated.(9) "Eligibility data" means demographic information for each individual member enrolled for medical or pharmacy benefits for one or more days of coverage at any time during a reporting period.(10) "General hospital" has the same meaning as in 18 V.S.A. § 1902(1)(A).(11) "Health care" has the same meaning as in 45 C.F.R. § 160.103.(12) "Health care database" means the VHCURES and VUHDDS data sets, collectively.(13) "Health care facility" has the same meaning as in 18 V.S.A. § 9432(8).(14) "Health care provider" has the same meaning as in 18 V.S.A. § 9432(9).(15) "Health insurer" has the same meaning as in 18 V.S.A. § 9410(j)(1).(16) "Insured" has the same meaning as in 18 V.S.A. § 9418(a)(10).(17) "Mandatory submitter" means any person required to submit data for inclusion in the health care database.(18) "Member" means the insured subscriber and any other person(s) eligible for health care benefits under the subscriber's policy, such as the subscriber's spouse or dependent.(19) "Patient" means any person in a data set that is the subject of the activities of the claim performed by the health care provider.(20) "Person" means any natural person, business entity, municipality, the State of Vermont or any department, agency, or subdivision of the State, and any partnership, unincorporated association, or other legal entity.(21) "Pharmacy benefit manager" or "PBM" has the same meaning as in 18 V.S.A. § 9471(5).(22) "Psychiatric hospital" has the same meaning as in 18 V.S.A. § 1902(1)(B).(23) "Reporting manual(s)" means either the VHCURES Reporting Manual or the VUHDDS Reporting Manual or the two documents collectively.(24) "Submitters" means mandatory submitters and voluntary submitters collectively.(25) "Subscriber" means the individual responsible for payment of premiums or whose employment, income, or other circumstances is the basis for eligibility for membership in a health benefit plan.(26) "Third-party administrator" or "TPA" means any person who receives or collects charges, contributions, or premiums for, or adjusts or settles claims on or for residents of Vermont or health insurers.(27) "Vermont Health Care Uniform Reporting and Evaluation System" or "VHCURES" means the data set containing information related to eligibility, health care claims, and related data submitted by health care insurers to the GMCB.(28) "Vermont Uniform Hospital Discharge Data Set" or "VUHDDS" means the data set consisting of inpatient discharge data, outpatient procedures and services data, and emergency department data submitted by general hospitals, ambulatory surgery centers, and psychiatric hospitals that is maintained by the Vermont Department of Health.(29) "VHCURES members" means members who are Vermont residents.(30) "VHCURES Reporting Manual" means the document created and maintained by the Board or the Data Governance Council that specifies data submission requirements for the VHCURES data set, including the required data submission schedule, required fields, file layouts, file components, edit specifications, instructions, and other technical information.(31) "Voluntary submitter" includes persons other than mandatory submitters, including any health benefit plan offered or administered by or on behalf of the federal government or a self-insured employer, that voluntarily submits data to the Board for inclusion in the health care database.(32) "VUHDDS Reporting Manual" means the document created and maintained by the Board or the Data Governance Council that specifies data submission requirements for the VUHDDS data set, including the required data submission schedule, required fields, file layouts, file components, edit specifications, instructions, and other technical information.8.200 VHCURES REGISTRATION AND SUBMISSION8.201 Registration. (a) Prior to doing business in Vermont and by each December 31 thereafter, health insurers shall register with the Board on the form(s) described in subsection (b) of this section. Health insurers that are VHCURES submitters shall also identify whether they are paying health care claims for VHCURES members.(b) The Board, in conjunction with the data collection vendor, shall issue and maintain registration forms for health insurers. The forms shall require health insurers to provide the Board with information on their organization and lines of business, including whether the health insurer is a VHCURES mandatory submitter and what data the health insurer will report to the Board.(c) Health insurers shall notify the Board when changes are made to any of the health insurer's contact information or the data being submitted to the Board. The amended registration form shall be submitted no later than fifteen (15) days after the applicable change goes into effect.8.202 VHCURES Submitters.(a)(1)VHCURES Mandatory Submitters. VHCURES mandatory submitters are health insurers with an average of two hundred (200) or more members in each month of the last calendar year who are VHCURES members.(2) A VHCURES mandatory submitter, as defined in subpart (a)(1) of this subsection, must, for each health line of business (e.g., comprehensive major medical, third-party administrator (TPA)/administrative services only (ASO), Medicare Part C, and Medicare Part D), regularly submit to the VHCURES data collection vendor medical claims data, dental claims data, pharmacy claims data, member eligibility data, provider data, and other non-claims information for all members who are VHCURES members. The data must be submitted in the manner and format(s) and at the times specified in this rule and the VHCURES Reporting Manual.(3) Each VHCURES mandatory submitter is responsible for the submission of data relating to all health care claims processed by a contractor or subcontractor on its behalf unless such contractor or subcontractor is already submitting identical data as a VHCURES mandatory submitter in its own right.(b)(1)VHCURES Voluntary Submitters. A VHCURES voluntary submitter may submit the data specified in subpart (a)(2) of this subsection to the VHCURES data collection vendor.(2) The Board encourages VHCURES voluntary submitters to follow the data submission specifications and schedule outlined in section 8.203 of this rule and the VHCURES Reporting Manual.8.203 VHCURES Data Submission.(a)File Organization. Data shall be submitted in the format(s) specified in the VHCURES Reporting Manual.(b)Submission Protocol. Files shall be submitted electronically by either secure sockets layer (SSL) web upload interface or secure file transfer protocol (FTP), or as specified in the VHCURES Reporting Manual. Email attachments shall not be accepted.(c)Testing of Files. At least sixty (60) days prior to the initial submission of files or whenever the data element content of the files as described in the VHCURES Reporting Manual is subsequently altered, each VHCURES submitter shall submit data to the data collection vendor in accordance with the VHCURES Reporting Manual for testing and validation.(d)Rejection of Files. Failure to conform to subsections (a) or (b) of this section shall result in the rejection and return of the applicable data file(s). All rejected and returned files shall be resubmitted in the appropriate corrected form to the VHCURES data collection vendor within ten (10) days.(e)Replacement of Data Files. In the event a complete data file submission is replaced more than one (1) year after the end of the month in which the file was submitted, the VHCURES submitter must notify the Board. Individual adjustment records may be submitted with any data file submission in accordance with the applicable data submission schedule.(f)Run-Out Period. VHCURES submitters shall submit data for at least a six (6) month period following the termination of coverage date for the particular VHCURES member.(h)(1)Reporting Period. The reporting period for submission for all VHCURES mandatory submitters shall be determined by the highest total number of VHCURES members for any one month of the calendar year. Data files are to be submitted in accordance with the schedule contained in the VHCURES Reporting Manual.(2) If data files submitted by an individual VHCURES submitter support or are related to files submitted by another VHCURES submitter, the Data Governance Council may establish a different reporting period for the parties involved.(i)Data Collection Vendor's Submission Requirements. The VHCURES data collection vendor may provide additional guidelines, information, and instructions regarding the submission of data to VHCURES. Subject to section 8.400 of this rule, VHCURES mandatory submitters shall comply with the guidelines, information, and instructions the VHCURES data collection vendor sets.8.204 GMCB VHCURES Reporting Manual. The Board, through its Data Governance Council, shall issue and maintain a publicly accessible document entitled "VHCURES Reporting Manual" addressing the following topics:
(a) The data VHCURES mandatory submitters shall submit;(b) Technical specifications for the data, including the member eligibility data, medical claims data, and pharmacy claims data;(c) The reporting schedule for VHCURES mandatory submitters; and(d) Any other matters the Board deems appropriate.8.205 Data Quality Assurance. The Board shall work in collaboration with the VHCURES data collection vendor to ensure that submitted data are accurate and consistent with the VHCURES Reporting Manual and the data collection vendor's submission requirements.
8.301 VUHDDS Submitters. (a)(1)VUHDDS Mandatory Submitters. VUHDDS mandatory submitters are ambulatory surgery centers, general hospitals, and psychiatric hospitals in Vermont.(2) A VUHDDS mandatory submitter, as defined in subpart (a)(1) of this subsection, must submit including inpatient discharge data, outpatient procedure and service data, emergency department data, and other financial, scope- and volume-of-service, and utilization data to the VUHDDS data collection vendor. The data must be submitted in the manner and format(s) and at the times specified in the VUHDDS Reporting Manual.(3) The submissions required under this section shall be in addition to any submissions required by the uniform reporting manual described in GMCB Rule 3.000.(b)(1)VUHDDS Voluntary Submitters. A VUHDDS voluntary submitter may submit the data specified in subsection 8.301(a)(2) to the VUHDDS data collection vendor.(2) The Board encourages VUHDDS voluntary submitters to follow the data submission specifications and schedule outlined in the VUHDDS Reporting Manual.(c)Data Collection Vendor's Submission Requirements. The VUHDDS data collection vendor may provide additional guidelines, information, and instructions regarding the submission of data to VUHDDS. Subject to section 8.400 of this rule, VUHDDS mandatory submitters shall comply with the guidelines, information, and instructions the VUHDDS data collection vendor sets.8.302 GMCB VUHDDS Reporting Manual. VUHDDS Reporting Manual. The Board, through its Data Governance Council, shall issue and maintain a publicly accessible guidance document, entitled "VUHDDS Reporting Manual," addressing topics including:
(a) The data VUHDDS mandatory submitters shall submit;(b) Technical specifications for the data submitted to VUHDDS;(c) The reporting schedule for VUHDDS mandatory submitters; and(d) Any other matters the Board deems appropriate.8.303 Data Quality Assurance. The Board shall work in collaboration with its data collection vendor to ensure that submitted data are accurate and consistent with the VUHDDS Reporting Manual and any additional guidelines, information, and instructions the data collection vendor may issue.
8.400 CHANGES TO A REPORTING MANUAL8.401 Modifications and Revisions to a Reporting Manual. The Data Governance Council may revise or modify reporting manuals as appropriate. Prior to approving any revisions or modifications, the Council will send each affected submitter notice and a copy of the proposed revisions or modifications. The Board will also post the notice and proposed revisions or modifications on its website. The Council will accept public comments on the proposed revisions or modifications for thirty (30) days from the date of posting and will review and consider all comments received before approving revisions or modifications.
8.402 Public Meeting. The Data Governance Council may hold a public meeting to discuss and receive comments on proposed revisions or modifications to reporting manuals. Such meetings, if held, must be held in accordance with the Vermont Open Meeting Law, 1 V.S.A. §§ 310, et seq.
8.403 Implementation. Revisions or modifications to reporting manuals shall become effective one hundred twenty (120) days, or such longer time specified by the Data Governance Council, after the Data Governance Council votes to approve them. The Data Governance Council shall review all comments related to the time required by submitters to comply with any revisions or modifications to the reporting manuals, and the Council shall consider such comments when determining whether to specify a time period longer than one hundred twenty days before revisions or modifications become effective. During that 120-day period (or longer, if specified by the Data Governance Council), affected mandatory submitters shall work with the Board and the data collection vendor to ensure the revisions or modifications can be implemented effectively. For good cause, an affected submitter may request a reasonable extension to the 120-day (or longer, if specified by the Data Governance Council) implementation period, which the Council may grant as it deems appropriate. Any such request shall be submitted to the Council chair in writing and contain the length of the extension requested and a detailed explanation as to why there is good cause to grant the extension.
8.404 Appeal Procedure. A decision by the Data Governance Council to deny a request for an extension to the 120-day (or longer, if specified by the Data Governance Council) implementation period may be appealed to the Board by filing a written request to the Board chair within thirty (30) days of the Council's decision. If the request does not include a request for a hearing, the Board may decide the appeal based on the record developed by the Data Governance Council.
8.501 Sanctions for Violations. Violations of data submission requirements, confidentiality requirements, or any other provisions of 18 V.S.A. § 9410 or this rule, may be subject to sanction by the Board in accordance with 18 V.S.A. § 9410(g) after written notice and an opportunity for a hearing. The Board's authority to impose sanctions is in addition to any other powers granted to the Board to investigate, subpoena, or seek other legal or equitable remedies, including the power of the Board to enforce the terms of a governing contract.
8.601 Waiver of Rules. In order to prevent unnecessary hardship, delay, or injustice, or for other good cause, the Board may waive the application of any provision of this rule upon such conditions as it may require, unless precluded by the rule itself or by statute.
8.602 Conflict. In the event this rule or any section thereof conflicts with a federal statute, rule, or regulation or a Vermont statute, the federal or state statute, or the federal rule or regulation shall govern.
8.603 Severability. If any provision of this rule or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of such provisions to other persons or circumstances shall be not affected thereby.
8.604 Effective Date. This rule shall become effective fifteen (15) days after adoption and supersedes all previously issued rules and policies related to the health care database, including Regulation H-2008-01 issued by the Vermont Department of Banking, Insurance, Securities and Health Care Administration.
80-006 Code Vt. R. 80-280-006-X
EFFECTIVE DATE:
1/20/2022 Secretary of State Rule Log #22-001STATUTORY AUTHORITY:
18 V.S.A. §§ 9375, 9380, 9404, 9410, 9453, and 9454.