The following definitions shall apply in this part:

1. (1) "Administrator" means the Arkansas Center for Health Improvement;
2. (2) "AID" means the State Insurance Department;
3. (3) "All-payer claims database" or "APCD" means the database created and maintained by the Arkansas Healthcare Transparency Initiative, including the ongoing all-payer claims database project funded through the State Insurance Department, that receives and stores data from submitting entities;
4. (4) "APCD Council" means a federation of government, private, nonprofit, and academic organizations focused on improving the development and deployment of state-based APCDs;
5. (5) "Arkansas Healthcare Transparency Initiative" or "initiative" means the initiative established pursuant to Acts 2015, No. 1233, to create and maintain a database, including the ongoing all-payer claims database project funded through the State Insurance Department, that receives and stores data from submitting entities;
6. (6) "Arkansas Healthcare Transparency Initiative Board" or "initiative board" means the advisory board established under Acts 2015, No. 1233;

7. (7)

   1. (A) "Arkansas resident" means an individual for whom a submitting entity has identified an Arkansas address as the individual's primary place of residence.
   2. (B) For individuals covered by a student health plan, “Arkansas resident” means any student enrolled in a student plan for an Arkansas college or university regardless of his or her address of record;
8. (8) "Commissioner" means the person in charge of the State Insurance Department;
9. (9) "Covered individual" means a natural person who is an Arkansas resident and is eligible to receive medical, dental, or pharmaceutical benefits under any policy, contract, certificate, evidence of coverage, rider, binder, or endorsement that provides for or describes coverage;

10. (10) "Data" means information consisting of, or derived directly from:

    1. (A) Enrollment files;
    2. (B) Medical claims files;
    3. (C) Dental claims files;
    4. (D) Pharmacy claims files;
    5. (E) Provider files; and
    6. (F) Validation reports;
11. (11) "Data set" means a collection of individual data records and data elements that comprises the file types for an enrollment file, medical claims file, dental claims file, pharmacy claims file, and a provider file submitted quarterly and in the format outlined in the DSG;
12. (12) "Data Submission Guide" or "DSG" means a document approved by the Insurance Commissioner in consultation with the Arkansas Healthcare Transparency Initiative Board that sets forth the required data file format, data elements, code tables, edit specifications, thresholds required for a submission to be deemed complete, methods for submitting data, validation reports, exception processes, adjustment files, and other information associated with the submitting entities' reporting duties;

13. (13)

    1. (A) "Dental claims file" means, as further defined in the DSG, a data file that contains service-level remittance information for all paid and denied claims for each billed dental service for covered individuals, including without limitation:

       1. (i) Unique identifiers, geographic and demographic information but not direct personal identifiers;
       2. (ii) Provider information and services rendered to a covered individual;
       3. (iii) Charge/payment information; and
       4. (iv) Clinical diagnosis/procedure codes.
    2. (B) Claims and benefits not subject to this part will not be included in a dental claims file.
    3. (C) The term may exclude certain data that is prohibited to release according to state or federal law;

14. (14)

    1. (A) "Direct personal identifiers" means information relating to a covered individual that contains primary or obvious identifiers, such as the individual's:

       1. (i) Name;
       2. (ii) Street address;
       3. (iii) Email address;
       4. (iv) Telephone number; and
       5. (v) Social Security number.
    2. (B) "Direct personal identifiers" does not include geographic or demographic information that would not allow the identification of a covered individual;
15. (15) "Enrollment file" means unique identifiers, demographic and geographic information relating to covered individuals;
16. (16) "HIPAA" means the Health Insurance Portability and Accountability Act, 42 U.S.C. §§ 1320d–1320d-8 and its implementing regulations, 45 C.F.R. pts. 160, 162, and 164, as may be amended;
17. (17) "Historical data" means a one-time data submission following submission of a test file and for a period commencing on January 1, 2013, and ending according to the data submission schedule in this part;

18. (18)

    1. (A) "Medical claims file" means, as further defined in the DSG, a data file that contains service-level remittance information for all paid and denied claims for each billed medical service for covered individuals, including without limitation:

       1. (i) Unique identifiers, geographic and demographic information but not personal identifiers;
       2. (ii) Provider information and services rendered to a covered individual;
       3. (iii) Charge/payment information; and
       4. (iv) Clinical diagnosis/procedure codes.
    2. (B) Claims and benefits not subject to this part will not be included in a medical claims file.
    3. (C) The term may exclude certain data that is prohibited to release according to state or federal law;

19. (19)

    1. (A) "Pharmacy claims file" means a data file containing service-level remittance information from all paid and denied claims for each prescription for covered individuals, including without limitation:

       1. (i) Unique identifiers, geographic and demographic information but not personal identifiers;
       2. (ii) Provider information;
       3. (iii) Charge/payment information; and
       4. (iv) National drug codes.
    2. (B) The term may exclude certain data that is prohibited to release according to state or federal law;

20. (20) "Provider file" means a data file that includes additional information as set forth in the DSG about the providers that are included in a:

    1. (A) Medical claims file;
    2. (B) Dental claims file; or
    3. (C) Pharmacy claims file;

21. (21)

    1. (A) "Submitting entity" means an entity that is subject to this part and its data reporting requirements.

    2. (B) "Submitting entity" includes the following entities:

       1. (i) An entity that provides health or dental insurance or a health or dental benefit plan in the state, including without limitation an insurance company, medical services plan, hospital plan, hospital medical service corporation, health maintenance organization, or fraternal benefits society, provided that the entity has covered individuals and the entity had at least two thousand (2,000) covered individuals as of December 31 in the previous calendar year;
       2. (ii) A health benefit plan offered or administered by or on behalf of the state or an agency or instrumentality of the state;
       3. (iii) A health benefit plan offered or administered by or on behalf of the federal government with the agreement of the federal government;
       4. (iv) The Arkansas Workers' Compensation Commission;
       5. (v) Any other entity providing a plan of health insurance or medical, dental, or pharmaceutical benefits subject to state insurance regulation, a third-party administrator, or a pharmacy benefits manager, provided that the entity has covered individuals and the entity had at least two thousand (2,000) covered individuals as of December 31 in the previous calendar year;
       6. (vi) An entity that contracts with institutions of the Division of Correction or Division of Community Correction to provide medical, dental, or pharmaceutical care to inmates; and
       7. (vii) A health benefit plan subject to the Employee Retirement Income Security Act of 1974 (ERISA), Pub. L. No. 93-406.
    3. (C) "Submitting entity" does not include an entity that provides health insurance or a health benefit plan that is accident-only, specified disease, hospital indemnity and other fixed indemnity, long-term care, disability income, Medicare supplement, or other supplemental benefit coverage from which benefit payments are directly to the covered individual.
    4. (D) In instances where more than one (1) submitting entity is involved in the administration of a policy, the payer shall be responsible for submitting the claims data on policies that it has written or sold as a bundle, provided, however, that in instances where more than one (1) submitting entity is involved in the administration of a policy, those entities will work together to use the same unique identifier for a covered individual across separate feeds for medical, prescription, and other claims.
    5. (E) If a "submitting entity" contracts with another entity to provide subcontracted claims processing services, the entity which contracts directly with the customer shall be the submitting entity for purposes of this part;
22. (22) "Test file" means a data file, as further defined by the DSG, that includes a sample of service-level remittance information for billed medical or dental services or prescriptions for covered individuals;
23. (23) "Unique identifier" means, as further defined in the DSG, an identifier that is guaranteed to be unique among all identifiers for covered individuals but does not include direct personal identifiers; and
24. (24) "Validation report" means, as further defined in the DSG, a report from the submitting entity that provides aggregated information about a quarterly data submission to provide control totals and record counts.