1. (a) A health benefit plan issuer subject to this subchapter shall not be required to report data that:

   1. (1) could reasonably be used to identify a specific enrollee in a health benefit plan; or
   2. (2) violates confidentiality requirements of state or federal law or regulation applicable to an enrollee in a health benefit plan.

2. (b) A health benefit plan issuer that is an HMO shall not be required to report data for a particular benefit or coverage if:

   1. (1) the HMO does not directly process the claim because the services are prepaid under a capitated payment arrangement; or
   2. (2) the HMO does not receive complete and accurate encounter data.

3. (c) A health benefit plan issuer that does not report data for a reason set forth in subsection (a) of this section must submit, in addition to the report required by this subchapter, an addendum containing:

   1. (1) a general description of the type of data that has been omitted;
   2. (2) the specific provision of each state or federal law or regulation that is the basis for omitting the data; and
   3. (3) a certification that the data could not be identified in such a way that would enable it to be included in the report without violating subsection (a) of this section.
4. (d) A health benefit plan issuer that omits data for a reason set forth in subsection (b) of this section must submit, in addition to the report required by this subchapter, an addendum containing a description of the arrangements or circumstances that except the health benefit plan issuer from reporting the data as required.

Source Note:The provisions of this §21.3405 adopted to be effective December 29, 2002, 27 TexReg 11990.