Claims Data Reporting

Claims Data Reporting A. Upon request by a large employer group (“group”) or the group’s agent or broker, the group’s health carrier shall make available the currently available summary health information, aggregate paid claims, and premium data accumulated for the current and the immediately preceding policy periods. The company shall make this data available within ten (10) business days of the request. B. The company may condition the remittance of the data on both the execution of an agreement for immunity from civil liability and a certification of compliance with the federal rules concerning privacy of individually identifiable health information found in 45 C.F.R. Section 164.504(f)(2). C. All group claims data reports provided pursuant to this regulation shall include all data available to the company as of the date of the request and shall include the following information: 1. The net claims paid by month during the current and the immediately preceding policy period. 2. The monthly enrollment by employee only, employee and spouse, employee and child(ren), and the employee and family during the current and the immediately preceding policy period. 3. The amount of any claims reserve established by the insurance company against future claims under the policy, to the extent the company maintains claims reserves on a group policyholder basis. 4. Claims over twenty-five thousand dollars ($25,000.00) including claim identifier, the date of occurrence, the amount of claims paid and those unpaid or outstanding, and claimant health condition or diagnosis during the current and the immediately preceding policy period. The data shall provide a unique identifying number or code for the claimant. D. Nothing in this section shall be construed to prohibit a plan and group from negotiating the release of additional information not described in this regulation. E. The provisions of this regulation shall not be construed to authorize the disclosure of the identity of a particular employee covered under the group policy, nor the disclosure of any individual employee’s particular health insurance claim, condition, diagnosis, or prognosis, which would violate federal or state law. Nothing in this regulation shall be construed to require an insurer to provide information protected as confidential by the Health Insurance Portability and Accountability Act of 1996 or any other provision of federal law.