Cal. Code Regs. tit. 22 § 97300

Current through Register 2024 Notice Reg. No. 49, December 6, 2024

Section 97300 - Definitions

The following definitions shall apply to the regulations contained in this Chapter:

(a) "APCD-CDLT" means one of the following:

(1) For monthly data files submitted or resubmitted pursuant to this Chapter on or before February 16, 2024, the Common Data Layout for All-Payer Claims Databases, Version 2.1, released July 1, 2021, as developed by the University of New Hampshire and the National Association of Health Data Organizations (NAHDO), and hereby incorporated by reference. This document is available through the APCD Council website; or

(2) For monthly data files submitted or resubmitted pursuant to this Chapter on or after February 17, 2024, the Common Data Layout for All-Payer Claims Databases, Version 3.0.1, released April 1, 2023, as developed by the University of New Hampshire and NAHDO, and hereby incorporated by reference. This document is available through the APCD Council website.

(b) "Data portal" means the secure data submission mechanism through which plans register to submit data and data files are submitted to the system. The data portal is available via the Department's website.

(c) "Data Submission Guide" means one of the following:

(1) For registrations and monthly data files submitted or resubmitted pursuant to this Chapter on or before February 16, 2024, the Health Care Payments Data Program: Data Submission Guide, Version 1.0, dated November 23, 2021, and hereby incorporated by reference. The Data Submission Guide is available on, and may be downloaded from, the Department's website; or

(2) For registrations and monthly data files submitted or resubmitted pursuant to this Chapter on or after February 17, 2024, the Health Care Payments Data Program: Data Submission Guide, Version 2.0, revised on July 17, 2023, and hereby incorporated by reference. The Data Submission Guide is available on, and may be downloaded from, the Department's website.

(d) "Delegated submitter" means an entity identified pursuant to Section 97318 as responsible for submitting data to the system on behalf of a plan.

(e) "Dental Data" means dental claims files as described in Section 97342, data for members who are exclusively enrolled for dental services, and data for providers who exclusively provided dental services.

(f) "Dental Plan" means a specialized health care service plan covering dental services only, a dental-only insurance plan, or a public self-insured plan covering dental services only.

(g) "Department" means the Department of Health Care Access and Information.

(h) "Designated submitter representative" means an individual or individuals designated by a registered submitter to submit data on behalf of the registered submitter and receive all communications from the System and the Department regarding data submissions.

(i) "Director" means the Director of the Department of Health Care Access and Information.

(j) "Health insurer" means an insurer licensed to provide health insurance, as defined in Section 106 of the Insurance Code, and an insurer offering specialized health insurance offering pharmacy, behavioral health (psychological), or dental services. Insurers providing only other specialized health insurance, or stop-loss insurance, student health insurance, supplemental insurance (including Medicare supplemental insurance), or discount-only insurance, are not considered health insurers.

(k) "Health plan" means a health care service plan as defined in the Knox-Keene Health Care Service Plan Act of 1975 (Chapter 2.2 (commencing with Section 1340) of Division 2 of the Health and Safety Code) or a specialized health care service plan offering pharmacy, behavioral health (psychological), or dental services. "Health plan" does not include a health care service plan that holds a restricted or limited license only under the Knox-Keene Health Service Plan Act of 1975. Student health plans and supplemental plans (including Medicare supplemental coverage) are not considered health plans.

(l) "Member" means a person who is enrolled in or covered by a health plan, health insurer, or public self-insured plan.

(m) "Plan" means a non-exempt health plan, health insurer, or public self-insured plan; and any voluntarily participating entity.

(n) "Program" means the Health Care Payments Data Program established pursuant to Health and Safety Code Section 127671.1.

(o) "Public self-insured plan" means:

(1) A self-insured plan subject to Health and Safety Code Section 1349.2, or

(2) A state entity, city, county, or other political subdivision of the state, or a public joint labor management trust, that offers self-insured or multiemployer-insured plans that pay for or reimburse any part of the cost of health care services.

(p) "Qualified Health Plan" means a Qualified Health Plan offered by the California Health Benefit Exchange.

(q) "Registered submitter" means a plan that has registered to submit data to the system. An entity that is a delegated submitter under Section 97318 and has registered to submit data will be considered a registered submitter.

(r) "System" means the Health Care Payments Data System.

(s) "Voluntarily participating entity" means an entity that chooses to voluntarily submit data to the Program, has been approved by the Department to submit data, and is one of the following business types:

(1) A self-insured employer that is not subject to Health and Safety Code Section 1349.2.

(2) A multiemployer self-insured plan that is responsible for paying for health care services provided to beneficiaries.

(3) The trust administrator for a multiemployer self-insured plan.

(4) A provider, as defined in Health and Safety Code Section 1367.50(b)(2), that is a hospital or clinic.

(5) A supplier, as defined in Health and Safety Code Section 1367.50(b)(3), that has an independent scope of practice and submits claims electronically.

(6) A health plan or health insurer exempt from the requirements of this Chapter.

Cal. Code Regs. Tit. 22, § 97300

Note: Authority cited: Section 127673, Health and Safety Code. Reference: Sections 127671, 127671.1, 127673, 127673.1 and 127673.2, Health and Safety Code.

1. New chapter 11 (articles 1-7, sections 97300-97370), article 1 (section 97300) and section filed 12-20-2021 as an emergency; operative 12/20/2021 (Register 2021, No. 52). Pursuant to Health and Safety Code section 12763(f), a Certificate of Compliance must be transmitted to OAL by 12-20-2023 or emergency language will be repealed by operation of law on the following day. For prior history of chapter 11, see Register 87, No. 15.
2. Certificate of Compliance as to 12-20-2021 order, including amendment of subsections (a)-(a)(1), new subsection (a)(2), amendment of subsections (c)-(c)(1) and new subsection (c)(2) transmitted to OAL 10-13-2023 and filed 11-17-2023; amendments effective 11/17/2023 pursuant to Government Code section 11343.4(b)(3) (Register 2023, No. 46).