N.M. Admin. Code § 7.1.21.7

Current through Register Vol. 35, No. 21, November 5, 2024

Section 7.1.21.7 - DEFINITIONS

In addition to the definitions in the health information system Act, Section 24-14A-1 et seq. NMSA 1978, the following definitions apply for purposes of this rule:

A.Consumer health information report means a report that provides the public with information on which to base health care purchasing decisions, published by the commission pursuant to Sections 24-14A-3 D(11) and 24-14A-3.1D(2) of the Health Information System Act, Section 24-14A-1 et seq. NMSA 1978, and 7 NMAC 1.22 [now 7.1.22 NMAC].

B.Director means the director of the commission

C.Health care means any care, treatment, service or procedure to maintain, diagnose or otherwise affect an individual's physical or mental condition.

D.Health care professional means any individual licensed, certified or otherwise authorized or permitted by law to provide health care in the practice of a profession.

E.Health care provider means any individual, corporation, partnership, organization, facility, institution or other entity licensed, certified or otherwise authorized or permitted by law to provide health care in the ordinary course of business or practice of a profession.

F.Health information system or HIS means the health information system established by the Health Information System Act, Section 24-14A-1 et seq. NMSA 1978.

G.Health plan report means the document or electronic submission required by this rule to be submitted annually to the commission, containing the HEDIS® reporting set and additional core performance measures required by the commission. ®NCQA registered trademark.

H.Health plan reporting period means the calendar year in which a reporting health plan delivers the services included in the health plan report. To illustrate, the 1996 reporting period is for services delivered in 1996.

I.HEDIS means the Health Plan Employer Data and Information set published by the national committee for quality assurance (NCQA).

J.HEDIS data elements means the rate, numerator, denominator, size of the eligible population and data collection methodology for non-tabular measures that are reported as percentages and are contained in HEDIS.

K.HEDIS reporting set means the full set of measures designated by the national committee for Quality Assurance as reporting measures in the current version of HEDIS.

L.HEDIS reporting version means the version of HEDIS published by the national committee for quality assurance applicable to the same reporting period designated by the national committee for quality assurance as the health plan reporting period defined in this rule.

M.HEDIS specifications means the specifications contained in the latest version or technical update of HEDIS applicable to the health plan reporting period, which may include separate reports for service populations and product types, such as health maintenance organization products, point of service products, preferred provider organization products, medicare risk products, and medicaid managed care products.

N.HIS advisory committee means the committee the commission establishes pursuant to Section 24-14A-3.1 of the Health Information System Act, Section 24-14A-1 et seq. NMSA 1978.

O.Managed health care plan means a health benefit plan offered by a health care insurer that provides for the delivery of comprehensive basic health care services and medically necessary services to individuals enrolled in such plans through its own employed health care professionals or by contracting with selected or participating health care providers that conform to explicit selection standards, or both, and which either requires a covered person to use, or creates incentives, including financial incentives, for a covered person to use, health care providers managed, employed by, or under contract with the managed health care plan or health care insurer.

P.Outcome measures means changes in patient health status and satisfaction resulting from specific medical and health interventions, as distinguished from the effects of other factors that influence patient health and satisfaction.

Q.Patient means a person for whom health information is contained in the health information system.

R.Performance measures include, but are not limited to, quality indicators, outcome measures and health care service information.

S.Proprietary information means confidential technical information, administrative information, and/or business methods that are the property of the reporting health plan and are perceived to confer a competitive position in the health care market by not being openly known by competitors.

T.Quality compass^SM means a national database maintained and disseminated by the NCQA which includes plan-specific comparative and descriptive information on managed health care plan performance.

U.Quality indicator means a standardized and nationally or professionally recognized measure of a discrete element or aspect of health care useful for the purpose of monitoring quality of care.

V.Quality of care means the degree to which health services for individuals and populations increase the likelihood of desired health outcomes or are consistent with current professional knowledge. The provision of health services should reflect appropriate use of the most current knowledge about scientific, clinical, technical, interpersonal, manual, cognitive, and organizational and management elements of health care.

W.Reporting health plan means a health care insurer that:

(1) is required to obtain a certificate of authority or licensure in New Mexico;

(2) has a total premium volume in excess of $5,000,000 in the year prior to the health plan reporting period; and

(3) offered one or more managed health care plans in New Mexico during the health plan reporting period.

X.Total premium volume means the annual premium volume in dollars reported by a health care insurer in its annual statement to the superintendent of insurance.

N.M. Admin. Code § 7.1.21.7

8-30-97; Recompiled 10/31/01