N.M. Admin. Code § 7.1.31.7

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

Section 7.1.31.7 - DEFINITIONS

A."Allowed amount" means the negotiated amount eligible for payment for a health care service or item rendered by a provider.

B."Billed amount" means the amount billed by a provider requesting payment for health care services or items rendered.

C."Claim" means a financial accounting of or a request for payment for health care items or services rendered by a provider.

D."Data" means the data required by this rule to be submitted to this database, including data on the following health factors: mortality and natality, including accidental causes of death; morbidity; health behavior; disability; health system costs, availability, utilization and revenues; environmental factors; health personnel; demographic factors; social, cultural and economic conditions affecting health, including language preference; family status; medical and practice outcomes as measured by nationally accepted standards and quality of care; and participation in clinical research trials.

E."Data provider" means a person that possesses health information, including any public or private sector licensed health care practitioner, primary care clinic, ambulatory surgery center, ambulatory urgent care center, ambulatory dialysis unit, home health agency, long-term care facility, hospital, pharmacy, third-party payer and any public entity that has health information.

F."Database" means the statewide all-payer health care claims database established in this rule.

G."Department" means the department of health.

H."Direct patient identifier" means a data variable that identifies an individual, including: names; telephone numbers; fax numbers; social security number; medical record numbers; health plan beneficiary numbers; account numbers; certificate or license numbers; vehicle identifiers and serial numbers, including license plate numbers; device identifiers and serial numbers; web universal resource locators; internet protocol address numbers; biometric identifiers, including finger and voice prints; elements of dates more granular than a year; un-aggregated ages over 89; geographic subdivisions smaller than the state, except the first three digits of ZIP, full face photographic images and any comparable images; and any other unique identifying number, characteristic, or code, except as permitted by 45 C.F.R 164.514(c).

I."ERISA plan" means an employee welfare benefit plan to the extent that the plan provides medical care to employees or their dependents under the Employee Retirement Income Security Act of 1974 directly or through insurance, reimbursement or other means.

J."Health information" or "health data" means any data relating to health care; health status, including environmental, social and economic factors; a health system or provider; health costs, financing, and including data that would customarily be collected in the ordinary course of business for the data provider; annual audited financial statements customarily prepared by a data provider; information on major capital expenditures; data established by regulation to be collected to carry out the requirements of the Health Information System Act; data required to be collected by other state or federal laws; and annual surveys or collection of data may be used as an alternative to collection of health data from some health service providers to the extent it can be shown that the information collected will meet validity and quality standards.

K."Health information system" or "HIS" means the health information system established by the Health Information System Act, Sections 24-14A-1 to 24-14A-10, NMSA 1978.

L."Health insurance carrier" means any entity that offers the following:

(1) group health and dental coverage governed by the provisions of the Health Care Purchasing Act;

(2) individual health and dental insurance policies, health benefits plans and certificates of insurance governed by the provisions of Chapter 59A, Article 22 NMSA 1978;

(3) health and dental multiple-employer welfare arrangements governed by the provisions of Section 59A-15-20 NMSA 1978;

(4) group and blanket health and dental insurance policies, health benefits plans and certificates of insurance governed by the provisions of Chapter 59A, Article 23 NMSA 1978;

(5) individual and group health and dental health maintenance organization contracts governed by the provisions of the Health Maintenance Organization Law Chapter 59A, Article 46 NMSA 1978; and

(6) individual and group health and dental nonprofit health benefits plans governed by the provisions of the Nonprofit Health Care Plan Law Chapter 59A, Article 47 NMSA 1978.

M."Indirect patient identifier" means a data variable that may identify an individual when combined with other information.

N."Proprietary financial information" means information that derives independent economic value, actual or potential, from not being generally known to and not being readily ascertainable by proper means by other persons who can obtain economic value from its disclosure or use; and is the subject of efforts that are reasonable under the circumstances to maintain its secrecy.

O."Secretary" means the secretary of the New Mexico department of health.

P."Unique identifier" means an obfuscated identifier assigned to an individual represented in the database to establish a basis for following the individual longitudinally throughout different payers and encounters in the data with out revealing the individual's identity.

N.M. Admin. Code § 7.1.31.7

Adopted by New Mexico Register, Volume XXXII, Issue 08, April 20, 2021, eff. 4/20/2021