As used in this chapter, unless amended, supplemented, or otherwise modified by regulations adopted under this chapter:
(1) “Board” means the Delaware Health Information Network Board of Directors.
(2) “Claims data” includes required claims data and additional health-care claims information that a voluntary reporting entity may elect, through entry into an appropriate data submission and use agreement under this subchapter, to submit to the Delaware Health Care Claims Database.
(3) “DHIN” means the Delaware Health Information Network.
(4) “Health-care services” means as defined in § 6403 of Title 18.
(5) “Health insurer” means as defined in § 4004 of Title 18. “Health insurer” does not include a provider of any of the following:
a. Casualty insurance, as “casualty insurance” is defined under § 906 of Title 18.
b. Group long-term care insurance, as “group long-term care insurance” is defined in § 7103 of Title 18.
c. A dental plan, as “dental plan” is defined under § 3802 of Title 18.
d. A dental plan organization, as “dental plan organization” defined under § 3802 of Title 18.
(6) “Mandatory reporting entity” means each of the following entities, to the extent permitted under federal law:
a. 1. The State Employee Benefits Committee and the Office of Management and Budget, under each entity’s respective statutory authority to administer the State Group Health Insurance Program in Chapter 96 of Title 29.
2. A health insurer, third-party administrator, or other entity that receives or collects charges, contributions, or premiums for, or adjusts or settles health claims for, a State employee, or a spouse or dependent of a State employee, participating in the State Group Health Insurance Program. However, a carrier, as defined in § 5290 of Title 29, that the State Group Health Insurance Program has selected to offer supplemental insurance program coverage under Chapter 52C of Title 29 is not included in the definition of “mandatory reporting entity”.
b. The Division of Medicaid and Medical Assistance, with respect to services provided under programs administered under Titles XIX and XXI of the Social Security Act (42 U.S.C. §§ 1396 et seq. and 1397aa et seq.).
c. A health insurer or other entity that is certified as a qualified health plan on the Delaware Health Insurance Marketplace for plan year 2017 or a subsequent plan year. However, a health insurer or other entity that is not otherwise required to provide claims data as a condition of certification as a qualified health plan on the Delaware Health Insurance Marketplace for plan year 2017 or a subsequent plan year is not included in the definition of “mandatory reporting entity”.
d. A federal health insurance plan providing health-care services to a resident of this State, including Medicare and the Federal Employees Health Benefits Plan.
e. A health insurer providing health-care coverage to a resident of this State.
(7) “Pricing information” includes all of the following:
a. The preadjudicated price that a provider or facility charges to a reporting entity for health-care services.
b. The amount a patient or insured individual pays, including copays and deductibles.
c. The postadjudicated price that a reporting entity pays to a provider for health-care services.
(8) “Provider” means a hospital or health-care practitioner that is licensed, certified, or authorized under state law to provide health-care services. “Provider” includes a hospital or health-care practitioner participating in a group arrangement, including an accountable care organization, in which the hospital or health-care practitioner agrees to assume responsibility for the quality and cost of health care for a designed group of beneficiaries.
(9) “Reporting date” means a calendar deadline that is scheduled on a regularly recurring basis, by which a mandatory reporting entity must submit required claims data to the Delaware Health Care Claims Database.
(10) “Required claims data” includes the basic claims information that a mandatory reporting entity must submit to the Delaware Health Care Claims Database by the reporting date, including all of the following:
a. Basic demographic information, including the patient’s gender, age, and geographic area of residency.
b. Basic information relating to an individual service, encounter, visit, or episode of care, including all of the following:
1. The date and time of a patient’s admission and discharge.
2. The identity of the health-care services provider.
3. The location and type of facility, such as a hospital, office, or clinic, where the service, encounter, visit, or episode of care was provided.
c. Information describing the nature of health-care services provided to the patient in connection with the service, encounter, visit, or episode of care, including diagnosis codes.
d. Health insurance product type, such as HMO or PPO.
e. Pricing information.
(11) “Third-party administrator” means as defined in § 102 of Title 18.
(12) “Voluntary reporting entity” includes, except as prohibited under applicable federal law, any of the following entities, unless the entity is a mandatory reporting entity:
a. A health insurer.
b. A third-party administrator.
c. An entity that is not a health insurer or third-party administrator, if the entity receives or collects charges, contributions, or premiums for, or adjusts or settles health-care claims for, residents of this State.