| (a) Exceptions for confidential information. A reporting
entity is not required to report data that:
(1) could reasonably be used to identify a specific
enrollee; or
(2) violates confidentiality requirements of state
or federal law or regulations applicable to an enrollee.
(b) Exceptions for certain HMOs. A reporting entity
that is an HMO is not required to report data for a particular benefit
or coverage if:
(1) the HMO does not directly process the claim because
the services are prepaid under a capitated payment arrangement; or
(2) the HMO does not receive complete and accurate
encounter data.
(c) Justification for exceptions. A reporting entity
that does not report data for a reason listed in subsection (a) of
this section must submit, in addition to the report required by this
subchapter, an addendum containing:
(1) a general description of the type of data that
has been omitted;
(2) the specific provision of each state or federal
law or regulation that is the basis for its omission; and
(3) a certification that the data could not be identified
in a way that would allow it to be included in the report without
violating subsection (a) of this section.
(d) Addendum required. A reporting entity that omits
data for a reason listed in subsection (b) of this section must submit,
in addition to the report required by this subchapter, an addendum
describing the arrangements or circumstances that except the reporting
entity from reporting the data as required.
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