The following words and terms, when used in this subchapter,
have the following meanings unless the context clearly indicates otherwise.
(1) Allowed amount--Has the meaning assigned by Insurance
Code §38.402, concerning Definitions.
(2) Center--The Center for Health Care Data at The
University of Texas Health Science Center at Houston.
(3) Data--Has the meaning assigned by Insurance Code §38.402.
(4) Data files--Files submitted under this subchapter,
including dental claims data files, enrollment and eligibility data
files, medical claims data files, pharmacy claims data files, and
provider files.
(5) Database--Has the meaning assigned by Insurance
Code §38.402.
(6) Dental claims data file--A file that includes data
as specified in the Texas APCD CDL about any dental claim or encounter
for which some action has been taken on the claim during the reporting
period, including payment, denial, adjustment, or other modification.
(7) Enrollment and eligibility data file--A file that
provides identifying data as specified in the Texas APCD CDL about
a person who is enrolled and eligible to receive health care coverage
from a payor, whether or not the member used services during the reporting
period, with one record per member, per month, per plan.
(8) Medical claims data file--A file that includes
data as specified in the Texas APCD CDL about medical claims and other
encounter information for which some action has been taken on the
claim during the reporting period, including payment, denial, adjustment,
or other modification.
(9) Payor--Has the meaning assigned by Insurance Code §38.402.
(10) Pharmacy claims data file--A file that includes
data as specified in the Texas APCD CDL about all claims filed by
pharmacies, including mail order and retail dispensaries, for prescriptions
that were dispensed, processed, and paid during the reporting period.
(11) Provider file--A file that includes information
as specified in the Texas APCD CDL about all providers (regardless
of network status) that submitted claims that are included in the
medical claims data file, dental claims data file, or pharmacy claims
data file, with a separate record provided for each unique physical
location for a provider who practices in multiple locations.
(12) Qualified research entity--Has the meaning assigned
by Insurance Code §38.402.
(13) Stakeholder advisory group--Has the meaning assigned
by Insurance Code §38.402.
(14) Submission guide--The document entitled "The Texas
All-Payor Claims Database Data Submission Guide," created by the Center,
that outlines administrative procedures and provides technical guidance
for submitting data files.
(15) Texas APCD CDL--The standardized format, or common
data layout (CDL), for All-Payor Claims Database (APCD) data files
published by the Center and based on the "All-Payer Claims Database
Common Data Layout" established by the National Association of Health
Data Organizations and used with permission.
(16) Texas resident member--Any policyholder or certificate
holder (subscriber) of a plan issued in Texas whose residence is within
the state of Texas and all covered dependents, regardless of where
the dependent resides.
|
