AN ACT ALLOWING THE NORTH CAROLINA STATE HEALTH PLAN FOR TEACHERS AND STATE EMPLOYEES TO ACCESS AND UTILIZE ITS OWN CLAIMS PAYMENT DATA WHILE CONTINUING TO PROTECT THE CONFIDENTIALITY OF THE INFORMATION.
Senate committee substitute to the 2nd edition makes the following changes. Amends GS 135-48.1, by amending the definition of the term Claim Payment Data to now define it as the data fields within a Claims Data Feed that reflect the provider and the amount the provider billed for services provided to a Plan member, the allowed amount applied to the claim by the Claim Processor, and the amount paid by the State Health Plan for Teachers and State Employees (Plan) on the claim (no longer includes the rate negotiated with, or agreed to by, the provider). Adds and defines the term non-contracted third party as a legal entity or individual that submits a claim for payment to a Claims Processor for items or services rendered to a Plan member that (1) has no direct contractual relationship with the Claims Processor that would govern the process and payment of the claim and (2) did not submit the claim directly to the Claims Processor for processing and payment.
Amends GS 135-48.32 as follows. Deletes the proposed changes in subsection (b) and instead provides as follows. Requires that the Claims Data Feed provided by each Claims Processor to the Plan include the Claim Payment Data on a member level. Deletes the provision that specified that the Claims Processor was not required to disclose Claim Payment Data that reflects rates negotiated with or agreed to by a noncontracted third party but allowed, upon request, providing the Plan with sufficient documentation to support the payment of claims for which the Claim Payment Data is withheld. Adds instead that a Claims Processor must also, upon request, provide the Plan with Claim Payment Data that reflects rates negotiated with or agreed to by a Non-Contracted Third Party that is available to or can be obtained by the Claims Processor or sufficient documentation to support the payment of the claims. Allows a Claims Processor to supply Claim Payment data or documentation related to a Non-Contracted Third Party separately from the Claims Data Feed.
Amends subsection (d) of the statue as follows. No longer specifies that administering and operating the State Health Plan for Teachers and State Employees in accordance with the specified state laws is the sole reason for which the Plan may use and disclose Claim Payment Data. Deletes the proposed language that would have prohibited the Plan from making any use or disclosure of the Claim Payment data that would compromise the proprietary nature of the data, or as applicable, its status as a trade secret, or otherwise misappropriate the data.
Amends subsection (e) of the statute as follows. Removes the proposed language that prohibited the Plan from using a provider's Claim Payment Data to negotiate rates, fee schedules, or other master changes with that or any other provider. Maintains the deletion of current (e).
Amends subsection (f) of the statute by removing the proposed changes and instead making the following changes. Allows the Plan to disclose Claim Payment Data to a third party to use on the Plan's behalf. Requires that before making the disclosure, the Plan must provide notice to the Claims Processor for each third party to whom the Plan seeks to disclose Claim Payment Data and for each use the third party will make of the data. Deletes the prohibition on disclosing Claim Payment Data to any third party without first entering into a contract with the third party that contains restrictions on the use and disclosure of the Data by the third party.
Amends subsection (g) of the statute by reinstating the existing language and adding that a Claims Processor who discloses Claim Payment Data in accordance with the statute is not subject to any monetary relief. Deletes the proposed civil penalty.
Adds a new provision specifying that the Plan and the Claims Processor who submitted the Claim Payment Data at issue are the only parties that have standing to initiate any civil or administrative proceeding to enforce this statute or to otherwise file a petition or complaint or initiate any cause of action seeking relief under this statute.
Changes the act's effective date to when it becomes law (was, January 1, 2022).
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