H134: SHP Claims Administrator Changes.-AB Latest Version

Passed 1st Reading

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, as recommended by the department of the state treasurer.

The General Assembly of North Carolina enacts:

SECTION 1.  G.S. 135‑48.1 reads as rewritten:

§ 135‑48.1.  General definitions.

(2b)      Claim Payment Data. – 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 Claims Processor, and the amount paid by the Plan on the claim. The term Claim Payment Data includes any document, material, or other work, whether tangible or electronic, that is derived from, is based on, or reflects any of the foregoing data fields or information contained therein. If the Claims Processor designates Claim Payment Data as a trade secret, the Claim Payment Data shall be treated as a trade secret as defined in G.S. 66‑152(3).claim.

(13a)    Non‑Contracted Third Party. – 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 (i) has no direct contractual relationship with the Claims Processor that would govern the processing and payment of the claim and (ii) did not submit the claim directly to the Claims Processor for processing and payment.


SECTION 2.  G.S. 135‑48.32 reads as rewritten:

§ 135‑48.32.  Contracts to provide benefits.

(a)        The Plan benefits shall be provided under contracts between the Plan and the claims processors selected by the Plan. The contracts necessarily will conform to applicable State law.

(b)        Unless otherwise directed by the Plan, each Claims Processor shall provide the Plan with a Claims Data Feed, which includes all Claim Payment Data, Data, on a member level, at a frequency agreed to by the Plan and the Claims Processor. The frequency shall be no less than monthly. The Claims Processor is not required to disclose Claim Payment Data that reflects rates negotiated with or agreed to by a noncontracted third party but, upon request, shall provide to the Plan sufficient documentation to support the payment of claims for which Claim Payment Data is withheld on such basis.A Claims Processor shall 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 if the Claim Payment Data is not available or cannot be obtained by the Claims Processor. A Claims Processor may supply Claim Payment Data or documentation related to a Non‑Contracted Third Party separately from the Claims Data Feed.

(c)        Any provision of any contract between a Claims Processor and a health care provider, subcontractor, or third party that would prevent or prohibit the Claims Processor from disclosing Claim Payment Data to the Plan, in accordance with this section, shall be void and unenforceable, but only to the extent the provision prevents and prohibits disclosure to the Plan.

(d)       The Plan may use and disclose Claim Payment Data solely for the purpose of administering and operating the State Health Plan for Teachers and State Employees in accordance with G.S. 135‑48.2 and the provisions of this Article. The Plan shall not make any use or disclosure of 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.In accordance with G.S. 135‑48.10(a), Claim Payment Data shall be exempt from the provisions of Chapter 132 of the General Statutes or any other provision requiring information and records held by State agencies to be made public or accessible to the public.

(e)        The Plan may not use a provider's Claim Payment Data to negotiate rates, fee schedules, or other master charges with that provider or any other provider.

(f)        The Plan may disclose Claim Payment Data to a third party to use on the Plan's behalf as agreed upon between the Plan and the Claims Processor. The behalf. Before making any disclosure, the Plan must obtain the agreement of 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. The Plan may not disclose 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 Claim Payment Data by the third party that are at least as restrictive as the provisions of this section.

(g)        A Claims Processor who discloses Claim Payment Data in accordance with this section shall not incur any civil liability and shall not be subject to any monetary or equitable relief in connection for with the disclosure.

(h)        The only parties that shall have standing to initiate any civil or administrative proceeding in any of the courts or administrative agencies of the State to enforce this section, or otherwise file a petition or complaint or initiate any cause of action seeking relief under this section, are the Plan and the Claims Processor who submitted the Claim Payment Data at issue in any action or proceeding.

SECTION 3.  This act is effective when it becomes law.