Exceptions to Required Reporting and Justification for Exceptions

(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.

Source Note: The provisions of this §21.3405 adopted to be effective December 29, 2002, 27 TexReg 11990; amended to be effective July 6, 2017, 42 TexReg 3384.