Definitions. For the purposes of this chapter, (a) “Claim” means (1) a bill for services, (2) a line item of service, or (3) all services for one member within a bill. (b) “Clean Claim” means one that is without material defect and can be processed without obtaining additional information from the provider of the service or from a third party. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. For the purposes of this paragraph, the term “material defect” means an imperfection in the submission of a claim consisting in the omission of information that is essential to process the claim in accordance with the Health Plan’s published claim filing requirements. * (c) “Commissioner” means the Insurance Commissioner established by 4 CMC § 7104. (d) “Date of Payment” means the date on which payment is issued by the Health Plan or the date of final adjudication by a Health Plan if no payment is issued. (e) “Date of Receipt” means the date the Health Plan receives a Claim whether electronic or written. (f) “Denied Claim” means the determination by the Health Plan that a Claim is not eligible for payment. (g) “Electronic Claim” means a claim that is submitted via electronic media. A claim submitted via direct data entry is considered to be an electronic claim. The requirements for electronic claim submissions shall be consistent with regulations promulgated by Secretary of Health and Human Services pursuant to SEC. 1173 of the Social Security Act (42 U.S.C. § 1320d−2). (h) “Electronic Media” means electronic storage material on which data is or may be recorded electronically, including, for example, devices in computers (hard drives) and any removable/transportable digital memory medium, such as magnetic tape or disk, optical disk, or digital memory card, and transmission media used to exchange information already in electronic storage media. Transmission media includes, for example, the internet, extranet or intranet, leased lines, dial-up lines, private networks, and the physical movement of removable/transportable electronic storage media. Certain transmissions, including of paper, via facsimile, and of voice, via telephone, are not considered to be transmissions via electronic media if the information being exchanged did not exist in electronic form immediately before the transmission. (i) “Health Plan” for the purposes of this chapter, means any accident, and health insurance policy or certificate, hospital and medical services corporation contract, health maintenance organization subscriber contract, plan provided by a multiple employer welfare arrangement, or plan provided by another benefit arrangement. The term “Health Plan” does not mean accident only, credit, or disability insurance; Medicare supplemental or long-term care insurance; dental
only or vision only insurance; specified disease insurance; Medicaid coverage; hospital confinement indemnity coverage; limited benefit health coverage; coverage issued as a supplement to liability insurance, insurance arising out of a workers’ compensation or similar law; automobile medical payment insurance; medical expense and loss of income benefits; or insurance under which benefits are payable with or without regard to fault and that is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.* (j) “Health Care Clearinghouse” means a public or private entity that processes or facilitates the processing of nonstandard data elements of health information into standard data elements. (k) “Health Care Provider” means a health care practitioner, group of health care practitioners, or other entity licensed, certified, or otherwise authorized by law to provide, for a fee, hospital, physician, or other health care or medical care services within the Commonwealth of the Northern Mariana Islands, and is eligible for compensation or reimbursement from a Health Plan. (l) “Health Insurance Issuer” means any entity licensed, or required to be licensed, by the Insurance Division of the Department of Commerce that offers health plans or policies, as defined in this chapter, covering eligible individuals or groups. (m) “Person” means an enrollee or subscriber in a Health Plan, provider, or physician. (n) “Process” or “Processed” means that a claim has been paid, pended or denied. *So in original. Source: PL 20-88 § 2(102) (Feb. 8, 2019), modified. Commission Comment: In codifying PL 20-88, the Commission numbered the section pursuant to 1 CMC § 3806(a) and changed capitalization for conformity pursuant to 1 CMC § 3806(f). The Commission changed “section 1173 of the Social Security Act (110 Stat. 2024; 42 U.S.C. § 1320d-2)” to “SEC. 1173 of the Social Security Act (42 U.S.C. § 1320d−2)” in (g) pursuant to 1 CMC § 3806(g).