(a) As used in this section:(1) “Exempt patient” means a patient, or the parent or legal guardian of a minor patient, who has declined a specific vaccination or series of vaccinations;(2) “Health insurance entity” has the same meaning as defined in § 56-7-109; and(3) “Quality measure” means a metric, standard, or benchmark used by a health insurance entity to determine a healthcare provider's reimbursement rate, incentive payments, bonus structure, star rating, or network participation status, capitation rate, shared-savings distribution, or downside risk-sharing arrangement, including, but not limited to, the Healthcare Effectiveness Data and Information Set (HEDIS).
(1) “Exempt patient” means a patient, or the parent or legal guardian of a minor patient, who has declined a specific vaccination or series of vaccinations;
(2) “Health insurance entity” has the same meaning as defined in § 56-7-109; and
(3) “Quality measure” means a metric, standard, or benchmark used by a health insurance entity to determine a healthcare provider's reimbursement rate, incentive payments, bonus structure, star rating, or network participation status, capitation rate, shared-savings distribution, or downside risk-sharing arrangement, including, but not limited to, the Healthcare Effectiveness Data and Information Set (HEDIS).
(b) A health insurance entity shall not calculate a final quality measure, quality rating, incentive payment, or reimbursement tier for a healthcare provider at the end of each measurement period that is used to calculate provider payments by including an exempt patient documented by a healthcare provider in the denominator of a vaccination-related metric.
(c) If a healthcare provider documents that a patient is an exempt patient in the patient's medical record and submits an electronic claim containing a standard diagnosis code indicating the immunization was not carried out, including, but not limited to, the International Classification of Diseases (ICD) codes Z28.0, Z28.1, or Z28.2, or such codes' equivalents in any subsequent revision of the ICD, then a health insurance entity must exclude the patient from the final calculation of the provider's vaccination rate performance, or any other quality metric derived from vaccination status, for the applicable measurement period.
(d) A health insurance entity shall not terminate a healthcare provider from a network, reduce a provider's reimbursement rate, or withhold an incentive payment, in whole or in part, because the provider retains exempt patients in the provider's practice.
(e) For purposes of timely reimbursement under § 56-7-109, a claim for reimbursement that is denied, reduced, or recouped by a health insurance entity in violation of subsection (b) or (d) is a clean claim, as defined in § 56-7-109, and is subject to the interest penalties and remediation requirements set forth under § 56-7-109.
(f) A health insurance entity shall not downcode a claim or reduce a reimbursement level solely because:(1) The patient is an exempt patient; or(2) A preventative care standard was not met due to the patient's exempt status.
(1) The patient is an exempt patient; or
(2) A preventative care standard was not met due to the patient's exempt status.