Department may obtain medical insurance information--failure toprovide information, attorney general to bring action,penalty--confidential information, penalty fordisclosure--definitions.
208.217. 1. As used in this section, the following terms mean:
(1) "Data match", a method of comparing the department's informationwith that of another entity and identifying those records which appear inboth files. This process is accomplished by a computerized comparison bywhich both the department and the entity utilize a computer readableelectronic media format;
(2) "Department", the Missouri department of social services or anydivision thereof;
(3) "Entity":
(a) Any insurance company as defined in chapter 375, RSMo, or anypublic organization or agency transacting or doing the business ofinsurance; or
(b) Any health service corporation or health maintenance organizationas defined in chapter 354, RSMo, or any other provider of health servicesas defined in chapter 354, RSMo;
(c) Any self-insured organization or business providing healthservices as defined in chapter 354, RSMo; or
(d) Any third-party administrator (TPA), administrative servicesorganization (ASO), or pharmacy benefit manager (PBM) transacting or doingbusiness in Missouri or administering or processing claims or benefits, orboth, for residents of Missouri;
(4) "Individual", any applicant or present or former participantreceiving public assistance benefits under sections 208.151 to 208.159 andsection 208.162*;
(5) "Insurance", any agreement, contract, policy plan or writingentered into voluntarily or by court or administrative order providing forthe payment of medical services or for the provision of medical care to oron behalf of an individual;
(6) "Request", any inquiry by the division of medical services forthe purpose of determining the existence of insurance where the departmentmay have expended MO HealthNet benefits.
2. The department may enter into a contract with any entity, and theentity shall, upon request of the department of social services, inform thedepartment of any records or information pertaining to the insurance of anyindividual.
3. The information which is required to be provided by the entityregarding an individual is limited to those insurance benefits that couldhave been claimed and paid by an insurance policy agreement or plan withrespect to medical services or items which are otherwise covered under theMO HealthNet program.
4. A request for a data match made by the department pursuant to thissection shall include sufficient information to identify each person namedin the request in a form that is compatible with the record-keeping methodsof the entity. Requests for information shall pertain to any individual orthe person legally responsible for such individual and may be requested ata minimum of twice a year.
5. The department shall reimburse the entity which is requested tosupply information as provided by this section for actual direct costs,based upon industry standards, incurred in furnishing the requestedinformation and as set out in the contract. The department shall specifythe time and manner in which information is to be delivered by the entityto the department. No reimbursement will be provided for informationrequested by the department other than by means of a data match.
6. Any entity which has received a request from the departmentpursuant to this section shall provide the requested information incompliance with HIPPAA required transactions within sixty days of receiptof the request. Willful failure of an entity to provide the requestedinformation within such period shall result in liability to the state forcivil penalties of up to ten dollars for each day thereafter. The attorneygeneral shall, upon request of the department, bring an action in a circuitcourt of competent jurisdiction to recover the civil penalty. The courtshall determine the amount of the civil penalty to be assessed. A healthinsurance carrier, including instances where they act in the capacity of anadministrator of an ASO account, and a TPA acting in the capacity of anadministrator for a fully insured or self-funded employer, is required toaccept and respond to the HIPPAA ANSI standard transaction for the purposeof validating eligibility.
7. The director of the department shall establish guidelines toassure that the information furnished to any entity or obtained from anyentity does not violate the laws pertaining to the confidentiality andprivacy of an applicant or participant receiving MO HealthNet benefits.Any person disclosing confidential information for purposes other than setforth in this section shall be guilty of a class A misdemeanor.
8. The application for or the receipt of benefits under sections208.151 to 208.159 and section 208.162* shall be deemed consent by theindividual to allow the department to request information from any entityregarding insurance coverage of said person.
Department may obtain medical insurance information--failure toprovide information, attorney general to bring action,penalty--confidential information, penalty fordisclosure--definitions.
208.217. 1. As used in this section, the following terms mean:
(1) "Data match", a method of comparing the department's informationwith that of another entity and identifying those records which appear inboth files. This process is accomplished by a computerized comparison bywhich both the department and the entity utilize a computer readableelectronic media format;
(2) "Department", the Missouri department of social services or anydivision thereof;
(3) "Entity":
(a) Any insurance company as defined in chapter 375, RSMo, or anypublic organization or agency transacting or doing the business ofinsurance; or
(b) Any health service corporation or health maintenance organizationas defined in chapter 354, RSMo, or any other provider of health servicesas defined in chapter 354, RSMo;
(c) Any self-insured organization or business providing healthservices as defined in chapter 354, RSMo; or
(d) Any third-party administrator (TPA), administrative servicesorganization (ASO), or pharmacy benefit manager (PBM) transacting or doingbusiness in Missouri or administering or processing claims or benefits, orboth, for residents of Missouri;
(4) "Individual", any applicant or present or former participantreceiving public assistance benefits under sections 208.151 to 208.159 andsection 208.162*;
(5) "Insurance", any agreement, contract, policy plan or writingentered into voluntarily or by court or administrative order providing forthe payment of medical services or for the provision of medical care to oron behalf of an individual;
(6) "Request", any inquiry by the division of medical services forthe purpose of determining the existence of insurance where the departmentmay have expended MO HealthNet benefits.
2. The department may enter into a contract with any entity, and theentity shall, upon request of the department of social services, inform thedepartment of any records or information pertaining to the insurance of anyindividual.
3. The information which is required to be provided by the entityregarding an individual is limited to those insurance benefits that couldhave been claimed and paid by an insurance policy agreement or plan withrespect to medical services or items which are otherwise covered under theMO HealthNet program.
4. A request for a data match made by the department pursuant to thissection shall include sufficient information to identify each person namedin the request in a form that is compatible with the record-keeping methodsof the entity. Requests for information shall pertain to any individual orthe person legally responsible for such individual and may be requested ata minimum of twice a year.
5. The department shall reimburse the entity which is requested tosupply information as provided by this section for actual direct costs,based upon industry standards, incurred in furnishing the requestedinformation and as set out in the contract. The department shall specifythe time and manner in which information is to be delivered by the entityto the department. No reimbursement will be provided for informationrequested by the department other than by means of a data match.
6. Any entity which has received a request from the departmentpursuant to this section shall provide the requested information incompliance with HIPPAA required transactions within sixty days of receiptof the request. Willful failure of an entity to provide the requestedinformation within such period shall result in liability to the state forcivil penalties of up to ten dollars for each day thereafter. The attorneygeneral shall, upon request of the department, bring an action in a circuitcourt of competent jurisdiction to recover the civil penalty. The courtshall determine the amount of the civil penalty to be assessed. A healthinsurance carrier, including instances where they act in the capacity of anadministrator of an ASO account, and a TPA acting in the capacity of anadministrator for a fully insured or self-funded employer, is required toaccept and respond to the HIPPAA ANSI standard transaction for the purposeof validating eligibility.
7. The director of the department shall establish guidelines toassure that the information furnished to any entity or obtained from anyentity does not violate the laws pertaining to the confidentiality andprivacy of an applicant or participant receiving MO HealthNet benefits.Any person disclosing confidential information for purposes other than setforth in this section shall be guilty of a class A misdemeanor.
8. The application for or the receipt of benefits under sections208.151 to 208.159 and section 208.162* shall be deemed consent by theindividual to allow the department to request information from any entityregarding insurance coverage of said person.
Department may obtain medical insurance information--failure toprovide information, attorney general to bring action,penalty--confidential information, penalty fordisclosure--definitions.
208.217. 1. As used in this section, the following terms mean:
(1) "Data match", a method of comparing the department's informationwith that of another entity and identifying those records which appear inboth files. This process is accomplished by a computerized comparison bywhich both the department and the entity utilize a computer readableelectronic media format;
(2) "Department", the Missouri department of social services or anydivision thereof;
(3) "Entity":
(a) Any insurance company as defined in chapter 375, RSMo, or anypublic organization or agency transacting or doing the business ofinsurance; or
(b) Any health service corporation or health maintenance organizationas defined in chapter 354, RSMo, or any other provider of health servicesas defined in chapter 354, RSMo;
(c) Any self-insured organization or business providing healthservices as defined in chapter 354, RSMo; or
(d) Any third-party administrator (TPA), administrative servicesorganization (ASO), or pharmacy benefit manager (PBM) transacting or doingbusiness in Missouri or administering or processing claims or benefits, orboth, for residents of Missouri;
(4) "Individual", any applicant or present or former participantreceiving public assistance benefits under sections 208.151 to 208.159 andsection 208.162*;
(5) "Insurance", any agreement, contract, policy plan or writingentered into voluntarily or by court or administrative order providing forthe payment of medical services or for the provision of medical care to oron behalf of an individual;
(6) "Request", any inquiry by the division of medical services forthe purpose of determining the existence of insurance where the departmentmay have expended MO HealthNet benefits.
2. The department may enter into a contract with any entity, and theentity shall, upon request of the department of social services, inform thedepartment of any records or information pertaining to the insurance of anyindividual.
3. The information which is required to be provided by the entityregarding an individual is limited to those insurance benefits that couldhave been claimed and paid by an insurance policy agreement or plan withrespect to medical services or items which are otherwise covered under theMO HealthNet program.
4. A request for a data match made by the department pursuant to thissection shall include sufficient information to identify each person namedin the request in a form that is compatible with the record-keeping methodsof the entity. Requests for information shall pertain to any individual orthe person legally responsible for such individual and may be requested ata minimum of twice a year.
5. The department shall reimburse the entity which is requested tosupply information as provided by this section for actual direct costs,based upon industry standards, incurred in furnishing the requestedinformation and as set out in the contract. The department shall specifythe time and manner in which information is to be delivered by the entityto the department. No reimbursement will be provided for informationrequested by the department other than by means of a data match.
6. Any entity which has received a request from the departmentpursuant to this section shall provide the requested information incompliance with HIPPAA required transactions within sixty days of receiptof the request. Willful failure of an entity to provide the requestedinformation within such period shall result in liability to the state forcivil penalties of up to ten dollars for each day thereafter. The attorneygeneral shall, upon request of the department, bring an action in a circuitcourt of competent jurisdiction to recover the civil penalty. The courtshall determine the amount of the civil penalty to be assessed. A healthinsurance carrier, including instances where they act in the capacity of anadministrator of an ASO account, and a TPA acting in the capacity of anadministrator for a fully insured or self-funded employer, is required toaccept and respond to the HIPPAA ANSI standard transaction for the purposeof validating eligibility.
7. The director of the department shall establish guidelines toassure that the information furnished to any entity or obtained from anyentity does not violate the laws pertaining to the confidentiality andprivacy of an applicant or participant receiving MO HealthNet benefits.Any person disclosing confidential information for purposes other than setforth in this section shall be guilty of a class A misdemeanor.
8. The application for or the receipt of benefits under sections208.151 to 208.159 and section 208.162* shall be deemed consent by theindividual to allow the department to request information from any entityregarding insurance coverage of said person.
