Accountability Act (HIPAA), 42 U.S.C. §1320d-2, as amended, and ICD-10 implementation costs
in excess of 0.3% of earned premium
• That portion of the activities of health care professional hotlines that does not meet the definition
of activities that improve health quality
• All retrospective and concurrent utilization review
• Fraud prevention activities
• The cost of developing and executing provider contracts and fees associated with establishing or
managing a provider network, including fees paid to a vendor for the same reason
• Provider credentialing
• Marketing expenses
• Costs associated with calculating and administering individual enrollee or employee incentives
• That portion of prospective utilization that does not meet the definition of activities that improve
health quality
• Any function or activity not expressly included in Lines 4.1 through 4.6, unless otherwise
approved by and within the discretion of the Secretary, upon adequate showing by the issuer that
the activity’s costs support the definitions and purposes in this Part or otherwise support
monitoring, measuring or reporting health care quality improvement
Expenses which otherwise meet the definition for QI activities but which were paid for with grant money
or other funding separate from premium revenues shall NOT be included in QI activities expenses.
Notes:
a.
Healthcare Professional Hotlines: Expenses for healthcare professional hotlines should be
included in Claims Adjustment Expenses to the extent they do not meet the criteria for the above
defined columns of Improve Health Outcomes, Prevent Hospital Readmissions, Improve Patient
Safety, Reduce Medical Errors, and Lower Infection and Mortality Rates, and Implement,
Promote, and Increase Wellness and Health Activities.
b.
Prospective Utilization Review: Expenses for prospective Utilization Review should be included
in Claims Adjustment Expenses to the extent they do not meet the criteria for the above defined
columns of Improve Health Outcomes, Prevent Hospital Readmissions, Improve Patient Safety,
Reduce Medical Errors, and Lower Infection and Mortality Rates, and Implement, Promote, and
Increase Wellness and Health Activities, AND the prospective utilization review activities are not
conducted in accordance with a program that has been accredited by a recognized accreditation
body.
Line 4.1 – Improve Health Outcomes
Include expenses for the direct interaction of the insurer (including those services delegated by
contract for which the insurer retains ultimate responsibility under the insurance policy),
providers, and the enrollee or the enrollee’s representatives (e.g., face-to-face, telephonic,
web-based interactions, or other means of communication) to improve health outcomes.
This category can include costs for associated activities such as:
• Effective case management, care coordination, and chronic disease management,
including through the use of the medical homes model as defined in section 3606 of the
Affordable Care Act
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