For purposes of this chapter, unless amended, supplemented, or otherwise modified by regulations adopted under this chapter:

(1) “Claims data” includes required claims data and any additional health-care claims information that a voluntary reporting entity elects, through entry into an appropriate data submission and use agreement under this subchapter, to submit to the Delaware Health Care Claims Database.

(2) “Health-care services” means as defined in § 6403 of Title 18.

(3) “Health insurer” means as defined in § 4004 of Title 18. “Health insurer” does not include providers of casualty insurance, as defined in § 906 of Title 18; providers of group long-term care insurance or long-term care insurance, as defined in § 7103 of Title 18; or providers of a dental plan or dental plan organization, as defined in § 3802 of Title 18.

(4) “Mandatory reporting entity” means all of the following entities, to the extent permitted under federal law:

a. The State Employee Benefits Committee and the Office of Management and Budget, under each entity’s respective statutory authority to administer the State Group Health Insurance Program in Chapter 96 of Title 29, and any health insurer, third-party administrator, or other entity that receives or collects charges, contributions, or premiums for, or adjusts or settles health claims for, any State employee, or their spouses or dependents, participating in the State Group Health Insurance Program, except for any carrier, as defined in § 5290 of Title 29, selected by the State Group Health Insurance Plan to offer supplemental insurance program coverage under Chapter 52C of Title 29.

b. The Division of Medicaid and Medical Assistance, with respect to services provided under programs administered under Titles XIX and XXI of the Social Security Act [42 U.S.C. §§ 1396 et seq. and 1397aa et seq.].

c. Any health insurer or other entity that is certified as a qualified health plan on the Delaware Health Insurance Marketplace for plan year 2017 or any subsequent plan year, except for any health insurer or other entity that is not otherwise required to provide claims data as a condition of certification as a qualified health plan on the Delaware Health Insurance Marketplace for plan year 2017 or any subsequent plan year.

d. Any federal health insurance plan providing health-care services to a resident of this State, including Medicare and the Federal Employees Health Benefits Plan.

e. Any health insurer providing health-care coverage to a resident of this State.

(5) “Pricing information” includes the preadjudicated price charged by a provider or facility to a reporting entity for health-care services, the amount paid by a patient or insured party, including copays and deductibles, and the postadjudicated price paid by a reporting entity to a provider for health-care services.

(6) “Provider” means a hospital or any health-care practitioner licensed, certified, or authorized under state law to provide health-care services and includes hospitals and health-care practitioners participating in group arrangements, including accountable care organizations, in which the hospital or health-care practitioners agree to assume responsibility for the quality and cost of health care for a designed group of beneficiaries.

(7) “Reporting date” means a calendar deadline, to be scheduled on a regularly recurring basis, by which required claims data must be submitted by a mandatory reporting entity to the Delaware Health Care Claims Database.

(8) “Required claims data” includes the basic claims information that a mandatory reporting entity is required to submit to the Delaware Health Care Claims Database by the reporting date, including all of the following:

a. Basic demographic information, including the patient’s gender, age, and geographic area of residency.

b. Basic information relating to an individual episode of care, including the date and time of the patient’s admission and discharge; the identity of the health-care services provider; and the location and type of facility, such as a hospital, office, or clinic, where the service was provided.

c. Information describing the nature of health-care services provided to the patient in connection with the encounter, visit, or service, including diagnosis codes.

d. Health insurance product type, such as HMO or PPO.

e. Pricing information.

(9) “Third-party administrator” means as defined in § 102 of Title 18.

(10) “Voluntary reporting entity” includes, except as prohibited under applicable federal law, any of the following entities, unless such entity is a mandatory reporting entity:

a. Any health insurer.

b. Any third-party administrator.

c. Any entity, which is not a health insurer or third-party administrator, when such entity receives or collects charges, contributions, or premiums for, or adjusts or settles health-care claims for, residents of this State.

80 Del. Laws, c. 329, § 5; 81 Del. Laws, c. 79, § 32; 81 Del. Laws, c. 392, § 3.