North Carolina § 90-414 - 4. Required participation in HIE Network for some providers.

§ 90-414. 4. Required participation in HIE Network for some providers.

Findings. - The General Assembly makes the following findings: That controlling escalating health care costs of the Medicaid program and other State-funded health care services is of significant importance to the State, its taxpayers, its Medicaid recipients, and other recipients of State-funded health care services. That the State and covered entities in North Carolina need timely access to certain demographic and clinical information pertaining to services rendered to Medicaid and other State-funded health care program beneficiaries and paid for with Medicaid or other State-funded health care funds in order to assess performance, improve health care outcomes, pinpoint medical expense trends, identify beneficiary health risks, and evaluate how the State is spending money on Medicaid and other State-funded health care services. The Department of Information Technology, the Department of State Treasurer, State Health Plan Division, and the Department of Health and Human Services, Division of Health Benefits, have an affirmative duty to facilitate and support participation by covered entities in the statewide health information exchange network. That making demographic and clinical information available to the State and covered entities in North Carolina by secure electronic means as set forth in subsection (b) of this section will improve care coordination within and across health systems, increase care quality for such beneficiaries, enable more effective population health management, reduce duplication of medical services, augment syndromic surveillance, allow more accurate measurement of care services and outcomes, increase strategic knowledge about the health of the population, and facilitate health care cost containment. Mandatory Connection to HIE Network. - Notwithstanding the voluntary nature of the HIE Network under G.S. 90-414.2, the following providers and entities shall be connected to the HIE Network and begin submitting data through the HIE Network pertaining to services rendered to Medicaid beneficiaries and to other State-funded health care program beneficiaries and paid for with Medicaid or other State-funded health care funds in accordance with the following time line: The following providers of Medicaid services licensed to operate in the State that have an electronic health record system shall begin submitting, at a minimum, demographic and clinical data by June 1, 2018: Hospitals as defined in G.S. 131E-176(13). Physicians licensed to practice under Article 1 of Chapter 90 of the General Statutes, except for licensed physicians whose primary area of practice is psychiatry. Physician assistants as defined in 21 NCAC 32S.0201. Nurse practitioners as defined in 21 NCAC 36.0801. Except as provided in subdivisions (3), (4), and (5) of this subsection, all other providers of Medicaid and State-funded health care services and their affiliated entities shall begin submitting demographic and clinical data by January 1, 2023. The following entities shall submit encounter and claims data, as appropriate, in accordance with the following time line: Prepaid Health Plans, as defined in G.S. 108D-1, by the commencement date of a capitated contract with the Division of Health Benefits for the delivery of Medicaid and NC Health Choice services as specified in Article 4 of Chapter 108D of the General Statutes. Local management entities/managed care organizations, as defined in G.S. 122C-3, by June 1, 2020. The following entities shall begin submitting demographic and clinical data by January 1, 2023: Physicians who perform procedures at ambulatory surgical centers as defined in G.S. 131E-146. Dentists licensed under Article 2 of Chapter 90 of the General Statutes. Licensed physicians whose primary area of practice is psychiatry. The State Laboratory of Public Health operated by the Department of Health and Human Services. The following entities shall begin submitting claims data by January 1, 2023: Pharmacies registered with the North Carolina Board of Pharmacy under Article 4A of Chapter 90 of the General Statutes. State health care facilities operated under the jurisdiction of the Secretary of the Department of Health and Human Services, including State psychiatric hospitals, developmental centers, alcohol and drug treatment centers, neuro-medical treatment centers, and residential programs for children such as the Wright School and the Whitaker Psychiatric Residential Treatment Facility. Extensions of Time for Establishing Connection to the HIE Network. - The Department of Information Technology, in consultation with the Department of Health and Human Services and the State Health Plan for Teachers and State Employees, may establish a process to grant limited extensions of the time for providers and entities to connect to the HIE Network and begin submitting data as required by this section upon the request of a provider or entity that demonstrates an ongoing good-faith effort to take necessary steps to establish such connection and begin data submission as required by this section. The process for granting an extension of time must include a presentation by the provider or entity to the Department of Information Technology, the Department of Health and Human Services, and the State Health Plan for Teachers and State Employees on the expected time line for connecting to the HIE Network and commencing data submission as required by this section. Neither the Department of Information Technology, the Department of Health and Human Services, nor the State Health Plan for Teachers and State Employees shall grant an extension of time (i) to any provider or entity that fails to provide this information to both Departments, and the State Health Plan for Teachers and State Employees, (ii) that would result in the provider or entity connecting to the HIE Network and commencing data submission as required by this section later than January 1, 2023. The Department of Information Technology shall consult with the Department of Health and Human Services and the State Health Plan for Teachers and State Employees to review and decide upon a request for an extension of time under this section within 30 days after receiving a request for an extension. Exemptions from Connecting to the HIE Network. - The Secretary of Health and Human Services, or the Secretary's designee, shall have the authority to grant exemptions to classes of providers of Medicaid and other State-funded health care services for whom acquiring and implementing an electronic health record system and connecting to the HIE Network as required by this section would constitute an undue hardship. The Secretary, or the Secretary's designee, shall promptly notify the Department of Information Technology of classes of providers granted hardship exemptions under this subsection. Neither the Secretary nor the Secretary's designee shall grant any hardship exemption that would result in any class of provider connecting to the HIE Network and submitting data later than December 31, 2022. Mandatory Submission of Demographic and Clinical Data. - Notwithstanding the voluntary nature of the HIE Network under G.S. 90-414.2 and, except as otherwise provided in subsection (c) of this section, as a condition of receiving State funds, including Medicaid funds, the following entities shall submit at least twice daily, through the HIE network, demographic and clinical information pertaining to services rendered to Medicaid and other State-funded health care program beneficiaries and paid for with Medicaid or other State-funded health care funds, solely for the purposes set forth in subsection (a) of this section: Each hospital, as defined in G.S. 131E-176(13) that has an electronic health record system. Each Medicaid provider, unless the provider is an ambulatory surgical center as defined in G.S. 131E-146, however, a physician who performs a procedure at the ambulatory surgical center must be connected to the HIE Network. Each provider that receives State funds for the provision of health services, unless the provider is an ambulatory surgical center as defined in G.S. 131E-146, however, a physician who performs a procedure at the ambulatory surgical center must be connected to the HIE Network. Each local management entity/managed care organization, as defined in G.S. 122C-3. Balance Billing Prohibition. - An in-network provider or entity who renders health care services, including prescription drugs and durable medical equipment, under a contract with the State Health Plan for Teachers and State Employees and who is not connected to the HIE Network in accordance with this Article, is prohibited from billing the State Health Plan or a Plan member more than either party would be billed if the entity or provider was connected to the HIE Network. Balance billing because the provider or entity did not connect to the HIE Network is prohibited. Exemption for Certain Records. - Providers with patient records that are subject to the disclosure restrictions of 42 C.F.R. § 2 are exempt from the requirements of subsection (b) of this section but only with respect to the patient records subject to these disclosure restrictions. Providers shall comply with the requirements of subsection (b) of this section with respect to all other patient records. A pharmacy shall only be required to submit claims data pertaining to services rendered to Medicaid and other State-funded health care program beneficiaries and paid for with Medicaid or other State-funded health care funds. Exemption from Twice Daily Submission. - A pharmacy shall only be required to submit claims data once daily through the HIE Network using pharmacy industry standardized formats. Method of Data Submissions. - The data submissions required under this section shall be by connection to the HIE Network periodic asynchronous secure structured file transfer or any other secure electronic means commonly used in the industry and consistent with document exchange and data submission standards established by the Office of the National Coordinator for Information Technology within the U.S. Department of Health and Human Services. Voluntary Connection for Certain Providers. - Notwithstanding the mandatory connection and data submission requirements in subsections (a1) and (b) of this section, the following providers of Medicaid services or other State-funded health care services are not required to connect to the HIE Network or submit data but may connect to the HIE Network and submit data voluntarily: Community-based long-term services and supports providers, including personal care services, private duty nursing, home health, and hospice care providers. Intellectual and developmental disability services and supports providers, such as day supports and supported living providers. Community Alternatives Program waiver services (including CAP/DA, CAP/C, and Innovations) providers. Eye and vision services providers. Speech, language, and hearing services providers. Occupational and physical therapy providers. Durable medical equipment providers. Nonemergency medical transportation service providers. Ambulance (emergency medical transportation service) providers. Local education agencies and school-based health providers. Confidentiality of Data. - All data submitted to or through the HIE Network containing protected health information, personally identifying information, or a combination of these, that are in the possession of the Department of Information Technology or any other agency of the State are confidential and shall not be defined as public records under G.S. 132-1. This subsection shall not be construed to prohibit the disclosure of any such data as otherwise permitted under federal law. If authorized by the Authority in accordance with this Article, the Department of Health and Human Services may submit the data required by this subsection on behalf of the entities specified in this subdivision. History (2015-241, s. 12A.5(d); 2017-57, s. 11A.5(b); 2018-41, s. 9(a); 2019-23, s. 1; 2019-81, s. 2; 2020-3, s. 3E.1(a), (b); 2020-97, s. 3.7B(b); 2020-26, ss. 1-5.) Editor's Note. - Session Laws 2015-241, s. 12A.5(f1), as added by Session Laws 2015-264, s. 86.5(d), provides: "Notwithstanding any provision of this section, covered entities that are required to submit demographic and clinical information through the successor HIE Network described in subsection (a) of this section pursuant to G.S. 90-414.4(b) , as enacted by subsection (d) of this section, shall not be required to submit such demographic and clinical information through the successor HIE Network until the Authority establishes a date for covered entities to begin submitting demographic and clinical information through the HIE Network or by other secure electronic means, as provided in G.S. 90-414.4(b) , as enacted by subsection (d) of this section." Session Laws 2015-241, s. 12A.5(g), as amended by Session Laws 2015-264, s. 86.5(e), provides: "Except as provided in subsection (f1) of this section, subsections (d) and (e) of this section become effective October 1, 2015. Subsection (f) of this section becomes effective on the date the State Chief Information Officer notifies the Revisor of Statutes that all contracts pertaining to the HIE Network established under Article 29A of Chapter 90 of the General Statutes (i) between the State and the NC HIE, as defined in G.S. 90-413.3, and (ii) between the NC HIE and any third parties have been terminated or assigned to the North Carolina Health Information Exchange Authority established under Article 29B of Chapter 90 of the General Statutes, as enacted by subsection (d) of this section. The remainder of this section becomes effective July 1, 2015." Session Laws 2015-241, s. 1.1, provides: "This act shall be known as 'The Current Operations and Capital Improvements Appropriations Act of 2015.'" Session Laws 2015-241, s. 33.6, is a severability clause. Session Laws 2017-57, s. 11A.5(g), (h), provides: "(g) The Department of Health and Human Services shall include as one of the terms and conditions of any contract it enters into on or after the effective date of this section with a local management entity/managed care organization (LME/MCO), as defined in G.S. 122C-3 , or Prepaid Health Plan (PHP), as defined in S.L. 2015-245, a requirement that the LME/MCO or PHP comply with the provisions of G.S. 90-414.4 , as amended by this subsection (b) of this section. "(h) The Department of Health and Human Services, the Department of Information Technology, and the Division in the Department of State Treasurer responsible for the State Health Plan for Teachers and State Employees shall conduct a joint study of the feasibility and appropriateness of providers and entities, other than those specified in subdivision (1) of subsection (a1) of G.S. 90-414.4 , as amended by subsection (b) of this section, connecting with and submitting demographic and clinical data through the HIE Network and the feasibility and appropriateness of providers and entities, other than those specified in subdivision (3) of G.S. 90-414.4 , as amended by subsection (b) of this section, connecting with and submitting encounter and claims data through the HIE Network. As part of this study, the Departments and the Division in the Department of State Treasurer responsible for the State Health Plan for Teachers and State Employees shall examine at least all of the following: "(1) The availability of connection, exchange, and data submission standards established by the Office of the National Coordinator for Information Technology within the U.S. Department of Health and Human Services. "(2) The adoption of national standards for the connection, exchange, and data submission standards by provider type. "(3) Cost estimates by provider type to connect and submit data to the HIE and any availability of federal or State funds to meet connection or submission requirements. "(4) Data captured in the treatment of patients, segmented by provider type. "(5) Activity of other states and payor plans with respect to the establishment of an HIE Network. "(6) Alternatives to the connection and submission of demographic, clinical, encounter, and claims data through the HIE Network. "By April 1, 2018, the Department of Health and Human Services, the Department of Information Technology, and the Division in the Department of State Treasurer responsible for the State Health Plan for Teachers and State Employees shall jointly submit a final report of their findings and recommendations to the Joint Legislative Oversight Committee on Health and Human Services and the Joint Legislative Oversight Committee on Information Technology." Session Laws 2017-57, s. 1.1, provides: "This act shall be known as the 'Current Operations Appropriations Act of 2017.'" Session Laws 2017-57, s. 39.4, provides: "Except for statutory changes or other provisions that clearly indicate an intention to have effects beyond the 2017-2019 fiscal biennium, the textual provisions of this act apply only to funds appropriated for, and activities occurring during, the 2017-2019 fiscal biennium." Session Laws 2017-57, s. 39.6, is a severability clause. Session Laws 2019-23, s. 3, provides: "Notwithstanding any provision of law to the contrary, a provider subject to G.S. 90-414.4(a1)(2) that fails to meet the June 1, 2019, deadline for connecting to the HIE Network and initiating the submission of demographic and clinical data shall not be (i) denied payment for any otherwise allowable Medicaid claims or claims for other State-funded health care services submitted between June 1, 2019, and May 31, 2020, or (ii) subjected to any other penalties, as long as that provider meets the June 1, 2020, deadline enacted by this act for submission of such data." Session Laws 2020-3, s. 3A.1(a), provides: "Unless the context clearly indicates otherwise, the following definitions apply in this Part: "(1) CDC. - The federal Centers for Disease Control and Prevention. "(2) COVID-19. - Coronavirus disease 2019. "(3) COVID-19 diagnostic test. - A test the federal Food and Drug Administration has authorized for emergency use or approved to detect the presence of the severe acute respiratory syndrome coronavirus 2. "(4) COVID-19 emergency. - The period beginning March 10, 2020, and ending on the date the Governor signs an executive order rescinding Executive Order No. 116, Declaration of a State of Emergency to Coordinate Response and Protective Actions to Prevent the Spread of COVID-19. "(5) COVID-19 antibody test. - A serological blood test the federal Food and Drug Administration has authorized for emergency use or approved to measure the amount of antibodies or proteins present in the blood when the body is responding to an infection caused by the severe acute respiratory syndrome coronavirus 2." Session Laws 2020-3, s. 3E.1(b), provided: "G.S. 90-414(a2) reads as rewritten:" and substituted "October 1, 2021" for "June 1, 2020" in clause (ii) of the next-to-last sentence of subsection (a2). However, G.S. 90-414 is a reserved section and therefore has no subsection (a2). The apparent intent of the act was to amend G.S. 90-414 .4(a2). The amendment was not given effect in this section at the direction of the Revisor of Statutes. Subsequently, however, Session Laws 2020-97, s. 3.7B(b), effective September 4, 2020, amended Session Laws 2020-3, s. 3E.1(b), by substituting "G.S. 90-414.4(a2)" for "G.S. 90-414(a2)" in the introductory language. The amendment is now reflected in the text of subsection (a2) of this section. Session Laws 2020-3, s. 5, is a severability clause. Session Laws 2020-97, s. 4.5, is a severability clause. Session Laws 2021-26, s. 7(a), (b), provides: "(a) On or before March 1, 2022, the NC HIE Advisory Board shall submit to the Joint Legislative Oversight Committee on Health and Human Services recommendations regarding appropriate features or actions to support enforcement of the Statewide Health Information Exchange Act contained in Article 29B of Chapter 90 of the General Statutes and the results of the outreach efforts in subsection (b) of this section. "(b) The HIE Authority shall work with the State Health Plan Division, Department of State Treasurer, and the Division of Health Benefits, Department of Health and Human Services, to identify the following: (i) all providers and entities who are required to connect to the HIE as a condition of receiving State funds, (ii) providers and entities who have not connected to the HIE in accordance with G.S. 90-414.4 , and (iii) providers and entities whose deadline for mandatory connection is approaching or has passed. The HIE Authority shall contact each entity or provider identified and ascertain the status of the entity's or provider's effort to connect to the HIE. The HIE Authority shall share information with each provider or entity about the Statewide Health Information Exchange Act and how to connect to the HIE Network. All licensing boards within the State overseeing the providers and entities required to connect to the HIE shall assist by providing contact information and addresses of licensees when that information is not readily available to the HIE Authority, Department of State Treasurer, and the Department of Health and Human Services. Contact information and addresses for providers and entities shall be provided by the Department of State Treasurer, the Department of Health and Human Services, and licensing boards on or before November 1, 2021. On or before November 1, 2021, the Department of State Treasurer, State Health Plan Division, shall provide claim encounter data to support but not exceed the requirements of this section and as part of its responsibilities to administer and operate the State Health Plan for Teachers and State Employees, the State Health Plan Division shall use and disclose Claim Payment Data and/or data from the Claims Data Feed, as necessary to satisfy the requirements of this subsection." Effect of Amendments. - Session Laws 2017-57, s. 11A.5(b), effective July 1, 2017, inserted subsection catchlines in subsections (a) and (b); added subsections (a1), (a2) and (c); inserted the subsection (d) designation and catchline; in subsection (b), inserted "except as otherwise provided in subsection (c) of this section"; in subdivision (b)(1), substituted "G.S. 131E-176(13)" for "G.S. 131E- 76(3)"; and in subdivision (d), substituted "The data" for "The daily" and made stylistic changes. Session Laws 2018-41, s. 9(a), effective June 22, 2018, substituted "subdivisions (3), (4), and (5)" for "subdivision (3)" and added subdivisions (4) and (5) in subsection (a1); added item (iii) to the third sentence in subsection (a2); added the last sentence in subsection (c); and added subsection (c1). Session Laws 2019-23, s. 1, effective June 6, 2019, rewrote subsections (a), (a1), and (a2); and added subsections (a3), (e), and (f). Session Laws 2019-81, s. 2, effective October 1, 2019, in sub-subdivision (a1)(3)a., substituted "G.S. 108D-1" for "S.L. 2015-245" and "Article 4 of Chapter 108D of the General Statutes" for "S.L. 2015-245". Session Laws 2020-3, s. 3E.1(a), effective May 4, 2020, substituted "October 1, 2021" for "June 1, 2020" in subdivision (a1)(2). Session Laws 2021-26, ss. 1-5, effective May 27, 2021, added the last sentence in subdivision (a)(2); in subdivision (a1)(2), inserted "and their affiliated entities” and substituted "January 1, 2023” for "October 1, 2021”; added the last sentence in subdivision (a1)(3)b.; substituted "January 1, 2023” for "June 1, 2021” in subdivision (a1)(4); substituted "Physicians who perform procedures at ambulator” for "Ambulatory” in subdivision (a1)(4)a.; substituted "January 1, 2023” for "June 1, 2021” in subdivision (a1)(5); rewrote subdivisions (b)(2) and (b)(3); and added subsection (b1).