Common use of Data Submission Requirements to the Exchange Clause in Contracts

Data Submission Requirements to the Exchange. Contractor shall submit a complete data set, inclusive of all member and provider identified data, claims, encounter and pharmacy data, on a quarterly basis to the Exchange or the Exchange’s designated recipient to be used by the Exchange as it determines to be necessary. Such submissions will conform to all applicable Federal and State personal health information and related privacy laws, rules and regulations, and shall comply with the terms and conditions set forth in the Agreement by and between Contractor and the Exchange. Contractor will bear the full cost of data collection, extraction and submission; provided, however, that except as expressly set forth in this Attachment or the Agreement, Contractor will not be required to pay for any expenses related to the analysis of that data in order to comply with the terms of this Agreement. Contractor is not required to provide the Exchange with Individually Identifiable Health Information as to any Enrollee unless authorized by law. When conformance with data submission requirements necessitates disclosure of Individually Identifiable Health Information not authorized by law, such information shall be submitted by Contractor to a third-party vendor selected by the Exchange and who enters into an agreement with the Contractor to do data analysis and provide reports and analyses to the Exchange. Such vendor must be a Business Associate of the Contractor who shall protect the information provided as required by applicable laws, rules and regulations. Any Personally Identifiable Health Information disclosed to the third party vendor shall be de-identified in any subsequent analysis provided to the Exchange. If the use of such a vendor is necessary, the details of the arrangement shall be set forth in a data use and reporting agreement mutually agreeable to the Exchange and the Contractor. When data is submitted to a vendor for the Exchange, that vendor will be a Business Associate of the Contractor and shall protect the information provided to the extent required under applicable laws, rules and regulations. The Exchange has provided the data file formats contained in Appendix 1 to this Attachment 7 as its initial expectation of Contractors’ provision of data to support oversight requirements, including actuarial review, clinical quality improvement, network management and fraud and waste reduction, delivery system reform goals, consumer information and research. Additional data and expanded file formats may be requested in the future in support of the Exchange contributing data to statewide collaborative efforts to advance development of an all payer claims database. Specific data submission areas in Appendix 1 include:  Plan and Product  Member  Member History  Contracted PMGs  Providers (all providers with paid claims, including non-contracted)  Hospitals (all providers with paid claims, including non-contracted)  Professional Claims  Hospital Claims Header  Hospital Claims Detail  Drug Claims Covered California – Final Health Plan Contract Attachments, May 6,20117, 2013 Attachment 7-7 Formatted: No bullets or numbering  Total Medical Expense (non-claims payment) If Contractor does not maintain such information and/or is unable to produce such information in the file format requested by the Exchange, Contractor shall coordinate with the Exchange with a plan to address data gaps or format preferences prior to the Contractor’s submission of such information by the fourth quarter of 2014. For any non-paid claims for capitated services, the Contractor shall provide full and complete encounter data. Covered California – Final Health Plan Contract Attachments, May 6,20117, 2013 Attachment 7-8

Data Submission Requirements to the Exchange. Contractor shall submit a complete data set, inclusive of all member member- and provider provider-identified data, all claims, encounter and pharmacy data, on a quarterly basis to the Exchange or the Exchange’s designated recipient to be used by the Exchange as it determines to be necessary. Such submissions will conform to all applicable State and Federal and State personal health information and related privacy laws, rules and regulations, and shall comply with the terms and conditions set forth in the Agreement by and between Contractor and the Exchange. Contractor will bear the full cost of data collection, extraction and submission; provided, however, that except as expressly set forth in this Attachment or the Agreement, Contractor will not be required to pay for any expenses related to the analysis of that data in order to comply with the terms of this Agreement. Contractor is not required to provide the Exchange with Individually Identifiable Health Information as to any Enrollee unless authorized by law. When conformance with data submission requirements necessitates disclosure of Individually Identifiable Health Information not authorized by law, such information Data shall be submitted by Contractor to a third-party vendor selected by for the Exchange and who enters into an agreement with the Contractor to do data analysis and provide reports and analyses to the Exchange. Such vendor must be that is a Business Associate of the Contractor who shall protect the information provided as required by applicable laws, rules and regulations. Any Personally Identifiable Health Information disclosed to the third party vendor shall be de-identified in any subsequent analysis provided to the Exchange. If the use of such a vendor is necessary, the details of the arrangement shall be set forth in a data use and reporting agreement mutually agreeable to the Exchange and the Contractor. When data is submitted to a vendor for the Exchange, that vendor will be a Business Associate of the Contractor and shall protect the information provided to the extent required under applicable laws, rules and regulations. The Exchange has provided Contractor shall submit such information at such times and in accordance with the data file formats contained attached as identified in Appendix 1 to this Attachment 7 as its initial expectation of Contractors’ provision of data set standards established by the Exchange, including, the technical specifications set forth in this Attachment 7. .set forth in separate attachments to support oversight requirements, including actuarial review, clinical quality improvement, network management and fraud and waste reduction, delivery system reform goals, consumer information and research. Additional data and expanded file formats may be requested in the future in support of the Exchange contributing data to statewide collaborative efforts to advance development of an all payer claims database. Specific data submission areas in Appendix 1 include: Administrative Manual  Plan and Product  Member  Member History  Contracted PMGs  Providers (all providers with paid claims, including non-contracted)  Hospitals (all providers with paid claims, including non-contracted)  Professional Claims  Hospital Claims Header  Hospital Claims Detail  Drug Claims Covered California – Final Health Plan Contract Attachments, May 6,20117, 2013 Attachment 7-7 Formatted: No bullets or numbering  Total Medical Expense (Expense( non-claims payment) If Contractor does not maintain such  Biometrics and Health Assessment ( provisional) its initial expectation of Contractors’ provision of data to support oversight requirements( actuarial review ,clinical quality improvement, network management and fraud and waste reduction), delivery system reform goals, consumer information and/or is unable to produce such information and research. Additional data and expanded file formats may be requested in the file format requested by future in support of statewide collaborateive efforts to advance development of an all payer claims database. Covered California and the Contractor recognize the importance of having appropriate data about Enrollees to address health disparities and health equity as well as provide appropriate quality care. Because of this, Contractor agrees to work with the Exchange to add additional data elements critical to the Exchange’s Enrollees and in order to refine existing quality related assessments. By 2015, Contractor shall coordinate with the Exchange with be collecting, on a plan to address data gaps or format preferences prior voluntary basis voluntary to the Contractor’s submission eEnrollee, capable of such information by stratifying claims and qualityEnrollee data based onto the fourth quarter of 2014. For any non-paid claims for capitated services, the Contractor shall provide full and complete encounter data. Covered California – Final Health Plan Contract Attachments, May 6,20117, 2013 Attachment 7-8following characteristicsategories: (i) Race (ii) Ethnicity (iii) Gender

Data Submission Requirements to the Exchange. Contractor shall submit a complete data set, inclusive of all member member- and provider provider-identified data, claims, encounter and pharmacy data, on a quarterly basis to the Exchange or the Exchange’s designated recipient to be used by the Exchange as it determines to be necessary. Such submissions will conform to all applicable State and Federal and State personal health information and related privacy laws, rules and regulations, and shall comply with the terms and conditions set forth in the Agreement by and between Contractor and the Exchange. Contractor will bear the full cost of data collection, extraction and submission; provided, however, that except as expressly set forth in this Attachment or the Agreement, Contractor will not be required to pay for any expenses related to the analysis of that data in order to comply with the terms of this Agreement. Contractor is not required to provide the Exchange with Individually Identifiable Health Information as to any Enrollee unless authorized by law. When conformance with data submission requirements necessitates disclosure of Individually Identifiable Health Information not authorized by law, such information Data shall be submitted by Contractor to a third-party vendor selected by for the Exchange and who enters into an agreement with the Contractor to do data analysis and provide reports and analyses to the Exchange. Such vendor must be that is a Business Associate of the Contractor who shall protect the information provided as required by applicable laws, rules and regulations. Any Personally Identifiable Health Information disclosed to the third party vendor shall be de-identified in any subsequent analysis provided to the Exchange. If the use of such a vendor is necessary, the details of the arrangement shall be set forth in a data use and reporting agreement mutually agreeable to the Exchange and the Contractor. When data is submitted to a vendor for the Exchange, that vendor will be a Business Associate of the Contractor and shall protect the information provided to the extent required under applicable laws, rules and regulations. Contractor shall submit such information at such times and in accordance with the data file formats attached as identified in Appendix 1 to this Attachment 7 , including, the technical specifications set forth in this Attachment 7. . • Plan • Member • Member History • Contracted PMGs • Providers (all providers with paid claims, including non-contracted) • Hospitals (all providers with paid claims, including non-contracted) • Professional Claims • Hospital Claims Header • Hospital Claims Detail • Drug Claims • Total Medical Expense( non-claims payment) • Biometrics and Health Assessment ( provisional) In the event Contractor does not pay claims, it shall provide full and complete encounter data. The Exchange has provided the data file formats contained in Appendix 1 to this Attachment 7 as its initial expectation of Contractors’ provision of data to support oversight requirements, including ( actuarial review, review ,clinical quality improvement, network management and fraud and waste reduction), delivery system reform goals, consumer information and research. Additional data and expanded file formats may be requested in the future in support of the Exchange contributing data to statewide collaborative collaborateive efforts to advance development of an all payer claims database. Specific data submission areas in Appendix 1 include:  Plan and Product  Member  Member History  Contracted PMGs  Providers (all providers with paid claims, including non-contracted)  Hospitals (all providers with paid claims, including non-contracted)  Professional Claims  Hospital Claims Header  Hospital Claims Detail  Drug Claims Covered California – Final Health Plan Contract Attachmentsand the Contractor recognize the importance of having appropriate data about Enrollees to address health disparities and health equity as well as provide appropriate quality care. Because of this, May 6,20117, 2013 Attachment 7-7 Formatted: No bullets or numbering  Total Medical Expense (non-claims payment) If Contractor does not maintain such information and/or is unable agrees to produce such information in work with the file format requested by Exchange to add additional data elements critical to the Exchange’s Enrollees and in order to refine existing quality related assessments. By 2015, Contractor shall coordinate with the Exchange with collect, on a plan to address data gaps or format preferences prior basis voluntary to the Contractor’s submission of such information by Enrollee, Enrollee data based on the fourth quarter of 2014. For any non-paid claims for capitated services, the Contractor shall provide full and complete encounter data. Covered California – Final Health Plan Contract Attachments, May 6,20117, 2013 Attachment 7-8following characteristics: (i) Race (ii) Ethnicity (iii) Gender

Data Submission Requirements to the Exchange. Contractor shall submit a complete data set, inclusive of all member and provider identified data, claims, encounter and pharmacy data, on a quarterly basis to the Exchange or the Exchange’s designated recipient to be used by the Exchange as it determines to be necessary. Such submissions will conform to all applicable Federal and State personal health information and related privacy laws, rules and regulations, and shall comply with the terms and conditions set forth in the Agreement by and between Contractor and the Exchange. Contractor will bear the full cost of data collection, extraction and submission; provided, however, that except as expressly set forth in this Attachment or the Agreement, Contractor will not be required to pay for any expenses related to the analysis of that data in order to comply with the terms of this Agreement. Contractor is not required to provide the Exchange with Individually Identifiable Health Information as to any Enrollee unless authorized by law. When conformance with data submission requirements necessitates disclosure of Individually Identifiable Health Information not authorized by law, such information shall be submitted by Contractor to a third-party vendor selected by the Exchange and who enters into an agreement with the Contractor to do data analysis and provide reports and analyses to the Exchange. Such vendor must be a Business Associate of the Contractor who shall protect the information provided as required by applicable laws, rules and regulations. Any Personally Identifiable Health Information disclosed to the third party vendor shall be de-identified in any subsequent analysis provided to the Exchange. If the use of such a vendor is necessary, the details of the arrangement shall be set forth in a data use and reporting agreement mutually agreeable to the Exchange and the Contractor. When data is submitted to a vendor for the Exchange, that vendor will be a Business Associate of the Contractor and shall protect the information provided to the extent required under applicable laws, rules and regulations. The Exchange has provided the data file formats contained in Appendix 1 to this Attachment 7 as its initial expectation of Contractors’ provision of data to support oversight requirements, including actuarial review, clinical quality improvement, network management and fraud and waste reduction, delivery system reform goals, consumer information and research. Additional data and expanded file formats may be requested in the future in support of the Exchange contributing data to statewide collaborative efforts to advance development of an all payer claims database. Specific data submission areas in Appendix 1 include:  • Plan and Product  • Member  • Member History  • Contracted PMGs  • Providers (all providers with paid claims, including non-contracted)  • Hospitals (all providers with paid claims, including non-contracted)  • Professional Claims  • Hospital Claims Header  • Hospital Claims Detail  • Drug Claims Covered California – Final Health Plan Contract Attachments, May 6,20117, 2013 Attachment 7-7 Formatted: No bullets or numbering  • Total Medical Expense (non-claims payment) If Contractor does not maintain such information and/or is unable to produce such information in the file format requested by the Exchange, Contractor shall coordinate with the Exchange with a plan to address data gaps or format preferences prior to the Contractor’s submission of such information by the fourth quarter of 2014. For any non-paid claims for capitated services, the Contractor shall provide full and complete encounter data. Covered California – Final Health Plan Contract Attachments, May 6,20117, 2013 Attachment 7-8.