VA Code Ann. § 32.1-276.7:1 - All- Payer Claims Database created; purpose; reporting requirements

The Virginia All-Payer Claims Database (APCD) is created to facilitate evidence-based improvements in health care quality and cost.  The Commissioner of Insurance may collect paid claims for covered benefits from data suppliers, which may include:

• Issuers of individual or group health insurance, corporations providing individual or group health subscriptions, and health maintenance organizations;
• Third party administrators;
• Department of Medical Assistance Services that provide Medicaid;
• Federal health insurance plans including TRICARE and Medicare.

A nonprofit entity is charged with storage, collecting, analysis and evaluation of the data submitted by the above data suppliers.  The Commissioner must ensure that the nonprofit entity enters into a data submission and use agreement with each entity that submits claims data to the APCD.  These agreements must include provisions for the submission, collection, aggregation, and distribution of data and must include the following provisions at a minimum:

• Protection of patient privacy and data security according to state and federal laws, including HIPAA, HITECH, and ARRA;
• Identification of the types of paid claims to be submitted to the APCD, submitting entities, and identification of specific data elements to be submitted;
• Geographic, demographic, economic, and peer group comparisons;
• Identification and comparisons of health plans by private and public health care purchasers,  providers, employers, consumers, and health insurers;
• Use of standard data collection standards;
• Prohibition over the disclosure of provider-specific, facility-specific, carrier-specific reimbursement information;
• Responsible use of claims data to improve health care value;
• Requiring analyses comparing providers or health plans to use national standards.

The Commissioner must appoint an advisory committee composed of various stakeholders, to assist in the development and formation of the APCD. 

The nonprofit organization implementing the APCD must:

• Report data to improve public health surveillance and population health, including reporting on injuries, chronic diseases, health conditions of pregnant women, children and infants, geographic and demographic information to be used for community assessments.  The data must allow for comparisons with other national databases and among employee health plans regionally and nationally;
• Report data that health care purchasers can use to compare the quality and efficiency of health care, including allowing comparisons among providers regionally and nationally;
• Report data that allows for the development of alternative delivery and payment models.

Data reporting may not occur until the data has been verified for accuracy.  Before a report is released identifying a provider or health plan, the nonprofit organization must give notice of the report and provide a 60 day comment period to the affected entities.

Information obtained through the APCD may replace other data submission guidelines used previously.  All information obtained through the APCD is confidential and exempt from the Virginia Freedom of Information Act. 

The APCD may not impose charges on providers for the formation of the APCD, but a reasonable fee may be assessed if a provider voluntarily subscribes for access for purposes other than for data verification.   The Department of Health must have access to the APCD at no charge for public health improvement research and activities.