Tex. Ins. Code Section 38.404
Establishment and Administration of Database


The department shall collaborate with the center under this subchapter to aid in the center’s establishment of the database. The center shall leverage the existing resources and infrastructure of the center to establish the database to collect, process, analyze, and store data relating to medical, dental, pharmaceutical, and other relevant health care claims and encounters, enrollment, and benefit information for the purposes of increasing transparency of health care costs, utilization, and access and improving the affordability, availability, and quality of health care in this state, including by improving population health in this state.


The center shall serve as the administrator of the database, design, build, and secure the database infrastructure, and determine the accuracy of the data submitted for inclusion in the database.


In determining the information a payor is required to submit to the center under this subchapter, the center must consider requiring inclusion of information useful to health policy makers, employers, and consumers for purposes of improving health care quality and outcomes, improving population health, and controlling health care costs. The required information at a minimum must include the following information as it relates to all health care services, supplies, and devices paid or otherwise adjudicated by the payor:


the name and National Provider Identifier, as described in 45 C.F.R. Section 162.410, of each health care provider paid by the payor;


the claim line detail that documents the health care services, supplies, or devices provided by the health care provider;


the amount of charges billed by the health care provider and the payor’s:


allowed amount or contracted rate for the health care services, supplies, or devices; and


adjudicated claim amount for the health care services, supplies, or devices;


the name of the payor, the name of the health benefit plan, and the type of health benefit plan, including whether health care services, supplies, or devices were provided to an individual through:


a Medicaid or Medicare program;


workers’ compensation insurance;


a health maintenance organization operating under Chapter 843 (Health Maintenance Organizations);


a preferred provider benefit plan offered by an insurer under Chapter 1301 (Preferred Provider Benefit Plans);


a basic coverage plan under Chapter 1551 (Texas Employees Group Benefits Act);


a basic plan under Chapter 1575 (Texas Public School Employees Group Benefits Program);


a primary care coverage plan under Chapter 1579 (Texas School Employees Uniform Group Health Coverage); or


a health benefit plan that is subject to the Employee Retirement Income Security Act of 1974 (29 U.S.C. Section 1001 et seq.); and


claim level information that allows the center to identify the geozip where the health care services, supplies, or devices were provided.


Notwithstanding Subsection (c), the center may not require a payor to collect or otherwise obtain from individuals covered by the payor data that is not included in a standard claim form, though the center may require submission of such data if it is otherwise collected by the payor, including provider and eligibility files.


Each payor shall submit the required data under Subsection (c) at a schedule and frequency determined by the center and adopted by the commissioner by rule.


In the manner and subject to the standards, requirements, policies, and procedures relating to the use of data contained in the database established by the center in consultation with the stakeholder advisory group, the center may use the data contained in the database for a noncommercial purpose:


to produce statewide, regional, and geozip consumer reports available through the public access portal described in Section 38.405 (Public Access Portal) that address:


health care costs, quality, utilization, outcomes, and disparities;


population health; or


the availability of health care services; and


for research and other analysis conducted by the center or a qualified research entity to the extent that such use is consistent with all applicable federal and state law, including the data privacy and security requirements of Section 38.406 (Data Privacy and Security) and the purposes of this subchapter.


The center shall establish data collection procedures and evaluate and update data collection procedures established under this section. The center shall test the quality of data collected by and reported to the center under this section to ensure that the data is accurate, reliable, and complete.
Added by Acts 2021, 87th Leg., R.S., Ch. 333 (H.B. 2090), Sec. 1, eff. September 1, 2021.
Amended by:
Acts 2023, 88th Leg., R.S., Ch. 603 (H.B. 3414), Sec. 3, eff. June 11, 2023.

Source: Section 38.404 — Establishment and Administration of Database, https://statutes.­capitol.­texas.­gov/Docs/IN/htm/IN.­38.­htm#38.­404 (accessed Jun. 5, 2024).

Jun. 5, 2024

§ 38.404’s source at texas​.gov