[RSA 420-J:27 effective 6 months after finalization of federal guidance under United States Presidential Executive Order 14221 pursuant to 2026, 5:2.]
420-J:27 Definitions. –
In this subdivision:
I. "Billed charge" means the total charges for an item or service billed to a health carrier by a provider.
II. "Billing code" means the code used by a health carrier or provider to identify health care items or services for purposes of billing, adjudicating, and paying claims for a covered item or service, including the current procedural terminology (CPT) code, health care common procedure coding system (HCPCS) code, diagnosis-related group (DRG) code, national drug code (NDC), or other common payer identifier.
III. "Bundled payment arrangement" means a payment model under which a provider is paid a single payment for all covered items and services provided to a covered person for a specific treatment or procedure.
IV. "Derived amount" means the price that a health carrier assigns to an item or service for the purpose of internal accounting, reconciliation with providers or submitting data in accordance with state or federal regulations.
V. "Health plan" means health carriers, third party administrators, and any other entity that is subject to claims data submission requirements under RSA 420-G:11, IV.
VI. "Historical net price" means the retrospective average amount a health carrier paid for a prescription drug, inclusive of any reasonably allocated rebates, discounts, chargebacks, fees, and any additional price concessions received by the carrier with respect to the prescription drug. The allocation shall be determined by dollar value for nonproduct-specific and product-specific rebates, discounts, chargebacks, fees, and other price concessions to the extent that the total amount of any such price concession is known to the health carrier at the time of publication of the historical net price in a machine-readable file in accordance with this subdivision. However, to the extent that the total amount of any nonproduct-specific and product-specific rebates, discounts, chargebacks, fees, or other price concessions is not known to the health carrier at the time of file publication, then the carrier shall allocate such rebates, discounts, chargebacks, fees, and other price concessions by using a good faith, reasonable estimate of the average price concessions based on the rebates, discounts, chargebacks, fees, and other price concessions received over a time period prior to the current reporting period and of equal duration to the current reporting period.
VII. "Items or services" means all encounters, procedures, medical tests, supplies, prescription drugs, durable medical equipment, and fees, including facility fees, provided or assessed in connection with the provision of health care.
VIII. "Machine-readable file" means a digital representation of data or information in a file that can be imported or read by a computer system for further processing without human intervention, while ensuring no semantic meaning is lost.
IX. "National drug code" means the unique 10- or 11-digit 3-segment number assigned by the United States Food and Drug Administration (FDA), which provides a universal product identifier for drugs in the United States.
X. "Negotiated rate" means the amount a health carrier has contractually agreed to pay an in-network provider, including an in-network pharmacy or other prescription drug dispenser, for covered items and services, whether directly or indirectly, including through a third-party administrator or pharmacy benefit manager.
XI. "Out-of-network allowed amount" means the maximum amount a health carrier will pay for a covered item or service furnished by an out-of-network provider.
XII. "Underlying fee schedule rate" means the rate for a covered item or service from a particular in-network provider, or providers that a health carrier uses to determine a participant's, beneficiary's, or enrollee's cost-sharing liability for the item or service, when that rate is different from the negotiated rate or derived amount.