Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS › Section 590-243-2 - Health Care Claims Data Set Filing Description

Current through 2024-29, July 17, 2024
Health care claims processors shall submit to the MHDO or its
				  designee a completed health care claims data set for all members who are Maine
				  residents in accordance with the requirements of this section. Each health care
				  claims processor is also responsible for the submission of all health care
				  claims processed by any sub-contractor on its behalf. The health care claims
				  data set shall include, where applicable, a member eligibility file containing
				  records associated with each of the claims files reported: a medical claims
				  file, a pharmacy claims file, and/or a dental claims file. The data set shall
				  also include supporting definition files for payor specific provider specialty
				  codes. Third-party administrators and carriers acting as third-party
				  administrators for self-funded employee benefit plans regulated by ERISA are
				  not required to submit data for members in such plans.
A.
General Requirements
(1)
Adjustment Records
.
				Adjustment records shall be reported with the appropriate positive or negative
				fields with the medical, pharmacy, and dental claims file submissions. Negative
				values shall contain the negative sign before the value. No sign shall appear
				before a positive value.
(2)
Capitated Payment Arrangements
. A capitated payment record shall
				be reported for every month that a member is covered under a particular payment
				arrangement. In addition, capitated service records shall be included in the
				medical claims file, if any services were provided to the member in a given
				month. Specific instructions for reporting capitated payments and services are
				provided below. For capitated payment arrangements that a payor indicates are
				42 CFR Part 2 SUD-related, the payor shall provide a de-identified payment
				record in the capitated payments file and a de-identified capitated service
				record in the medical claims file for every SUD-related service provided.
				Associated 42 CFR Part 2 SUD-related payment and service records shall contain
				the same CSUM IDs. Follow the additional instructions in Appendices D-1 and
				G-1.
(a)
Payment Record
. The
				purpose of a capitation payment summary record is to indicate the payment made
				to a provider each month for a member covered by a capitated service contract,
				regardless of whether any services were provided to the member in a given
				month. Only one summary claim record or line per member per month on a
				capitated service contract is reported in the capitated payments file, as
				specified in Appendix G-1.
(b)
Service Record
. Separate service lines for each service provided
				under a capitated service contract shall be reported in the medical claims
				file, Appendix D-1, and flagged as capitated services. If no services were
				provided to a member on a capitated service contract in a given month, then no
				service lines are reported. All data fields should be treated as on any other
				claim, except for the following ones, which are populated or left blank as
				specified: Paid Amount (MC063) is '0'; Payment Arrangement Type Indicator field
				(MC331) is '09'; the Procedure Code (MC055) for the specific procedure or
				service; Service Line Dates (MC334 and MC335) for the specific procedure or
				service; and the appropriate Quantity (MC061) greater than or equal to
				'1'.
(3)
Claims
				Records
. Records for the medical, pharmacy, and dental claims file
				submissions shall be reported at the visit, service, or prescription level. The
				submission of the medical, pharmacy, and dental claims is based upon the paid
				dates and not upon the dates of service associated with the claims.
(4)
Codes
(a)
Code Sources
. Unless
				otherwise specified, the code sources listed and described in Appendix A are to
				be utilized in association with the member eligibility file and medical,
				pharmacy, and dental claims file submissions.
(b)
Specific/Unique Coding
.
				Except for provider, provider specialty, and individual, non-bundled
				procedure/diagnosis codes, specific or unique coding systems shall not be
				permitted as part of the health care claims data set submission.
(5)
Co-Insurance/Co-Payment
. Co-insurance and co-payment are to be
				reported in two separate fields in the medical, pharmacy, and dental claims
				file submissions.
(6)
Coordination of Benefits Claims
. Claims where multiple parties
				have financial responsibility shall be included with all medical, pharmacy, and
				dental claims file submissions.
(7)
Denied Claims
. Denied claims shall be excluded from all medical,
				pharmacy, and dental claims file submissions. When a claim contains both
				approved and denied service lines, only the approved service lines shall be
				included as part of the health care claims data set submittal.
(8)
Eligibility Records
. Records
				for the member eligibility file submission shall be reported at the individual
				member level with one record submitted for each claim type if the product codes
				are different. If a member is covered as both a subscriber and a dependent on
				two different policies during the same month, two records must be
				submitted.
(9)
Exclusions
(a)
Filing
. Health care claims processors that have less than
				$2,000,000 per calendar year of adjusted premiums or claims processed, for
				premiums or claims subject to required reporting, are excluded from filing
				health care claim data sets and from the annual registration requirements of
				Section 3(A).
(b)
Medical
				Claims File Exclusions
. All claims related to health care policies
				issued for specific disease, accident, injury, hospital indemnity, disability,
				long-term care, student comprehensive health, or vision coverage of durable
				medical equipment are to be excluded from the medical claims file submission.
				Claims related to Medicare supplemental, Tricare supplemental, or other
				supplemental health insurance policies are to be excluded if the claims are not
				considered to be primary. If the policies cover health care services entirely
				excluded by the Medicare, Tricare, or other program, the claims must be
				submitted. Claims for dental services containing current dental terminology
				codes are to be excluded from the medical claims file.
(c)
Member Eligibility File
				Exclusions
. Members without medical, pharmacy, and/or dental coverage
				during the month reported shall be excluded.
(d)
Pharmacy Claims File
				Exclusions
. Pharmacy services claims generated from non-retail
				pharmacies that do not contain national drug codes are part of the medical
				claims file and not the pharmacy claims file.
(10)
File Format
. Each data file
				submission shall be an encrypted (AES-256) ASCII file, variable field length,
				and asterisk delimited.
(11)
Header and Trailer Records
. Each member eligibility file and each
				medical, pharmacy, and dental claims file submission shall contain a header
				record and a trailer record. The header record is the first record of each
				separate file submission, and the trailer record is the last. The header and
				trailer record formats are described in Appendices B-1 and B-2.
(12)
Non-Duplicated Claims.
A
				carrier or health care claims processor and any contracted entity acting on its
				behalf shall use best efforts to ensure that duplicate claims are not submitted
				to the MHDO or its designee.
(13)
Subscriber or Member Identification
(a)
Social Security Numbers
.
				Health care claims processors shall assign to each of their members a unique
				identification code that is the member's social security number. If a health
				care claims processor does not collect the social security numbers for all
				members, the health care claims processor shall use the number of the
				subscriber and then assign a discrete two-digit suffix for each member under
				the subscriber's contract.
(b)
Contract Numbers
. If the subscriber's social security number is
				not collected by the health care claims processor, the subscriber's certificate
				or contract number shall be used in its place. The discrete two-digit suffix
				shall also be used with the certificate or contract number.
The unique member identification code assigned by each health
				  care claims processor shall remain with each subscriber or member for the
				  entire period of coverage for that individual.
(c)
Names
. Health care claims
				processors shall submit the complete names of all subscribers and
				members.
(d)
Consistent,
				Inter-file Identifiers.
A carrier or health care claims processor and
				any contracted entity acting on its behalf shall ensure that member and
				subscriber identifiers for the same individuals are unique and consistent
				across all eligibility and claims files.
(e)
Carrier Specific Unique Member
				(CSUM) ID.
As an inter-file identifier, the CSUM ID should uniquely and
				consistently identify a member in both the medical claims and the capitated
				payments files. The CSUM ID shall be used when the payor indicates that related
				records in the medical and capitation files contain 42 CFR Part 2 SUD-related
				data, and other inter-file identifiers shall be left blank. For fully
				identifiable data records that do not contain 42 CFR Part 2-related data, the
				CSUM ID shall be left blank, and all other inter-file identifiers shall be
				populated, when available. This ID must differ from any of the other
				identifiers on the record and may not be derived from any of these in a manner
				that the original values could be determined.