Code of Maine Rules › 90 - INDEPENDENT AGENCIES › 590 - MAINE HEALTH DATA ORGANIZATION › Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS › Section 590-243-3 - Submission Requirements

Current through 2024-29, July 17, 2024
A.
Registration/Contact and Enrollment Update
. Each health care
				claims processor not excluded from submitting claims data under Section
				2(A)(9)(a) shall complete a registration survey or update an existing one at
https://mhdo.maine.gov/portal
by
				February 28th of each year. It is the responsibility
				of the health care claims processor to amend, as needed, all company, contact
				and enrollment information.
B.
File Organization
. The member eligibility file, medical claims
				file, pharmacy claims file, and the dental claims file are to be submitted to
				the MHDO or its designee as separate ASCII files. Each record shall be
				terminated with a carriage return (ASCII 13) or a carriage return line feed
				(ASCII 13, ASCII 10).
C.
Filing Method
. Data files must be submitted to the MHDO's Data
				Warehouse Portal via secure FTP or secure web upload interface. E-mail
				attachments shall not be accepted.
D.
Testing of Files
. Within one
				hundred and eighty days of the adoption of any changes to the data element
				content of the files as described in Section 2 and at least sixty days prior to
				the initial submission of the files or whenever the data element content of the
				files as described in Section 2 is subsequently altered, each health care
				claims processor shall submit to the MHDO or its designee a data set for
				comparison to the standards listed in Section 4. Based upon a calendar period
				of one month or one quarter, the size of the data files submitted shall
				correspond to the filing period established for each health care claims
				processor under subsection F of this Section.
E.
Rejection of Files
. Failure
				to conform to the requirements subsections A, B, or C of this Section shall
				result in the rejection of the applicable data file(s). All rejected files must
				be resubmitted in the appropriate, corrected form to the MHDO or its designee
				within 15 days.
F.
Filing
				Periods
. The filing period for each applicable claims data file listed
				in Section 2 shall be determined by the minimum monthly total of Maine-resident
				members for whom claims are being paid by each health care claims processor.
				The data files are to be submitted in accordance with the following schedule:
Total # of
								Members
Filing
								Period
Filing
								Schedule
[GREATER THAN EQUAL TO] 2,000
monthly
prior to the end of the month following the month
								in which claims were paid
[LESS THAN EQUAL TO] 2,000
quarterly
prior to April 30, July 31, October 31, January 31
								for each preceding calendar quarter in which claims were paid
If the data files submitted by an individual health care
				  claims processor support or are related to the files submitted by another
				  health care claims processor, the MHDO shall determine a filing period that is
				  consistent for all parties involved.
G.
Replacement of Data Files
. No
				health care claims processor may replace a complete data file submission more
				than one year after the end of the month in which the file was submitted unless
				it can establish exceptional circumstances for the replacement. Any
				replacements after this period must be approved by the MHDO. Individual
				adjustment records may be submitted with any monthly data file
				submission.
H.
Run-Out
				Period
. Health care claims processors shall submit medical, pharmacy,
				and/or dental claims files for a six-month period following the termination of
				coverage date for all members who are Maine residents.