Private Duty Nursing — continuous, specialized skilled nursing services. Prosthetic Services and Devices — prosthetic devices, including the evaluation, fabrication, and fitting of a prosthesis. Coverage includes related supplies, repair, and replacement. Radiology and X-ray — all X-rays, including portable X-rays, magnetic resonance imagery (MRI), radiation therapy, and radiological services. Therapy — individual treatment (including the design, fabrication, and fitting of an orthotic, prosthetic, or other assistive technology device), comprehensive evaluation, and group therapy. Physical — evaluation, treatment, and restoration to normal or best possible functioning of neuromuscular, musculoskeletal, cardiovascular, and respiratory systems. Occupational — evaluation and treatment of an Enrollee in his or her own environment for impaired physical functions. Speech and Hearing — evaluation and treatment of speech, language, voice, hearing, fluency, and swallowing disorders. Transportation — ambulance (air and land), taxi, and chair car transport for medical reasons. Vision Care Services — the professional care of the eyes for purposes of diagnosing and treating all pathological conditions. They include eye examinations, vision training, prescriptions, and glasses and contact lenses.
The MCEs that provide services to MassHealth and Commonwealth Care members should include services for both populations in the financial report. Please see “Monthly Financial Report” under section 6.0 “Media Requirements” for specific instructions on report layout and submission. How to Use this Document This Encounter Data Set Request is intended as a reference document. Its purpose is to identify the data elements that MassHealth needs to load into encounter database. The goal of this document is to clarify the standard record layout, format, and values that MassHealth will accept. Data Element Clarifications In 2.0 “Data Set Clarification” section provides clarifications and expectations on data elements like DRG, Diagnosis Codes, Procedure Codes, and Provider IDs. Data Elements The information contained in the Data Elements sections defines each of the fields included in the record layout. When appropriate, a list of valid values is included there. Nationally recognized coding schemes have been used whenever they exist. Encounter Record Layout Section 4.0 “Encounter Record Layout” specifies encounter file layout. All the MCEs must use that format when compiling the Encounter Data file that might contain all or any Claim Category (facility, professional, dental, etc.). MassHealth requests that the encounter data file is provided in a pipe-delimited text file with each service on a separate line. Contact MassHealth if you need further clarification. Media Requirements and Data Formats Section 6.0 “Media Requirements and Data Formats” contains complete information about all the files that should be submitted to EHS DW. MCEs submit their data to MassHealth through a secure FTP server. Each MCE has a home directory on this server and is given an ID with public key/private key-based login. Please also note the security requirements for Internet transmissions noted in the Media Requirements section. Standard Data Values Section 7.0 “Standard Data Values” contains tables referenced in the specific fields of the Data Elements section (Tables A through H). Data Quality Checks This section within 8.0 “Quantity and Quality Edits, Reasonability and Validity Checks” provides the validity and quality criteria that encounter data are expected to meet.
TABLE E Discharge Status (UB Patient Status) Value Description Discharged alive to home / self-care (routine discharge) Discharged/Transferred to short term general hospital Discharged/Transferred to skilled nursing facility (SNF) Discharged/Transferred to intermediate care facility (ICF) Discharged/Transferred to other facility Discharged/Transferred to home care Left against medical advice Discharged/Transferred to home under care of a home IV drug therapy provider Admitted as an inpatient to this hospital – 19 Discharged to be defined at State level if necessary 20 Expired (Did not recover – Christian Science Patient) 21 – 29 Expired to be defined at State level if necessary Still a patient – 39 Still a patient to be defined at State level if necessary Expired at home (Hospice claims only) Died in a medical facility (Hospice claims only) Place of death unknown (Hospice claims only) 43 – 99 Reserved for National Assignment
TABLE I – C Service Category (Using the One Care - ICO reporting groups) Value Description Acute Inpatient Inpatient – MH/SA Hospital Outpatient Outpatient – MH/SA Professional 210 Pharmacy Pong-Term Care (LTC) Facility Homer and Community Based Services (HCBS)/Home Health Transportation Durable Medical Equipment (DME) and Supplies *All Other *Should follow the definition in the “Quarterly Financial Report” submitted to EOHHS Budget Unit
Exhibit 1: Quality Measures EOHHS has defined the following quality measures pursuant to Section 2.14 of the Contract. For measures that are not HEDIS, EOHHS will further define measure specifications, including due dates, sample size, and submission requirements. These measures are to be submitted annually to EOHHS. The Contractor should report measures separately for Dual Eligible and Medicaid only eligible Enrollees. This list is subject to modifications. Measure Name ID Set Domain Annual monitoring for patients on persistent medications (MPM) Antidepressant Medication Management (AMM) 2371 HEDIS Patient Safety 0105 HEDIS Behavioral Health and Substance Abuse Board Certification NA HEDIS Care for Older Adult (COA) - Advanced care planning Colorectal Cancer Screening (COL) Controlling high blood pressure (CBP) Eye examination every two years: percentage of Enrollees who received vision screening in the past two years Follow-Up After Hospitalization for Mental Illness (FUH) Hearing examination every two years: percentage of Enrollees who received a hearing screening in the past two years. 0326 HEDIS Care Coordination & Transitions 0034 HEDIS Screening and Prevention 0018 HEDIS At Risk Populations N/A CMS/EHS requireme nt 0576 HEDIS Behavioral Health and Substance Abuse N/A CMS/EHS requireme nt Influenza immunization 0041 Screening and Prevention Medication Reconciliation Post- Discharge (MRP) Consumer Assessment of Healthcare Providers and Services (CAHPS) Osteoporosis Management in Women Who Had a Fracture (OMW) Persistence of Beta-Blocker Treatment after Heart Attack (PBH) Pharmacotherapy Management of COPD Exacerbation (PCE) 0097 HEDIS Care Coordination & Transitions N/A