5. Voluntary File Submissions Any self-funded employee benefit plan by ERISA may voluntarily submit completed healthcare data sets for Maine residents. The MHDO shall collect such data sets in accordance with the provisions of this chapter for uniform reporting system for health care claims data sets. Any such data shall be subject to the same laws as other MHDO data. 5 6. Public Access Information collected, processed and/or analyzed under this rule shall be subject to release to the public or retained as confidential information in accordance with 22 M.R.S.A. Chapter 1683 and Code of Maine Rules 90-590, Chapter 120, unless prohibited by state or federal law. 6 7. Extensions or Waivers to Data Submission Requirements If a health care claims processor due to circumstances beyond its control is temporarily unable to meet the terms and conditions of this Chapter, a written request must be made to the Compliance Officer of the MHDO as soon as it is practicable after the health care claims processor has determined that an extension or waiver is required. The written request shall include: the specific requirement to be extended or waived; an explanation of the cause; the methodology proposed to eliminate the necessity of the extension or waiver; and the time frame required to come into compliance. If the Compliance Officer does not approve the requested extension or waiver, the health claims processor making the request may submit a written request appealing the decision to the MHDO Board. The appeal shall be heard by the MHDO Board at the next regularly scheduled meeting following receipt of the request at the MHDO. 7 8. Compliance The failure to file, report, or correct health care claims data sets when required in accordance with the provisions of this Chapter may be considered a violation under 22 M.R.S.A. Sec. 8705-A and Code of Maine Rules 90-590, Chapter 100: Enforcement Procedures. STATUTORY AUTHORITY: 22 M.R.S.A. §§ 8703(1), 8704(4), 8708(6-A) and 8712(2) EFFECTIVE DATE: July 29, 2002 AMENDED: June 2, 2003 – filing 2003-173 NON-SUBSTANTIVE CORRECTIONS: September 8, 2003 – formatting only AMENDED:
Data Element Date Maximum # Data Element Name Effective Type Length Description/Codes/Sources ME001 Submitter 1/1/2003 Text 8 MHDO-assigned identifier of payer submitting claims data. Do not leave blank. ME002 Payer 7/1/2012 Text 8 MHDO-assigned code of the insurer/underwriter in the case of coverage, or of the administrator in the case of self-funded coverage. Do not leave blank. ME003 Insurance Type/Product Code 1/1/2003 Text 2 Code identifying the type of insurance policy within a specific insurance program. to Appendix A HN Medicare Part C MD Medicare Part D ME004 Year 1/1/2003 Number 4 Year for which eligibility is reported in this submission ME005 Month 1/1/2003 Text 2 Month for which eligibility is reported in this submission ME006 Insured Group or Policy Number 1/1/2003 Text 30 Group or policy number – not the number that uniquely identifies the subscriber ME007 Coverage Level Code 1/1/2003 Text 3 Benefit coverage level Refer to Appendix A ME008 Subscriber Social Security Number 1/1/2003 Text 9 Subscriber’s social security number Leave blank if unavailable ME009 Plan Specific Contract Number 1/1/2003 Text 80 Plan assigned subscriber’s contract number Leave blank if contract number = subscriber’s social security number ME010 Member Suffix or Sequence Number 1/1/2003 Text 20 Unique number of the member within the contract ME011 Member Identification Code 1/1/2003 Text 50 Member’s social security number Leave blank if unavailable
Data Element # Data Element Name Date Effective Type Maximum Length Description/Codes/Sources MC001 Submitter 1/1/2003 Text 8 MHDO-assigned identifier of payer submitting claims data. Do not leave blank. MC002 Payer 7/1/2012 Text 8 MHDO-assigned code of the insurer/underwriter in the case of coverage, or of the administrator in the case of self-funded coverage. Do not leave blank. MC003 Insurance Type/Product Code 1/1/2003 Text 2 Code identifying the type of insurance policy within a specific insurance program. to Appendix A 16 Medicare Part C MD Medicare Part D SP Supplemental Policy MC004 Payer Claim Control Number 1/1/2003 Text 35 Must apply to the entire claim and be unique within the payer’s system MC005 Line Counter 4/1/2004 Number 4 Line number for this service The line counter begins with 1 and is incremented by 1 for each additional service line of a claim. MC005A Version Number 1/1/2010 Number 4 The version number of this claim service line.
the payer for internal identification purposes, and does not routinely change. MC108 National Provider ID – Attending Provider 2/1/2016 Text 20 National Provider ID for attending provider to Appendix A MC109 Attending Provider First Name 2/1/2016 Text 40 Individual first name MC110 Attending Provider Middle Name 2/1/2016 Text 25 Individual middle name or initial MC111 Attending Provider Last Name 2/1/2016 Text 60 Individual last name MC112 Attending Provider Suffix 2/1/2016 Text 10 Individual name suffix The attending provider suffix shall be used to capture the generation of the individual clinician (e.g., Jr., Sr., III), if applicable, rather than the clinician’s degree (e.g., MD, LCSW). Attending Provider Specialty 2/1/2016 Text 10 to Appendix A If defined by payer, then dictionary for specialty code values must be supplied during testing.
Provider Number provider number. This number should be the identifier used by the payer for internal identification purposes, and does not routinely change. MC121 National Provider ID – Referring Provider 2/1/2016 Text 20 National Provider ID for referring provider Refer to Appendix A Referring Provider Name 2/1/2016 Text 40 Individual first name MC123 Referring Provider Middle Name 2/1/2016 Text 25 Individual middle name or initial MC124 Referring Provider Last Name 2/1/2016 Text 60 Individual last name Referring Provider Suffix 2/1/2016 Text 10 Individual name suffix The referring provider suffix be used to capture the generation of the individual clinician (e.g., Jr., Sr., III), if applicable, rather than the clinician’s degree (e.g., MD, LCSW). MC200 Principal Diagnosis 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. to Appendix A
Indicator - 6 MC218 External of Injury - 7 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC219 Present On Admission Indicator - 7 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC220 External Cause of Injury - 8 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC221 Present On Admission Indicator - 8 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC222 External Cause of Injury - 9 10/1/2014 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A Present On Admission Indicator - 9 10/1/2014 Text 1 Standard POA code set to Appendix A MC224 External Cause of Injury - 10 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC225 Present On Admission Indicator - 10 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC226 External Cause 10/1/2014 Text 7 ICD-10-CM Do not code
Admission Indicator – 4 Refer to Appendix A MC262 Diagnosis – 5 10/1/2004 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A Present On Admission Indicator – 5 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC264 Other Diagnosis – 6 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC265 Present On Admission Indicator – 6 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC266 Other Diagnosis – 7 10/1/2004 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC267 Present On Admission Indicator – 7 10/1/2014 Text 1 Standard POA code set Refer to Appendix A Other Diagnosis – 8 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A Present On Admission Indicator – 8 10/1/2014 Text 1 Standard POA code set Refer to Appendix A
Indicator – 17 Other Diagnosis – 18 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC289 Present On Admission Indicator – 18 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC290 Other Diagnosis – 19 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC291 Present On Admission Indicator – 19 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC292 Other Diagnosis – 20 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC293 Present On Admission Indicator – 20 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC294 Other Diagnosis – 21 10/1/2004 Text 7 ICD-10-CM Do not code decimal Refer to Appendix A MC295 Present On Admission Indicator – 21 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC296 Other Diagnosis 10/1/2014 Text 7 ICD-10-CM Do not code
– 22 decimal Refer to Appendix A MC297 Present On Admission Indicator – 22 10/1/2014 Text 1 Standard POA code set Refer to Appendix A Diagnosis – 23 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. to Appendix A Present On Admission Indicator – 23 10/1/2014 Text 1 Standard POA code set Refer to Appendix A MC300 Other Diagnosis – 24 10/1/2014 Text 7 ICD-10-CM Do not code decimal point. Refer to Appendix A MC301 Present On Admission Indicator – 24 10/1/2014 Text 1 Standard POA code set to Appendix A MC302 Principal Procedure Code 10/1/2014 Text 7 IDC-10-PCSCM Primary procedure code for this line of service Do not code decimal point. Refer to Appendix A Other Procedure Code - 1 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A MC304 Other Procedure Code - 2 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A
Code - 20 decimal Refer to Appendix A MC323 Other Procedure Code - 21 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A Other Procedure Code - 22 10/1/2014 Text 7 ICD-10 PCS Do not code decimal Refer to Appendix A MC325 Other Procedure Code - 23 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A MC326 Other Procedure Code - 24 10/1/2014 Text 7 ICD-10 PCS Do not code decimal point. Refer to Appendix A MC899 Record Type 1/1/2003 Text 2 Value = MC