CHAPTER
Ins 4000 UNIFORM
REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS
Statutory Authority: RSA 400-A:15 I; RSA 420-G:11; RSA 420-G:11-a; RSA 420-G:14
PART Ins 4001 PURPOSE AND SCOPE
Ins 4001.01 Purpose and Scope. This chapter contains procedures and
substantive requirements for the submission of health care data under RSA
420-G:11, II to the New Hampshire Comprehensive Health Information System by
insurance companies, third-party payers, third-party administrators, and
carriers that provide administrative services for a plan sponsor.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136, eff 11-24-20
PART Ins 4002 DEFINITIONS
Ins 4002.01 Definitions. Unless the context indicates otherwise, the
following words and phrases shall have the following meanings:
(a)
“Address” means street addresses, post office box numbers,
apartment numbers, e-mail addresses, web universal resource locators (URLs),
and internet protocol (IP) address numbers.
(b)
“Alternative payment arrangements” means those claims considered paid
by the carrier or third-party administrator under a capitated services
arrangement or a global payment, resulting in zero paid amounts on the claim.
(c)
“Blanket health insurance” means that form of accident and health
insurance defined under RSA 415:18, I-a that is not “health coverage” under RSA
420-G:2, IX, that does not require individual applications from covered
persons, and that does not require a carrier or third-party administrator to
furnish each person with a certificate of coverage.
(d)
“Capitated services” means services rendered by a provider
through a contract in which payment is based upon a fixed dollar amount for
each member on a monthly basis.
(e) “Carrier” means
any entity subject to the insurance laws and rules of this state, or subject to
the jurisdiction of the commissioner, that contracts or offers to provide,
deliver, arrange for, pay for, or reimburse any of the costs of health
services, or to administer on behalf of a third-party payer, and includes an
insurance company, a health maintenance organization, a nonprofit health
services corporation, a dental benefits administrator, a third-party
administrator, or any other entity arranging for or providing health coverage,
Medicare Supplemental, and Medicare Advantage plans.
(f) “Commissioner” means the insurance commissioner.
(g)
“Dental claims file” means a data file composed of service level
remittance information for all adjudicated claims for each billed dental
service provided to members, including data for services provided under
alternative payment arrangements with zero paid amounts.
(h)
“Department (NHID)” means the New Hampshire insurance department.
(i) “Designee” means an entity with which
the department or the department of health and human services have entered into
an arrangement pursuant to which the entity performs data management and
collecting functions and under which the entity is strictly prohibited from
using or releasing the information and data obtained in such a capacity for any
purposes other than those specified in the agreement.
(j)
“Department of Health and Human Services (DHHS)” means the New
Hampshire department of health and human services.
(k)
“Direct identifier” means any information, other than case or
code numbers used to create anonymous or encrypted data, that plainly discloses
the identity of an individual as referenced in 45 CFR Part 164.514 (e)(2).
(l)
“Encryption” means a method by which the true value of data has
been disguised in order to prevent the identification of persons or groups and
which does not provide the means for recovering the true value of the data.
(m)
“Exchange” means a governmental agency or non-profit entity that
meets the applicable standards of 42 U.S.C. section 13031 and makes qualified
health plans available to qualified individuals and qualified employers in
accordance with federal law.
(n)
“Health care claims data” means the set of data files that are
filed by carriers and third-party administrators under this chapter consisting
of, or derived directly from, member eligibility, medical claims, pharmacy
claims, and dental claims files, including a provider file. "Health care claims data" does not
include analysis, reports, or studies containing information from health care
claims data sets, if those analyses, reports, or studies have already been
released in response to another request for information or as part of a general
distribution of public information by the department.
(o)
“Hospital” means a licensed acute or specialty care institution.
(p)
“Insured” means an individual in whose name an insurance policy
is issued.
(q)
“Medical claims file” means a data file composed of service level
remittance information for all adjudicated claims for each billed medical
service provided to members, including data for services provided under
alternative payment arrangements with zero paid amounts.
(r)
“Members” means all individuals, employees, and dependents for
which the health carrier or third-party administrator has an obligation to
adjudicate, pay, or disburse claim payments.
The term includes covered lives.
For employer-sponsored group coverage, members include certificate
holders and their dependents.
(s)
“Member eligibility file” means a data file containing
demographic information for each individual member eligible for medical,
pharmacy, or dental benefits for one or more days of coverage at any time
during the reporting month as well as any retrospective updates that correspond
to previously submitted eligibility data.
The term also includes benefits attributed and associated effective
periods.
(t)
“New Hampshire Comprehensive Health Information System (NHCHIS)”
means the system established and operated by the department and the department
of health and human services or its designee to collect, store, and analyze
health care claims data.
(u)
“Pharmacy claims file” means a data file composed of service
level remittance information from all adjudicated claims for each billed
prescription provided to members, including data for services provided under
alternative payment arrangements with zero paid amounts.
(v)
“Plan ID” means the 14-character Health Insurance and Oversight System
(HIOS) Plan ID, standard component. The
full HIOS ID is unique to each fully insured carrier, product, or plan.
(w)
“Plan sponsor” means any persons, other than an insurer, who
establishes or maintains a plan covering residents of the state of New
Hampshire, including plans established or maintained by employers or jointly by
one or more employers and one or more employee organizations, committee, joint
board of trustees, or other similar group of representatives of the parties
that establish or maintain the plan.
(x)
“Prepaid amount” means the amount that would have been paid by
the health care claims processor for a specific service if the service had not
been capitated or otherwise did not result in a transfer of funds.
(y)
“Provider” means a health care facility, medical, dental or
behavioral health care practitioner, health product manufacturer, health
product vendor, or pharmacy.
(z)
“Provider file” means a data file listing information about the
service providers identified in the medical claims, pharmacy claims, and the
dental claims file as servicing billing, prescribing, or primary providers.
(aa)
“Release” means to make data or information available for inspection
and copying to persons other than the data submitter.
(ab)
“Subcontractor” means a vendor or contractor who manages carved
out categories of services, including behavioral health services, pharmacy
services, or any other subcontractor that processes claims on behalf of a
carrier.
(ac)
“Subscriber” means the certificate holder who receives coverage
from a carrier or third-party administrator as defined in these rules. For employer-sponsored group coverage, the
employee or subscriber is considered the certificate holder. For individual coverage, the policyholder is
considered the certificate holder. For
other types of group coverage, the certificate holder is considered the person
who is the principal insured.
(ad)
“Third party administrator” means any persons licensed by the
department that receives or collects charges, contributions, or premiums for,
or adjusts or settles claims for, residents of the state on behalf of a plan
sponsor, health care services plan, dental services plan, nonprofit hospital or
medical service organization, health maintenance organization, or insurer.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136, eff 11-24-20
PART Ins 4003 ANNUAL REGISTRATION REQUIREMENT
Ins 4003.01 Annual Registration
Requirement.
(a) Each carrier and
each third-party administrator shall submit a completed NHCHIS registration
form, available at https://nhchis.com/, to the department or its
designee by March 15 of every calendar year.
(b) Carriers and
third-party administrators shall notify the department or its designee within
30 days of changes to any of the annual NHCHIS registration information.
(c) Carriers and
third-party administrators shall notify the department or its designee of any
changes to the individual contact information submitted on the NHCHIS
registration form as soon as possible, but no later than 30 days after a
reassignment occurs.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20
Ins 4003.02 Contents
of NHCHIS Registration Form. The
NHCHIS registration form for carriers and third-party administrators submitting
data under RSA 420-G:11, II shall contain the fields required under Ins 4009.01.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20
Ins 4003.03 Submission of NHCHIS
Registration Form. Carriers and
third-party administrators shall submit the NHCHIS registration form through
the NHCHIS website.
Source. #10877, eff 7-10-15; ss by #13136 eff 11-24-20
PART Ins 4004 FILING SCHEDULES
Ins 4004.01 Filing Schedules.
(a) The deadline for
submitting NHCHIS data files shall be determined by the total number of members
for whom claims are being paid or processed by each carrier or third-party
administrator.
(b) Carriers and
third-party administrators that have 10,000 or more New Hampshire members shall
submit required NHCHIS files monthly, no later than 30 days after the close of
the reporting month.
(c) Carriers and
third-party administrators that have fewer than 10,000 New Hampshire members,
but do not meet the exclusion criteria in Ins 4005.02,
shall submit required NHCHIS files quarterly, no later than 30 days after the
end of the reporting quarter.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20
Ins 4004.02 First-time
Filers.
(a) Carriers and
third-party administrators that have not previously submitted files to the
department or its designee and that have never registered under this rule shall
register no later than 30 days after the first applicable requirement to submit
data, using the NHCHIS registration form outlined in Ins
4003.02.
(b) First-time submitters
shall provide test files within 120 days after registration. The test file size shall correspond to the
size required for that carrier or third-party administrator as specified in Ins 4004.01 (a).
(c) No later than
150 days after registration, newly-submitting carriers
and third-party administrators shall submit files containing the 3 most recent
calendar years of data, January through December. Year-to-date information and monthly or
quarterly files shall be provided no later than 180 days after registration.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20
Ins 4004.03 Changes
to Data Submitter’s Process, Format, or Sources.
(a) Carriers and
third-party administrators that change health plan identifiers or implement new
data submission platforms through acquisitions, mergers, or reorganization
shall be subject to the requirements for first-time submitters.
(b) Carriers and
third-party administrators filing under new health plan identifiers or through
new production systems shall provide additional documentation pursuant to
instructions from the department or its designee to ensure that NHCHIS
maintains a continuous record of member enrollment and claims history before
and after the changes.
Source. #10877, eff 7-10-15; ss by #13136 eff 11-24-20
PART
Ins 4005 REQUIRED FILERS AND EXCLUSIONS
Ins 4005.01 Required Filers and Data
Sets.
(a) In accordance
with the submission schedule set forth in Ins 4004,
each carrier and third-party administrator shall submit to the department or
its designee a complete and accurate health care claims data set.
(b) Carriers and
third-party administrators shall submit health care claims data for all
residents of New Hampshire and for all members who receive services under a
policy issued in New Hampshire, as follows:
(1) Any policy that provides coverage to the
employees of a New Hampshire employer that has a business location in New
Hampshire shall be considered a policy that is issued in New
Hampshire;
(2) An out-of-state employer’s branch location in
New Hampshire shall be considered a New Hampshire employer, and the carrier and
third-party administrator shall submit a claims data set for all members who
are employed at that branch location; and
(3) Carriers and third-party administrators shall
submit health care claims data for New Hampshire state and municipal employees.
(c) When more than
one entity is involved in the administration of a policy, data shall be
submitted in accordance with the following:
(1) A carrier shall be responsible for submitting
the claims data on policies that it has written;
(2) A third-party administrator shall be
responsible for submitting claims data on self-insured plans that it administers;
(3) Each carrier and third-party administrator
shall submit all health care claims processed by any subcontractor on its
behalf, including claims related to pharmacy services, dental services, and
behavioral health, mental health, and substance abuse treatment services;
(4) Each carrier and third-party administrator
shall ensure that the subcontractor is not submitting duplicate claims to the
department or its designee if the subcontractor falls under the definition of a
carrier, meets the requirements of this section, and is required to submit data
as a separate entity; and
(5) Each carrier and third-party administrator
shall ensure that member and subscriber identifiers in any files processed by
subcontracts are consistent with member and subscriber identifiers in the
medical and pharmacy claims files and the member eligibility files.
(d) Carriers and
third-party administrators shall continue to submit claims data for each month
in which they meet the criteria and for the 180 days after the month in which
the carrier or third-party administrator withdraws or falls below the exclusion
criteria listed in Ins 4005.02.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20
Ins 4005.02 Exclusions from
Filing Requirements.
(a) Carriers and
third-party administrators shall not be required to submit health care claims
data files, Health Care Effectiveness Data and
Information Set (HEDIS®) data, or Consumer Assessment of Health Plans Survey
(CAHPS) survey data if they meet the following criteria:
(1) For carriers that do not offer any products
on the health insurance exchange for residents of New Hampshire and that did
not cover more than 9,999 members in New Hampshire at any point in any medical,
pharmacy, or dental coverage class during the prior calendar year; or
(2) For third-party administrators that did not
cover more than 9,999 members in New Hampshire at any point in any medical,
pharmacy, or dental coverage class during the prior calendar year.
(b) Carriers and
third-party administrators shall perform the calculation for (a) above at the
entity level, meaning the level at which major governance decisions are made
under a senior leadership team, regardless of the number of companies operating
under separate corporate divisions.
Carriers or third-party administrators experiencing a drop in membership
below the de minimis threshold shall submit claims data and any corrections to
membership files for a period of 180 days from the point the carrier or
third-party administrator meets the de minimis exemption.
(c) Carriers and
third-party administrators shall not be required to submit health care claims
data about coverage that is not part of a comprehensive medical insurance
policy, including the following:
(1) Specific disease;
(2) Accident;
(3) Injury;
(4) Hospital indemnity;
(5) Disability;
(6) Long-term care;
(7) Vision coverage;
(8) Durable medical equipment; or
(9) Blanket health insurance.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20
Ins 4005.03 Opt-In by Self-Funded
Private Employers.
(a)
Each third-party administrator or carrier
providing claims administration services to any self-funded private employer
that maintains a business location in New Hampshire, including a branch
location, shall, within 60 days of the effective date of this rule for current
clients or, for new or renewing clients, within 30 days of the date its claims
administration services are retained or renewed, present to each such
self-funded employer a copy of the “NHID Opt-In Form” for purposes of
determining whether the employer directs the carrier or third-party
administrator to submit its health care claims data pursuant to Ins 4000.
(b)
The “NHID Opt-In Form” shall be presented at least once for each
contractual period but need not be presented annually if the contractual period
exceeds one year.
(c)
Health care claims data for each self-funded private employer that
directs the submission of its data shall be included as part of the carrier’s
or third-party administrator’s data submission as indicated on the “NHID Opt-In
Form” for that employer.
(d)
Each carrier and third-party administrator
shall provide to the department annually on March 15 an attestation of
compliance with this section with respect to all accounts to which this section
was applicable during the prior year.
The attestation shall include a list of the self-funded private
employers to whom the “NHID Opt-In Form” was presented. However, the association of a particular
employer with a particular carrier or third-party administrator may be designated
as proprietary information which the department shall, if so designated, hold
confidential.
(e)
A carrier whose submission includes all relevant data under Ins 4000, without regard to whether the data relate to a
self-funded private employer, shall not be required to comply with paragraphs
(a) through (d).
(f)
The types of employers listed in RSA 420-G:11, IV shall not be
considered self-funded private employers under this section, and the “NHID Opt-In
Form” shall not be presented to any such employer.
(g)
If a self-funded private employer chooses to include the health care
claims data of its employees in the state’s All-Payer Claims Database (APCD),
the employer, or its designee, shall:
(1) Complete and sign the “NHID Opt-In Form”
(2016); and
(2) Submit the completed form to its claims
administrator.
(h)
If the employer has questions about NH’s APCD or the department’s
efforts to improve health care cost transparency, the employer may contact the
department at 603-271-2261, or requests@ins.nh.gov, or visit http://www.nh.gov/insurance/.
Source. #12044, eff 11-17-16; ss by #13136 eff 11-24-20
PART Ins 4006 HEALTH CARE CLAIMS DATA SET FILING
Ins 4006.01 General Requirements.
(a) Carriers and
third-party administrators shall comply with all the technical specifications
contained in Ins 4009 and shall include all data
elements contained in Ins 4010, including required formats, definitions, and
sources.
(b) Carriers and
third-party administrators shall utilize a data transmission tool provided by
the department or its designee to assign a unique identification code to each
member and subscriber’s record in every file, transform direct identifiers,
encrypt the files, and securely transmit the files to the department or its
designee.
(c) Upon an
amendment to this chapter, carriers and third-party administrators shall submit
data that conform to the updated specifications no later than 180 days after
the effective date of the new version of the rule.
(d) If the
department or its designee identifies technical deficiencies in data submitted
by a carrier or third-party administrator, the carrier or third-party
administrator shall respond to the department within 10 days with a corrective
action plan that the department determines will remove the deficiencies.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20
Ins 4006.02 Subscriber and Member
Identification Data Elements.
(a) Carriers and
third-party administrators shall:
(1) Provide a unique identification number for
each member and subscriber included in the submitted files; and
(2) Maintain that unique identifier for each
member and subscriber for the entire period of coverage for that individual by
that carrier or third-party administrator.
(b) Subscriber and
member identifiers shall be:
(1) Consistent across all files that contain
information about the subscriber or member;
(2) Matched across the member eligibility,
medical claims, pharmacy, and dental files, as well as behavioral health
claims, as applicable, even where the claims are processed by a subcontractor
such as a pharmacy benefits manager; and
(3) Consistent with the technical specifications
in Ins 4009.02.
Source. #10877, eff 7-10-15;
ss by #13136 eff 11-24-20
Ins 4006.03 Included Records and Data
Requirements.
(a) Carriers and
third-party administrators shall report health care claims data for all members
meeting the criteria set forth in Ins 4005.01 (b).
(b) Records for
medical, pharmacy, and dental claims file submissions shall be reported at the
visit, service, or prescription level.
(c) Medical,
pharmacy, and dental claims files shall contain all of
a claim’s payment and adjustment activity during the reporting month regardless
of the date of service on the claim.
(d) Claims where
multiple parties have financial responsibility shall be included with all
medical and pharmacy claims file submissions.
(e) Co-payment or
co-insurance amounts shall be reported in 2 separate fields in the medical,
pharmacy, and dental claims file submissions.
(f) Carriers and
third-party administrators shall include records for services provided under
alternative payment arrangements with zero paid amounts.
(g) Carriers and
third-party administrators shall include records for services provided by out
of network providers and services provided after member exceeds benefits with
complete patient liability paid.
(h) Carriers and
third-party administrators shall include all service lines associated with fully-processed claims that have gone through an accounts
payable run and been booked to the health plan ledger in all medical, dental,
and pharmacy claims file submissions.
Source. #10877, eff 7-10-15; ss by #13136 eff 11-24-20
Ins 4006.04 Observation Period for
Record Selection.
(a) Carriers and
third-party administrators shall submit a member eligibility file that contains
data for each member eligible for medical, dental, or pharmacy benefits for one
or more dates of coverage at any time during a reporting month as well as any
retrospective updates that correspond to previously submitted eligibility
data. It shall include benefits,
attributes, and associated effective periods.
(b) Carriers and
third-party administrators shall include all claims adjudicated during the
reporting month for all members in the member eligibility file for that month.
(c) Carriers’ and
third-party administrators’ data submissions shall contain 180 days claims run
out for members in all current or previously submitted files.
Source. #10877, eff 7-10-15; ss by #13136 eff 11-24-20
Ins 4006.05 Health Care Effectiveness
Data and Information Set (HEDIS®) Reporting Requirements.
(a) Each carrier
that calculates using HEDIS®, a system of performance measures maintained by
the national committee for quality assurance (NCQA), and submits those data to
NCQA, shall report those data that pertain to members who receive their
benefits under a policy or plan issued in New Hampshire.
(b) The carrier
shall submit HEDIS® data to the DHHS or its designee by July 31st of each year
as follows:
(1) The carrier shall submit the data utilizing
the appropriate NCQA interactive data submission system (IDSS) import template;
and
(2) The carrier shall also submit the results via
a workbook, generated with results for each HEDIS® measure appearing on its own
worksheet.
Source. #10877, eff 7-10-15; ss by #13136 eff 11-24-20
Ins 4006.06 Consumer Assessment of
Health Plans Survey (CAHPS®) Reporting Requirements.
(a) Each carrier
that collects CAHPS® data, a survey overseen by the United States Department of
Health and Human Services, agency for healthcare research and quality (AHRQ)
and used by NCQA as part of HEDIS® reporting, shall report those data that are
collected and that pertain to members who receive their benefits under a policy
or plan issued in New Hampshire.
(b) The carrier
shall submit CAHPS® data to the DHHS or its designee by July 31st of each year,
as follows:
(1) The carrier shall submit the NCQA generated
survey results reports; and
(2) The carrier shall also
submit all results generated via the NCQA CAHPS® analysis program.
Source. #10877, eff 7-10-15; ss by #13136 eff 11-24-20
PART Ins 4007 DATA STANDARDS COMPLIANCE
Ins 4007.01 Data Standards Compliance.
(a) Carriers and third-party
administrators shall submit files that conform to the formats and standards in
these rules, including the technical specifications in Ins
4009.
(b) Carrier and
third-party administrator files shall be evaluated upon receipt by the
department or its designee to assess compliance with the data quality standards
in the submission instructions.
(c) Carriers and
third-party administrators shall:
(1) Resubmit nonconforming files at the direction
of the department or its designee;
(2) Resubmit a corrected and conforming version
of the original submission within 10 business days of the rejection
notification from the department or its designee; and
(3) Not submit partial replacement files or
record specific corrections.
(d) Carriers and third-party administrators shall submit
tables and descriptions about all nonconforming and plan-specific codes
appearing in the submission. Files with
nonconforming and plan-specific codes without such explanatory information
shall be rejected.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09;
ss by #10877, eff 7-10-15; ss by #13136 eff 11-24-20
PART Ins 4008 WAIVERS
Ins 4008.01 Waiver of Requirement to Submit
Specific Data Element.
(a) Upon application
of a carrier or third-party administrator, the department shall grant a waiver
of the requirement to submit a particular data element required under these
rules, upon a showing by the carrier or third-party administrator that:
(1) The data element does not exist on the
carrier’s or third-party administrator’s transaction system;
(2) The data element cannot be derived reliably
from other information available on the carrier’s or third-party administrator’s
transaction system; and
(3) The data element does not reflect information
necessary to process claims or to conduct business operations in accordance
with generally accepted industry standards, such that it should reasonably be
available.
(b) A carrier or
third-party administrator granted a waiver shall populate that data field in
its claims data submissions in the manner specified in the waiver.
Source. #10877, eff 7-10-15;
ss by #13136 eff 11-24-20
PART Ins 4009 TECHNICAL SPECIFICATIONS
Ins 4009.01 Subscriber and Member
Identification Data Elements.
(a) The following
table lists the subscriber and member identifiers that must be identical when reporting
information about a subscriber or a member:
|
Table 1: Matching Requirements for Subscriber/Member Identifiers Across Files |
||||
|
Data Element Name* |
Subscriber and Member Identifiers |
|||
|
Member Eligibility |
Medical Claims** |
Dental Claims |
Pharmacy Claims |
|
|
Subscriber Social Security
Number |
ME008 |
MC007 |
DC007 |
PC007 |
|
Plan Specific Contract
Number |
ME009 |
MC008 |
DC008 |
PC008 |
|
Member Suffix or Sequence
Number |
ME010 |
MC009 |
DC009 |
PC009 |
|
Member Identification Code |
ME011 |
MC010 |
DC010 |
PC010 |
|
Subscriber Last Name |
ME101 |
MC101 |
DC101 |
PC101 |
|
Subscriber First Name |
ME102 |
MC102 |
DC102 |
PC102 |
|
Subscriber Middle Initial |
ME103 |
MC103 |
DC103 |
PC103 |
|
Member Last Name |
ME104 |
MC104 |
DC104 |
PC104 |
|
Member First
Name |
ME105 |
MC105 |
DC105 |
PC105 |
|
Member Middle
Initial |
ME106 |
MC106 |
DC106 |
PC106 |
|
*The NHCHIS
preprocessor hashes these data elements as part of the file encryption and
transmission process. |
||||
|
**Also
pertains to Behavioral Health. |
||||
(b) The NHCHIS preprocessor
application will hash all subscriber and member identification codes and names
before data are transmitted to the department’s designee. To ensure consistent
hashing, subscriber and member identifiers should not be encrypted or hashed on
the initial extract loaded into the preprocessor.
(c) If a third-party
administrator does not collect the social security numbers for its members, the
third-party administrator shall provide the social security number of the
subscriber and assign a discrete two digit suffix for
each member under the subscriber’s contract using the following criteria:
(1) If the subscriber's social security number is
not collected by the third-party administrator, the subscriber's certificate or
contract number shall be used in its place.
This data element is de-identified by the NHCHIS preprocessor
application.
(2) The discrete two-digit suffix shall also be
used with the certificate or contract number.
This data element is de-identified by the NHCHIS preprocessor
application.
(3) The certificate or contract number with the
two-digit suffix shall be at least 11, but no more than 30 characters in
length. This data element is
de-identified by the NHCHIS preprocessor application.
Source. #10877, eff 7-10-15;
ss by #13136 eff 11-24-20 (formerly Ins 4009.02)
Ins 4009.02 Technical Specifications and
Format for File Transfer.
(a) Carriers and
third-party administrators shall use the values in the data tables contained in
Ins 4010 or the corresponding externally maintained
code tables referenced therein, and:
(1) Carriers and third-party administrators shall
submit tables and descriptions for all non-conforming and plan-specific codes
appearing in the submission; and
(2) The department and DHHS or its designee shall
reject files with non-conforming and plan-specific codes if explanatory
information is not provided in advance of the data submission.
(b) Carriers and
third-party administrators shall report adjustment records with the appropriate
positive or negative fields with the medical, pharmacy, and dental file
submissions. Negative values shall contain the negative sign before the value.
No sign shall appear before a positive value.
(c) When more than
one version of a fully-processed claim service line is
submitted, each version of a claim service line shall be enumerated
sequentially with a higher version number (MC005A) so that the latest version
of that service line is the record with the highest version number (MC005A) and
the same claim number + line counter. Where a version number is not available,
provide the former claim number in data element MC211. Similar requirements
apply to the pharmacy claim file.
(d) All service
lines associated with fully-processed claims that have
gone through an accounts payable run and been booked to the health plan ledger
shall be included on medical, pharmacy, and dental claims data
submissions. Do not include service
lines:
(1) Rejected due to failed edits;
(2) That are duplicates;
(3) That are from an inactive member; or
(4) Claims that are voided for point
of sale adjustments.
(e) Subsequent
incremental claims submissions shall include all reversal and adjustment or
restated versions of previously submitted claim service lines and all new, fully-processed service lines associated with the claim,
provided that they have paid dates in the reporting period, and:
(1) Each version of a claim service line shall be enumerated sequentially with a higher line version number (MC005A); and
(2) Reversal versions of a claim service line shall be indicated by a claim
status code = '22' (Field MC038).
(f) Capitated
service claims, sometimes known as encounter claims, for capitated services
shall be reported with all medical and pharmacy file submissions.
(g)
If a claim contains
service lines that do
not contain a payment because their costs are covered on another line of the claim line, such as under a global payment arrangement, those line(s) shall be:
(1) Included in the data submission; and
(2) Clearly indicated by a
claim
status code = ‘04’ (Field MC038).
(h) Member eligibility
data suppliers must provide a data set that contains information on every
covered plan member, regardless of whether the member utilized services during
the reporting period. One record per
member per month per plan is required.
For example, if a member is covered as both a subscriber and a dependent
on two different policies during the same month, 2 records must be
submitted. If a member has 2 contract
numbers for 2 different coverage types, 2 member
eligibility records must be submitted.
(i) The Provider ID (MP003) is the unique
identifier for a single provider. The Provider ID should only occur once in the
table. However, in the event the same provider delivered, and was reimbursed
for, services rendered from two or more different physical locations, then the
provider data file shall contain two separate records for that same provider
reflecting each of those physical locations. One record should be provided for
each unique physical location.
(j) Carriers and third-party
administrators must use the File Submission “Preprocessor” provided by the DHHS
and their designee. The preprocessor
hashes or de-identifies member and subscriber information before the data
leaves the carrier’s and third-party administrator’s system.
(k) Carriers and third party administrators must report the minimum value for
fully insured and self-insured products to support the department’s
supplemental reporting reviews. The minimum value is defined as the percentage
of the total allowed costs of benefits provided under a group health plan or
health insurance coverage. The minimum value measure is outlined in Section
1302 (d)(2)(C) of the Affordable Care Act. Plans may use the HHS MV
calculator available at http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html;
may apply a safe harbor developed by
(l) Each member
eligibility file and each medical, pharmacy, and dental claims file submission
must 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.
(m) All carriers and
third-party administrators submitting APCD files shall be provided with code in
the form of a pre-processor, which generates the files in the required format
and encrypts them prior to submission. The pre-processor code shall be provided
to all carriers and third-party administrators as a down load
through a password protected portal.
(n) Carriers and
third-party administrators may submit APCD files using the following methods:
(1) Secure File Transport Protocol (SFTP) is the
preferred method for submitting files.
This method requires logging on to the appropriate SFTP site and sending
or receiving files using the SFTP client server. This protocol assumes that it
is run over a secure channel, that the server has already authenticated the
client, and that the identity of the client user is available to the protocol.
(2) The web upload method allows the sending and
receiving of files and messages without the installation of additional
software. This method requires internet access, a username, and password. It is not the preferred method due to
limitations on the size of the files that can be received,
but can be utilized if it is the only method available to the healthcare
claims processor.
(o) The member
eligibility file, medical claims file, pharmacy claims file, dental claims
file, and provider file shall be
submitted as separate ASCII files, with variable field lengths and pipe
delimited, and shall comply with the following standards:
(1) Each record shall be terminated with a
carriage return and line feed (ASCII 13, ASCII 10).
(2) All fields shall be filled where applicable.
(3) Text and date fields shall be left blank when
not applicable or if a value is not available.
(4) “Blank” means do not supply any value at all between
consecutive field delimiters or last field delimiter and line terminator. Numeric fields without a value shall be
filled with a single
zero.
(5) Only one record per row shall be submitted.
No single line item of data shall contain carriage return or line feed
characters.
(6) Text fields shall not be padded with leading
or trailing spaces or tabs.
(7) Numeric fields:
a. Shall not be padded with leading zeroes;
b. The integer portion of numeric fields shall
not be padded with leading zeros;
c. The decimal portion of numeric fields, if
required, shall be padded with trailing zeros up to the number of decimal
places indicated; and
d. Positive values are assumed and need not be
indicated as such. Negative values shall be indicated with a minus sign and
shall appear in the left-most position of all numeric fields;
(8) Date fields:
a. Shall be CCYYMMDD,
when a value is provided, unless otherwise indicated;
b. Shall not be padded with leading or trailing
spaces or tabs; and
c. Shall be left blank when not applicable or if
a value is not available.
Source. #10877, eff 7-10-15; ss by #13136 eff
11-24-20(formerly Ins 4009.03)
Ins 4009.03 Data
Quality Requirements.
(a) A validation process
shall be employed to ensure that the format and content of the submitted files
are valid and complete. The validation process is primarily composed of three
groups of audits, field level audits, quality audits, and post data
consolidation reasonableness, longitudinal, and relational audits, as follows:
(1) All transmitted files are first checked to
determine if they are in the correct form and have been created using the
provided pre-processor. Field level
audits are then employed to evaluate field length and type, code values, and
the percentage at which the fields are filled;
(2) Quality audits are employed to determine if
the data submitted meet a pre-determined level of reasonableness, for example,
percent of institutional claims versus percent of professional claims.
Default thresholds, which
can be rates or ranges, have been established for approximately 200 quality audits; and
(3) After the files are loaded into staging
tables, additional audits are run on the consolidated data to identify any
global issues that would not be evident during the field and quality level
audit process. The reasonableness,
longitudinal, and relational audits confirm whether the appropriate and correct
amount of data was received for the corresponding membership volume. Examples of these audits include frequency of
individual field values, volume reconciliation, and cost or utilization
reasonableness.
(b) Default
thresholds or rates shall be applied to the field level audits for each element
in the eligibility, claims files, and provider file, and for each quality
audit. The standard acceptable threshold
for field length, field type, and data value audits is 100 percent. However, there are some fields where the
acceptable thresholds for data value will be set at less than 100 percent. Individual field completeness thresholds are
established for each data element in the eligibility, medical, pharmacy,
dental, and provider files and will vary accordingly. All of the
pre-determined default thresholds can be individually adjusted if extenuating
circumstances arise which may impact the data completeness or content. If a file is processed and rejected for
failing to meet the field level or quality audit default thresholds, the
healthcare claims processor can request an exemption to the default threshold
through a standardized process.
Exemptions or adjustments may be granted for data variances that cannot
be corrected due to systematic issues.
(c) At least 30 days
prior to the initial submission of the files, or whenever the data element
content of the files is subsequently altered, each healthcare claims processor
must submit a data set for comparison to the same validation process used for
actual submissions. Iterative rounds of testing may be necessary until the
files conform to the submission requirements.
A test file should contain data covering a period of one month.
(d) Failure to
conform to any of the submission requirements shall result in the rejection and
return of the applicable data file(s). All rejected and returned files shall be
resubmitted in the appropriate, corrected form within 10 days, or the
healthcare claims processor may request an exemption to adjust the threshold
for the failing field(s). Due to the large amount and complexity of the data
processed, it is more efficient to resubmit an entire file rather than to
correct data within the file.
Source.
#10877, eff 7-10-15; ss by #13136, eff 11-24-20 (formerly Ins 4009.04)
Ins 4009.04 External Code Sources.
(a) Countries
American National Standards
Institute
http://webstore.ansi.org/SdoInfo.aspx?sdoid=39&source=iso_member_body
(b) States, Zip
Codes and Other Areas of the US
U.S. Postal Service
https://www.usps.com/
(c) National
Provider Identifiers
National Plan & Provider
Enumeration System
https://nppes.cms.hhs.gov/NPPES/
(d) Health Care
Provider Taxonomy
National Uniform Claim Committee
(NUCC)
(e) International
Classification of Diseases 9 & 10
American Medical Association
http://www.who.int/classifications/icd/en/
(f) HCPCS, CPTs and
Modifiers
American Medical Association
(g) Dental Procedure
Codes and Identifiers
American Dental Association
(h) National Drug
Codes and Names
U.S. Food and Drug
Administration
http://www.fda.gov/drugs/informationondrugs/ucm142438.htm
(i) Standard Professional Billing Elements
Centers for Medicare and
Medicaid Services (Rev. 10/26/12)
http://www.cms.gov/Regulations-and-fGuidance/Guidance/Manuals/downloads/clm104c26.pdf
(j) Standard
Facility Billing Elements
National Uniform Billing
Committee (NUBC)
(k) DRGs, APCs and
POA Codes
Centers for Medicare and
Medicaid Services
(l) Claim Adjustment
Reason Codes
Washington Publishing
Company
http://www.wpc-edi.com/reference/
Source. #10877, eff 7-10-15; ss by #13136, eff
11-24-20 (formerly Ins 4009.05)
PART
Ins 4010 DATA
TABLES
Ins 4010.01 Member Eligibility Data
Tables.
(a) Use Table 4010.7
(a) to determine member eligibility file mapping and formatting.
(b) Member File
Header Record Layout
|
Table 4010.01(b) Member File Header Record Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
HD001 |
Record Type |
Text |
2 |
HD |
|
HD002 |
Payer |
Text |
8 |
Payer submitting
payments. NHID Submitter Code |
|
HD003 |
National Plan
ID |
Text |
30 |
CMS National
Plan ID |
|
HD004 |
Type of File |
Text |
2 |
ME Member
Eligibility |
|
HD005 |
Period
Beginning Date |
Date |
8 |
Beginning of paid
period for claims or beginning of month covered for eligibility |
|
HD006 |
Period Ending
Date |
Date |
8 |
End of paid
period for claims or end of month covered for eligibility |
|
HD007 |
Comments |
Text |
80 |
Submitter may
use to document this submission by assigning a filename, system source, etc. |
(c) Member File
Trailer Record Layout
|
Table 4010.01(c) Member File Trailer Record Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
TR001 |
Record Type |
Text |
2 |
TR |
|
TR002 |
Payer |
Text |
8 |
Payer
submitting payments. NHID Submitter Code |
|
TR003 |
National Plan
ID |
Text |
30 |
CMS National
Plan ID |
|
TR004 |
Type of File |
Text |
2 |
ME Member
Eligibility |
|
TR005 |
Period Beginning Date |
Date |
8 |
Beginning of paid period for
claims or beginning of month covered for eligibility |
|
TR006 |
Period Ending Date |
Date |
8 |
End of paid period for
claims or beginning of month covered for eligibility |
|
TR007 |
Extraction Date |
Date |
8 |
Date file was created |
|
TR008 |
Record Count |
Number |
10 (0) |
Total number
of records submitted in this file |
(d) Member File
Detailed Specification
|
|
Table
4010.01(d) Member File Detailed Specification |
||||
|
|
|
||||
|
Column Position |
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
1 |
ME001 |
Payer |
Text |
8 |
Payer
submitting payments NHID Submitter Code |
|
2 |
ME002 |
National Plan
ID |
Text |
30 |
CMS National
Plan ID |
|
3 |
ME003 |
Insurance Type
Code/Product |
Text |
2 |
See Table 4010.6 (a) Insurance
Type/Product Code-Eligibility File |
|
4 |
ME004 |
Start Year |
Number |
4 (0) |
Year for which
eligibility is reported in this submission. CCYY format |
|
5 |
ME005 |
Start Month |
Number |
2 (0) |
Month for
which eligibility is reported in this submission. MM format. Leading zero is
required for reporting January through September files |
|
6 |
ME006 |
Insured Group
or Policy Number |
Text |
50 |
Group or policy
number (not the number that uniquely identifies the subscriber) |
|
7 |
ME007 |
Coverage Level
Code |
Text |
3 |
Benefit
Coverage Level |
|
|
|
|
|
|
CHD Children
Only |
|
|
|
|
|
|
DEP Dependents
Only |
|
|
|
|
|
|
ECH Employee
and Children |
|
|
|
|
|
|
EMP Employee
Only |
|
|
|
|
|
|
ESP Employee
and Spouse |
|
|
|
|
|
|
FAM Family |
|
|
|
|
|
|
|
|
|
|
|
|
|
SPC Spouse and
Children |
|
|
|
|
|
|
SPO Spouse
Only |
|
8 |
ME008 |
Subscriber
Social Security Number |
Text |
9 |
Subscriber's social
security number. Do not include dashes.
Leave blank if not available. |
|
9 |
ME009 |
Plan Specific
Contract Number |
Text |
50 |
Plan assigned
contract number. Leave blank if Plan Specific Contract Number is subscriber's social security number. If this is a Medicaid member, provide
Medicaid ID |
|
10 |
ME010 |
Member Suffix
or Sequence Number |
Text |
20 |
Uniquely
identifies the member within the contract |
|
11 |
ME011 |
Member Social
Security Number |
Text |
9 |
Member's
social security number. Do not include
dashes. Leave blank if not available. |
|
12 |
ME012 |
Individual
Relationship Code |
Text |
2 |
See Table 4010.6 (b)
Relationship Codes |
|
13 |
ME013 |
Member Gender |
Text |
1 |
M Male |
|
|
|
|
|
|
F Female |
|
|
|
|
|
|
U Unknown |
|
|
|
|
|
|
O Other |
|
14 |
ME014 |
Member Date of
Birth |
Date |
8 |
Date of birth
of member |
|
15 |
ME015 |
|
Text |
30 |
City name of
member |
|
16 |
ME016 |
|
Text |
2 |
As defined by
the US Postal Service |
|
17 |
ME017 |
Member ZIP
Code |
Text |
9 |
ZIP Code of
member – may include non- US codes. Do not include dash. |
|
18 |
ME018 |
Medical
Coverage |
Text |
1 |
Y Yes |
|
|
|
|
|
|
N No |
|
19 |
ME019 |
Prescription
Drug Coverage |
Text |
1 |
Y Yes, member has
prescription drug coverage in the period defined with this payer |
|
|
|
|
|
|
N No, member
does not have prescription drug coverage in the period defined with this
payer |
|
20 |
ME020 |
Dental
Coverage |
Text |
1 |
Y Yes, member
has dental coverage in the period defined with this payer |
|
|
|
|
|
|
N No, member
does not have dental coverage in the period defined with this payer |
|
21 |
ME021 |
Race 1 |
Text |
6 |
See Table 4010.6 (c) Race
1/Race 2 |
|
22 |
ME022 |
Race 2 |
Text |
6 |
See Table 4010.6 (c) Race
1/Race 2 |
|
23 |
ME023 |
Placeholder |
|
|
|
|
24 |
ME024 |
Hispanic
Indicator |
Text |
1 |
Y Yes, member
is Hispanic/Latino/Spanish |
|
|
|
|
|
|
N No, member
is not Hispanic/Latino/Spanish |
|
|
|
|
|
|
U Unknown |
|
25 |
ME025 |
Ethnicity 1 |
Text |
6 |
See Table
4010.6 (d): Ethnicity 1/ Ethnicity 2 |
|
26 |
ME026 |
Ethnicity 2 |
Text |
6 |
See Table
4010.6 (d): Ethnicity 1/ Ethnicity 2 |
|
27 |
ME027 |
Placeholder |
|
20 |
|
|
28 |
ME028 |
Primary
Insurance Indicator |
Text |
1 |
Y Yes, this is
the member’s primary insurance |
|
|
|
|
|
|
N No, this is
not the member’s primary insurance |
|
29 |
ME029 |
Coverage Type |
Text |
3 |
ASW
Self-funded plans that are administered by a third party
administrator, where the employer has purchased stop-loss, or group excess
insurance coverage |
|
|
|
|
|
|
ASO
Self-funded plans that are administered by a third party
administrator, where the employer has not purchased stop-loss, or group
excess insurance coverage |
|
|
|
|
|
|
STN Short-term
non-renewable health insurance, as defined pursuant to RSA 415:5 III |
|
|
|
|
|
|
MCD Medicaid |
|
|
|
|
|
|
MCR Medicare |
|
|
|
|
|
|
UND Plans underwritten
by the carrier |
|
|
|
|
|
|
OTH Any other
plan. Carriers and third-party administrators using this code shall obtain
prior approval from the N.H. Insurance Department |
|
30 |
ME030 |
Market
Category |
Text |
4 |
Three or four digit character code for
identifying market category. Employer size is based on the number of eligible
employees in the group as define in INS 4100, (INS 4103.03 (g) for the Small
Group market, INS 4104.03 (i) for the Large Group
market) |
|
|
|
|
|
|
IND Policies
sold and issued directly to individuals, other than those sold on a franchise
basis, as defined pursuant to RSA 415:19, or as group conversion Policies as
defined pursuant to RSA 415:18 VII (a) |
|
|
|
|
|
|
FCH Policies sold
and issued directly to individuals on a franchise basis as defined pursuant
to RSA 415:19 |
|
|
|
|
|
|
GCV Policies
sold and issued directly to individuals as group conversion Policies as
required pursuant to RSA 415:18 VII (a) |
|
|
|
|
|
|
GS1 Policies
sold and issued directly to employers having exactly one employee |
|
|
|
|
|
|
GS2 Policies
sold and issued directly to employers having between 2 and 9 employees |
|
|
|
|
|
|
GS3 Policies sold
and issued directly to employers having between 10 and 25 employees |
|
|
|
|
|
|
GS4 Policies
sold and issued directly to employers having between 26 and 50 employees |
|
|
|
|
|
|
GLG1 Policies sold
and issued directly to employers having between 51 and 99 employees |
|
|
|
|
|
|
GLG2 Policies
sold and issued directly to employers having 100 or more employees |
|
|
|
|
|
|
GSA Policies sold
and issued directly to small employers through a qualified association trust |
|
|
|
|
|
|
OTH Policies
sold to other types of entities. Carriers and third-party administrators using
this market code shall obtain prior approval from the NH Insurance Department |
|
|
|
|
|
|
BLC Policies
sold and issued as blanket health insurance Policies to a common carrier |
|
|
|
|
|
|
BLE Policies
sold and issued as blanket health insurance Policies to an employer |
|
|
|
|
|
|
BLV Policies
sold and issued as blanket health insurance Policies to a volunteer fire
department, first aid, or other such volunteer group |
|
|
|
|
|
|
BLS Policies sold
and issued as blanket health insurance Policies to a sports team or a camp |
|
|
|
|
|
|
BLT Policies
sold and issued as blanket health insurance Policies to a travel agency, or
other organization that provides travel-related services |
|
|
|
|
|
|
BLU Policies
sold and issued as blanket health insurance Policies to a university or
college |
|
|
|
|
|
|
SLG Policies
sold and issued as student major medical expense large group coverage to
enrolled students at an accredited college, university, or other educational
institution |
|
|
|
|
|
|
STS Policies
sold and issued as group short term student health insurance |
|
|
|
|
|
|
SMG Policies
sold and issued as student major medical group health insurance |
|
|
|
|
|
|
SNM Policies sold
and issued as student group health insurance that is not major medical
coverage |
|
|
|
|
|
|
SIM Policies
sold and issued as student individual major medical health insurance |
|
|
|
|
|
|
SIN Policies sold
and issued as student individual health insurance that is not major medical
coverage |
|
31 |
ME031 |
NH Health
Protection Program |
Text |
60 |
For enrollees
in the New Hampshire Health Protection Program (NHHPP), indicate if enrollee
is part of the Premium Assistance Program (PAP) or Health Insurance Premium
Payment (HIPP). Leave blank if
enrollee is not a member of the NHHPP |
|
32 |
ME032 |
Group Name |
Text |
4 |
Name of the group that the
member is covered by. If the member is
part of a group of one or non-group, indicate I |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
33 |
ME101 |
Subscriber
Last Name |
Text |
60 |
|
|
34 |
ME102 |
Subscriber
First Name |
Text |
35 |
|
|
35 |
ME103 |
Subscriber
Middle Initial |
Text |
1 |
|
|
36 |
ME104 |
Member Last
Name |
Text |
60 |
|
|
37 |
ME105 |
Member First
Name |
Text |
35 |
|
|
38 |
ME106 |
Member Middle
Initial |
Text |
1 |
|
|
39 |
Placeholder |
||||
|
40 |
ME203 |
Member’s
Assigned PCP |
Text |
20 |
National
Provider ID of the member’s Primary Care Physician as designated by
healthcare claims processor. |
|
41 |
ME204 |
HIOS
Plan ID |
Text |
16 |
The
16 character HIOS Plan ID (Standard component).
Including a five digit issuer ID, two character
state ID, three digit product number, four digit standard component number
and two digit variant component ID. This field may not be available for all
market segments; |
|
42 |
ME205 |
Plan Effective Date |
Date |
8 |
For the plan reported in
ME204, report the date eligibility started for this member under this plan
type. The purpose of this data element is to maintain an eligibility span for
each member. |
|
43 |
ME206 |
Minimum Value |
Number |
3 (0) |
For the plan
reported in ME204, report the Minimum Value as
described in
Part Ins4009.03 (j). This is reported as a
percentage. |
|
44 |
ME207 |
Exchange
Indicator |
Text |
1 |
The plan reported
in ME204 was available on the Exchange Marketplace in the month and year
reflected in ME004 and ME005 |
|
|
|
|
|
|
Y Yes |
|
|
|
|
|
|
N No |
|
45 |
ME208 |
High
deductible health plan |
Text |
1 |
The plan reported
in ME204 meets the IRS definition of a HDHP |
|
|
|
|
|
|
Y Yes |
|
|
|
|
|
|
N No |
|
|
|
|
|
|
U Unknown |
|
46 |
ME209 |
Active
enrollment |
Text |
1 |
The plan reported
in ME204 was open for enrollment in the year and month reflected in ME004 and
ME005 |
|
|
|
|
|
|
Y Yes |
|
|
|
|
|
|
N No |
|
47 |
ME210 |
New Coverage |
Text |
1 |
The plan reported
in ME204 was being offered for the first time in the reporting year reflected
in ME004 |
|
|
|
|
|
|
Y Yes |
|
|
|
|
|
|
N No |
|
48 |
ME211 |
Placeholder |
|
||
|
49 |
ME899 |
Record Type |
Text |
2 |
ME |
|
50 |
ME900 |
Plan State |
Text |
2 |
State in which
the plan is sold or used. State codes
are maintained by the US Postal Service |
|
51 |
ME901 |
Advanced
Premium Tax Credit |
Number |
2(2) |
Dollar value
of Advanced Premium Tax Credit (APTC) subsidy |
|
52 |
ME902 |
NAIC Number |
Text |
5 |
Number that the
National Association of Insurance Commissioners (NAIC) assigns to each
individual underwriting company |
|
53 |
ME903 |
Grandfather
Plan indicator |
Text |
1 |
Indicates if a
plan qualifies as a “Grandfathered” or “Transitional Plan” under the
Affordable Care Act (ACA). Please see definition for “grandfathered” and
“transitional” in HHS rules 45-CFR-147.140:
https://www.federalregister.gov/select- citation/2013/06/03/45-CFR-147. The
values of the indicator are as follows: 1= Grandfathered; 2 =
Non-Grandfathered; 3 =Transitional; 4 = Not Applicable |
|
54 |
ME904 |
Metal Level |
Text |
10 |
The metal representation
of the plan reported in ME204 on the Exchange Marketplace |
Source. #10877, eff 7-10-15; ss by #13136, eff 11-24-20
Ins 4010.02 Member
Claims Data Tables.
(a) Medical
Eligibility File Mapping and Format Information. Use Table 4010.7 (b) to determine medical
eligibility file mapping and formatting.
(b) Medical Claims
File Header Record Layout
|
Table 4010.02 (b) Medical
Claims File Header Record Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
HD001 |
Record Type |
Text |
2 |
HD |
|
HD002 |
Payer |
Text |
8 |
Payer
submitting payments. NHID Submitter Code |
|
HD003 |
National Plan
ID |
Text |
30 |
CMS National
Plan ID |
|
HD004 |
Type of File |
Text |
2 |
MC Medical
Claims |
|
HD005 |
Period
Beginning Date |
Date |
8 |
Beginning of
paid period for claims or beginning of month covered for eligibility |
|
HD006 |
Period Ending
Date |
Date |
8 |
End of paid
period for claims or end of month covered for eligibility |
|
HD007 |
Comments |
Text |
80 |
Submitter may
use to document this submission by assigning a filename, system source, etc. |
(c) Medical Claims
Files Trailer Record Layout
|
Table 4010.02 (c) Medical
Claims File Trailer Record Layout |
||||
|
Data Element # |
Element |
Type |
Length (decimal places |
Description/Codes/Sources |
|
TR001 |
Record Type |
Text |
2 |
TR |
|
TR002 |
Payer |
Text |
8 |
Payer
submitting payments. NHID Submitter Code |
|
TR003 |
National Plan
ID |
Text |
30 |
CMS National
Plan ID |
|
TR004 |
Type of File |
Text |
2 |
MC Medical
Claims |
|
TR005 |
Period
Beginning Date |
Date |
8 |
Beginning of
paid period for claims or beginning of month covered for eligibility |
|
TR006 |
Period Ending Date |
Date |
8 |
End of paid period for claims
or beginning of month covered for eligibility |
|
TR007 |
Extraction Date |
Date |
8 |
Date file was created |
|
TR008 |
Record Count |
Number |
10 (0) |
Total number
of records submitted in this file |
(d) Medical Claims File
Detailed Specifications
|
Table 4010.02 (d) Medical
Claims File Detailed Specifications |
||||
|
Data Element # |
Element |
Type |
Length (decimal places) |
Description/Codes/Sources |
|
MC001 |
Payer |
Text |
8 |
Payer submitting
payments NHID Submitter Code |
|
MC002 |
National Plan
ID |
Text |
30 |
CMS National
Plan ID |
|
MC003 |
Insurance
Type/Product Code |
Text |
2 |
As established by X12
Accredited Standards Committee available at https://ushik.ahrq.gov/ViewItemDetails?system=sdo&itemKey=133161000 |
|
MC004 |
Payer Claim
Control Number |
Text |
35 |
Must apply to the
entire claim and be unique within the payer's system |
|
MC005 |
Line Counter |
Text |
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 |
Number |
4 (0) |
Version number
of this claim service line. The version number begins with 0 and is
incremented by 1 for each subsequent version of that service line |
|
MC006 |
Insured Group
or Policy Number |
Text |
50 |
Group or
policy number (not the number that uniquely identifies the subscriber) |
|
MC007 |
Subscriber
Social Security Number |
Text |
9 |
Subscriber's
social security number. Do not include dashes. Leave blank if not available. |
|
MC008 |
Plan Specific
Contract Number |
Text |
50 |
Plan assigned contract
number. Leave blank if Plan Specific Contract Number is subscriber’s social
security number. If this is a
Medicaid claim, provide Medicaid ID. |
|
MC009 |
Member Suffix
or Sequence Number |
Text |
20 |
Uniquely
identifies the member within the contract |
|
MC010 |
Member Social
Security Number |
Text |
9 |
Member’s
social security number. Do not include dashes. Leave blank if not available. |
|
MC011 |
Individual
Relationship Code |
Text |
2 |
See Table 4010.6 (b)
Relationship Codes |
|
MC012 |
Member Gender |
Text |
1 |
M Male |
|
|
|
|
|
F Female |
|
|
|
|
|
U Unknown |
|
|
|
|
|
O Other |
|
MC013 |
Member Date of
Birth |
Date |
8 |
Date of birth
of member |
|
MC014 |
|
Text |
30 |
City name of
member |
|
MC015 |
|
Text |
2 |
As defined by
the US Postal Service |
|
MC016 |
Member ZIP
Code |
Text |
9 |
ZIP Code of
member – may include non- US codes. Do not include dash. |
|
MC017 |
Paid Date (AP
Date) |
Date |
8 |
|
|
MC018 |
Admission Date |
Date |
8 |
Required for
all inpatient claims. |
|
MC019 |
Admission Hour |
Text |
2 (0) |
Required for
all inpatient claims. Time is expressed in military time – HH |
|
MC020 |
Admission Type |
Text |
1 |
Required for
all inpatient claims (SOURCE: National Uniform Billing Data Element
Specifications): |
|
|
|
|
|
1 = Emergency |
|
|
|
|
|
2 = Urgent |
|
|
|
|
|
3 = Elective |
|
|
|
|
|
4 = Newborn |
|
|
|
|
|
5 = |
|
|
|
|
|
9 =
Information not available |
|
MC021 |
Admission
Source |
Text |
1 |
See Table
4010.6 (i) Point of Origin Codes |
|
MC022 |
Discharge Hour |
Text |
2 (0) |
Required for all
inpatient claims. Time is expressed in military time – HH |
|
MC023 |
Discharge
Status |
Text |
2 |
See Table
4010.6 (f): Discharge Status |
|
MC024 |
Service
Provider Number |
Text |
30 |
Payer assigned
servicing provider number by the payer for internal identification purposes |
|
MC025 |
Service
Provider Tax ID Number |
Text |
10 |
Federal
taxpayer's identification number – if the tax id is a provider’s social
security number, use ‘SSN’ and ‘NA’ if unavailable |
|
MC026 |
National
Service Provider ID |
Text |
20 |
Provider NPI |
|
MC027 |
Service
Provider Entity Type Qualifier |
Text |
1 |
HIPAA provider
taxonomy classifies provider groups (clinicians who bill as a group practice
or under a corporate name, even if that group is composed of one provider) as
“Person”. |
|
|
|
|
|
1 Person |
|
|
|
|
|
2 Non-Person
Entity |
|
MC028 |
Service
Provider First Name |
Text |
35 |
Individual
first name. Leave blank if provider is a facility or organization |
|
MC029 |
Service
Provider Middle Name |
Text |
25 |
Individual middle
name or initial. Leave blank if provider is a facility or organization |
|
MC030 |
Servicing
Provider Last Name or Organization Name |
Text |
60 |
Report the
name of the organization or last name of the individual provider. MC027
determines if this is an organization or Individual Name reported here. |
|
MC031 |
Service
Provider Suffix |
Text |
10 |
Suffix to
individual name. Leave blank if provider is a facility or organization.
Should 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’,
‘LICSW’]. |
|
MC032 |
Service
Provider Specialty |
Text |
10 |
National Uniform
Claims Committee (NUCC) standard code that defines this provider for this
line of service. Taxonomy values allow
for the reporting of nurses, assistants and
laboratory technicians, where applicable, as well as Physicians, Medical
Groups, Facilities, etc. |
|
MC033 |
|
Text |
30 |
City name of
rendering provider - practice location |
|
MC034 |
|
Text |
2 |
As defined by
the US Postal Service |
|
MC035 |
Service
Provider ZIP Code |
Text |
9 |
ZIP Code of
provider - may include non-US codes. |
|
MC036 |
Type of Bill –
Institutional |
Text |
3 |
For facility claims only submitted using UB04 forms Type of
Facility - First Digit |
|
|
|
|
|
1 Hospital |
|
|
|
|
|
2 Skilled
Nursing |
|
|
|
|
|
3 Home Health |
|
|
|
|||