Section 2.09 - Coding and Claims Submission RulesCarriers shall file claims data in compliance with 129 CMR 2.09.
(1)Adjustment Records. Carriers and health care claims processors shall report adjustment records with the appropriate positive or negative fields with the medical and pharmacy file submissions. Negative values shall contain the negative sign before the value. No sign shall appear before a positive value .(2)Capitated Services Claims. Claims for capitated services shall be reported with all medical and pharmacy file submissions.(3)Data Fields. Carriers shall make every effort to report the data fields outlined in these requirements. However, if a field is not used for medical or pharmacy claim adjudication, is not captured on the carrier's transaction system (nor on that of its subcontractors), or cannot be derived reliably from other information available on the carrier's transaction system, the health plan shall notify the Council, or its designee, and shall identify the field that cannot be provided. After notification, the carrier shall not be required to populate that data field in its reports. The carrier shall report on an annual basis its efforts to populate this field, and the expected data as of which this field will be available, if there is such data.(4)Code Sources. Unless otherwise specified, the member eligibility file and medical and pharmacy claims files submissions shall use the code sources listed in 129 CMR 2.10. Member Identification Codes. Carriers shall assign, according to a standard algorithm provided by the Council, or its designee, a unique identification code to each of their members using the method developed by the Council or its designee.
(6)Specific/Unique Coding. With the exception of provider codes and provider specialty codes, specific or unique coding systems shall not be permitted as part of the health care claims data set submission.(7)Rules Governing Claims Submissions.(a)Claimant and Member Records. Claims records and member records for medical and pharmacy claims shall be reported only for Massachusetts resident members who receive their benefits under a policy or plan issued in Massachusetts.(b)Claim Records. Records for medical and pharmacy claims file submissions shall be reported at the visit, service, or prescription level. The submission of the medical, and pharmacy claims shall be based upon the paid dates and not upon the dates of service associated with the claims.(c)Co-insurance/Co-payment. Co-insurance and co-payment are to be reported in two separate fields in the medical and pharmacy claims file submission.(d)Coordination of Benefit Claims. Claims where multiple parties have financial responsibility shall be included with all medical and pharmacy claims file submissions.(e)Version Number. 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.(f)Fully-processed Claim Lines. Only fully-processed claim service lines that have gone through an accounts payable run and been booked to the health plan ledger shall be included on medical and pharmacy claims data submissions.(g)Subsequent Incremental Claims. Subsequent incremental claims submissions shall include all reversal and adjustment/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: 1. Each version of a claim service line shall be enumerated sequentially with a higher line version number (MC005A); and2. Reversal versions of a claim service line shall be indicated by a claim status code = '22' (Field MC038).(h)Eligibility Records. Records for the member eligibility submission shall be reported at the individual member level so that:1. Members without medical and/or pharmacy coverage during the month reported shall be excluded;2. If a member is covered as both a subscriber and a dependent on two different policies during the same month, two records shall be submitted; and3. If a member has two contract numbers for two different coverage types, two member eligibility records shall be submitted.(i)Retroactive Changes. For the purpose of capturing retroactive changes, carriers shall not be:1. Required to resend eligibility data for a prior reporting period; and2. Considered errors in the submitted eligibility data.(j)Quarterly Submission of Data. Carriers that submit data quarterly shall:1. Include one member record for each calendar month in which a member was covered; and2. Submit one record for each reporting month in which the member was eligible for medical or pharmacy benefits for one or more days.(k)Behavioral or Mental Health Claims. All claims related to behavioral, mental health, or substance abuse shall be included in the medical claims file.(l)Medicare, Tricare or Other Supplemental Health Insurance. Claims related to Medicare, Tricare, or other supplemental health insurance policies are to be excluded unless the policies are for health care services entirely excluded by the Medicare, Tricare, or other program.
(m)Prepaid Amount. Any prepaid amounts shall be reported in a separate field in the medical and pharmacy claims file submissions.(n)Detailed File Specifications. All carriers shall use the following file specifications in their submissions: 1.Filled Fields. All fields shall be filled where applicable. Non-applicable text and data fields shall be set to null. Non-applicable integer and decimal fields shall be filled with one zero and shall not include decimal points.2.Position. All text fields shall be left justified. All integer and decimal fields shall be right justified.3.Signs. All signs (+ or -) shall appear in the left-most position of all integer and decimal fields. Over-punched signed integers or decimals shall not be utilized.4.Individual Elements and Mapping. Individual data elements, data types, field lengths, field description/code assignments, and mapping locators (UB92, HCFA 1500, ANSI X12N 270/271, 835, 837) for each file type shall conform to the file specification described in 129 CMR 2.10.