Section 590-243-2 - Health Care Claims Data Set Filing DescriptionHealth care claims processors shall submit to the MHDO or its designee a completed health care claims data set for all members who are Maine residents in accordance with the requirements of this section. Each health care claims processor is also responsible for the submission of all health care claims processed by any sub-contractor on its behalf. The health care claims data set shall include, where applicable, a member eligibility file containing records associated with each of the claims files reported: a medical claims file, a pharmacy claims file, and/or a dental claims file. The data set shall also include supporting definition files for payor specific provider specialty codes. Third-party administrators and carriers acting as third-party administrators for self-funded employee benefit plans regulated by ERISA are not required to submit data for members in such plans.
A.General Requirements(1)Adjustment Records. Adjustment records shall be reported with the appropriate positive or negative fields with the medical, pharmacy, and dental claims file submissions. Negative values shall contain the negative sign before the value. No sign shall appear before a positive value.(2)Capitated Payment Arrangements. A capitated payment record shall be reported for every month that a member is covered under a particular payment arrangement. In addition, capitated service records shall be included in the medical claims file, if any services were provided to the member in a given month. Specific instructions for reporting capitated payments and services are provided below. For capitated payment arrangements that a payor indicates are 42 CFR Part 2 SUD-related, the payor shall provide a de-identified payment record in the capitated payments file and a de-identified capitated service record in the medical claims file for every SUD-related service provided. Associated 42 CFR Part 2 SUD-related payment and service records shall contain the same CSUM IDs. Follow the additional instructions in Appendices D-1 and G-1.(a)Payment Record. The purpose of a capitation payment summary record is to indicate the payment made to a provider each month for a member covered by a capitated service contract, regardless of whether any services were provided to the member in a given month. Only one summary claim record or line per member per month on a capitated service contract is reported in the capitated payments file, as specified in Appendix G-1.(b)Service Record. Separate service lines for each service provided under a capitated service contract shall be reported in the medical claims file, Appendix D-1, and flagged as capitated services. If no services were provided to a member on a capitated service contract in a given month, then no service lines are reported. All data fields should be treated as on any other claim, except for the following ones, which are populated or left blank as specified: Paid Amount (MC063) is '0'; Payment Arrangement Type Indicator field (MC331) is '09'; the Procedure Code (MC055) for the specific procedure or service; Service Line Dates (MC334 and MC335) for the specific procedure or service; and the appropriate Quantity (MC061) greater than or equal to '1'.(3)Claims Records. Records for the medical, pharmacy, and dental claims file submissions shall be reported at the visit, service, or prescription level. The submission of the medical, pharmacy, and dental claims is based upon the paid dates and not upon the dates of service associated with the claims.(4)Codes(a)Code Sources. Unless otherwise specified, the code sources listed and described in Appendix A are to be utilized in association with the member eligibility file and medical, pharmacy, and dental claims file submissions.(b)Specific/Unique Coding. Except for provider, provider specialty, and individual, non-bundled procedure/diagnosis codes, specific or unique coding systems shall not be permitted as part of the health care claims data set submission.(5)Co-Insurance/Co-Payment. Co-insurance and co-payment are to be reported in two separate fields in the medical, pharmacy, and dental claims file submissions.(6)Coordination of Benefits Claims. Claims where multiple parties have financial responsibility shall be included with all medical, pharmacy, and dental claims file submissions.(7)Denied Claims. Denied claims shall be excluded from all medical, pharmacy, and dental claims file submissions. When a claim contains both approved and denied service lines, only the approved service lines shall be included as part of the health care claims data set submittal.(8)Eligibility Records. Records for the member eligibility file submission shall be reported at the individual member level with one record submitted for each claim type if the product codes are different. If a member is covered as both a subscriber and a dependent on two different policies during the same month, two records must be submitted.(9)Exclusions(a)Filing. Health care claims processors that have less than $2,000,000 per calendar year of adjusted premiums or claims processed, for premiums or claims subject to required reporting, are excluded from filing health care claim data sets and from the annual registration requirements of Section 3(A).(b)Medical Claims File Exclusions. All claims related to health care policies issued for specific disease, accident, injury, hospital indemnity, disability, long-term care, student comprehensive health, or vision coverage of durable medical equipment are to be excluded from the medical claims file submission. Claims related to Medicare supplemental, Tricare supplemental, or other supplemental health insurance policies are to be excluded if the claims are not considered to be primary. If the policies cover health care services entirely excluded by the Medicare, Tricare, or other program, the claims must be submitted. Claims for dental services containing current dental terminology codes are to be excluded from the medical claims file.(c)Member Eligibility File Exclusions. Members without medical, pharmacy, and/or dental coverage during the month reported shall be excluded.(d)Pharmacy Claims File Exclusions. Pharmacy services claims generated from non-retail pharmacies that do not contain national drug codes are part of the medical claims file and not the pharmacy claims file.(10)File Format. Each data file submission shall be an encrypted (AES-256) ASCII file, variable field length, and asterisk delimited.(11)Header and Trailer Records. Each member eligibility file and each medical, pharmacy, and dental claims file submission shall 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. The header and trailer record formats are described in Appendices B-1 and B-2.(12)Non-Duplicated Claims. A carrier or health care claims processor and any contracted entity acting on its behalf shall use best efforts to ensure that duplicate claims are not submitted to the MHDO or its designee.(13)Subscriber or Member Identification(a)Social Security Numbers. Health care claims processors shall assign to each of their members a unique identification code that is the member's social security number. If a health care claims processor does not collect the social security numbers for all members, the health care claims processor shall use the number of the subscriber and then assign a discrete two-digit suffix for each member under the subscriber's contract.(b)Contract Numbers. If the subscriber's social security number is not collected by the health care claims processor, the subscriber's certificate or contract number shall be used in its place. The discrete two-digit suffix shall also be used with the certificate or contract number. The unique member identification code assigned by each health care claims processor shall remain with each subscriber or member for the entire period of coverage for that individual.
(c)Names. Health care claims processors shall submit the complete names of all subscribers and members.(d)Consistent, Inter-file Identifiers. A carrier or health care claims processor and any contracted entity acting on its behalf shall ensure that member and subscriber identifiers for the same individuals are unique and consistent across all eligibility and claims files.(e)Carrier Specific Unique Member (CSUM) ID. As an inter-file identifier, the CSUM ID should uniquely and consistently identify a member in both the medical claims and the capitated payments files. The CSUM ID shall be used when the payor indicates that related records in the medical and capitation files contain 42 CFR Part 2 SUD-related data, and other inter-file identifiers shall be left blank. For fully identifiable data records that do not contain 42 CFR Part 2-related data, the CSUM ID shall be left blank, and all other inter-file identifiers shall be populated, when available. This ID must differ from any of the other identifiers on the record and may not be derived from any of these in a manner that the original values could be determined.B.Detailed File Specifications(1)Filled Fields. All required fields shall be filled where applicable. Non-required text and number fields shall be left blank when unavailable.(2)Position. All text fields are to be left justified. All numeric fields are to be right justified.(3)Signs. Positive values are assumed and need not be indicated as such. Negative values must be indicated with a minus sign and must appear in the left-most position of all numeric fields. Signed over punch characters are not to be utilized.(4)Individual Elements and Mapping. Individual data elements, data types, field lengths, field description/code assignments, and mapping locators (UB-04, CMS 1500, ANSI X12N 270/271, 835, 837) for each file type are presented in the following appendices:(a)(i) Member Eligibility File Specifications - Appendix C-1(ii) Member Eligibility File Mapping to National Standard Formats - Appendix C-2(b)(i) Medical Claims File Specifications - Appendix D-1(ii) Medical Claims File Mapping to National Standard Formats - Appendix D-2(c)(i) Pharmacy Claims File Specifications - Appendix E-1(ii) Pharmacy Claims File Mapping to National Standard Formats - Appendix E-2(d)(i) Dental Claims File Specifications - Appendix F-1(ii) Dental Claims File Mapping to National Standard Formats - Appendix F-2(e)(i) Capitated Payments File Specifications - Appendix G-1(ii) Capitated Payments File Mapping to National Standard Formats - Appendix G-290-590 C.M.R. ch. 243, § 2