90-590-247 Me. Code R. § 2

Current through 2024-51, December 18, 2024

Section 590-247-2 - Non-Claims-Based Payments and Other Supplemental Health Care Data Set Filing Description

A.General Requirements

(1) Payors that:

a) provide medical benefits to Maine residents; and

b) are not excluded from submitting health care claims data sets under 90-590 Chapter 243 Sec 2(A)(9)(a-b); and

c) reimburse providers by means other than a Fee-for-Service model shall submit to the MHDO or its designee complete non-claims-based (NC) payment data and/or aggregated, redacted claims-based (AC) payment data, if applicable, and each data set type must be accompanied by the appropriate supporting information file in accordance with the requirements of this section. NC and AC payments are payments from payors to providers based on the definitions above. The supporting information file for an NC payment data set must describe the methods used to reimburse behavioral health care providers. The supporting information file for an AC payment data set must detail the methods used to redact the substance use disorder claims, the specific code lists that are used for procedure codes, revenue codes and diagnosis codes, provider types and any other detail on the claim that is required to select the substance use disorder redacted claim. See https://mhdo.maine.gov/portal for sample NC and AC supporting information files.

(2) The above payors shall report NC and AC payments for all plans or certify that these are not applicable via the annual registration update at https://mhdo.maine.gov/portal by February 28^th of each year. The payor(s) that administer(s) health insurance for State of Maine employees and the Maine Education Association Benefits Trust to pay for behavioral health care shall also submit separate data sets and supporting information for these two groups. It is the responsibility of the payor to amend the information, as needed, and to have an authorized user electronically sign to confirm/attest that the information provided is complete and accurate.

(3) Payors shall report NC payments for Medicare and non-Medicare Advantage (commercially insured) populations separately, combining plans as needed within those populations. It may be necessary to estimate portions of NC payments by population if amounts are paid to provider systems for plans that include both populations. Population counts encompass all eligible members, not just those associated with providers who received Non-Claims-Based Payments. Payors shall aggregate redacted claims (AC) payments by the product code identified in AC003 and report totals for each product code. The total members and total member months in the AC file include all members eligible for the product code in the performance period, not just those with redacted claims.

(4) Each payor is responsible for the submission of all information related to NC and AC payments and applicable supporting information made by any sub-contractor on its behalf.

(5) Any self-funded employee benefit plan regulated by ERISA that submits claims data under 90-590 CMR Chapter 243 Section 5, may voluntarily submit completed data sets for Maine residents regarding NC and AC payments and applicable supporting information in accordance with the provisions of this rule. Any such data shall be subject to the same laws and regulations as other MHDO data.

(6) Payors shall prepare the NC and AC files for the prior calendar year, using the most recent information available at the time of file generation with a minimum of 3 months of run-out. For the NC file, the performance period is defined to include payments made to providers in the prior calendar year. For the AC file, the performance period is retrospective and defined to include claims incurred during the prior calendar year (no limitation on paid date).

B.Data Elements and Attributes by Header Record, Trailer Record and File Type

Header Record (for All File Types)

Data Element #	Data Element Name	Type	Maximum Length	Definition/Description
HD001	Record Type	Text	2	HD
HD002	Submitter	Text	8	MHDO-assigned identifier of payor submitting data. Do not leave blank.
HD003	Payor	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage
HD004	Type of File	Text	2	AC Aggregated, Redacted Claims-Based Payments NC Non-Claims-Based Payments
HD005	Period Beginning Date	Text	6	CCYYMM
Beginning of paid period for payments
HD006	Period Ending Date	Text	6	CCYYMM
End of paid period
HD007	Record Count	Number	10	Total number of records submitted in this file
Exclude header record in count
HD008	Comments	Text	80	Submitter may use to document this submission by assigning a filename, system source, etc.

Trailer Record (for All File Types)

Data Element #	Data Element Name			Type	Maximum Length	Definition/Description
TR001	Record Type			Text	2	TR
TR002	Submitter			Text	8	MHDO-assigned identifier of payor submitting data. Do not leave blank.
TR003	Payor			Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage
TR004	Type of File		Text	2	AC Aggregated, Redacted Claims-Based Payments NC Non-Claims-Based Payments
TR005	Period Beginning Date		Text	6	CCYYMM
		Beginning of paid period for payments
TR006	Period Ending Date			Text	6	CCYYMM
		End of paid period
TR007	Data Processed			Text	8	CCYYMMDD
		Date file was created

File Type NC - Non-Claims-Based Payments

Data Element #	Data Element Name	Type	Maximum Length	Definition/Description
NC001	Submitter	Text	8	MHDO-assigned identifier of payor submitting data. Do not leave blank.
NC002	Payor	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage
NC003	Insurance Type/Product Code	Text	2	Do not code as part of this data extract AND leave blank. Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix B for standard code list. Coding should match MHDO Chapter 243 Data Element ME003. In addition, MHDO uses the following non-standard codes: HN Medicare Part C MD Medicare Part D
NC004	Performance Period Start Date	Text	6	CCYYMM Effective date of performance period. Performance period refers to payment date.
NC005	Performance Period End Date	Text	6	CCYYMM End date of performance period. Performance period refers to payment date.
NC006	Total Number of Members	Number	10	The count of individual members with any eligibility in the performance period in the population identified in NC012. No decimal places; round to nearest integer Example: 12345
NC007	Total Member Months	Number	10	The total number of member months of eligibility in the performance period in the population identified in NC012. No decimal places; round to nearest integer Example: 12345
NC008	Total Dollars Non-Claims-Based Payments	Number	10	Do not code decimal point. Two decimal places implied.
NC009	Total Dollars Non-Claims-Based Payments (Primary Care Only Portion)	Number	10	Do not code decimal point. Two decimal places implied. See definition of Primary Care above (1Q) for reporting Primary Care Only.
NC010	Total Dollars Non-Claims-Based Payments (BH/SUD Only Portion)	Number	10	Do not code decimal point. Two decimal places implied. See definition of Behavioral Health/Substance Use Disorder above (1A) and Appendix C for reporting BH/SUD Only.
NC011	Total Dollars Non-Claims-Based Payments (non-PC/non-BH/SUD)	Number	10	Do not code decimal point. Two decimal points implied.
NC012	Population	Text	2	Population to which the payments apply. CI Commercially Insured (non-Medicare Advantage) MA Medicare Advantage MC MaineCare
NC013	Payor Notes	Text	320	Clarification about the population to which the payments apply, limitations in ability to report the measure, and/or explanation of why the data is not reported.

File Type AC - Aggregated, Redacted Claims-Based Payments

Data Element #	Data Element Name	Type	Maximum Length	Definition/Description
AC001	Submitter	Text	8	MHDO-assigned identifier of payor submitting data. Do not leave blank.
AC002	Payor	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage
AC003	Insurance Type/Product Code	Text	2	Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix B for standard code list. Coding should match MHDO Chapter 243 Data Element ME003. In addition, MHDO uses the following non-standard codes: HN Medicare Part C MD Medicare Part D
AC004	Performance Period Start Date	Text	6	CCYYMM Effective date of performance period for reported Insurance Type/Product Code. Performance period refers to incurred date on redacted claims.
AC005	Performance Period End Date	Text	6	CCYYMM End date of performance period for reported Insurance Type/Product Code. Performance period refers to incurred date on redacted claims.
AC006	Total Number of Members	Number	10	The count of individual members with any eligibility in the performance period in the product code identified in AC003. No decimal places; round to nearest integer Example: 12345
AC007	Total Member Months	Number	10	The total number of member months of eligibility in the performance period in the product code identified in AC003. No decimal places; round to nearest integer Example: 12345
AC008	Total Plan-Paid Dollars SUD Claims-Based Payments Not Reported to MHDO	Number	10	Do not code decimal point. Two decimal places implied.
AC009	Total Plan-Paid Dollars on Claims/Claim Lines Sent to MHDO where SUD Codes Were Removed	Number	10	Do not code decimal point. Two decimal places implied.
AC010	Coverage Type	Text	2	Type of coverage with which payments are associated. 01 Medical 02 Pharmacy
AC011	Payor Notes	Text	320	Clarification about the population to which the payments apply, limitations in ability to report the measure, and/or explanation of why the data is not reported.

C.File-Level Specifications

1)File Formats.

(a) Each data file submission shall be an encrypted (AES-256) ASCII file, variable field length, and asterisk delimited. It 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. Each record shall be terminated with a carriage return (ASCII 13) or a carriage return line feed (ASCII 13, ASCII 10).

(b) Each supporting information file shall be a Microsoft Excel^®-compatible spreadsheet.

2)Filled Fields. All required fields shall be filled where applicable. Non-requiredtext and number fields shall be left blank when unavailable.

3)Position. All text fields are to be left justified. All numeric fields are to be right justified.

4)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.

90-590 C.M.R. ch. 247, § 2