Section 0780-01-79-.03 - HEALTH CARE CLAIMS DATA SET FILING DESCRIPTION(1) Beginning on June 1, 2010, and continuing thereafter in accordance with the submission schedule set forth in Rule 0780-01-79-.05, each health insurance issuer shall submit to the Department, or its designee, a completed health care claims data set for all residents of Tennessee. Each health insurance issuer shall also submit all health care claims processed by any sub-contractor on its behalf. The health care claims data set shall include member eligibility files (for the pharmacy benefit and the medical benefit), a medical claims file, and a pharmacy claims file.(2) The Department, or its designee, shall provide a phone number, e-mail address and mailing address of a contact person who can provide information on the status of data files submitted.(3) The Department will prepare the All Payer Claims Database Procedure Manual that will list the variables to be reported, their descriptions and reporting format, the thresholds required for a submission to be deemed complete, the method for sending data, and other information associated with data submission. The Department shall make future changes in the Procedure Manual when the Commissioner deems changes to be necessary. Reporting entities will be notified in writing by the Department of all revisions. These revisions become effective one hundred and eighty (180) calendar days following the date of written notification. At that time, failure to meet the amended requirements are subject to the penalties as prescribed by T.C.A. § 56-2-125.(4) The minimum data set for each reported member eligibility file will include the following elements, except as otherwise set forth in the All Payer Claims Database Procedure Manual: (d) Encrypted index numbers for linking procedures by patient;(e) Member's relationship to subscriber;(g) Member year of birth;(h) Member age in months; and(i) Member city, state, and zip code of residence.(5) The minimum data set for each reported medical claims file will include the following elements, except as otherwise set forth in the All Payer Claims Database Procedure Manual:(c) Payer claim control number;(e) Insured group or policy number for non-individual groups;(f) Encrypted index numbers for linking procedures by patient;(g) Member's relationship to subscriber;(i) Member year of birth; (j) Member age in months;(k) Member city, state, and zip code of residence;(m) Admission time and date;(r) Service provider number;(s) Service provider tax ID;(t) National service provider ID;(u) Type of service provider;(v) Service provider name;(w) Service provider specialty;(x) Service provider address;(bb) Admitting diagnosis;(dd) Principal diagnosis;(ff) Onset of diagnosis code;(hh) ICD-9-CM procedure codes;(ii) Current claims terminology;(jj) Health care common procedural coding system;(ll) Quantity of services performed;(ss) DRG and version number;(tt) APC and version number;(vv) Billing provider number; and(ww) Billing provider name.(6) The minimum data set for each reported pharmacy claims file will include the following elements, except as otherwise set forth in the All Payer Claims Database Procedure Manual: (c) Payer claim control number;(e) Insured group or policy number;(f) Encrypted index numbers for linking procedures by patient;(g) Member's relationship to subscriber;(i) Member year of birth; (j) Member age in months;(k) Member city, state, and zip code of residence;(l) Date service approved;(o) Pharmacy country code;(s) New prescription or refill;(t) Generic drug indicator;(u) Dispense as written code;(v) Compound drug indicator;(w) Date prescription filled;(bb) Ingredient cost/list price;(cc) Postage amount claimed;(dd) Dispensing fee paid;(gg) Prescribing physician name; and(hh) Prescribing physician number.(7) The Department, or its designee, shall also provide an electronic newsletter or other method of communicating information to health insurance issuers regarding the receipt, processing and loading of data files.(8) Health insurance issuers that are not pharmacy benefits managers and that paid a total of less than $5,000,000 for covered residents of Tennessee during the previous calendar year shall not be required to submit their health care claims data set. In calculating its paid claims, each health insurance issuer must include all health care claims for covered individuals processed by any subcontractor on its behalf.(9) Pharmacy benefit managers that paid a total of less than $1,000,000 for covered residents of Tennessee during the previous calendar year shall not be required to submit their health care claims data set. In calculating its paid claims, each pharmacy benefits manager must include all health care claims for covered individuals processed by any subcontractor on its behalf.(10) In instances where more than one entity is involved in the administration of a policy, the health insurance issuer responsible for submitting the claims data on policies shall be the one that has written the policies.(11) The Department may enter into an agreement with a third party designee to collect and process the data. The agreement shall provide that the third party designee shall be strictly prohibited from collecting direct identifiers and from releasing or using data or information obtained in its capacity as a collector and processor of the data for any purposes other than those specifically authorized by the agreement.Tenn. Comp. R. & Regs. 0780-01-79-.03
Emergency rule filed March 11, 2010; effective through September 7, 2010. Original rule filed June 10, 2010; effective September 8, 2010.Authority: 2009 Public Acts, Chapter 611 and T.C.A. § 56-2-125.