Section 0780-01-79-.04 - GENERAL REQUIREMENTS FOR HEALTH CARE CLAIMS DATA SUBMISSION(1) Capitated services claims. Claims for capitated services shall be reported with all medical and pharmacy file submissions.(2) 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.(3) 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.(4) Medical Claims File Exclusions. Claims for stand-alone insurance policies shall be excluded if the stand-alone coverage is provided for the following types of services: (h) Durable medical equipment.(5) Claims for the types of services in (4) above shall be included in the medical claims file submission if they are covered by a comprehensive medical insurance policy.(6) Behavioral or Mental Health Claims. All claims related to behavioral, mental health, or substance abuse treatment shall be included in the medical claims file.(7) Claims related to Medicare supplemental, TRICARE supplemental, or other supplemental health insurance policies are to be excluded if the plan of benefits 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.(8) Member Eligibility File Exclusions. Members without medical and/or pharmacy coverage during the month reported shall be excluded.(9) Pharmacy Claims File Exclusions. Claims for pharmacy services generated from non-retail pharmacies that do not contain national drug codes shall be included in the following files:(a) If the pharmacy claims are covered under the medical benefit they shall be included in the medical claims file and not the pharmacy claims file;(b) If the claim is covered under the prescription benefit then the claim shall be included in the pharmacy claims file;(c) If the claims are submitted as standard UB04, NSF, or ANSI 935 formatted transactions without NDC codes, the claim shall be included in the medical claims file.(10) Registration Form. (a) Each health insurance issuer, whether they are subject to the reporting requirements of Rule 0780-01-79-.05 or not, shall submit an annual registration form to the Department, or the Department's designee, every year by July 1. The form shall be in the format approved by the Commissioner.(b) At a minimum, the form shall contain the following information: 4. Information about whether the company conducts health insurance-related business;5. Number of Tennessee members covered; 6 The total amount paid by the health insurance issuer during the year on covered lives in Tennessee; and,7. Name, e-mail address and address of the person completing the form.(c) Health insurance issuers shall submit a registration form by April 1, 2010, and annually thereafter.(11) No health insurance issuer shall replace a complete data file submission more than one year after the end of the month in which the file was submitted unless it can establish exceptional circumstances for the replacement. Any replacements after this period shall be approved by the Department. Individual adjustment records shall be submitted with a monthly data file submission.Tenn. Comp. R. & Regs. 0780-01-79-.04
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, T.C.A. §§ 56-2-125 and 56-2-301.