W. Va. Code R. § 114A-1-4

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114A-1-4 - Development of Submission Manual

4.1. The Secretary shall develop and maintain an APCD Submission Manual that shall include, at a minimum, the following:

4.1.1. Specifications based on existing standards for claims transactions developed and maintained by standards development organizations, the NAHDO, or the APCD Council. Where a standard does not currently exist or is not feasible for use, a standard shall be established by the Secretary.

4.1.2. Reporting requirements related to submission of adjustment records, capitated service claims, co-insurance/co-payments, coordination of benefit claims, denied claims and exclusions.

4.1.3. File format, data elements and mapping locators, and code value sources to be submitted for each required file; and file transmission procedures, file testing, and run-out period;

4.1.4. A data submission schedule; and

4.1.5. Data quality standards, including but not limited to thresholds for determining the completeness and accuracy of a submitted file; and procedures for notifying data submitters of file rejections; procedures and timelines for correcting or resubmitting files that do not meet quality standards.

4.2. After a proposed Submission Manual has been developed, the Secretary will adopt the same as a legislative rule as defined by W. Va. Code § 29A-1-2(e), subject to the provisions of W. Va. Code § 29A-3-1et seq. and will post it online at https://dhhr.wv.gov/secretary/Pages/All-Payer-Claims-Database.aspx.

W. Va. Code R. § 114A-1-4