N.H. Admin. Code § Ins 4009.02 - Technical Specifications and Format for File Transfer
(a)
Carriers and third-party administrators shall use the values in the data tables
contained in Ins 4010 or the corresponding externally maintained code tables
referenced therein, and:
(1) Carriers and
third-party administrators shall submit tables and descriptions for all
non-conforming and plan-specific codes appearing in the submission;
and
(2) The department and DHHS or
its designee shall reject files with non-conforming and plan-specific codes if
explanatory information is not provided in advance of the data
submission.
(b) Carriers
and third-party administrators shall report adjustment records with the
appropriate positive or negative fields with the medical, pharmacy, and dental
file submissions. Negative values shall contain the negative sign before the
value. No sign shall appear before a positive value.
(c) When more than one version of a
fully-processed claim service line is submitted, each version of a claim
service line shall be enumerated sequentially with a higher version number
(MC005A) so that the latest version of that service line is the record with the
highest version number (MC005A) and the same claim number + line counter. Where
a version number is not available, provide the former claim number in data
element MC211. Similar requirements apply to the pharmacy claim file.
(d) All service lines associated with
fully-processed claims that have gone through an accounts payable run and been
booked to the health plan ledger shall be included on medical, pharmacy, and
dental claims data submissions. Do not include service lines:
(1) Rejected due to failed edits;
(2) That are duplicates;
(3) That are from an inactive member;
or
(4) Claims that are voided for
point of sale adjustments.
(e) Subsequent incremental claims submissions
shall include all reversal and adjustment or restated versions of previously
submitted claim service lines and all new, fully-processed service lines
associated with the claim, provided that they have paid dates in the reporting
period, and:
(1) Each version of a claim
service line shall be enumerated sequentially with a higher line version number
(MC005A); and
(2) Reversal versions
of a claim service line shall be indicated by a claim status code = '22' (Field
MC038).
(f) Capitated
service claims, sometimes known as encounter claims, for capitated services
shall be reported with all medical and pharmacy file submissions.
(g) If a claim contains service lines that do
not contain a payment because their costs are covered on another line of the
claim line, such as under a global payment arrangement, those line(s) shall be:
(1) Included in the data submission; and
(2) Clearly indicated by a claim
status code = '04' (Field MC038).
(h) Member eligibility data suppliers must
provide a data set that contains information on every covered plan member,
regardless of whether the member utilized services during the reporting period.
One record per member per month per plan is required. For example, if a member
is covered as both a subscriber and a dependent on two different policies
during the same month, 2 records must be submitted. If a member has 2 contract
numbers for 2 different coverage types, 2 member eligibility records must be
submitted.
(i) The Provider ID
(MP003) is the unique identifier for a single provider. The Provider ID should
only occur once in the table. However, in the event the same provider
delivered, and was reimbursed for, services rendered from two or more different
physical locations, then the provider data file shall contain two separate
records for that same provider reflecting each of those physical locations. One
record should be provided for each unique physical location.
(j) Carriers and third-party administrators
must use the File Submission "Preprocessor" provided by the DHHS and their
designee. The preprocessor hashes or de-identifies member and subscriber
information before the data leaves the carrier's and third-party
administrator's system.
(k)
Carriers and third party administrators must report the minimum value for fully
insured and self-insured products to support the department's supplemental
reporting reviews. The minimum value is defined as the percentage of the total
allowed costs of benefits provided under a group health plan or health
insurance coverage. The minimum value measure is outlined in Section 1302
(d)(2)(C) of the Affordable Care Act. Plans may use the HHS MV calculator
available at
http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html;
may apply a safe harbor developed by HHS and the IRS; or may, for nonstandard
plans, provide an actuarial certification from a member of the American Academy
of Actuaries.
(l) Each member
eligibility file and each medical, pharmacy, and dental claims file submission
must 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.
(m) All carriers and
third-party administrators submitting APCD files shall be provided with code in
the form of a pre-processor, which generates the files in the required format
and encrypts them prior to submission. The pre-processor code shall be provided
to all carriers and third-party administrators as a down load through a
password protected portal.
(n)
Carriers and third-party administrators may submit APCD files using the
following methods:
(1) Secure File Transport
Protocol (SFTP) is the preferred method for submitting files. This method
requires logging on to the appropriate SFTP site and sending or receiving files
using the SFTP client server. This protocol assumes that it is run over a
secure channel, that the server has already authenticated the client, and that
the identity of the client user is available to the protocol.
(2) The web upload method allows the sending
and receiving of files and messages without the installation of additional
software. This method requires internet access, a username, and password. It is
not the preferred method due to limitations on the size of the files that can
be received, but can be utilized if it is the only method available to the
healthcare claims processor.
(o) The member eligibility file, medical
claims file, pharmacy claims file, dental claims file, and provider file shall
be submitted as separate ASCII files, with variable field lengths and pipe
delimited, and shall comply with the following standards:
(1) Each record shall be terminated with a
carriage return and line feed (ASCII 13, ASCII 10).
(2) All fields shall be filled where
applicable.
(3) Text and date
fields shall be left blank when not applicable or if a value is not
available.
(4) "Blank" means do not
supply any value at all between consecutive field delimiters or last field
delimiter and line terminator. Numeric fields without a value shall be filled
with a single zero.
(5) Only one
record per row shall be submitted. No single line item of data shall contain
carriage return or line feed characters.
(6) Text fields shall not be padded with
leading or trailing spaces or tabs.
(7) Numeric fields:
a. Shall not be padded with leading
zeroes;
b. The integer portion of
numeric fields shall not be padded with leading zeros;
c. The decimal portion of numeric fields, if
required, shall be padded with trailing zeros up to the number of decimal
places indicated; and
d. Positive
values are assumed and need not be indicated as such. Negative values shall be
indicated with a minus sign and shall appear in the left-most position of all
numeric fields;
(8) Date
fields:
a. Shall be CCYYMMDD, when a value is
provided, unless otherwise indicated;
b. Shall not be padded with leading or
trailing spaces or tabs; and
c.
Shall be left blank when not applicable or if a value is not
available.
Notes
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