N.H. Admin. Code § Ins 4009.03 - Data Quality Requirements
(a) A
validation process shall be employed to ensure that the format and content of
the submitted files are valid and complete. The validation process is primarily
composed of three groups of audits, field level audits, quality audits, and
post data consolidation reasonableness, longitudinal, and relational audits, as
follows:
(1) All transmitted files are first
checked to determine if they are in the correct form and have been created
using the provided pre-processor. Field level audits are then employed to
evaluate field length and type, code values, and the percentage at which the
fields are filled;
(2) Quality
audits are employed to determine if the data submitted meet a pre-determined
level of reasonableness, for example, percent of institutional claims versus
percent of professional claims.
Default thresholds, which can be rates or ranges, have been established for approximately 200 quality audits; and
(3) After the files are loaded into staging
tables, additional audits are run on the consolidated data to identify any
global issues that would not be evident during the field and quality level
audit process. The reasonableness, longitudinal, and relational audits confirm
whether the appropriate and correct amount of data was received for the
corresponding membership volume. Examples of these audits include frequency of
individual field values, volume reconciliation, and cost or utilization
reasonableness.
(b)
Default thresholds or rates shall be applied to the field level audits for each
element in the eligibility, claims files, and provider file, and for each
quality audit. The standard acceptable threshold for field length, field type,
and data value audits is 100 percent. However, there are some fields where the
acceptable thresholds for data value will be set at less than 100 percent.
Individual field completeness thresholds are established for each data element
in the eligibility, medical, pharmacy, dental, and provider files and will vary
accordingly. All of the pre-determined default thresholds can be individually
adjusted if extenuating circumstances arise which may impact the data
completeness or content. If a file is processed and rejected for failing to
meet the field level or quality audit default thresholds, the healthcare claims
processor can request an exemption to the default threshold through a
standardized process. Exemptions or adjustments may be granted for data
variances that cannot be corrected due to systematic issues.
(c) At least 30 days prior to the initial
submission of the files, or whenever the data element content of the files is
subsequently altered, each healthcare claims processor must submit a data set
for comparison to the same validation process used for actual submissions.
Iterative rounds of testing may be necessary until the files conform to the
submission requirements. A test file should contain data covering a period of
one month.
(d) Failure to conform
to any of the submission requirements shall result in the rejection and return
of the applicable data file(s). All rejected and returned files shall be
resubmitted in the appropriate, corrected form within 10 days, or the
healthcare claims processor may request an exemption to adjust the threshold
for the failing field(s). Due to the large amount and complexity of the data
processed, it is more efficient to resubmit an entire file rather than to
correct data within the file.
Notes
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