Or. Admin. R. 409-025-0125 - Payment Arrangement Reporting: File Layout, Format, and Coding Requirements
(1)
All mandatory reporters other than PBMs shall report payment arrangements for
all contracts sitused in Oregon. For contracts issued at the group level, the
contract is considered sitused where the contract is sold. For contracts that
are issued at the individual level, the contract is considered sitused where
the individual resides.
(2) All
data files shall include:
(a) Payment
arrangement file described in Appendix 1; and
(b) Payment arrangement control file
described in Appendix 2.
(3) The Payment arrangement file shall be
submitted using the approved layout, format, and coding described in Appendix
1, Payment Arrangement File .
(4)
The Payment arrangement control file shall be submitted using the approved
layout, format, and coding described in Appendix 2, Payment Arrangement Control
File.
(5) All data elements are
required unless specified as optional or situational in the file
layout.
(6) All required data files
shall be submitted as delimited ASCII files or the template provided by the
Authority. Both Appendix 1 and Appendix 2 are required regardless of method
used.
(7) Numeric data are positive
integers unless otherwise specified.
(a)
Negative values are allowed for quantities, charges , payment, copayment,
coinsurance, deductible, and prepaid amount.
(b) Negative values shall be preceded by a
minus sign.
(8) All data
values shall pass edit checks and validations implemented by the Authority or
the Authority's data vendor .
(a) Data vendor
may perform quality and edit checks on data file submissions. If data files do
not pass data vendor edit checks or validation, mandatory reporters must make
corrections and resubmit data. Mandatory reporters must submit corrected data
that passes all edit checks and validations or receive an approved exemption
within 14 calendar days of notification by the Authority or the Authority's
data vendor of the error.
(b)
Mandatory reporters must participate in efforts to validate and check the
quality of current and historic APAC data, as prescribed and requested by the
Authority.
(A) The Authority may request from
any mandatory reporter information from their internal records that is
reasonably necessary to validate and check the quality of APAC data. This
information may include, but is not limited to, aggregated number of enrolled
members, number of claims and claim lines, charges , allowed amounts, paid
amounts, coinsurance, copayments, premiums, number of visits to primary care,
emergency department, inpatient, and other health care treatment settings, and
number of prescriptions.
(B)
Mandatory reporters shall provide the aggregated information within 30 days of
the Authority's request or request an extension .
(C) If the Authority finds errors through
edit checks or validation, mandatory reporters must make corrections and
resubmit data or receive an approved extension or exemption within 30 days or
at the next regularly scheduled submission due date.
(9) These submissions shall meet
the requirement that all Coordinated Care Organizations report primary care
services to the Oregon Health Authority each year through 2027 for the prior
calendar year's data. The findings generated from these submissions will be
presented to the legislature no later than February 1 of each year through
2028.
Notes
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 442.373
Statutes/Other Implemented: ORS 442.373 & ORS 442.372
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(1) All mandatory reporters other than PBMs shall report payment arrangements for all contracts sitused in Oregon. For contracts issued at the group level, the contract is considered sitused where the contract is sold. For contracts that are issued at the individual level, the contract is considered sitused where the individual resides.
(2) All data files shall include:
(a) Payment arrangement file described in Appendix 1; and
(b) Payment arrangement control file described in Appendix 2.
(3) The Payment arrangement file shall be submitted using the approved layout, format, and coding described in Appendix 1, Payment Arrangement File.
(4) The Payment arrangement control file shall be submitted using the approved layout, format, and coding described in Appendix 2, Payment Arrangement Control File.
(5) All data elements are required unless specified as optional or situational in the file layout.
(6) All required data files shall be submitted as delimited ASCII files or the template provided by the Authority. Both Appendix 1 and Appendix 2 are required regardless of method used.
(7) Numeric data are positive integers unless otherwise specified.
(a) Negative values are allowed for quantities, charges, payment, copayment, coinsurance, deductible, and prepaid amount.
(b) Negative values shall be preceded by a minus sign.
(8) All data values shall pass edit checks and validations implemented by the Authority or the Authority's data vendor.
(a) Data vendor may perform quality and edit checks on data file submissions. If data files do not pass data vendor edit checks or validation, mandatory reporters must make corrections and resubmit data. Mandatory reporters must submit corrected data that passes all edit checks and validations or receive an approved exemption within 14 calendar days of notification by the Authority or the Authority's data vendor of the error.
(b) Mandatory reporters must participate in efforts to validate and check the quality of current and historic APAC data, as prescribed and requested by the Authority.
(A) The Authority may request from any mandatory reporter information from their internal records that is reasonably necessary to validate and check the quality of APAC data. This information may include, but is not limited to, aggregated number of enrolled members, number of claims and claim lines, charges, allowed amounts, paid amounts, coinsurance, copayments, premiums, number of visits to primary care, emergency department, inpatient, and other health care treatment settings, and number of prescriptions.
(B) Mandatory reporters shall provide the aggregated information within 30 days of the Authority's request or request an extension.
(C) If the Authority finds errors through edit checks or validation, mandatory reporters must make corrections and resubmit data or receive an approved extension or exemption within 30 days or at the next regularly scheduled submission due date.
(9) These submissions shall meet the requirement that all Coordinated Care Organizations report primary care services to the Oregon Health Authority each year through 2027 for the prior calendar year's data. The findings generated from these submissions will be presented to the legislature no later than February 1 of each year through 2028.
Notes
To view attachments referenced in rule text, click here to view rule.
Statutory/Other Authority: ORS 442.373
Statutes/Other Implemented: ORS 442.373 & ORS 442.372