Statutory Authority: RSA 400-A:15 I; RSA 420-G:14
PART Ins 4001 PURPOSE AND SCOPE
Ins 4001.01 Purpose
and Scope. This chapter contains the
provisions for submission of health care claims data sets from third-party
payers, third-party administrators, and carriers and health care claims
processors that provide only administrative services for a plan sponsor.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09
PART Ins 4002 DEFINITIONS
Ins 4002.01 Definitions. Unless the context indicates otherwise, the
following words and phrases shall have the following meanings:
(a)
"Address" means street address, post office box numbers,
apartment numbers, e-mail addresses, web universal resource locator (URL) and
internet protocol (IP) address number.
(b) "Bank
account" means any checking, savings, certificate of deposit, or any
account utilized for the payment of third parties.
(c) "Capitated
services" means services rendered by a provider through a contract in which
payment are based upon a fixed dollar amount for each member on a monthly
basis.
(d)
"Carrier" means any entity subject to the insurance laws and
rules of this state, or subject to the jurisdiction of the commissioner that
contracts or offers to provide, deliver, arrange for, pay for or reimburse any
of the costs of health services, and includes an insurance company, a health
maintenance organization, a nonprofit health services corporation, third party
administrator or any other entity arranging for or providing health coverage.
(e) "Clinical
data" means health care claims and information about health care claims
for services delivered in hospitals or other setting.
(f)
"Co-insurance" means the percentage a member pays toward the
cost of a covered service.
(g)
"Commissioner" means the insurance commissioner.
(h)
"Confidential agency data" means data collected or produced by
the department that:
(1) Has not been revealed to the general public;
(2) Can be withheld from public access without
violation of RSA 91-A; and
(3) Shall not, in the opinion of the
commissioner, be released.
(i)
"Confidential clinical data" means data provided to the
department that:
(1) Has not been revealed to the general public;
and
(2) Relates to provision of medical or other
services to a specific individual.
(j)
"Confidential financial data" means data provided to the
department that:
(1) Has not been revealed to the general public;
and
(2) Would directly result in the data provider
being placed at a competitive economic disadvantage.
(k) "Consumer
assessment of health plans survey" or "CAHPS" (CAPHS®) means a
survey tool that measures consumer experience with carriers and health care
claims processors.
(l)
"Co-payment" means the fixed dollar amount a member pays to a
health care provider at the time a covered service is provided or the full cost
of a service when that is less than the fixed dollar amount.
(m) "Data
submission tool (DST)" means the NCQA provided tool for submitting HEDIS
data.
(n) "Department
(NHID)" means the
(o)
"Designee" means an entity with which the department and/or
the department of health and human services have entered into an arrangement
pursuant to which the entity performs data management and collecting functions,
and under which the entity is strictly prohibited from using or releasing the
information and data obtained in such a capacity for any purposes other than
those specified in the agreement.
(p) "DHHS"
means the department of health and human services.
(q) "Direct
identifier" means any information, other than case or code numbers used to
create anonymous or encrypted data, that plainly discloses the identity of an
individual, including:
(1) Names;
(2) Postal address information other than town or
city, state and zip code;
(3) Telephone and fax numbers;
(4) Electronic mail addresses;
(5) Social security numbers;
(6) Vehicle identifiers and serial numbers;
(7) Personal internet ID addresses and URLs;
(8) Biometric identifiers, including finger and
voice prints; and
(9) Personal photographic images.
(r)
"Disclosure" means, with respect to clinical or financial data,
to communicate information to a person not already in possession of that
information or to use information for a purpose not originally authorized.
(s)
"Encryption" means a method by which the true value of data
has been disguised in order to prevent the identification of persons or groups,
and which does not provide the means for recovering the true value of the data.
(t)
"Family" means spouse, children, parents, siblings, and legal
guardians.
(u) "Financial
data" means information collected that includes, but is not limited to:
(1) Costs of operation;
(2) Revenues;
(3) Assets;
(4) Liabilities;
(5) Fund balances;
(6) Other income;
(7) Rates;
(8) Charges; and
(9) Units of services.
(v) "Health
care claims data" means information consisting of, or derived directly
from, member eligibility, medical claims, and pharmacy claims, files submitted
by health care claims processors.
"Health care data" does not include analysis, reports, or
studies containing information from health care claims data sets, if those
analyses, reports, or studies have already been released in response to another
request for information or as part of a general distribution of public
information by the department.
(w) "Health
care claims processor" means a third-party payer, third-party
administrator, or carrier that provides administrative services for a plan
sponsor.
(x) "Health
care practitioner" means physicians and all others certified, registered
or licensed in the healing arts, including, but not limited to:
(1) Nurses;
(2) Podiatrists;
(3) Optometrists;
(4) Pharmacists;
(5) Chiropractors;
(6) Physical therapists;
(7) Dentists;
(8) Psychologists; and
(9) Physicians' assistants.
(y)
"HEDIS®" means the set of performance measures in the managed
care industry that were developed and are maintained by the National Committee
for Quality Assurance (NCQA) covering various areas of measurement from general
health plan information to utilization rates.
(z)
"Hospital" means a licensed acute or specialty care
institution.
(aa)
"Insured" means an individual in whose name an insurance
policy is carried.
(ab) "Medical
claims file" means a data file composed of service level remittance
information for all non-denied adjudicated claims for each billed service
including, but not limited to:
(1) Member demographics;
(2) Provider information;
(3) Charge/payment information; and
(4) Clinical diagnosis/procedure codes.
(ac)
"Member" means the subscriber and any spouse and/or dependent
who is covered by the subscriber's policy.
(ad) "Member
eligibility file" means a data file containing demographic information for
each individual member eligible for medical or pharmacy benefits for one or
more days of coverage at any time during the reporting month.
(ae) "National
Committee for Quality Assurance" or "NCQA" means the private,
not-for-profit organization that assesses and reports on the quality of the
nation's managed care plans through an accreditation and performance
measurement program, including quality of care, member satisfaction, access and
customer service.
(af)
"Non-hospital provider" means a provider of health care
services other than a hospital.
(ag) "Pharmacy
claims file" means a data file containing service level remittance
information from all non-denied adjudicated claims for each prescription
including, but not limited to:
(1) Member demographics;
(2) Provider information;
(3) Charge/payment information; and
(4) National drug codes.
(ah) "Plan
sponsor" means any persons, other than an insurer, who establishes or
maintains a plan covering residents of the state of New Hampshire, including,
but not limited to, plans established or maintained by employers or jointly by
one or more employers and one or more employee organizations, committee, joint
board of trustees or other similar group of representatives of the parties that
establish or maintain the plan.
(ai) "Prepaid
amount" means the fee for the service equivalent that would have been paid
by the health care claims processor for a specific service if the service had
not been capitated.
(aj)
"Privileged medical information" means information other than
hospital, non-hospital health care facility, or health care claims data that
identifies individual patients and that is derived from communications that
were:
(1) Made for the purpose of diagnosis or
treatment among a provider or health care, persons assisting the provider or
patient, and a patient;
(2) Made for the purpose of payment of health
care services among a provider of health care, a health care claims processor,
and a patient;
(3) Not intended to be disclosed except to
persons necessary to transmit or record the communication and persons
participating in the diagnosis, treatment or payment; and
(4) Not previously disclosed to the general
public.
(ak)
"Provider" means a health care facility, health care
practitioner, health product manufacturer, health product vendor or pharmacy.
(al)
"Release" means to make data or information available for
inspection and copying to persons other than the data provider.
(am)
"Subscriber" means the certificateholder.
(an) "Tab and
banner format" means the NCQA methodology for submitting CAHPS survey
data.
(ao) "Third
party administrator" means any persons licensed by the department, that,
on behalf of a plan sponsor, health care services plan, nonprofit hospital or
medical service organization, health maintenance organization or insurer,
receives or collects charges, contributions or premiums for, or adjusts or
settles claims on residents of the state.
(ap) "Third
party payer" means a state agency that pays for health care services or a
health insurer, nonprofit hospital, medical services organization, or managed
care organization licensed in the state of
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09
PART Ins 4003 REPORTING REQUIREMENTS FOR ALL LICENSED
CARRIERS AND HEALTH CARE CLAIMS PROCESSORS
Ins 4003.01 HEDIS
Reporting Requirements. Each carrier
that collects data for use in calculating health plan employer data and information
set managed care measures shall report those data that are collected and that
pertain to members or subscribers who receive their benefits under a policy or
plan issued in
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09
Ins 4003.02 CAHPS
Reporting Requirements. Each carrier
that collects CAHPS survey data shall report those data collected that are
collected and that pertain to members or subscribers who receive their benefits
under a policy or plan issued in
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09
PART Ins 4004 HEALTH CARE CLAIMS DATA SET FILING
Ins 4004.01 Data
Set Filing Description.
(a) Beginning on
June 1, 2005, and continuing thereafter in accordance with the submission
schedule set forth in Ins 4005.05, each carrier and each health care claims
processor shall submit to the NHID and to the DHHS, or their designee, a
completed health care claims data set for all residents of New Hampshire and
for all members who receive services under a policy issued in New
Hampshire. Data submission requirements
apply to members that meet either criterion.
A policy that is issued in
(b) The NHID and the
DHHS, or their designee, shall provide a phone number, e-mail address and
mailing address of a contact person who can provide information on the status
of data files submitted.
(c) The NHID and the
DHHS shall also provide an electronic newsletter or other method of communicating
information to plans and carriers and health care claims processors regarding
the receipt, processing and loading of data files.
(d) Third party
payers that write less than $250,000 in accident and health insurance premiums
in
(e) Third party
administrators that administer health insurance plans covering fewer than 200
(f) In instances
where more than one entity is involved in the administration of a policy, the
health carrier shall be responsible for submitting the claims data on policies
that it has written, and the third party administrator shall be responsible for
submitting claims data on self-insured plans that it administers.
(g) The NHID and/or
the DHHS may enter into an agreement with a third party designee to collect and
process the data. The agreement shall
provide that the third party designee shall be strictly prohibited from
collecting any social security numbers or direct identifiers and from releasing
or using data or information obtained in its capacity as a collector and
processor of the data for any purposes other than those specifically authorized
by the agreement. The agreement shall
provide that the designee shall transmit all data that it collects and
processes to the NHID and the DHHS.
Source. #8279, eff 2-3-05; ss by #9500, eff 7-6-09
Ins 4004.02 General
Requirements for Data Submission.
(a) Adjustment
records. Carriers and health care claims
processors shall report adjustment records with the appropriate positive or
negative fields with the medical and pharmacy file submissions. Negative values shall contain the negative
sign before the value. No sign shall
appear before a positive value.
(b) Capitated
services claims. Claims for capitated
services shall be reported with all medical and pharmacy file submissions.
(c) Data
fields. Carriers and health care claims
processors shall make every effort to report the data fields outlined in these
requirements if the data field is present in any part of their data
systems. Carriers shall submit data
fields even in circumstances where the data is integrated from multiple
systems. However, if a field is not
available for submission, or cannot be derived reliably from other information
available on the carrier's transaction system, the health plan shall notify the
NHID and the DHHS, or their designee, and shall identify the field that cannot
be provided. After notification, the
carrier shall not be required to populate that data field in its reports. The carrier shall report on an annual basis
its efforts to populate this field, and the expected date as of which this
field will be available, if there is such a date.
(d) Claimant and
member records. Claims records and
member records for medical and pharmacy claims shall be reported if either
selection criteria are met: enrollees
that are residents of
(e) 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.
(f) Code
sources. Unless otherwise specified, the
following code sources are to be utilized in association with the member
eligibility file and medical and pharmacy claims files submissions. The required source codes are found in
Appendix I. If codes specified in these
rules are updated by the code source, whether the update includes new codes or
a modification of descriptions, the changes provided by the source preempt the
definitions and descriptors provided in these rules.
(g) Member
Identification Codes. Carriers and
health care claims processors shall assign, according to a standard algorithm provided
by the NHID and the DHHS, or their designee, a unique identification code to
each of their members that is the member's encrypted social security
number. If a health care claims
processor does not collect the social security numbers for its members, the
health care claims processor shall encrypt the social security number of the
subscriber and assign a discrete two digit suffix for each member under the
subscribers contract using the following criteria:
(1) If the subscriber's social security number is
not collected by the health care claims processor, an encrypted version of the
subscriber's certificate or contract number shall be used in its place.
(2) The NHID shall provide a
standard encrypted algorithm.
(3) The discrete two digit suffix shall also be
used with the encrypted certificate or contract number.
(4) The encrypted certificate or contract number
with the two digit suffix shall be at least 11, but no more than 30 characters
in length.
(5) For encrypting the social security number of
the member/subscriber, the carrier and health care claims processor shall
utilize a standard methodology provided by the NHID.
(6) The unique member identification code
assigned by each carrier and health care claims processor shall remain with
each member for the entire period of coverage for that individual.
(7) 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.
(8) Co-insurance/Co-payment. Co-insurance and co-payment are to be
reported in 2 separate fields in the medical and pharmacy claims file
submission.
(9) Coordination of Benefit Claims. Claims where multiple parties have financial
responsibility shall be included with all medical and pharmacy claims file
submissions.
(10) Version Number. 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.
(11) Fully-Processed Claim Lines: Only fully-processed claim service lines that
have gone through an accounts payable run and been booked to the health plan
ledger shall be included on medical and pharmacy claims data submissions.
(12) Denied Claims. Denied claims shall be excluded from all
medical and pharmacy claims file submissions whenever possible so that when a
claim contains both fully-processed paid service lines and partially processed
or denied service lines, an effort shall be made to include only the
fully-processed, paid service lines as part of the health care claims data set
submittal.
(13) Subsequent Incremental Claims. Subsequent incremental claims submissions
shall include all reversal and adjustment/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:
a. Each version of a claim service line shall be
enumerated sequentially with a higher line version number (MC005A); and
b. Reversal versions of a claim service line
shall be indicated by a claim status code = '22' (Field MC038).
(14) Global Payment Arrangements. If a claim contains service lines that have
been denied because their costs are covered on another line of the claim line,
such as under a global payment arrangement, those denied line(s) shall be:
a. Included in the data submission; and
b. Clearly indicated by a claim status code =
'04' (Field MC038).
(15) Exclusions of Denied Claims or Service
Lines. Carriers and health care claims
processors that are unable to exclude denied claims or service lines without
compromising the completeness of their claims submission may submit all
versions of fully-processed paid and denied claims service lines, provided that
lines and versions thereof are clearly indicated by a claim status code = '04',
and the line version number is sequentially noted on any reversal and
adjustment versions of those lines to clearly indicate the order in which all
changes to these lines were processed.
(16) Eligibility Records. Records for the member eligibility submission
shall be reported at the individual member level so that:
a. If a member is covered as both a subscriber
and a dependent on 2 different policies during the same month, 2 records shall
be submitted; and
b. If a member has 2 contract numbers for 2
different coverage types, 2 member eligibility records shall be submitted.
(17) Retroactive Charges. For the purpose of capturing retroactive
charges, carriers and health care claims processors shall not be:
a. Required to resend eligibility data for a
prior reporting period; and
b. Considered errors in the submitted
eligibility data.
(18) Quarterly Submission of Data. Carriers and health care claims processors
that submit data quarterly shall:
a. Include one member record for each calendar
month in which a member was covered; and
b. Submit one record for each reporting month in
which the member was eligible for medical or pharmacy benefits for one or more
days.
(19) 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:
a. Specific disease;
b. Accident;
c. Injury;
d. Hospital indemnity;
e. Disability;
f. Long-term care;
g. Vision coverage; or
h. Durable medical equipment.
(20) Claims for the types of services in (19)
above shall be included in the medical claims file submission if they are
covered by a comprehensive medical insurance policy.
(21) Behavioral or Mental Health Claims. All claims related to behavioral or mental health shall be included in
the medical claims file.
(22) Medicare, Tricare or Other Supplemental
Health Insurance. Claims related to Medicare, Tricare, or other supplemental
health insurance policies are to be excluded unless the policies are for health
care services entirely excluded by the Medicare, Tricare, or other program.
(23) Member Eligibility File Exclusions. Members without medical and/or pharmacy
coverage during the month reported shall be excluded.
(24) Pharmacy Claims File Exclusions. Claims for pharmacy services claims 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 UB92,
NSF, or ANSI 935 formatted transactions without NDC codes, the claim shall be included
in the medical claims file.
(h) File
Format. Each data file submission shall
be an ASCII file, variable field length, and asterisk delimited. When asterisks are used in any field values,
they shall be enclosed in double quotes.
(i) Header and
Trailer Records. Each member eligibility
file and each medical claims file, and pharmacy claims file that is submitted
shall contain a header record and a trailer record. The "Header record" means the first
record of each separate file that is submitted and the "Trailer
record" means the last record of each submitted file. The header and trailer record format shall
conform to the following record specifications:
(1) Record Specifications. Health care claims processors and carriers
shall use the following record specifications in submitting their claims
records:
a. The file header record layout shall be
submitted using the following data elements:
1. HD001.
This element is named "record type". The data type of this element is text. Its length is 2.
2. HD002.
This element is named "payer".
The data type of this element is text.
Its length is 6. Carriers and
health care claims processors shall code according to payer submitting
payments, NHID submitter code.
3. HD003.
This element is named "National Plan ID". The data type of this element is text. Its length is 30. Carriers and health care claims processors
shall code according to CMS National Plan ID.
4. HD004.
This element is named "type of file". The data type of this element is text. Its length is 2. Carriers and health care claims processors
shall code according to ME member eligibility, MC medical claims, PC pharmacy.
5. HD005.
This element is named "period beginning date". The data type of this element is
integer. Its length is 6. Carriers and health care claims processors
shall code according to CCYYMM, beginning of paid period for claims, beginning
of month covered for eligibility.
6. HD006.
This element is named "period ending date". The data type of this element is
integer. Its length is 6. Carriers and health care claims processors
shall code according to CCYYMM, end of paid period for claims, end of month
covered for eligibility.
7. HD007.
This element is named "record count". The data type of this element is
integer. Its length is 10. Carriers and health care claims processors
shall code according to total number of records submitted in this file, with
the header and trailer record excluded from the count.
8. HD008.
This element is named "comments". The data type of this element is text. Its length is 80. Carriers and health care claims processors
shall code according to their own option.
b. The file header record layout shall conform
to the following:
Table 4000.1 File Header
Record Layout
Data
Element #
|
Element
|
Type
|
Maximum Length |
Description/Codes/Sources
|
|
|
|
|
|
|
|
HD001 |
Record Type |
Text |
2 |
HD |
|
|
|
|
|
|
|
HD002 |
Payer |
Text |
6 |
Payer
submitting payments |
|
|
|
|
|
NHID Submitter
Code |
|
|
|
|
|
|
|
HD003 |
National Plan ID |
Text |
30 |
CMS National
Plan ID |
|
|
|
|
|
|
|
HD004 |
Type of File |
Text |
2 |
NH Member
Eligibility |
|
|
|
|
|
MC Medical
Claims |
|
|
|
|
|
PC Pharmacy
Claims |
|
|
|
|
|
|
|
HD005 |
Period Beginning Date |
Integer |
6 |
CCYYMM |
|
|
|
|
|
Beginning of
paid period for claims |
|
|
|
|
|
Beginning of
month covered for eligibility |
|
|
|
|
|
|
|
HD006 |
Period Ending Date |
Integer |
6 |
CCYYMM |
|
|
|
|
|
End of paid
period for claims |
|
|
|
|
|
End of month
covered for eligibility |
|
|
|
|
|
|
|
HD007 |
Record Count |
Integer |
10 |
Total number
of records submitted in this file |
|
|
|
|
|
|
|
HD008 |
Comments |
Text |
80 |
Submitted may
use to document this submission by assigning a filename, system source, etc. |
c. The trailer header record layout shall be
submitted using the following data elements:
1. TR001.
This element is named "record type". The data type of this element is text. Its length is 2.
2. TR002.
This element is named "payer".
The data type of this element is text.
Its length is 6. Carriers and
health care claims processors shall code according to payer submitting
payments, NHID submitter code.
3. TR003.
This element is named "National Plan ID". The date type of this element is text. Its length is 30. Carriers and health care claims processors
shall code according to CMS National Plan ID.
4. TR004.
This element is named "type of file". The data type of this element is text. Its length is 2. Carriers and health care claims processors
shall code according to ME member eligibility, MC medical claims, PC pharmacy
claims.
5. TR005.
This element is named "period beginning date". The data type of this element is
integer. Its length is 6. Carriers and health care claims processors
shall code according to CCYYMM, beginning of paid period for claims, beginning
of month covered for eligibility.
6. TR006.
This element is named "period ending date". The date type of this element is
integer. Its length is 6. Carriers and health care claims processors
shall code according to CCYYMM, end of paid period for claims, end of month
covered for eligibility.
7. TR007.
This element is named "date processed". The data type of this element is date. Its length is 8. Carriers and health care claims processors
shall code according to CCYYMMDD, the date the file was created.
d. The trailer record layout shall conform to
the following:
Table 4000.2 Trailer Record
Layout
Data
Element #
|
Element
|
Type
|
Maximum Length |
Description/Codes/Sources
|
|
|
|
|
|
|
|
TR001 |
Record
Type |
Text |
2 |
TR |
|
|
|
|
|
|
|
TR002 |
Payer |
Text |
6 |
Payer
submitting payments |
|
|
|
|
|
NHID Submitter
Code |
|
|
|
|
|
|
|
TR003 |
National
Plan ID |
Text |
30 |
CMS National
Plan ID |
|
|
|
|
|
|
|
TR004 |
Type
of File |
Text |
2 |
NH Member
Eligibility |
|
|
|
|
|
MC Medical
Claims |
|
|
|
|
|
PC Pharmacy
Claims |
|
|
|
|
|
|
|
TR005 |
Period
Beginning Date |
Integer |
6 |
CCYYMM |
|
|
|
|
|
Beginning of
paid period for claims |
|
|
|
|
|
Beginning of
month covered for eligibility |
|
|
|
|
|
|
|
TR006 |
Period
Ending Date |
Integer |
6 |
CCYYMM |
|
|
|
|
|
End of paid
period for claims |
|
|
|
|
|
End of month
covered for eligibility |
|
|
|
|
|
|
|
TR007 |
Date
Processed |
Date |
8 |
CCYYMMDD |
|
|
|
|
|
Date file was
created |
(j) Prepaid
Amount. Any prepaid amounts shall be
reported in a separate field in the medical and pharmacy claims file
submissions.
(k) Detailed File
Specifications. All carriers and health
care claims processors shall use the following file specifications in their
submissions:
(1) Filled Fields. All fields shall be filled where
applicable. Non-applicable text and date
fields shall be set to null.
Non-applicable integer and decimal fields shall be filled with one zero
and shall not include decimal points.
(2) Position.
All text fields shall be left justified.
All integer and decimal fields shall be right justified.
(3) Signs.
All signs (+ or -) shall appear in the left-most position of all integer
and decimal fields. Over-punched signed
integers or decimals shall not be utilized.
(4) Individual Elements and Mapping. Individual data elements, data types, field
lengths, field description/code assignments, and mapping locators (UB92, HCFA
1500, ANSI X12N 270/271, 835, 837) for each file type shall conform to the
following file specifications:
a. The specifications for the member eligibility
file shall be as follows:
1. ME001.
This element is named "payer".
The data type of this element is text.
Its length is 8. Carriers and
health care claims processors shall code according to payer submitting
payments, NHID submitter code.
2. ME002.
This element is named "National Plan ID". The data type of this element is text. Its length is 30. Carriers and health care claims processors
shall code according to CMS National Plan ID.
3. ME003.
This element is named "insurance type code/product". The data type of this element is text. Its length is 2. Carriers and health care claims processors
shall code according to the following:
Table 4000.3 Insurance Type
Code/Product
|
Code |
Description |
|
|
|
|
12 |
Medicare Secondary Working
Aged Beneficiary or Spouse with Employer Group Health Plan |
|
|
|
|
13 |
Medicare Secondary
End-Stage Renal Disease Beneficiary in the 12-month coordination period with
an Employer Group Health Plan |
|
|
|
|
14 |
Medicare Secondary
No-Fault Insurance including Insurance in which Auto is Primary |
|
|
|
|
15 |
Medicare Secondary
Workers' Compensation |
|
|
|
|
16 |
Medicare Secondary Public
Health Service or Other Federal Agency |
|
|
|
|
41 |
Medicare Secondary Black
Lung |
|
|
|
|
42 |
Medicare Secondary
Veterans' Administration |
|
|
|
|
43 |
Medicare Secondary
Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) |
|
|
|
|
47 |
Medicare Secondary Other
Liability Insurance is Primary |
|
|
|
|
AP |
Auto Insurance Policy |
|
|
|
|
CP |
Medicare Conditionally
Primary |
|
|
|
|
D |
Disability |
|
|
|
|
DB |
Disability Benefits |
|
|
|
|
EP |
Exclusive Provider
Organization |
|
|
|
|
HM |
Health Maintenance
Organization (HMO) |
|
|
|
|
HN |
Health Maintenance
Organization (HMO) Medicare Advantage |
|
|
|
|
HS |
Special Low Income
Medicare Beneficiary |
|
|
|
|
IN |
Indemnity |
|
|
|
|
LC |
Long Term Care |
|
|
|
|
LD |
Long Term Policy |
|
|
|
|
LI |
Life Insurance |
|
|
|
|
LT |
Litigation |
|
|
|
|
MA |
Medicare Part A |
|
|
|
|
MB |
Medicare Part B |
|
|
|
|
MD |
Medicare Part D |
|
|
|
|
MC |
Medicaid |
|
|
|
|
MH |
Medigap Part A |
|
|
|
|
MI |
Medigap Part B |
|
|
|
|
MP |
Medicare Primary |
|
|
|
|
PR |
Preferred Provider
Organization (PPO) |
|
|
|
|
PS |
Point of Service (POS) |
|
|
|
|
QM |
Qualified Medicare
Beneficiary |
|
|
|
|
SP |
Supplemental Policy |
|
|
|
|
WC |
Workers' Compensation |
4. ME004.
This element is named "year".
The data type of this element is integer. Its length is 4. Carriers and health care claims processors
shall code according to the year for which eligibility is reported in this
submission.
5. ME005.
This element is named "month".
The date type of this element is integer. Its length is 2. Carriers and health care claims processors
shall code according to the month for which eligibility is reported in this
submission.
6. ME006.
This element is named "insured group or policy number". The data type of this element is text. Its length is 50. Carriers and health care claims processors
shall code according to the group or policy number and not the number that
uniquely identifies the subscriber.
7. ME007.
This element is named "coverage level code". The data type of this element is text. Its length is 3. Carriers and health care claims processors
shall code according to the benefit coverage level:
(i) CHD Children Only;
(ii) DEP Dependents Only;
(iii) ECH Employee and Children;
(iv) EMP Employee Only;
(v) ESP Employee and Spouse;
(vi) FAM Family;
(vii) IND Individual;
(viii) SPC Spouse and Children; and
(ix) SPO Spouse Only.
8. ME008.
This element is named "encrypted subscriber social security
number". The data type of this
element is text. Its length is 128. Carriers and health care claims processors
shall code according to the encrypted subscriber's social security number. Carriers and health care claims processors
shall set as null if unavailable.
9. ME009.
This element is named "plan specific contact number". The data type of this element is text. Its length is 128. Carriers and health care claims processors
shall code according to the encrypted plan assigned contract number. Carriers and health care claims processors
shall set as null if contract number is the same as the subscriber's social
security number.
10. ME010.
This element is named "member suffix or sequence number". The data type of this element is integer. Its length is 2. Carriers and health care claims processors
shall code according to the unique number of the member within the contract.
11. ME011.
This element is named "member identification code". The data type of this element is text. Its length is 128. Carriers and health care claims processors
shall code according to the encrypted member's social security number, and
carriers and health care claims processors shall set as null if the social
security number is unavailable.
12. ME012.
This element is named "individual relationship code". The data type of this element is
integer. Its length is 2. Carriers and health care claims processors
shall code according to the member's relationship to the insured as shown on
the following:
Table 4000.4 Individual Relationship Code
|
Code |
Description |
|
|
|
|
01 |
Spouse |
|
|
|
|
18 |
Self/Employee |
|
|
|
|
19 |
Child |
|
|
|
|
21 |
Unknown |
|
|
|
|
34 |
Other Adult |
13. ME013.
This element is named "member gender". The data type of this element is text. Its length is one. Carriers and health care claims processors
shall code according to:
(i) M = Male;
(ii) F = Female; and
(iii) U = Unknown.
14. ME014.
This element is named "member date of birth". The data type of this element is date. Its length is 8. Carriers and health care claims processors
shall code according to CCYYMMDD.
15. ME015.
This element is named "member city name". The data type of this element is text. Its length is 30. Carriers and health care claims processors
shall code according to the city location of the member.
16. ME016.
This element is named "member state or province". The data type of this element is text. Its length is 2. Carriers and health care claims processors
shall code as defined by the U.S. Postal Service.
17. ME017.
This element is named "member zip code". The data type of this element is text. Its length is 11. Carriers and health care claims processors
shall code according to ZIP code of member, which may include non-US
codes. Carriers and health care claims
processors shall not include the dash in the coding.
18. ME018.
This element is named "medical coverage". The data type of this element is text. Its length is one. Carriers and health care claims processors
shall code according to:
(i) Y = Yes; and
(ii) N = No.
19. ME019. This element is named "prescription drug
coverage". The data type of this
element is text. Its length is one. Carriers and health care claims processors
shall code according to:
(i) Y = Yes; and
(ii) N = No.
20. ME020.
This element is named "dental coverage". The data type is text, with a length of one. Carriers and health care claims processors
shall code according to:
(i) Y = Yes; and
(ii) N - No
21. ME021.
This element is named "Race 1". The data type of this element is text. Its length is 6. Carriers and health care claims processors
shall code according to:
(i) R1 = American Indian/Alaskan Native;
(ii) R2 - Asian;
(iii) R3 = Black/African American;
(iv) R4 = Native Hawaiian or other Pacific
Islander;
(v) R5 = White;
(vi) R9 = Other Race; and
(vii) UNKNOW = Unknown/Not Specified
22. ME022.
This element is named "Race 2". The data type of this element is text. Its length is 6. Carriers and health care claims processors
shall code according to:
(i) R1 = American Indian/Alaskan Native;
(ii) R2 - Asian;
(iii) R3 = Black/African American;
(iv) R4 = Native Hawaiian or other Pacific
Islander;
(v) R5 = White;
(vi) R9 = Other Race; and
(vii) UNKNOW = Unknown/Not Specified
23. ME023.
This data element is a placeholder.
24. ME024.
This element is named "Hispanic indicator". The data type of this element is text. Its length is one. Carriers shall code according to:
(i) Y = Yes Patient is Hispanic/Latino/Spanish
(ii) N = No Patient is not
Hispanic/Latino/Spanish; and
(iii) U = Unknown
25. ME025.
This element is named "Ethnicity 1". The data type of this element is text. Its length is 6. Carriers and health care claims processors
shall code according to:
(i) 2182-4 = Cuban
(ii) 2184-0 = Dominican
(iii) 2148-5 = Mexican, Mexican American, Chicano
(iv) 2180-8 = Puerto Rican
(v) 2161-8 = Salvadoran
(vi) 2155-0 = Central American (not otherwise
specified)
(vii) 2165-9 = South American (not otherwise
specified)
(viii) 2060-2 = African
(ix) 2058-6 = African American
(x) AMERCN - American
(xi) 2028-9 = Asian
(xii) 2029-7 = Asian Indian
(xiii)
(xiv) 2033-9 = Cambodian
(xv) CVERDN =
(xvi) CARIBI =
(xvii) 2034-7 = Chinese
(xviii) 2169-1 = Columbian
(xix) 2108-9 = European
(xx) 2036-2 = Filipino
(xxi) 2157-6 = Guatemalan
(xxii)
2071-9 = Haitian
(xxiii)
2158-4 = Honduran
(xxiv) 2039-6 = Japanese
(xxv) 2040-4 = Korean
(xxvi) 2041-2 = Laotian
(xxvii) 2118-8 = Middle Eastern
(xxviii) PORTUG = Portuguese
(xxix) EASTEU = Eastern European
(xxx) 2047-9 = Vietnamese
(xxxi) OTHER = Other Ethnicity
(xxxii) UNKNOW = Unknown/Not Specified
26. ME026.
This data element is named "Ethnicity 2". The data type of this element is text. Its length is 6. Carriers and health care claims processors
shall code according to:
(i) 2182-4 = Cuban
(ii) 2184-0 = Dominican
(iii) 2148-5 = Mexican, Mexican American, Chicano
(iv) 2180-8 = Puerto Rican
(v) 2161-8 = Salvadoran
(vi) 2155-0 = Central American (not otherwise
specified)
(vii) 2165-9 = South American (not otherwise
specified)
(viii) 2060-2 = African
(ix) 2058-6 = African American
(x) AMERCN - American
(xi) 2028-9 = Asian
(xii) 2029-7 = Asian Indian
(xiii)
(xiv) 2033-9 = Cambodian
(xv) CVERDN =
(xvi) CARIBI =
(xvii) 2034-7 = Chinese
(xviii) 2169-1 = Columbian
(xix) 2108-9 = European
(xx) 2036-2 = Filipino
(xxi) 2157-6 = Guatemalan
(xxii)
2071-9 = Haitian
(xxiii) 2158-4 = Honduran
(xxiv) 2039-6 = Japanese
(xxv) 2040-4 = Korean
(xxvi) 2041-2 = Laotian
(xxvii) 2118-8 = Middle Eastern
(xxviii) PORTUG = Portuguese
(xxix) EASTEU = Eastern European
(xxx) 2047-9 = Vietnamese
(xxxi) OTHER = Other Ethnicity
(xxxii)
UNKNOW = Unknown/Not Specified
27. ME027.
This data element is a place holder.
28. ME028.
This element is named "primary insurance indicator". The data type of this element is text. Its length is one. Carriers and health care claims processors
shall code according to:
(i) Y = Yes, primary insurance; and
(ii) N = No, secondary or tertiary insurance
29. ME029.
This element is named "coverage type". The data type of this element is text. Its length is 3. Carriers and health care claims processors
shall code according to:
(i) ASW = for self-funded plans that are
administered by a third party administrator, where the employer has purchased
stop-loss, or group excess insurance coverage
(ii) ASO = for self-funded plans that are
administered by a third party administrator, where the employer has not
purchased stop-loss, or group excess insurance coverage
(iii) STN = for short-term non-renewable health
insurance, as defined pursuant to RSA 415:5 III
(iv) UND = for plans underwritten by the carrier
(v) OTH = for any other plan. Carriers using this code shall obtain prior
approval from the N.H. insurance department
30. ME030.
This element is named "market category". The data type of this element is text. Its length is 4. Carriers and health care claims processors
shall code according to:
(i) IND = for policies sold and issued directly
to individuals, other than those sold on a franchise basis, as defined pursuant
to RSA 415:19, or a group conversion policies required pursuant to RSA 415:18
VII (a)
(ii) FCH = for policies sold and issued directly
to individuals on a franchise basis as defined pursuant to RSA 415:19
(iii) GCV = for policies sold and issued directly
to individuals as group conversation policies as defined pursuant to RSA 415:18
VII (a)
(iv) GS1 = for policies sold and issued directly
to employers having exactly one employee
(v) GS2 = for policies sold and issued directly
to employers having between 2 and 9 employees
(vi) GS3 = for policies sold and issued directly
to employers having between 10 and 25 employees
(vii) GS4 = for policies sold and issued directly
to employers having between 26 and 50 employees
(viii) GLG1 = for policies sold and issued directly
to employers having between 51 and 99 employees
(ix) GLG2 = for policies sold and issued directly
to employers having 100 or more employees
(x) GSA = for policies sold and issued directly
to small employers through a qualified association trust
(xi) OTH = for policies sold to other types of
entities. Carriers using this market
code shall obtain prior approval from the N.H. insurance department
31. ME031.
This element is named "special coverage". The data type of this element is text. Its length is 3. Carriers and health care claims processors
shall code according to:
(i) 0 = Not applicable, member not enrolled in a
special coverage plan
(ii) 1 = Yes, member enrolled in a HealthFirst
plan
32. ME032.
This element is named "group name". The data type of this element is text. Its length is 128. Carriers and health care claims processors
shall provide the name of the group which the member is covered by. If the member is part of a group of one or
non-group policy (when ME030 is coded as "
33. ME101.
Encrypted subscriber last name.
34. ME102.
Encrypted subscriber first name.
35. ME103.
Encrypted subscriber middle initial.
36. ME104.
Encrypted member last name.
37. ME105.
Encrypted member first name.
38. ME106.
Encrypted member middle initial.
39. ME899.
This element is named "record type". The data type of this element is text. Its length is 2. Its value is literally "ME".
b. The
specifications for the member eligibility file shall be submitted using the
following:
Table
4000.5 Member Eligibility File Specifications
|
Data Element # |
Element |
Type |
Max. Length |
Description/Codes/Sources |
|
|
|
|
|
|
|
ME001 |
Payer |
Text |
8 |
Payer
submitting payments |
|
|
|
|
|
NHID
Submitter Code |
|
|
|
|
|
|
|
ME002 |
National
Plan ID |
Text |
30 |