To support the collection of the data described in part 4653.0200, a data submitter must:
submit the data described in part 4653.0200 to the data processor in electronic format using the submission, file layouts, record formats, coding specifications, and authentication and de-identification specifications in Appendix D; and
report to the data processor any significant discrepancies in the data with respect to consistency, completeness, accuracy, or any other issue that may affect further review and verification of the accuracy of the data.
Health plan companies, third-party administrators, and pharmacy benefit managers that meet the definition of data submitter in part 4653.0100, subpart 8, on December 31, 2008, must submit the required data on or before July 1, 2009, and at least once every six months thereafter. Health plan companies, third-party administrators, and pharmacy benefit managers that meet the definition of data submitter in part 4653.0100, subpart 8, on December 31 of any year subsequent to 2008 must submit the required data on or before July 1 of the following year and at least once every six months thereafter. Data submitters may submit the required data more frequently than every six months, but no more frequently than monthly.
The first submission by a data submitter must be made on or before July 1 and must consist of enrollment data and data from all claims paid from January 1 of the previous year through March 31 of the current year, according to the specifications in Appendix D, to allow for testing of the compatibility of the data submitter's submissions with the data processor's system.
Data submitters' subsequent data submissions, following the first submission, must consist of enrollment data and data from all claims paid since the last submission through at least the last day of the quarter prior to the month of submission, according to the specifications in Appendix D. For purposes of this item, a quarter ends on the last day of March, June, September, and December.
Data submitters must use the code sources in Appendix D in association with the submission of member enrollment files, institutional and professional health care claims data, and pharmacy drug claims data.
The data processor will notify a data submitter of receipt of a data transmission within two business days of a data submission. Within 30 calendar days after receipt of the data submission, the data processor will notify the data submitter whether the data qualifies as a complete submission.
If the data processor notifies a data submitter that a data submission is incomplete, it will include in the notification a statement describing why the data is incomplete. The data submitter must resubmit the complete data or request an extension or reconsideration within ten business days after the data submitter receives the notification.
If the data processor notifies a data submitter of a material error in a complete submission, the data submitter must file a corrected submission or request an extension reconsideration within 30 days.
If a data submitter discovers a material error in a complete submission in any of its data submissions that have been ascertained by the data processor to be complete, the data submitter must immediately inform the data processor of the error and, within 30 days, file a corrected submission. Submission of an amendment under this item does not affect the date of filing.
If a data submitter disagrees with the data processor's determination that a submission is incomplete or that it contains a material error, the data submitter may submit a written request for reconsideration to the data processor within ten days, stating its reasons that the submission should be considered complete or why it does not contain a material error. If the data processor denies the request, the data submitter may submit a written request for reconsideration to the commissioner within ten days after receiving the data processor's written denial. The commissioner's decision shall be final.
A data submitter may discontinue submitting health care claims data if it pays less than $1,000,000 in health care claims for covered individuals for each of two consecutive calendar years, except that a pharmacy benefit manager may discontinue submitting health care claims data if it pays less than $100,000 in health care claims for covered individuals for each of two consecutive calendar years. The data submitter must provide three months' written notice to the commissioner before it discontinues reporting.
34 SR 10
July 24, 2009