Minnesota Legislature
Office of the Revisor of Statutes
Minnesota Administrative Rules
CHAPTER 4653, HEALTH CARE CLAIMS REPORTING SYSTEM
DEPARTMENT OF HEALTH
| Part | Title |
|---|---|
| 4653.0100 | DEFINITIONS. |
| 4653.0200 | DATA COLLECTED. |
| 4653.0300 | DATA SUBMISSION REQUIREMENTS. |
| 4653.0500 | INDIVIDUAL VARIANCES. |
| 4653.0600 | INCORPORATION BY REFERENCE. |
4653.0100 DEFINITIONS.
Subpart 1.
Scope.
The terms used in parts 4653.0200 to 4653.0600 have the meanings given them in this part.
Subp. 3.
Complete submission.
"Complete submission" means data submitted to the data processor by a data submitter that the data processor has determined to contain the required data meeting the required threshold in a format that allows further review and verification of the accuracy of the data.
Subp. 4.
Covered individual.
"Covered individual" means a natural person who is a resident of Minnesota and is eligible to receive health care benefits under any policy, contract, certificate, evidence of coverage, rider, binder, or endorsement that provides for or describes health care coverage with the exception of coverage that is explicitly excluded from the definition of a health plan in Minnesota Statutes, section 62A.011, subdivision 3, clauses (1) to (9) and (11).
Subp. 5.
Data element.
"Data element" means the smallest named unit of information in a transaction.
Subp. 6.
Data element characteristic.
"Data element characteristic" means an attribute of a data element required to be submitted for enrollment data and health care claims data: element number, element name, encrypt, type, max len, description, threshold, and reference standard.
Subp. 7.
Data processor.
"Data processor" means the private entity selected by the commissioner to collect and process health care claims.
Subp. 8.
Data submitter.
"Data submitter" means a health plan company or third-party administrator that has covered individuals and that paid a total of at least $3,000,000 in health care claims for covered individuals during the previous calendar year, or a pharmacy benefit manager that has covered individuals and that paid at least $300,000 in claims for covered individuals during the previous calendar year. In calculating its paid claims, each data submitter must include all health care claims for covered individuals processed by any subcontractor on its behalf.
Subp. 9.
Enrollment data.
"Enrollment data" means demographic information and other information relating to all covered individuals eligible to receive health care benefits.
Subp. 10.
Health care claims data.
"Health care claims data" means information included in an institutional, professional, or pharmacy drug claim or equivalent encounter information transaction for a covered individual that is required under Minnesota Statutes, section 62J.536.
Subp. 11.
Health plan company.
"Health plan company" has the meaning given in Minnesota Statutes, section 62U.01, subdivision 8.
Subp. 12.
Material error.
"Material error" means omission of records or of data within records, or submission of inaccurate information that is of sufficient magnitude to cause the results of analysis performed with the data to be inaccurate or biased.
Subp. 13.
Minnesota resident.
"Minnesota resident" means a natural person for whom the data submitter has identified a Minnesota address as the individual's primary place of residence.
Subp. 14.
Pharmacy benefit manager.
"Pharmacy benefit manager" means a third-party administrator under contract to administer drug benefit programs for self-insurance or health insurance plans.
Subp. 15.
Pricing data.
"Pricing data" means the amount paid by a data submitter to a provider on a claim plus any amount owed by the covered individual, including prepayment, deductible, coinsurance, or co-payment.
Subp. 16.
Provider or health care provider.
"Provider" or "health care provider" has the meaning given in Minnesota Statutes, section 62J.03, subdivision 8.
Subp. 17.
Subcontractor.
"Subcontractor" means an individual or entity that performs on behalf of a health care company or third-party administrator any function or activity involving enrollment data or health care claims data, and is not a part of the health care company's or third party administrator's workforce.
Subp. 18.
Third-party administrator.
"Third-party administrator" means a vendor of risk-management services or an entity administering a self-insurance or health insurance plan as defined in Minnesota Statutes, section 60A.23, subdivision 8.
Subp. 19.
Threshold.
"Threshold" means the required completeness percentage for a particular data element.
History:
34 SR 10
Published Electronically:
July 24, 2009
4653.0200 DATA COLLECTED.
A.
All health plan companies and third-party administrators must register with the data processor no later than June 15, 2009, and April 1 of each subsequent year. For the purposes of identifying data submitters, minimizing administrative burden, and assessing data completeness, all health plan companies and third-party administrators must submit the dollar amount of paid health care claims for covered individuals during the previous calendar year according to the instructions in Appendix D. The appendix is incorporated by reference in part 4653.0600.
B.
Data submitters are responsible for submission of the following data for each covered individual, including health care claims processed by any subcontractor on the data submitter's behalf.
(1)
Data submitters must submit all enrollment data elements as set forth in Appendix A. The appendix is incorporated by reference in part 4653.0600.
(2)
Data submitters must submit encounter data elements and pricing data for all institutional and professional health care claims paid by the data submitter under Appendix B. The appendix is incorporated by reference in part 4653.0600.
(3)
Data submitters must submit encounter data elements and pricing data for all pharmacy drug claims paid by the data submitter under Appendix C. The appendix is incorporated by reference in part 4653.0600.
The data processor will accept data submitted directly by a data submitter's subcontractor.
History:
34 SR 10
Published Electronically:
July 24, 2009
4653.0300 DATA SUBMISSION REQUIREMENTS.
Subpart 1.
Duties of data submitters.
To support the collection of the data described in part 4653.0200, a data submitter must:
A.
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
B.
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.
Subp. 2.
Submission schedule.
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.
A.
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.
B.
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.
Subp. 3.
Code sources.
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.
Subp. 4.
Complete submissions.
A.
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.
B.
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.
Subp. 5.
Material error.
A.
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.
B.
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.
Subp. 6.
Dispute resolution.
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.
Subp. 7.
Discontinuance of data submission.
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.
History:
34 SR 10
Published Electronically:
July 24, 2009
4653.0500 INDIVIDUAL VARIANCES.
A.
The commissioner must grant a variance to a data submitter with respect to submission of a specific data element or submission specification if the data submitter demonstrates good cause. To request a variance, a data submitter must submit a petition, according to Minnesota Statutes, section 14.056, and demonstrate that it meets the criteria in subitems (1) to (3):
(3)
the variance would not prejudice the substantial legal or economic rights of any person or entity.
B.
The commissioner must grant a variance to a data submitter with respect to a threshold for one year if the data submitter demonstrates good cause. To request a variance, the data submitter must submit a petition stating the reason it is unable to meet the standard threshold, the proposed threshold, and the basis for the proposed threshold.
History:
34 SR 10
Published Electronically:
July 24, 2009
4653.0600 INCORPORATION BY REFERENCE.
"Minnesota Health Care Claims Reporting System: Appendices to Minnesota Administrative Rules, Chapter 4653," issued by the Minnesota Department of Health, May 2009, is incorporated by reference. It is available through the Minitex interlibrary loan system and the Minnesota Department of Health Web site at http://www.health.state.mn.us/healthreform/encounterdata. They are not subject to frequent change.
History:
34 SR 10
Published Electronically:
July 24, 2009
Official Publication of the State of Minnesota
Revisor of Statutes