Code of Maine Rules
90 - INDEPENDENT AGENCIES
590 - MAINE HEALTH DATA ORGANIZATION
Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS
Section 590-243-3 - Submission Requirements
Current through 2024-38, September 18, 2024
A. Registration/Contact and Enrollment Update. Each health care claims processor not excluded from submitting claims data under Section 2(A)(9)(a) shall complete a registration survey or update an existing one at https://mhdo.maine.gov/portal by February 28th of each year. It is the responsibility of the health care claims processor to amend, as needed, all company, contact and enrollment information.
B. File Organization. The member eligibility file, medical claims file, pharmacy claims file, and the dental claims file are to be submitted to the MHDO or its designee as separate ASCII files. Each record shall be terminated with a carriage return (ASCII 13) or a carriage return line feed (ASCII 13, ASCII 10).
C. Filing Method. Data files must be submitted to the MHDO's Data Warehouse Portal via secure FTP or secure web upload interface. E-mail attachments shall not be accepted.
D. Testing of Files. Within one hundred and eighty days of the adoption of any changes to the data element content of the files as described in Section 2 and at least sixty days prior to the initial submission of the files or whenever the data element content of the files as described in Section 2 is subsequently altered, each health care claims processor shall submit to the MHDO or its designee a data set for comparison to the standards listed in Section 4. Based upon a calendar period of one month or one quarter, the size of the data files submitted shall correspond to the filing period established for each health care claims processor under subsection F of this Section.
E. Rejection of Files. Failure to conform to the requirements subsections A, B, or C of this Section shall result in the rejection of the applicable data file(s). All rejected files must be resubmitted in the appropriate, corrected form to the MHDO or its designee within 15 days.
F. Filing Periods. The filing period for each applicable claims data file listed in Section 2 shall be determined by the minimum monthly total of Maine-resident members for whom claims are being paid by each health care claims processor. The data files are to be submitted in accordance with the following schedule:
|
Total # of Members |
Filing Period |
Filing Schedule |
|
[GREATER THAN EQUAL TO] 2,000 |
monthly |
prior to the end of the month following the month in which claims were paid |
|
[LESS THAN EQUAL TO] 2,000 |
quarterly |
prior to April 30, July 31, October 31, January 31 for each preceding calendar quarter in which claims were paid |
If the data files submitted by an individual health care claims processor support or are related to the files submitted by another health care claims processor, the MHDO shall determine a filing period that is consistent for all parties involved.
G. Replacement of Data Files. No health care claims processor may replace a complete data file submission more than one year after the end of the month in which the file was submitted unless it can establish exceptional circumstances for the replacement. Any replacements after this period must be approved by the MHDO. Individual adjustment records may be submitted with any monthly data file submission.
H. Run-Out Period. Health care claims processors shall submit medical, pharmacy, and/or dental claims files for a six-month period following the termination of coverage date for all members who are Maine residents.
