Code of Maine Rules
90 - INDEPENDENT AGENCIES
590 - MAINE HEALTH DATA ORGANIZATION
Chapter 243 - UNIFORM REPORTING SYSTEM FOR HEALTH CARE CLAIMS DATA SETS
Section 590-243-4 - Standards for Data; Notification; Response

Universal Citation: 90 ME Code Rules ยง 590-243-4

Current through 2024-38, September 18, 2024

A. Standards. The MHDO or its designee shall evaluate each member eligibility file, medical claims file, pharmacy claims file, and dental claims file submission in accordance with the following standards:

(1) The applicable code for each data element identified in Appendices C-1, D-1, E-1, and F-1 shall be included within eligible values for the element;

(2) Coding values indicating "data not available", "data unknown", or the equivalent shall not be used for individual data elements unless specified as an eligible value for the element;

(3) Member sex, diagnosis and procedure codes, and date of birth and all other date fields shall be consistent within an individual record; and

(4) Member identifiers shall be consistent across files.

B. Notification. Upon completion of this evaluation, the MHDO or its designee will promptly notify each health care claims processor whose data submissions do not satisfy the standards for any filing period. This notification will identify the specific file and the data elements within them that do not satisfy the standards.

C. Response. Each health care claims processor notified under subsection 4(B) will respond within 60 days of the notification by making the changes necessary in order to satisfy the standards.

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