Current through Register Vol. 63, No. 9, September 1, 2024
(1) All mandatory reporters shall submit
claims-based data for all claims where the subscriber's residence is in Oregon
or the subscriber is enrolled in a plan for which the State of Oregon is the
payer.
(2) Claims-based data files
shall include:
(a) Enrollment;
(b) Medical claims;
(c) Pharmacy claims;
(d) Dental claims;
(e) Provider;
(f) Subscriber-billed premiums; and
(g) Control totals files.
(3) Mandatory reporters must
include plan-specific identifiers for members, subscribers, providers and
contracts in required files. Mandatory reporters authorized by the Centers for
Medicare and Medicaid Services or contracted through an insurer must provide
the member's identifier for those organizations in addition to the mandatory
reporters' member specific identifier. All identifiers must be:
(a) Sufficient length to be unique within the
mandatory reporters' solution;
(b)
Assigned to a single individual, entity or contract;
(c) Consistent across all files for the
submission; and
(d) Persistent over
time unless change in identifier is required due to change in coverage or
contract.
(4) The
enrollment file shall be submitted by all mandatory reporters except CCOs using
the approved layout, format, and coding described in Appendix A, Enrollment.
(a) Mandatory reporters shall report race and
ethnicity data as outlined in Appendix A, Enrollment. This layout aligns with
the Office of Management and Budget's (OMB) Federal Register Notice of October
30, 1997 (62 FR 58782-58790).
(b)
Mandatory reporters shall report primary language in accordance with ANSI/NISO
guidance using the three-character string outlined in Codes for the
Representation of Languages for Information Interchange.
(c) Race, ethnicity and primary language data
shall be collected in a manner that aligns with the following principles:
(A) To the greatest extent practicable, race,
ethnicity, and preferred language shall be self-reported.
(i) Collectors of race, ethnicity and primary
language data may not assume or judge ethnic and racial identity or preferred
signed, written and spoken language, without asking the individual.
(ii) If an individual is unable to
self-report and a family member, advocate, or authorized representative is
unable to report on his or her behalf, the information shall be recorded as
unknown.
(B) When an
individual declines to identify race, ethnicity or preferred language, the
information shall be reported as refused.
(5) The membership total and claims control
files shall be submitted by all mandatory reporters except CCOs using the
approved layout, format, and coding described in Appendix G, Membership Total
and Claims Control.
(6) The
subscriber-billed premium file shall be submitted by all mandatory reporters
except CCOs using the approved layout, format, and coding described in Appendix
F, Subscriber-Billed Premium.
(7)
The provider file shall be submitted by all mandatory reporters other than PBMs
and CCOs using the approved layout, format, and coding described in Appendix E,
Provider.
(8) The medical claims
file shall be submitted by all mandatory reporters other than PBMs, CCOs, and
dental carriers using the approved layout, format, and coding described in
Appendix B, Medical Claims.
(9) The
pharmacy claims file shall be submitted by PBMs and carriers using the approved
layout, format, and coding described in Appendix C, Pharmacy Claims.
(10) The dental claims file shall be
submitted by all mandatory reporters other than PBMs and CCOs who provide
dental coverage using the approved layout, format, and coding described in
Appendix D, Dental Claims.
(11) All
data elements are required unless specified as optional or situational within
the file layout.
(12) All required
data files shall be submitted as delimited ASCII files.
(13) Numeric data are positive integers
unless otherwise specified.
(a) Negative
values are allowed for quantities, charges, payment, co-payment, co-insurance,
deductible, and prepaid amount.
(b)
Negative values shall be preceded by a minus sign.
(14) All data files shall pass edit checks
and validations implemented by the Authority or the Authority's data vendor.
(a) Data vendors may perform quality and edit
checks on data file submissions. If data files do not pass data vendor edit
checks or validation, mandatory reporters must make corrections and resubmit
data. Mandatory reporters must submit corrected data that passes all quality
and edit checks or receive an approved exemption within 14 calendar days of
notification by the Authority or the Authority's data vendor of the
error.
(b) Mandatory reporters must
participate in efforts to validate and check the quality of current and
historic APAC data, as prescribed and requested by the Authority.
(A) The Authority may request from mandatory
reporter's information from their internal records that is reasonably necessary
to validate and check the quality of APAC data. This information may include,
but is not limited to, aggregated number of enrolled members, number of claims
and claim lines, charges, allowed amounts, paid amounts, co-insurance,
co-payments, premiums, number of visits to primary care, emergency department,
inpatient, and other health care treatment settings, and number of
prescriptions.
(B) Mandatory
reporters shall provide the aggregated information within 30 days of the
Authority's request.
(C) If the
Authority finds errors through edit checks or validation, mandatory reporters
must make corrections and resubmit data or receive an approved extension or
exemption within 30 days or at the next regularly scheduled submission due
date.
To view attachments referenced in rule text,
click here to view
rule.
Statutory/Other Authority: ORS
442.373
Statutes/Other Implemented: ORS
442.373 & ORS
442.372
