Rhode Island Code of Regulations
Title 216 - Department of health
Chapter 10 - Public Health Administration
Subchapter 10 - Registries
Part 5 - Rhode Island All-Payer Claims Database
Section 216-RICR-10-10-5.6 - Technical Requirements

Universal Citation: 216 RI Code of Rules 10 10 5.6

Current through September 18, 2024

5.6.1 Code Sources and File Specifications

Only code sources and file specifications specified in this Part and/or the RIAPCD Technical Specification Manual shall be utilized in submission of the Health Care Claims Data Sets required pursuant to § 5.5 of this Part.

5.6.2 Schedule for Submissions

A. Insurers shall submit information to the RIAPCD and the Encrypted Unique Identifier Vendor in the specified format in accordance with the following schedule:
1. Test Data Submissions
a. Within one hundred twenty (120) days of notification by the Department, or other date mutually agreed upon by the Department and Insurer, Insurers shall submit test files containing a month of representative Member Eligibility Files or as specified in the RIAPCD Technical Specification Manual to the Encrypted Unique Identifier Vendor.

b. The Encrypted Unique Identifier Vendor shall return the Member Eligibility File to the Insurer with an assigned Encrypted Unique Identifier within fifteen (15) days of a test file submission by an Insurer.

c. Within one hundred and fifty (150) days of notification by the Department, or other date mutually agreed upon by the Department and Insurer, Insurers shall submit part one of their test files containing a month of representative Member Eligibility Files, Medical Claims Files, Pharmacy Files, Dental Files, and Provider Files as specified in the RIAPCD Technical Specification Manual to the Data Aggregator.

2. Health Care Claims Data Set Historical Data Submissions
a. Within two hundred seventy (270) days of notification by the Department, or other date mutually agreed upon by the Department and Insurer, Insurers shall submit Member Eligibility Files as specified in the RIAPCD Technical Specification Manual to the Encrypted Unique Identifier Vendor.

b. The Encrypted Unique Identifier Vendor shall return the historical Member Eligibility File to the Insurer with an assigned Encrypted Unique Identifier within thirty (30) days of a submission of historical files by an Insurer. Within three hundred thirty (330) days of notification by the Department, or other date mutually agreed upon by the Department and Insurer, Insurers shall submit Member Eligibility Files, Medical Claims Files, Pharmacy Files, Dental Files, and Provider Files as specified in the RIAPCD Technical Specification Manual, to the Data Aggregator.
(1) This submission period may be extended within the discretion of the Director to up to three hundred sixty (360) days from notification by the Department, or other date mutually agreed upon by the Department and Insurer.

c. Submissions of additional Health Care Claims Data Sets for remaining dates of service for months up to thirty (30) days prior to three hundred thirty (330) days of notification by the Department shall be submitted according to a schedule provided within the RIAPCD Technical Specification Manual.

3. Health Care Claims Data Set Regular Data Submissions
a. Upon completion of Historical Data Submissions as required by § 5.6.2(A)(2) of this Part, Insurers shall commence Regular Data Submissions.
(1) The timeline for Regular Data Submissions shall commence with the next month following the completion of Historical Data Submissions.

b. Insurers shall submit a Member Eligibility File for each of its Members, as specified in the RIAPCD Technical Specification Manual, to the Encrypted Unique Identifier Vendor.
(1) Monthly data files are due twenty-one (21) business days after the month's end.

(2) For example, files containing data relating to eligibility during September 2018 shall be submitted by October 30, 2018 (accounts for weekends and holidays).

c. The Encrypted Unique Identifier Vendor shall return the Member Eligibility File to the Insurer with an assigned Encrypted Unique Identifier within ten (10) business days of a regular data submission by an Insurer.

d. Effective upon ten (10) business days after the receipt of the Member Eligibility File from the Encrypted Unique Identifier Vendor, Insurers shall submit Member Eligibility Files, Medical Claims Files, Pharmacy Claims Files, Dental Claims Files, and Provider Files, as specified in the RIAPCD Technical Specification Manual, to the Data Aggregator.
(1) Monthly data files are due within ten (10) business days of receipt of the assigned Encrypted Unique Identifier by the Insurer.

(2) For example, files containing data relating to services paid during September 2018 shall be submitted to the Data Aggregator by November 29, 2018 (accounts for weekends and holidays).

e. Within five (5) business days of the Insurer's submission to the Data Aggregator, the Insurer will submit data resubmissions as required by the Data Aggregator, which will communicate discrepancies, failures, and resubmissions.

4. Alternative Payment Model Test Data Submissions Within one hundred fifty (150) days of notification by the Department, or other date mutually agreed upon by the Department and Insurer, Insurers shall submit their test files containing one (1) calendar year of representative APM Files, as specified in the RIAPCD Technical Specification Manual, to the Data Aggregator.

5. Alternative Payment Model Historical Data Submissions
a. Within three hundred thirty (330) days of notification by the Department, or other date mutually agreed upon by the Department and Insurer, Insurers shall submit three (3) calendar years of representative APM Files as specified in the RIAPCD Technical Specification Manual to the Data Aggregator.
(1) This submission period may be extended within the discretion of the Director to up to three hundred sixty (360) days from notification by the Department, or other date mutually agreed upon by the Department and Insurer.

6. Alternative Payment Model Regular Data Submission
a. Upon completion of Historical Data Submissions, Insurers shall commence Regular Annual Data Submissions.
(1) The Regular Annual Data Submissions shall commence the January following the Historical Data Submissions and shall be due by the last day of January each year thereafter.

(2) Each Regular Annual Data Submission shall include information on all payments made to providers, or contracts under payment arrangements outside of the traditional FFS model, made two (2) calendar years prior.

(3) For example, if Historical Data is submitted to the Data Aggregator on March 20th 2022, the first Regular Data Submission shall be due by the end of January 2023 and shall include all payments made to providers, or contracts under payment arrangements outside of the traditional FFS model made during calendar year 2021.

7. All Health Care Claims Data Sets submitted to the Data Aggregator will have a Unique Identifier attached and shall be protected by the removal of all Direct Personal Identifiers and/or hashed. The Department or Data Aggregator shall not collect any data containing Direct Personal Identifiers.

8. The Director has the authority within his or her discretion to modify the RIAPCD Technical Specification Manual to effect changes to the submissions schedule.

Disclaimer: These regulations may not be the most recent version. Rhode Island may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.