1.7 - Discount Instructions.pdf

Version CY2019.1

March 9, 2020

DISCOUNT DATA SPECIFICATIONS

The Uniform Discount and Data Specification (UDS) workgroup was created to develop a standardized data specification in order to simplify the data development process for carriers. The workgroup is only focused on what data elements should be included in the submission. No discussion of use is permitted at any UDS meeting. Any discussion about data use should take place directly between data submitters and data receivers.

Time Period

• Include all medical claims incurred 1/1/2019-12/31/2019 and paid through 2/29/2020. Please note that for Inpatient claims, admission date should be considered the incurred date.

Data Content

• Include Group claims only o Private exchange business should be included

• Include all claims from all providers except as noted in exclusions below o Include claims for both contracted and non-contracted providers o Include high cost claims - do not exclude any claim because of high dollar amounts o Include all claims for services covered under medical benefits, regardless of the discount percentage amount o Include claims that are paid through networks that your organization rents if these rental networks are normally part of the product offering you make to your customers o Include all other provider payments not already included in the claims data in the Other Provider Payments portion of Appendix A. All types of payments that are applicable to medical coverage that would not be included in a self-insured admin fee should be captured. These types of payments should be included both if they are passed back to the employer or are not directly passed back to the employer. These payments should be included both if they relate to self-insured or fully insured business. Examples of these payments (but not an exclusive list) include: withholds, pay for performance payments, risk settlements, bonus payments, pre-payments, provider incentives due to risk sharing arrangements, care collaboration fees, and provider fees to fund administrative functions.

o Include Minnesota provider tax payments in both the 'Eligible Billed $' and 'Allowed $' fields.

• All adjudication adjustments for a claim should be applied to that claim before the claim is summarized

• Exclude the following:

o Claims for members age 65 or older where age is measured as the difference between the date of service and member’s birth date rounded down to the integer o All Medicare Supplement, Medicare Advantage and Individual claims o All Medicare and Medicaid claims o All claims with COB where your organization is the secondary payer o All mail order prescription drug, retail prescription drug, dental and vision hardware claims not covered under medical benefits o Payments for interest expense, regulatory fees and prompt pay penalties o Claims paid through custom network arrangements established for specific customers that are not generally available to other groups o Claim lines that include ineligible services and related charges as defined below in “Data Layout” o All capitation paid as well as any claim lines and/or encounter data associated with or paid through capitated arrangements o All surcharges and covered life assessments such as NYCHRA o All network access fees including access fees for rental networks o All members in the following group types:

Prison groups (prisoners, not prison employees) Railroad groups o All denied and pended claims and claim lines.

o All claims for medical provider customers that have an SIC code of 8061 or 8062

Only applies to customers with a physician group that accounts for at least 5% of professional spend or an acute care hospital.

DATA AGGREGATION METHODOLOGY

All terminology shown in italics will be further defined in the “Data Layout” section of this document

1. Data should be separated into one of the following three groups based on type of service:

A. Inpatient Facility (facility charges only; does not include associated professional charges) B. Outpatient Facility (facility charges only; does not include associated professional charges) C. Professional and Other services (including professional charges associated with facility claims)

2. Service lines should be summarized into an Event. An Event is defined according to the type of service it is associated with:

A. Inpatient Facility Event = Admission

• If a patient is transferred to a different facility, a new admission record should be created B. Outpatient Facility Event = “Case” or “Procedure”

• Determining whether an Outpatient Event should be reported as either a Case or Procedure is based on the Revenue Codes and logic shown in Appendix C of this document

• If the Event type is a Case, make sure the Case includes all service lines incurred in a facility by the claimant in one day

• If the Event type is not “Case” and there are multiple dates of service on the claim, assume all claim lines are incurred on the minimum service date (i.e., first day of service) listed on the claim

C. Professional and Other Services Event = “Procedure”

For Inpatient and Outpatient Facility Events, there are situations where Emergency Room visits turn into Inpatient Admissions. In addition, it is also possible that an Emergency Room visit could have an Outpatient Surgery related to it. As such, a hierarchy to define types of Events is needed:

• If any portion of an Event occurs in an Inpatient setting, then the claim and all charges associated with it should be classified as Inpatient

• If an Event is not an Inpatient Admission and has any Revenue Codes that indicate Emergency Room services, it should be classified as an Emergency Room case

• If an Event is not an Inpatient Admission or Emergency Room case and has any Revenue Codes that indicate Outpatient Surgery, the entire claim shall be considered Outpatient Surgery

When summarizing service lines associated with admissions and cases to the Event level, a claim identification number or similar field should be used to identify all service lines that should be included in the Event.

3. Each Event should be assigned a Benefit/Contract Status Indicator and Pay as Billed Provider

Indicator as defined below in the “Data Layout” section

4. Each Inpatient Event should also be assigned a Catastrophic Indicator based on the Total Allowed

Amount level of the Event. If the Total Allowed Amount for the Inpatient Event equals or exceeds $150,000, the Event is considered a catastrophic claim. There are two categories of catastrophic claims: one for claims with Total Allowed Amounts between $150,000.00 and $299,999.99 and a second for claims equal to or exceeding $300,000.

5. Events are then aggregated as specified in the layout and output in different records according to

“Group By” categories specified in Appendix A of this document

Specific instructions on how to categorize Events as well as a list of fields and definitions are provided below.

DATA LAYOUT

DATA SUBMISSION FILE FORMATS

Files should be submitted in text format. All fields requested in this document are summarized in Appendix A.

FIELD DEFINITIONS

The information presented in this section applies to all types of claims (Inpatient, Outpatient and Professional/Other). After this section, there is a definition and instruction section that addresses additional instructions and fields by claim type (Inpatient, Outpatient and Professional/Other claims).

All indicators in the data should be mutually exclusive. That is, when aggregating amounts on any given field, the sum of data for charge and utilization fields will be the actual total for that field (i.e., no double counting).

Organization Name Name of organization providing data

Service Period Dates of service represented by data submission in format MMDDYY-MMDDYY. First date should be the start date and second date should be end date. As an example, for calendar year 2019 data, this field would be populated as 010119-123119. If period is not equal to 12 months, it should be disclosed on the actuarial certification

3 Digit Patient Zip Code All of the records in this data submission should include the patient’s residential 3-digit Zip Code. If the patient’s residential zip code is not available, the zip code of the employee to which the member is related should be used. If there is no patient or employee zip code available, a dummy zip code of “ZZZ” should be submitted.

Product Indicator The “Product Indicator” will be used to identify and differentiate submitted data for each product a carrier would potentially offer an employer group. Data should be aggregated separately for each unique product a carrier wishes to submit for evaluation.

Positions 1 through 3 of the Product Indicator should indicate the product type (PPO, HMO, POS, EPO, TRA) and positions 4 and 5 should be used as a suffix (e.g., 01, 02, 03) in case a carrier submits more than one product of the given type. Please note that no formal naming convention is prescribed for the remaining positions in this submission. This should allow carriers flexibility in providing product indicators that most appropriately reflect their product portfolio. It is expected that each carrier will provide a translation table or key for the “Product Indicator” field in their data submission. The format under which a carrier should submit this information is provided as Appendix G of this document. This key should allow users to easily identify products. It is recommended that both the product’s marketing name and description be supplied along with the “Product Indicator” on this key.

For purpose of illustration, examples of characteristics that could cause reimbursement to vary among products are shown below. This is neither an all-inclusive list nor are the items shown intended to be addressed by all carriers. Also, there are other examples that may require product differentiation. As stated above, it is expected that each carrier will appropriately identify key characteristics that differentiate products in their portfolio and provide Product Indicators reflecting these differences.

• Product type: PPO vs. Open Access POS vs. Gatekeeper POS vs. EPO etc.

• Group’s Funding Arrangement: Fully Insured vs. Self-Insured

• Multiple Networks available in the same area

• Product with Multiple In-Network Benefit Levels vs. Open Access PPO

Please note above that unique products should be identified based on three factors:

- Network size

- Provider contracts

- Benefit Tiers (1 vs 2+ tiers)

Products that differ in any of these three areas should be submitted under different Product Indicators.

Benefit/Contract Status Indicator

The “Benefit/Contract Status Indicator” indicates whether a claim is paid using in-network or out-of-network benefits as well as whether the claim is paid to a contracted or non-contracted provider. The table below shows the categories and codes to be used for this indicator.

Please note that for products with multiple in-network benefit levels or provider tiers, all in-network providers should be reported as IC regardless of their in-network tier. Tiered products should be reported separately from other products (i.e., tiered product should be reported separately from open access PPO).

Detailed data will only be collected for Benefit/Contract Status Indicator “IC”. Data for “OC”, “IX”, and “OX” claims will be aggregated at the 3-Digit zip code, Product and Type of Service (Inpatient, Outpatient or Professional) level.

There may be some facility admissions where the Benefit/Contract Status indicator for a facility changes during the admission. In these cases, the admission should be classified with the Benefit/Contract Status indicator in effect for the facility on the first day of the admission.

Arrangement/Group Size Indicator The “Arrangement/Group Size Indicator” groups data based on Funding Arrangement and Group size.

For Fully Insured groups, the Group Size Indicator should reflect the Line of Business under which the plan was filed with the relevant state. Self-insured groups should be classified as Large Group.

Pay as Billed Provider Indicator Claims that a carrier requests be considered for Pay as Billed status should be indicated with a “Y” in this field. Carriers should be prepared to substantiate this classification at the provider level with proof

Code Notes

IC Services where the provider is contracted with the health plan and benefits are paid at an in-network benefit level

OC Services where the provider is contracted with the health plan and benefits are paid at an out-of-network benefit level.

An example of this is when a plan has a "wrap" network for out-of-network claims

IX Services where the provider is not contracted with the health plan and benefits are paid at an in-network benefit level.

Examples of when this code should be used include ER services used at a non-contracted hospital in a state where it is mandated that all ER claims are paid in-network or when hospital based physicians or anesthesiologists are not contracted but paid as in-network

OX Services where the provider is not contracted with the health plan and benefits are paid at an out-of-network benefit level that the provider either routinely files claims with Submitted Charges = Allowed Charges or the provider does not file Submitted Charges. If the overall discount for a provider is greater than 2.0%, the claims filed by that provider may not be classified as Pay as Billed. Explanation for all claims coded as “Pay as Billed” should be provided in the actuarial certification provided with the data.

Financial Data The definitions provided below are intended to standardize terminology as it relates to this claim charge data submission for Provider Reimbursement Analysis.

Submitted Charges All charges submitted by the provider for payment

Ineligible Charges Sometimes referred to as "Non-covered Charges". These are charges not covered due to denial of services, claim duplication, medical policy, ineligible members or the plan of benefits.

Detailed descriptions of types of Submitted Charges that are considered Ineligible are provided below.

Eligible Billed Charges Sometimes referred to as "Covered Charges". Eligible Billed Charges = (Submitted Charges less Ineligible Charges) before application of fee schedules, contractual reimbursement provisions, and R&C cutbacks

Negotiated Savings Sometimes referred to as "Provider Discount". Savings resulting from fee schedules or contractual reimbursement provisions.

Reductions that could result in member balance billing should not be included as Negotiated Savings

Reasonable & Customary Cutback Amount

Any difference between Submitted Charges and Allowed Amount that is not accounted for in Ineligible Charges. These amounts should only be considered for IX and OX claims.

Allowed Amount Allowed Amount = (Eligible Billed Charges less Negotiated Savings resulting from fee schedules or contractual reimbursement provisions, OR R&C cutbacks for IX and OX claims) prior to member cost sharing.

Paid Amount Sometimes referred to as “Plan Paid Amount”. This is the Allowed Amount reduced for member cost sharing. It represents the actual amount paid by the health plan.

Member Cost Sharing This is the portion of the Allowed amount that is the member’s responsibility to pay. This includes deductibles, copays, and coinsurance. Member cost sharing, as defined here, should not include balance billing on IX and OX claims.

Allowed Amount for IC/OC Claims

= Submitted Charges

Minus

Ineligible Charges

Minus

Negotiated Savings

Allowed Amount for IX/OX Claims

= Submitted Charges

Minus

Ineligible Charges

(Negotiated Savings

OR

R&C cutbacks)

Paid Amount = Allowed Amount

Member Cost Sharing Amounts

Ineligible Charges

These are charges for services not considered eligible for payment under the plan. Examples include:

• Duplicate bills

• Pending or denied claims

• A type of service that is not covered by the plan of benefits:

o For example, if cosmetic surgery is not covered under the plan and a claim is submitted that includes cosmetic procedures, the charges for these procedures would be considered ineligible charges o Claim lines with the non-covered cosmetic procedure above would be excluded from this data submission

• Services incurred in excess of plan limits o For example, if the plan imposes a 40 visit annual limit on outpatient mental health visits and a claim is submitted for a 41st visit, the charges for this visit would be considered ineligible o Another example is a plan that covers up to 5 inpatient days for a certain diagnosis and a claim is submitted for 6 days, the charges for the 6th day would be considered ineligible o The visits/days and associated charges not covered in the examples above would be excluded from all Claim data in this data submission o Should only exclude services that are not covered due to the plan limit

• Claims denied due to medical management/medical necessity decisions such as length of stay cutbacks and medical claim review

• Pre-Existing Condition Exclusions

As illustrated in the examples above, all claim lines, units and Submitted Charges associated with Ineligible Charges should be excluded prior to summarizing data into the Events described above in “Data Aggregation Methodology”.

All claim lines and related Submitted Charges for services which are covered by a plan but are “bundled” through business rules/edits in a carrier’s claim processing system should be included as Eligible Billed Charges. These amounts should not be treated as denied claims.

Actual, Adjusted and Projected Data

In order to provide accurate historical information as well as projections for future periods, data is to be provided in three categories as outlined below. Please note that values should be provided for all actual, adjusted and projected fields regardless of whether a carrier is making adjustments or projections. To aid users of the data, two fields are provided that should be used to indicate if adjusted data different than actual is submitted or if projected data different than adjusted is submitted:

• The field “AdjCopyof Actual” should be coded as “Y” for all records if Adjusted is always a copy of Actual. If Adjusted is always or sometimes different than Actual, this field should be populated as “N” for all records.

• The field “ProCopyof Adj” should be coded as “Y” for all records if Projected is always a copy of Adjusted. If Projected is always or sometimes different than Adjusted, this field should be populated as “N” for all records.

A - Actual: Historical claims incurred and paid in the requested time period with no adjustments. All data submissions require an actuarial certification that confirms that no adjustments have been made to the historical data included in the “Actual” fields. “Actual” data should be reported for all utilization data (admissions, days, cases and procedures) and financial data (Eligible Billed Charges, Negotiated Savings and Allowed Amount).

B - Adjusted: “Adjusted” data is historical data that has been changed or modified to more accurately reflect a carrier’s actual discounts. Examples of when the “Adjusted” fields might be used:

• A carrier has access to a new network in a specific area due to acquisition or merger

• A carrier changes rental network partners used in an area

• A carrier has little or no experience in a new product and uses “Actual Allowed Amount” data from an established product with “adjustments” for provider contract differences to represent the new product’s “Adjusted Allowed Amount”

• A carrier cannot explicitly remove access fees from their data and instead uses an assumption/adjustment method to remove access fees

It is expected that a product for which “Adjusted Allowed Amount” data is provided would be based on the “Actual Allowed Amount” data of a similar product or network. In the case of new networks from acquisition/merger or changes in rental network partners, it is possible that the “Adjusted” data is simply “Actual” data from the new network (before merger or selection as a partner) to be substituted for the carriers “Actual” data.

For all claim types, “Adjusted” data should be reported for all utilization data (admissions, days, cases and procedures) and financial data (Eligible Billed Charges, Negotiated Savings, Allowed Amount, and Paid Amount), even if only one of the fields is affected by the network change. All methods used to create “Adjusted” data should be disclosed in the Actuarial Certification (Appendix I).

C – Projected: Includes any adjustments to the data file that are based on finalized future changes to provider discounts for which historical data is not representative of future discount results based on finalized contract changes. The most common reason for supplying “Projected” data is recognition of recent changes in provider discounts that have yet to be recognized in the “Actual” or “Adjusted” data provided. Projections should also be used to recognize the impact of contractual fee escalators and/or multi-year guarantees a carrier has with providers. Appendix H gives other examples of situations where “Projected” data would be submitted. Carriers should only project discounts for providers for whom a change in discount will occur.

“Projected” data is different from “Adjusted” data as “Adjusted” data is intended to reflect the same time period as “Actual” data while “Projected” data is intended to reflect claims in a future period.

The following presents additional guidance around submission of “Projected” data:

o Appendix H must be completed and submitted for all geographic areas where “Projected” data is provided.

o In all cases, “Projected” data should only be provided for contracts or changes that have been negotiated and finalized. Projections should not be based on negotiation targets or situations that are “likely” to occur.

o Projections should be submitted for any 3-digit zip code where a change will occur and should include all known changes in that 3 digit zip code, not just discount improvements. Both discount improvements and deterioration should be reflected in “Projected” data.

o Discount changes in any 3-digit zip code should be calculated such that the overall “Projected

Discount” for that zip code reflects the percentage of claims serviced by providers affected by the event justifying the projection o “Projected Discounts” should only be calculated for providers affected by the event justifying the projection o Provider specific ”Actual/Adjusted Discounts” should be used for claims serviced by providers that are not affected by the event justifying the projection o The overall “Projected Discount” for a 3-digit zip code should represent a blend of the “Projected Discount” for providers affected by the event justifying the projection and the “Actual/Adjusted Discounts” of those providers not affected by the event o The discount changes submitted on Appendix H should reflect the discount change over all providers and claims in the 3-digit zip code.

o An example of this calculation is shown on page 9.

For each data submission, the timeframe of the submission and effective dates of claims that drive the “Projected” data must be recognized. For this data submission, a projection period of 1/1/2020 –

12/31/2020 should be used. All “Projected” changes that are effective after 1/1/2020 should be pro-rated for the number of months it will impact discounts in 2020. In this way, the projected discount will represent the expected discount over the period 1/1/2020 - 12/31/2020. Only contracts executed by March 31, 2020 (3 months after the ending incurred date for this submission) for future effective dates should be considered for projections.

“Projected” amounts should only differ from the “Actual”/“Adjusted” data it is based upon for Negotiated Savings and Allowed Amounts. While “Projected” fields for all utilization (admissions, days, cases and procedures) and Eligible Billed Charge data should not differ from the “Actual”/”Adjusted” data, we require that “Projected” amounts for all fields be provided to ensure that the intended discount amount is determined.

“Projected” Allowed Amounts should be calculated such that the discount off of 1/1/2019-12/31/2019

Eligible Billed Charges is the discount that is expected to be achieved in the prospective period (1/1/2020-12/31/2020). In order to complete this calculation, a standardized billed charge trend should be used. The billed charge trends for this data submission are included in Appendix B. These trends should be assumed for all discount projections regardless of geographical area. Milliman has also provided appropriate caveats and disclosures for the use of these billed charge trends that should be communicated to field staff.

An illustration of how the projection should be calculated and reported is shown on the next page using a projection period of 1/1/2018 – 12/31/2018 and a historical period of 1/1/2017 – 12/31/2017. Please note that for discount projections based on mid-year historical data (i.e., historical data period begins in July of one year and ends in June of the next), 18 months of the billed charge trend should be used in the calculation. In addition to this example, two examples of how the Expected Change in Allowed Amount and Discount Projection are calculated for contracts where all or a portion of the reimbursement is based on a Percentage of Billed Charge method are also provided below.

Projections when Reimbursed as Percentage of Billed Charges - Example 1 A provider is reimbursed at 50% of billed charges for OP services. No change in the percentage of charges reimbursed for OP Services occurs in the projection period (it remains 50%). While the percentage of billed charges does not change, the amount reimbursed will increase by the same rate as billed charges. In this situation, the Expected Change in Allowed Amount is expected to increase by the prescribed billed trend of 6%.

Projections when Reimbursed as Percentage of Billed Charges - Example 2

A provider is reimbursed 50% of billed charges for OP services. A contract change occurs where OP services are now reimbursed at 52% of billed charges. The Expected Change in the Negotiated Savings Amount should be calculated as:

((1 + Prescribed Billed Trend) Multiplied by

(1 - New Percentage of Billed Charge Reimbursement) Divided by

(1 - Prior Percentage of Billed Charge Reimbursement)) Minus 1

OR

(1.06 * (1 - 0.52) / (1 - 0.50)) – 1 = 1.8%

Illustration of Projected Data Submission

(A) (B) (C)

3-digit Zip Code Actual Eligible Billed Actual Allowed Actual Discount

AAA Inpatient - Hospital 1 400 200 50.0%

AAA Outpatient - Hospital 1 375 180 52.0%

AAA Inpatient - Hospital 2 210 141 32.9%

AAA Outpatient - Hospital 2 230 125 45.7%

AAA Inpatient - Hospital 3 50 35 30.0%

AAA Outpatient - Hospital 3 60 42 30.0%

AAA Inpatient Total 660 376 43.0%

AAA Outpatient Total 665 347 47.8%

Formulas 1- (B)/(A)

Example: Three hospitals service all facility claims in 3-digit zip code AAA

Hospital 1 signed a new contract for 0% Inpatient increase effective 1/1/2020, Outpatient is reimbursed at % of charges and is not changing

Hospital 2 has a multi-year guarantee that requires an 11.0% increase to both Inpatient and Outpatient reimbursement on 1/1/2020

Hospital 3 is reimbursed as a % of charges and has no change from 2019 to 2020

Key data and calculation of 1/1/2020 - 12/31/2020 projected is as follows:

Projection needed for:

(D)

Actual Discount

(E)

Expected Change in Allowed

Amounts

1/20 - 12/20

(F)

Prescribed Billed Charge

Trend

(G)

Projected Discount 1/20 -

12/20

Inpatient - Hospital 1 50.0% 0.0% 6.0% 52.8%

Inpatient - Hospital 2 32.9% 11.0% 6.0% 29.7%

Outpatient - Hospital 2 45.7% 11.0% 7.0% 43.6%

Formulas

(C) above Carrier determines Prescribed in Data

Specifications

1 - ((1 - D) x (1 + E)/(1 +

F)

(H) (I) (J)

Actual or Projected Eligible Billed Allowed Discount

Inpatient - Hospital 1 Projected 400 189 52.8%

Outpatient - Hospital 1 Actual 375 180 52.0%

Inpatient - Hospital 2 Projected 210 148 29.7%

Outpatient - Hospital 2 Projected 230 130 43.6%

Inpatient - Hospital 3 Actual 50 35 30.0%

Outpatient - Hospital 3 Actual 60 42 30.0%

Total Inpatient 660 371 43.7%

Total Outpatient 665 352 47.1%

Formulas from (A) (1 - (J)) x (H) from (G) if expect a change, otherwise from (C)

Populate Projected Allowed Amount fields for affected areas and types of service so that 1/20 - 12/20 expected discount is achieved

Please note that for purposes of Projected data submission, you should make no changes to Eligible Billed Charges

(K) (L) (M)

Area Projected Eligible Billed Projected Allowed Projected Discount

AAA Inpatient 660 371 43.7%

AAA Outpatient 665 352 47.1%

Formulas from (A) from (I) from (J)

Key Observations

Projected Eligible Billed Charges = Actual Eligible Billed Charges

Projected Allowed Amount Calculated so that Projected Allowed Amount divided by Historical Eligible Billed Charges equal Projected Discount in (G) above

Actual 1/19 - 12/19

Projected 1/20 - 12/20

Calculation of Projected Amounts

FIELDS FOR INPATIENT FACILITY CLAIMS

For Benefit/Contract Status “IC” (In-Network/Contracted) Only

• All admissions and claims, including high cost claims, should be included

• When coding inpatient facility claims, use coding system MS-DRG v35

• Data should be included for all discharges, including due to death of the patient

• This is for facility claims only. No professional fees associated with facility services should be included

• Include data for all inpatient facility types (hospital, rehabilitation center, skilled nursing facility and mental health hospitals)

• Exclude utilization and charge data for any unpaid, non-covered days associated with ineligible charges as defined below

• Incurred dates for Inpatient Claims should be represented by the date of admission.

• There may be some admissions where the Benefit/Contract Status indicator for a facility changes during the admission. In these cases, the admission should be classified with the Benefit/Contract Status indicator in effect for the facility on the first day of the admission.

Catastrophic Indicator Indicator set to “0” for Inpatient Events (admissions) with between $150,000 and $299,999.99 of total Actual Allowed Amount. The indicator should be set to “1” for Inpatient Events (admissions) with total Actual Allowed Amount equal to or exceeding $300,000. Utilization and claim charges submitted with a Catastrophic Indicator = “0” or “1” should include all utilization and claim amounts associated with the Inpatient Event, not just excess portion of the Inpatient Event that exceeds the high cost threshold.

As an example, if a 25 covered day inpatient event with $300,000 in Actual Allowed amounts occur, the entire claim ($300,000 in Actual Allowed amount and all 25 covered days) should be summarized into one event and included with a catastrophic indicator of “1”.

All charges and utilization for claims coded with a Catastrophic Indicator of “0” or “1” should be excluded from the aggregation of non-catastrophic claims (Catastrophic Indicator = “N”) so that double counting is avoided.

DRG

Based on the discharge DRG. For this submission, use coding system MS-DRG v36. Carriers should ensure one DRG version is used for all inpatient data and should not submit data with a mix of DRG versions.

If a carrier must submit data based on a version other than MS-DRG v36, it is important that the carrier ensure that all inpatient claims are based on this alternate version and that there is not a mix of data where some claims are coded as MS-DRG v36.

DRG Version Indicator Indicates DRG version submitted in the data. Appendix J shows coding to be used for this field. This field should be coded for all records submitted in the Inpatient claims data file.

MDC

Use standard MDC definitions. Include data for all MDCs. Some claims can be mapped to more than one MDC. Admissions at Skilled Nursing Facilities should be coded as MDC 95. For all admissions where the MDC is unknown or ungroupable, MDC 99 should be used.

Number of Admissions If a patient is transferred to a different facility, a new admission record should be created. Please ensure that your admission counts are net of any reversals (negative adjustments). Reversals should offset admission counts and financial data in your dataset and should not be counted as additional admissions.

# of Covered Days Total number of covered inpatient days related to the admissions defined above. All non-covered days should be excluded from the day count. For claims where the admission and discharge date are the same, Number of Covered days should be set to 1. There should be no IP claims with 0 days. Please ensure that your day counts are net of any reversals (negative adjustments). Reversals should offset day counts and financial data in your dataset and should not be counted as additional days.

FIELDS FOR OUTPATIENT FACILITY CLAIMS

For Inpatient and Outpatient Facility Events, there are situations where Emergency Room visits turn into Inpatient Admissions. In addition, it is also possible that an Emergency Room visit could have an Outpatient Surgery related to it. As such, a hierarchy to define types of Events is needed. Please refer to page 2 of this document for classification of facility events into Inpatient and Outpatient categories.

• All claims should be included

• This is for facility claims only. No professional fees associated with facility services should be included.

• If a carrier is unable to separate the facility and professional components of a claim, all lines of the claim should be included as Outpatient Facility events (use Appendix C to determine if the event type should be summarized into a Case or included by Procedure). For these events, a modifier of “GF” (Global Fee) should be used to indicate that the facility and professional components of the claim are both included in Outpatient Facility.

• Carriers should use the actuarial certification to disclose the number of Outpatient Facility events and associated Eligible Billed charges where the following occur:

o Facility and professional utilization and/or charges cannot be separated and o a CPT Code Modifier of “GF” is not used (see definition of CPT Code Modifier below)

• Include data for all outpatient facility types (hospital, independent/freestanding labs and centers, ambulatory surgery centers, rehabilitation center, and mental health hospitals)

• Any Professional claims with Revenue Codes and/or CPT/HCPCS codes in the ranges defined as “Ancillary” Outpatient Facility claims (see Appendix C) should be excluded from Professional claims and included as Outpatient Facility “Ancillary” claims

• For claim lines coded with Revenue Codes 960-989, the following criteria should be used to determine if the claim line should be included in Outpatient Facility or Professional claims:

o If the claim line has a Revenue Code between 960 and 989 AND has a CPT/HCPCS code coded on the claim line, the claim line should be included as a Professional claim and the CPT/HCPCS code should be reported as prescribed for Professional claims o Otherwise, the claim should be categorized as an Outpatient Facility claims

• Exclude utilization and charge data for any unpaid, non-covered services associated with ineligible charges as defined above

For the most part, Outpatient Facility Claims use the same definitions as Inpatient Facility Claims.

Several Inpatient Facility Claim fields are not collected for Outpatient Facility Claims. They are:

Catastrophic Indicator, DRG, MDC, Number of Admissions and Number of Covered Days.

Outpatient Facility Claim fields that are different than fields for other claim types and their related definitions are as follows:

Outpatient Type of Service There are six types of services for outpatient facility claims. Appendix C defines the types of services for outpatient facility claims and also describes how to count the number of services for each category

CPT Code and CPT Code Modifiers For Radiology and Pathology services, there are situations where a service will have both a Revenue Code and CPT code. In order to ensure consistent collection and treatment of data among carriers, this data submission requires that the combination of CPT Code and Modifier (as defined in Appendix E of this document) be submitted as aggregation variables for any Outpatient Facility Radiology or Pathology services coded with both a Revenue Code and CPT code.

Number of Services The requested counting methods for each Outpatient Type of Service are shown in Appendix C. Please ensure that your numbers of service counts are net of any reversals (negative adjustments). Reversals should offset service counts and financial data in your dataset and should not be counted as additional services.

FIELDS FOR PROFESSIONAL CLAIMS

• All claims should be included

• This is for professional claims only. For claims where there is a facility (technical) and professional component, only the professional component should be included.

• If a carrier is unable to separate the facility and professional components of a claim, all lines of the claim should be included as Outpatient Facility events (see page 9 for coding of these claims)

• Any Professional claims with Revenue Codes and/or CPT/HCPCS codes in the ranges defined as “Ancillary” Outpatient Facility claims should be excluded from Professional claims and included as Outpatient Facility “Ancillary” claims (see Appendix C for these codes)

• For claim lines coded with Revenue Codes 960-989, the following criteria should be used to determine if the claim line should be included in Outpatient Facility or Professional claims:

o If the claim line has a Revenue Code between 960 and 989 AND has a CPT/HCPCS code coded on the claim line, the claim line should be included as a Professional claim o Otherwise, the claim should be categorized as an Outpatient Facility claims

• Exclude utilization and charge data for any unpaid, non-covered services associated with ineligible charges as defined above

For Professional claims, data for 300 specific CPT/HCPCS codes has been requested. Codes not specified in this list of 300 should be grouped into ranges based on the first character of the code.

Appendix D outlines the requested codes and ranges.

In addition, data by modifier associated with specified and grouped CPT/HCPCS codes has been requested. Appendix D shows the modifiers by CPT code range that should be submitted. As carriers may have homegrown modifiers or CPT/HCPCS codes, it is required that each carrier affirm that they have been diligent in researching homegrown codes and mapping them appropriately into the CPT/HCPCS and modifier combinations requested.

Where fields have similar names, Professional Claims use the same definitions as Outpatient Facility Claims. Professional Claim fields that are different than fields for other claim types and their related definitions are as follows:

CPT Code Appendix D of this document includes both the 320 specified codes as well as the grouping of codes not specified.

CPT Code Modifier Defined in Appendix E. Modifiers to be submitted for Professional claims vary by code range as shown in Appendix D

Number of Procedures For all codes, code ranges and modifier combinations, the number of procedures equals the number of claim lines that the code and modifier combination occur. Please ensure that your procedure counts are net of any reversals (negative adjustments). Reversals should offset procedures and financial data in your dataset and should not be counted as additional claim lines.

FIELDS FOR ALL CLAIMS WITH BENEFIT/CONTRACT STATUS OF “OC”,

“IX” or “OX”

• Definitions should be the same as used above in the Inpatient, Outpatient and Professional definitions

• Data will be aggregated at the 3-Digit Zip Code, Product and Type of Service level for these claims

Noncontracted Savings Indicator for Negotiated Savings with Noncontracted Providers Default value is “N”. The Noncontracted Savings Indicator should be set to “Y” for claims categorized with Benefit/Contracting Status of IX or OX where:

• A carrier is able to negotiate a contracted savings with the noncontracted provider and

• The provider cannot balance bill the member for the contracted savings.

Please note that all claims submitted should be coded with an indicator for this field and that this field should not be left blank.

Type of Service Indicator Indicates whether the record represents Inpatient (I), Outpatient (O) or Professional/Other claims (P).

Claims with Revenue codes and/or CPT/HCPCS codes defined as Outpatient Facility “Ancillary” on Appendix C should be labeled as Outpatient (O).

FIELDS FOR OTHER PROVIDER PAYMENTS

• The information presented in this section applies to the Other Provider Payments data file as shown in Appendix A.

• All other provider payments paid to providers during the requested time period from all sources above the amounts reported in the Claims Data files. This amount is intended to capture ALL additional payments to providers that are not already included in the Claims Data file, except for those amounts excluded in the Data Content section. Other provider payments are to be included if paid during the requested time period. The Other Provider Payment amounts should be split into the two categories described below.

• Please elaborate on the methodology used to gather and assign Other Provider Payment amounts in the Data Certification.

Other Provider Payment Type

Carriers should identify which type of service the Other Provider Payments payment covered. For example: Inpatient Facility, Outpatient Facility, or Professional. If the carrier believes other values are needed please define the additional Other Provider Payments Types used in the Data Certification.

Other Provider Payment $ - Direct

Should include all other provider payments that are applicable to medical coverage and directly charged back to the employer. Examples of these payments (but not an exclusive list) include: withholds, pay for performance payments, risk settlements, bonus payments, pre-payments, provider incentives due to risk sharing arrangements, care collaboration fees, unit cost escalator buy-downs, and provider fees to fund administrative functions.

Other Provider Payment $ - Indirect

Should include all other provider payments that are applicable to medical coverage and not directly charged back to the employer. Examples of these payments (but not an exclusive list) include:

withholds, pay for performance payments, risk settlements, bonus payments, pre-payments, provider incentives due to risk sharing arrangements, care collaboration fees, unit cost escalator buy-downs, and provider fees to fund administrative functions.

Appendix A – Detailed Data Layout

INPATIENT FACILITY CLAIMS (“IC” Claims Only) File should be provided in tab-delimited format

Field

Notes/Sample Values

Aggregation

Function

REQUIRED FIELDS

1 Organization Name Name of organization providing data Group by

2 Service Period

Dates of service represented by data submission in format MMDDYY-MMDDYY. First date should be the start date and second date should be end date. As an example, calendar year

2019 data, this field would be populated as 010119-123119. If period is not equal to 12 months, it should be disclosed on the actuarial certification

Group by

3 3 Digit Patient ZIP Code

Use patient’s residential zip code. If the patient’s zip code is not available, use employee zip code. If neither the patient or employee zip code are available, zip code should be set to “ZZZ”

Group by

4 Product Indicator See page 3 for instructions Group by

5 Benefit/Contract Status Indicator This level of detail only required for “IC” claims. IC claims are services rendered by contracted providers where the benefit is paid at in-network levels

Group by

6 Arrangement/Group Size Indicator

FS - Fully-insured; Small Group

FL - Fully-insured; Large Group

FU - Fully-insured; Unknown Group Size

SL - Self-insured; Large Group See page 5 for instructions.

Group by

7 Pay as Billed Provider Indicator Y= Claims carrier requests to be considered Pay as Billed

N= Other

Group by

8 Catastrophic Indicator 0 = IP Event with total Allowed amount between $150,000 and $299,999.99

1 = IP Event with total Allowed amount equal to or more than $300,000

N = All other IP events

Group by

9 Diagnosis Related Groups

(DRG)

Based on discharge DRG. Use coding system MS-DRG v36 Group by

10 DRG Version Indicator Indicates the DRG version submitted in the data. Should be populated with a value for all records. See Appendix J for coding instructions.

Group by

11 Major Diagnostic Category

(MDC)

Report data for all MDCs. Should be based on DRG submitted Group by

12 Actual Data Filler Indicates beginning of “Actual” financial fields. Fill field with

“AC”

13 Actual Number of Admissions

If a patient is transferred to a different facility, a new admission record should be created. Please ensure that your admission counts are net of any reversals (negative adjustments). Reversals should offset admission counts and financial data in your dataset and should not be counted as additional admissions.

Sum

Function

14 Actual Number of Covered Days

Total number of covered inpatient days related to the admissions defined above. All non-covered days should be excluded from the day count. For claims where the admission and discharge date are the same, Number of Covered days should be set to 1.

There should be no IP claims with 0 days. Please ensure that your day counts are net of any reversals (negative adjustments).

Reversals should offset day counts and financial data in your dataset and should not be counted as additional days.

Sum

15 Actual Eligible Billed $

Submitted charges after ineligible charges are removed, but before the savings due to negotiated discounts are taken.

Sum

16 Actual Negotiated Savings $

Savings due to negotiated discount Sum

17 Actual Allowed $

Total plan approved amount prior to member cost-sharing, net of R&C cutbacks for IX and OX claims.

Sum

18 Actual Paid $

Sometimes referred to as “Plan Paid Amount”. This is the Allowed Amount reduced for member cost sharing. It represents the actual amount paid by the health plan.

Sum

19 Filler 1 Future Use

20 Filler 2 Future Use

21 Filler 3 Future Use

22 AdjCopyofActual If Adjusted is a copy of Actual data, code as “Y”. Otherwise code as “N”.

Group by

23 Adjusted Data Filler Indicates beginning of “Adjusted” financial fields. Fill field with

“AD”

24 Adjusted

If a patient is transferred to a different facility, a new admission record should be created. Please ensure that your admission counts are net of any reversals (negative adjustments). Reversals should offset admission counts and financial data in your dataset and should not be counted as additional admissions.

Sum

25 Adjusted Number of Covered Days

Total number of covered inpatient days related to the admissions defined above. All non-covered days should be excluded from the day count. For claims where the admission and discharge date are the same, Number of Covered days should be set to 1.

There should be no IP claims with 0 days. Please ensure that your day counts are net of any reversals (negative adjustments).

Reversals should offset day counts and financial data in your dataset and should not be counted as additional days.

Sum

26 Adjusted Eligible Billed $

Submitted charges after ineligible charges are removed, but before the savings due to negotiated discounts are taken.

Sum

27 Adjusted Negotiated Savings $

Savings due to negotiated discount

28 Adjusted Allowed $

Total plan approved amount prior to member cost-sharing, net of R&C cutbacks for IX and OX claims.

Function

29 Adjusted Paid $

Sometimes referred to as “Plan Paid Amount”. This is the Allowed Amount reduced for member cost sharing. It represents the actual amount paid by the health plan.

Sum

30 Filler 5 Future Use

31 Filler 6 Future Use

32 Filler 7 Future Use

33 ProCopyofAdj If Projected is a copy of Adjusted data, code as “Y”. Otherwise code as “N”.

34 Projected Data Filler

Indicates beginning of “Projected” financial fields. Fill field with

“PR”

35 Projected

If a patient is transferred to a different facility, a new admission record should be created. Please ensure that your admission counts are net of any reversals (negative adjustments). Reversals should offset admission counts and financial data in your dataset and should not be counted as additional admissions.

Sum

36 Projected Number of Covered Days

Total number of covered inpatient days related to the admissions defined above. All non-covered days should be excluded from the day count. For claims where the admission and discharge date are the same, Number of Covered days should be set to 1.

There should be no IP claims with 0 days. Please ensure that your day counts are net of any reversals (negative adjustments).

Reversals should offset day counts and financial data in your dataset and should not be counted as additional days.

Sum

37 Projected Eligible Billed $

Submitted charges after ineligible charges are removed, but before the savings due to negotiated discounts are taken.

Sum

38 Projected Negotiated Savings $

Savings due to negotiated discount Sum

39 Projected Allowed $

Total plan approved amount prior to member cost-sharing, net of R&C cutbacks for IX and OX claims.

Sum

40 Filler 8 Future Use

41 Filler 9 Future Use

42 Filler 10 Future Use

43 Filler 11 Future Use

44 Filler 12 Future Use

45 Filler 13 Future Use

46 Filler 14 Future Use

47 Filler 15 Future Use

OUTPATIENT FACILITY CLAIMS (“IC” Claims Only)

Function

REQUIRED FIELDS

second date should be end date. As an example, for calendar year

2019 data, this field would be populated as 010119-123119. If period is not equal to 12 months, it should be disclosed on the actuarial certification available, use employee zip code. If neither the patient or employee zip code are available, zip code should be set to “ZZZ”

Group by

4 Product Indicator See page 3 for instructions Group by

5 Benefit/Contract Status Indicator This level of detail only required for “IC” claims. IC claims are services rendered by contracted providers where the benefit is paid at in-network levels

Group by

6 Arrangement/Group Size Indicator

FS - Fully-insured; Small Group

FL - Fully-insured;…