Should previously paid but Yes. Claims that were paid The reporting of Voided now Voided be and reported in one period Claims maintains logic reported? and voided by either the integrity related to medical Provider or the Carrier in a costs and utilization. subsequent period should be reported in the subsequent file. See MC139 below. What types of claims are to The Medical Claims file is CHIA has adopted the most be included? used to report both widely used specification at institutional and this time. It is important to professional claims. The note that adhering to claim unique elements that apply rules for each specific type to each are included; will provide cleaner however only those analysis. elements that apply to the claim type should be submitted. Example: Diagnostic Pointer is a Professional Claim element and would not be a required element on an Institutional Claim record. See MC094 below for claim type ID. The word is used Yes. Member and Patient Member is used in the claim ‘Member’ in the specification. Are are to be used in the same specification to strengthen and manner in this specification the reporting bond between ‘Member’ ‘Patient’ used synonymously? Member Eligibility and the claims attached to a Member. If claims are processed by a In instances where more CHIA’s objective is to third-party administrator, than one entity administers create a comprehensive who is responsible for a health plan, the health All-Payer database which submitting the data and how care carrier and third-party must include data from all should the data be administrators are health care carriers and all submitted? responsible for submitting their third-party data according to the administrators (TPAs, specifications and format PBMs, DBAs, CSOs, etc.). defined in the Submission Guides. CHIA expects each party to report the Organization ID of the other party in the Delegated Benefit Organization ID (MC100) field to assist in
Should previously paid but now Voided be reported? Yes. Claims that were paid and reported in one period and voided by either the Provider or the Carrier in a subsequent period should be reported in the subsequent file. See MC139 below. The reporting of Voided Claims maintains logic integrity related to medical costs and utilization. What types of claims are to be included? The Medical Claims file is used to report both institutional and professional claims. The unique elements that apply to each are included; however only those elements that apply to the claim type should be submitted. Example: Diagnostic Pointer is a Professional Claim element and would not be a required element on an Institutional Claim record. See MC094 below for claim type ID. CHIA has adopted the most widely used specification at this time. It is important to note that adhering to claim rules for each specific type will provide cleaner analysis. The word ‘Member’ is used in the specification. Are ‘Member’ and ‘Patient’ used synonymously? Yes. Member and Patient are to be used in the same manner in this specification Member is used in the claim specification to strengthen the reporting bond between Member Eligibility and the claims attached to a Member. If claims are processed by a third-party administrator, who is responsible for submitting the data and how should the data be submitted? In instances where more than one entity administers a health plan, the health care carrier and third-party administrators are responsible for submitting data according to the specifications and format defined in the Submission Guides. CHIA expects each party to report the Organization ID of the other party in the Delegated Benefit Organization ID (MC100) field to assist in CHIA’s objective is to create a comprehensive All-Payer database which must include data from all health care carriers and all their third-party administrators (TPAs, PBMs, DBAs, CSOs, etc.).
v6-apcd-medical-claim-file-submission-guide-Redline-.docx