PV Provider File – BP Benefit Plan Control Total File – The APCD Monthly Dental Claims File As part of the MA APCD, submitters with dental lines of business will be required to submit a Dental Claims File. CHIA, in an effort to decrease any programming burden, is maintaining its adopted file layout but adjusting some of the elements to insure quality, linkage to other files and continuity of the data set. There are minor changes to this layout so that it will connect appropriately across other required filings for the MA APCD and a few added elements to aid with line of business identification for editing of the data. Below we have provided details on business rules, data definitions and the potential uses of this data. Specification Question Clarification Rationale Frequency of submission Dental claim files are to be CHIA requires this submitted monthly frequency to maintain a current dataset for analysis. What is the format of the Each submission must be a An asterisk cannot be used file variable length asterisk within an element in lieu of delimited file another character. Example: if the file includes in the Last Name, the system will read an incorrect number of elements and drop the file. What each row in the file Each row represents a It is necessary to obtain line represents line. If there are multiple item data to understand how services performed and services are utilized and billed on a claim, each of adjudicated by different those services will be submitters. uniquely identified and reported on a line.
PV – Provider File BP – Benefit Plan Control Total File The APCD Monthly Dental Claims File As part of the MA APCD, submitters with dental lines of business will be required to submit a Dental Claims File. CHIA, in an effort to decrease any programming burden, is maintaining its adopted file layout but adjusting some of the elements to insure quality, linkage to other files and continuity of the data set. There are minor changes to this layout so that it will connect appropriately across other required filings for the MA APCD and a few added elements to aid with line of business identification for editing of the data. Below we have provided details on business rules, data definitions and the potential uses of this data. Specification Question Clarification Rationale Frequency of submission Dental claim files are to be submitted monthly CHIA requires this frequency to maintain a current dataset for analysis. What is the format of the file Each submission must be a variable length asterisk delimited file An asterisk cannot be used within an element in lieu of another character. Example: if the file includes in the Last Name, the system will read an incorrect number of elements and drop the file. What each row in the file represents Each row represents a line. If there are multiple services performed and billed on a claim, each of those services will be uniquely identified and reported on a line. It is necessary to obtain line item data to understand how services are utilized and adjudicated by different submitters.
v3-1-apcd-dental-claim-file-submission-guide-2013-06.docx