The APCD Monthly Medical Claims File As part of the MA APCD, submitters are required to submit a Medical Claims File. CHIA, in an effort to decrease any programming burden, has maintained the file layout previously used. 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 better-directed 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 Medical 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 field length asterisk within an element in lieu of delimited file another character. Example: if the file includes in the Last “Smith*Jones” Name, the system will read an incorrect number of elements and drop the file. What each row in the file Each row represents a claim It is necessary to obtain line represents line. If there are multiple item data to better services performed and understand how services are billed on a claim, each of perceived and adjudicated those services will be by different carriers. uniquely identified and reported on a line. Won’t reporting lines Yes, certain data elements Claim-line level data is create redundancy? of claim level data will be required to capture accurate repeated in every row in details of claims and order to report unique line encounters. item processing. The repeated claim level data will be de-duplicated at CHIA.
The APCD Monthly Medical Claims File As part of the MA APCD, submitters are required to submit a Medical Claims File. CHIA, in an effort to decrease any programming burden, has maintained the file layout previously used. 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 better-directed 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 Medical 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 field length asterisk delimited file An asterisk cannot be used within an element in lieu of another character. Example: if the file includes “Smith*Jones” 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 claim 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 better understand how services are perceived and adjudicated by different carriers. Won’t reporting lines create redundancy? Yes, certain data elements of claim level data will be repeated in every row in order to report unique line item processing. The repeated claim level data will be de-duplicated at CHIA. Claim-line level data is required to capture accurate details of claims and encounters.
v3-1-apcd-medical-claim-file-submission-guide-2013-06.docx