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 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 claim lines Yes, certain data elements 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. Are denied claims to be No. Wholly denied claims Denied line items of an reported? should not be reported at adjudicated claim aid with this time. However, if a cost analysis. single procedure is denied within a paid that denied line should be reported. Should claims that are paid Yes. Any medical that The reporting of Zero Paid a payment’, or is considered by the Medical Claims is required ‘global ‘paid’ payment’ thus carrier should appear in this to accurately capture ‘capitated zero paid, be reported in filing. Paid amount should encounters and to further this file. be reported as 0 and the understand contractual corresponding Allowed, arrangements. Contractual, Deductible Amounts should be calculated accordingly. Should previously paid but Yes. Claims that were paid The reporting of Voided now Voided claims 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.
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 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 claim 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. level data is required to capture accurate details of claims and encounters. Are denied claims to be reported? No. Wholly denied claims should not be reported at this time. However, if a single procedure is denied within a paid that denied line should be reported. Denied line items of an adjudicated claim aid with cost analysis. Should claims that are paid a ‘global payment’, or ‘capitated payment’ thus zero paid, be reported in this file. Yes. Any medical that is considered ‘paid’ by the carrier should appear in this filing. Paid amount should be reported as 0 and the corresponding Allowed, Contractual, Deductible Amounts should be calculated accordingly. The reporting of Zero Paid Medical Claims is required to accurately capture encounters and to further understand contractual arrangements. Should previously paid but now Voided claims 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.
v5-apcd-medical-claim-file-submission-guide-REDLINE.docx