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 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. Won’t reporting claim lines Yes, claim level data will be It is necessary to maintain create redundant data? repeated in every row in the link between line item order to report unique line processing and claim level item processing. The data. 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 analysis in the MA APCD single procedure is denied in terms of covered benefits within a paid claim that and/or eligibility. denied line should be reported. Should claims that are paid Yes. Any dental that is The reporting of Zero Paid under a payment’, considered by the Dental Claims aids with the ‘global ‘paid’ thus zero paid, be reported carrier should appear in this analysis of services utilized, in this file. filing. Paid amount should Member Eligibility and be reported as 0 and the deductibles applied. corresponding Allowed, Contractual, Deductible Amounts should be calculated and reported 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 between services Provider or the Submitter utilized and deductibles should be reported in the applied. next file. See DC060 below. 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.
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 understand how services are utilized and adjudicated by different submitters. Won’t reporting claim lines create redundant data? Yes, 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. It is necessary to maintain the link between line item processing and claim level data. 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 claim that denied line should be reported. Denied line items of an adjudicated claim aid with analysis in the MA APCD in terms of covered benefits and/or eligibility. Should claims that are paid under a ‘global payment’, thus zero paid, be reported in this file. Yes. Any dental 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 and reported accordingly. The reporting of Zero Paid Dental Claims aids with the analysis of services utilized, Member Eligibility and deductibles applied. 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 Submitter should be reported in the next file. See DC060 below. The reporting of Voided Claims maintains logic integrity between services utilized and deductibles applied. 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.
v5-apcd-dental-claim-file-submission-guide-REDLINE.docx