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 claim The reporting of Zero Paid under a payment’, that is considered by Medical Claims is required ‘global ‘paid’ or payment’ thus the carrier should appear in to accurately capture ‘capitated zero paid, be reported in this filing. Paid amount encounters and to further this file. should be reported as 0 and understand contractual the 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. 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 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 ‘Member’ in the specification. Are are to be used in the same specification to strengthen manner in this specification the reporting bond between
will be de-duplicated at CHIA. 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 under a ‘global payment’, or ‘capitated payment’ thus zero paid, be reported in this file. Yes. Any medical claim 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. 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 rules for each specific type will provide cleaner analysis. The word ‘Member’ is used in the specification. Are Yes. Member and Patient are to be used in the same manner in this specification Member is used in the specification to strengthen the reporting bond between
apcd-medical-claim-file-submission-guide.docx