1 Del. Admin. Code § 103-4.0
Current through Register Vol. 28, No. 7, January 1, 2025
Section 103-4.0 - Claims Data Submission4.1 Data Submission and Use Agreement: Reporting Entities shall enter into the HCCD Data Submission and Use Agreement, or "DSUA," no later than 90 days after the effective date of this rule. Such agreement shall be incorporated into this regulation as Attachment B.4.2 Submission Guide: The HCCD Administrator shall develop and disseminate a Submission Guide, included as Addendum One to the DSUA. All files must conform to the formats and data quality requirements established in the Submission Guide, generally as follows: | * | Medical Claims File. As detailed in the Submission Guide, Reporting Entities shall report information about all covered services provided to Members in all settings of care under all reimbursement arrangements, including but not limited to fee for service, capitated arrangements, and any other claims-based payment methods. |
| * | Pharmacy Claims File. As detailed in the Submission Guide, Reporting Entities shall report pharmacy paid claims for covered pharmacy benefits that were dispensed to Members. |
| * | Member Eligibility File. As detailed in the Submission Guide, Reporting Entities shall report information on every Member enrolled during the reporting month whether or not the Member utilized services during the reporting period. |
| * | Provider File. As detailed in the Submission Guide, Reporting Entities shall report information that will uniquely identify health care Providers and allow retrieval of related information from eligibility, medical and pharmacy claims files. (1) Tax id numbers shall be submitted as part of the data set except in the case that a provider uses their personal social security number as their tax id number in which case the tax id number need not be submitted. |
4.3 Submission Schedule: Reporting Entities shall submit data files pursuant to the schedule in Attachment A.4.4 Data Submitter Responsibilities: Each Reporting Entity is responsible for the submission of all Required Claims Data processed by any subcontractor on its behalf unless such subcontractor is already submitting the identical Required Claims Data as a Reporting Entity. 4.4.1 Upon notification by the HCCD Administrator, Reporting Entities shall provide corrected, conforming files within 10 business days. The HCCD Administrator may grant extensions of deadlines.4.4.2 The HCCD Administrator may grant temporary or permanent approvals of a Reporting Entity's request for an override of a data submission requirement.4.5 Replacement of Data Files. No Reporting Entity may replace a complete data file submission more than one year after the end of the month in which the file was submitted unless it can establish exceptional circumstances for the replacement. Any replacements after this period must be approved by the HCCD Administrator. Individual adjustment records may be submitted with any monthly data file submission.4.6 Updating Submission Guide: The HCCD Administrator may update reporting specifications annually. Reporting Entities shall submit data that conforms to the updated specifications within 180 days after the effective date of the new version of the Submission Guide.4.7 Submitting Additional Information: The HCCD Administrator may require Reporting Entities to submit information about the insurance product covering each member, including covered services, market sector, plan characteristics, total premiums, deductibles, co-insurance and copayments, by amending the Submission Guide.1 Del. Admin. Code § 103-4.0
21 DE Reg. 293 (10/1/2017) (Final)