Section Ins 4005.01 - Required Filers and Data Sets(a) In accordance with the submission schedule set forth in Ins 4004, each carrier and third-party administrator shall submit to the department or its designee a complete and accurate health care claims data set.(b) Carriers and third-party administrators shall submit health care claims data for all residents of New Hampshire and for all members who receive services under a policy issued in New Hampshire, as follows: (1) Any policy that provides coverage to the employees of a New Hampshire employer that has a business location in New Hampshire shall be considered a policy that is issued in New Hampshire;(2) An out-of-state employer's branch location in New Hampshire shall be considered a New Hampshire employer, and the carrier and third-party administrator shall submit a claims data set for all members who are employed at that branch location; and(3) Carriers and third-party administrators shall submit health care claims data for New Hampshire state and municipal employees.(c) When more than one entity is involved in the administration of a policy, data shall be submitted in accordance with the following: (1) A carrier shall be responsible for submitting the claims data on policies that it has written;(2) A third-party administrator shall be responsible for submitting claims data on self-insured plans that it administers;(3) Each carrier and third-party administrator shall submit all health care claims processed by any subcontractor on its behalf, including claims related to pharmacy services, dental services, and behavioral health, mental health, and substance abuse treatment services;(4) Each carrier and third-party administrator shall ensure that the subcontractor is not submitting duplicate claims to the department or its designee if the subcontractor falls under the definition of a carrier, meets the requirements of this section, and is required to submit data as a separate entity; and(5) Each carrier and third-party administrator shall ensure that member and subscriber identifiers in any files processed by subcontracts are consistent with member and subscriber identifiers in the medical and pharmacy claims files and the member eligibility files.(d) Carriers and third-party administrators shall continue to submit claims data for each month in which they meet the criteria and for the 180 days after the month in which the carrier or third-party administrator withdraws or falls below the exclusion criteria listed in Ins 4005.02.N.H. Admin. Code § Ins 4005.01
#8279, eff 2-3-05; ss by #9500, eff 7-6-09
Amended by Volume XXXV Number 32, Filed August 13, 2015, Proposed by #10877, Effective 7/10/2015, Expires7/10/2025.Amended by Volume XL Number 50, Filed December 10, 2020, Proposed by #13136, Effective 11/24/2020, Expires 11/24/2030