N.M. Admin. Code § 7.1.31.9

Current through Register Vol. 35, No. 21, November 5, 2024

Section 7.1.31.9 - SUBMISSION OF CLAIMS DATA TO DATABASE

A.All-payer claims database data providers:

(1) Data providers must submit all available data and health information with necessary identifiers to the database as described in the APCD-Common Data Layout (APCD-CDLT, Version 2.1 with errata, Copyright 2021 by APCD Council, National Association of Health Data Organizations, the University of New Hampshire) within the time frames in this rule and in accordance with procedures established herein.

(2) Any data provider used by an entity that participates in the database such as a third-party administrator or pharmacy benefit manager must provide claims data to the department or the data vendor upon request of the entity.

(3) The following plans or entities may voluntarily provide claims data to the database within the time frames and in accordance with procedures established by the department:

(a) Employer sponsored plans subject to the Employee Retirement Income Security Act of 1974; and

(b) any governmental or tribal program or facility that provides health care services to American Indians and Alaska Natives.

(4) Health insurance carriers that only offer the following excepted benefit coverages are not required to report:

(a) specific disease;

(b) accident or injury;

(c) hospital indemnity and other fixed indemnity;

(d) disability;

(e) long-term care; and

(f) vision coverage.

(5) Medicaid managed care organizations provide claims data to the New Mexico human services division (HSD), and who will then submit that data to the department of health.

(6) Health insurance carriers covering less than 500 individuals are not required to submit files to the database but are required to report the number of individuals with coverage during the previous year on March 1st.

B.Data submission procedures:

(1) The department shall:

(a) utilize an internet-based user interface (or similar technology) that allows for secure submission and acceptance of data submissions;

(b) perform quality assurance and validation of all submitted data and provide feedback to the data providers; and

(c) provide data submissions procedures to data providers in a data submission guide that is based on a current version of the APCD-Common Data Layout.

(2) Data submission frequency: data shall be submitted at least monthly.

(3) Data providers shall make every effort to initially submit complete, accurate, and valid data in the APCD-Common Data Layout and shall correct all identified errors within the timelines established by the department or its designee.

(4) An initial test submission of data may be required.

(5) Data dating to January 1, 2020 must be submitted initially.

(6) The department may sanction data providers who do not comply with this rule.

(7) Data shall be submitted beginning January 1, 2023.

N.M. Admin. Code § 7.1.31.9

Adopted by New Mexico Register, Volume XXXII, Issue 08, April 20, 2021, eff. 4/20/2021, Amended by New Mexico Register, Volume XXXIV, Issue 08, April 25, 2023, eff. 4/25/2023