Direct Data Submission (DDS) 2014 Report Year Insurance Coverage Data Field Specifications & Codes

Transcription

1 Why is submitting accurate insurance data important? The insurance coverage code and member ID number are required data for Direct Data Submission (DDS). MNCM shares this information with the identified health plan who maps the member ID to the insurance product category (e.g., Commercial/Private insurance, Medicare, Minnesota Health Care Programs). Submitting accurate data is important and can benefit your clinic. This information will be used the following ways: 1. Minnesota Department Health: Risk adjustment of statewide data by product. 2. MNCM Health Care Disparities Report: Segments results by product and makes comparisons by product. 3. Payment incentives: MN Bridges to Excellence purchasers uses counts to calculate incentive payments for clinics. What insurance data is collected and submitted? Code. Enter one of the designated insurance codes (see page 3) into the Code field of the DDS data file. The insurance code must reflect the name of the payer as seen on the patient s card (logo and name). The code and patient s member ID must correspond with the patient s insurance coverage at the most recent encounter on or prior to the last day of the measurement period (e.g., 12/31/YYYY, 01/31/YYYY, 03/31/YYYY, 06/30/YYYY). Health Plan/Member ID. Enter the member ID of the patient. Do not enter group numbers and do not enter member IDs that are Social Security Numbers. Examples of health plan names shown on a patient s card: Blue Cross Blue Shield of Minnesota HealthPartners (Medicare managed care plan) Medica (Minnesota Health Care Programs managed by health plan) Medicare Health Insurance Minnesota Department of Human Services UCare Enter the following code: [1] BCBS of MN [3] HealthPartners [4] Medica [8] Medicare fee-for-service [13] MN DHS, Medicaid fee-for-service [7] Ucare XYZ Health Insurance Co. Use the payer name and logo on the patient s insurance card to identify the correct code to enter in the DDS data file Health Plan Product Patient Name Group Number Member ID Number Find the Member ID on the patient s insurance card Enter this ID in the DDS data file Page 1

2 Field Specifications for Patient Data Below are the field specifications and codes for reporting patient insurance coverage information for DDS. Summary of Changes New Code If a patient has requested to restrict disclosure of PHI to a health plan per the HITECH Act, please enter Code 37 into the Code and enter the payer type in the Other Description field. Please see table of codes for more information. Field Name Notes Excel Format Example Code Using the list of codes on page 3, enter the code that corresponds with the patient s insurance coverage at the most recent encounter on or prior to the last day of the measurement period: Optimal Diabetes Care, Optimal Vascular Care: 12/31/2013 Depression Care: 05/31/2013 (file 1) 09/30/2013 (file 2) 01/31/2014 (file 3) Total Knee Replacement: 03/31/2014 Optimal Asthma Care, Colorectal Cancer Screening, Maternity Care: Primary C-section: 06/30/2014 Look at the patient s insurance card and note the name and logo of the payer. If the payer name does not correspond to one of the codes listed on page 3, enter code 99 and the name of the payer in the Other Description field. Blank values will create an ERROR upon submission. Number 1 Other Description If code 99 was entered in the Code field (above field), enter the name of the insurance payer. If Code (above field) is not 99, leave blank. Text Assurant Health Page 2

3 Insurance Plan Member ID Enter the patient's Health Plan/Insurance Plan Member ID. IMPORTANT: Format Excel field as TEXT in the Excel spreadsheet. Always work in the Excel file (do not work in a.csv file as this will alter the format of the data.) Include leading zeros (e.g., ) Do NOT enter hyphens or spaces. Do NOT enter Social Security Numbers (e.g., code 8, Medicare Fee-for- Service product), enter 999. If the patient does not use or have insurance (self-pay or uninsured), leave this field blank. Leave BLANK if Code 37 is used in the Code field Please note the helpful member ID formatting tips on for payers on the following page. Please refer to card examples in Appendix A to assist in identifying the Insurance Plan Member ID. Text FBOXZ79269 Page 3

4 Codes for Patient Information Code Payer Name Notes 18 Aetna 33 Allina Partners Care 27 America s PPO 22 American Family 1 Blue Cross Blue Shield of Minnesota 15 Blue Cross Blue Shield (not Minnesota) Including but not limited to Aware Gold, Blue Plus, Options Blue, Preferred Gold, Simply Blue, PMAP, MinnesotaCare, MSHO, Medicare managed care products Please see Appendix A in this document for examples of Blue Cross Blue Shield of Minnesota insurance cards NOTE the following: Commercial member IDs always start with a three character prefix followed an XZ followed by nine digits. Public Program member IDs always start with the three character prefix XZG followed by nine digits that start with the number eight. Federal employee member IDs start with an R followed by eight digits. Anthem, etc. 17 Cigna Including but not limited to Great West, etc. 23 Comprehensive Care Services 32 HealthEOS 3 HealthPartners Including but not limited to individual or group plans, PMAP, MinnesotaCare, MSHO, Medicare managed care products NOTE: Member IDs are always numeric 37 HITECH Act Only use this code if patient requested restriction per the HITECH Act and a description must be included in Other Description Field to indicate with payer type the patient has using one of the following descriptions: Commercial Medicare MHCP If patient is covered by Medicare Fee-for-Service, enter Code 8 If patient is truly self-pay/uninsured, enter Code 16 Do not enter an Insurance Plan Member ID if this code is used 14 Humana 21 Indian Health Services Page 4

5 Code Payer Name Notes 11 Itasca Medical Care Including but not limited to PMAP, MinnesotaCare, MSHO, Medicare managed care products 4 Medica Including but not limited to Patient Choice, Definity Health, Elect, Essential, Insights, LaborCare, Medica Choice, Premier, Primary, Select Care, PMAP, MinnesotaCare, MSHO, Medicare managed care products 13 Minnesota Department of Human Services (DHS) 20 Medicaid (not Minnesota) 8 Medicare Health Insurance (Fee-for- Service and supplemental plans) 5 Metropolitan Health Plan (MHP) 30 MMSI (Mayo Management Services Inc.) Medicaid Fee-For-Service Including but not limited to Pyramid Life, Tricare (including TriWest), Unicare, ZMedicare NOTE: Member IDs are typically SSNs, therefore enter the code (8) but leave the Member ID field blank. Including but not limited to PMAP, MinnesotaCare, MSHO, Medicare managed care products 6 Preferred One NOTE: Member IDs are always 11 digits, typically starting with 8 10 PrimeWest Including but not limited to PMAP, MinnesotaCare, MSHO, Medicare managed care products 25 Prudential 12 Sanford Health Plan 34 Security Health Plan 16 Self-pay Patient pays for services out-of-pocket Includes sliding fee payments 9 South Country Health Alliance (SCHA) 24 State Farm 26 Travelers Insurance Including but not limited to PMAP, MinnesotaCare, MSHO 7 UCare Including but not limited to PMAP, MinnesotaCare, MSHO, Medicare managed care products NOTE: Member ID format is typically 000######00 where the # is a numeric digit 28 UMR (formerly Wausau) 29 Uninsured Patient does not have health insurance Page 5

6 Code Payer Name Notes 31 United Health Care 19 Veterans Administration (VA, CHAMPVA) 99 Other If 99 is entered, description on plan must be included in Insurance Coverage Other Description Field Other information Medicare managed care plans Enter the code of the payer that manages the Medicare managed care plan (e.g., 1,3,4,5,7,10) Minnesota Health Care Programs (MHCP) Medical Assistance MSHO (Minnesota Senior Health Options) MinnesotaCare PMAP (Prepaid Medical Assistance Program) Motor vehicle insurance Sage (breast and cervical cancer screening coverage) PLEASE NOTE: It benefits your clinic to accurately identify the payer. The information is used for the purposes of pay-for-performance programs (e.g. health plans, MN Bridges to Excellence). Therefore, please identify the payer that manages the coverage and enter the appropriate code. If you are unable to identify the payer but know that the coverage is MHCP, enter code 36 Please do not enter these types of coverage. Instead, please enter the code of the patient s most recent health care coverage prior to or after these types of coverage, within the measurement period Workers Compensation Insurance coverage code not listed (Other) If the payer is not one of the codes listed above, enter code 99 and write in the name of the payer in the Other Description field Page 6

7 Appendix A Insurance Card Examples Blue Cross Blue Shield of Minnesota Below are examples of BlueCross BlueShield insurance cards. Please use these examples to assist in determining the patient s insurance plan member ID. Commercial Member Insurance Card State Public Program Member Insurance Card Federal Employee Member Insurance Card Page 7

8 HealthPartners Below are examples of HealthPartners insurance cards. Please use these examples to assist in determining the patient s insurance plan member ID. HealthPartners Open Access Page 8

9 Medica Below are examples of Medica insurance cards. Please use these examples to assist in determining the patient s insurance plan member ID. Medica Direct HSA Medica Choice Classic Page 9

10 Metropolitan Health Plan Below are examples of Metropolitan Health Plan insurance cards. Please use these examples to assist in determining the patient s insurance plan member ID. Hennepin Health Plan Cornerstone Solutions MSHO: Clinic Selected MSHO: Clinic not selected Page 10

11 PreferredOne Direct Data Submission (DDS) 2014 Report Year Below are examples of PreferredOne insurance cards. Please use these examples to assist in determining the patient s insurance plan member ID. PreferredOne Insurance Company Card 1 PreferredOne Insurance Company Card 2 Page 11

12 PreferredOne Administrative Services Card 1 PreferredOne Administrative Services Card 2 Page 12

13 PreferredOne Community Health Plan Card 1 PreferredOne Community Health Plan Card 2 Page 13