AGENCY FOR HEALTH CARE ADMINISTRATION
Hospital and Nursing Home Reporting Systems and Other Provisions Relating to Hospitals
RULE NO.:RULE TITLE:
59E-9.010Claims Data Collection
NOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 43 No. 238, December 12, 2017 issue of the Florida Administrative Register.
This change is being made to address comments received from the public and Joint Administrative Procedures Committee. The following sections of the proposed rule will be changed to read:
59E-9.010 Claims Data Collection
(1) Definitions.
(a) through (f) No change.
(g) “Payer” means health insurers as defined in Chapter 624 627 or Health Maintenance Organizations as defined in Chapter 641, including their Affiliates, that participate in the Florida state group health insurance plan created under s. 110.123, F.S. or Medicaid managed care pursuant to Part IV of Chapter 409.
(h) through (j) No change.
(2) Claims Data Collected.
(a) No change.
(b) Payers shall be exempt from providing Claims Data from health plans covered by the Employer Retirement Income Security Act (ERISA) of 1974 when such employer(s) affirmatively elects not to share these Claims Data. The Vendor shall collect Claims Data from employers with health plans covered by the Employee Retirement Income Security Act (ERISA) of 1974 held by Payers with permission from the self-insured employers.
(c) through (d) No change.
(3) Claims Data Submission.
(a) through (b) No change.
(c) The submission of Claims Data by Payers will be pursuant to a Data Contribution Agreement hereby incorporated by reference as Exhibit B, AHCA Form 4200-0008, November 2017, in the Submission Guide and specified by the Agency and subject to federal and state law and regulation. Payers cannot condition submission on any additional terms, conditions, or restrictions.
(4) Claims Data Audit, Resubmission, and Certification Procedures.
(a) No change.
(b) All Payers submitting data in compliance with this rule shall certify that the data submitted is accurate, complete and verifiable using the Certification of Claims Form hereby incorporated by reference in Exhibit A, AHCA Form 4200-0007, November 2017, in the Submission Guide.
(5) Requirements for Claims Data Publication.
(a) through (d) No change.
Rulemaking Authority: s. 408.05(3)(e), F.S., Law Implemented: s. 408.05(3), F.S. New______
The following changes have been made to Florida Claims Data Submission Guide “AKA Submission Guide” incorporated by reference in 59E-9.010 Claims Data Collection:
On Page 4:
Payer definition will be changed to: “Payer - health insurers as defined in Chapter 624 627, F.S., or Health Maintenance Organizations as defined in Chapter 641, F.S., including their Affiliates, that participate in the Florida state group health insurance plan created under Section 110.123, F.S. or Medicaid managed care pursuant to Part IV of Chapter 409, F.S.”
On Page 5:
Revised the Payer’s submission requirements of which Employer Retirement Income Security Act (ERISA) claims in “a. Which Claims”: “If a Payer holds Claims Data from employers insured under the Employee Retirement Income Security Act (ERISA), Payers shall be exempt from providing Claims Data from health plans covered by the ERISA when such employer(s) affirmatively elects not to share these Claims Data. these data may be submitted pursuant to permission from the self-insured employers.
Clarified submission requirements for “b. For Which Individuals”: For each Payer -- all Claims Data held for Florida Covered Lives. as well as claims data held by Payers for ERISA plans as voluntarily submitted.
Revised submission requirements for “c. For Which Years” for initial data contribution: Initial Data Contribution: Each Payer shall provide the prior three complete calendar years (2015, 2016, and 2017 2014, 2015, and 2016) of Member Eligibility, Medical and Pharmacy Claims Data per the File Specifications and Data Dictionary documented in the following sections.
On Page 88:
Revised delivery timetable for “Initial Year of Data Submission”:
Sample file initial year of data submission: Effective Date of Final Rule and Plus 105 90 days
Production file initial year of data submission: Effective Date of Final Rule and Plus 165 120 days
Sample file initial year of data “Incurred Years”: 2015–2017 2014 -2016
Production file initial year of data “Incurred Years”: 2015–2017 2014 -2016
Claims Paid Date Cutoff for sample file initial year of data: 06/30/2018 2017
Claims Paid Date Cutoff for production file initial year of data: 06/30/2018 2017
File Type
Due Date
Incurred YRs
Claims Paid Date Cutoff
Sample
Effective Date of Final Rule and Plus 105 90 days
2015-2017 2014-2016
06/30/2018 2017
Production
Effective Date of Final Rule and Plus 165 120 days
2015-2017 2014-2016
06/30/2018 2017
Revised delivery timetable for “Subsequent Years of Data Submission”: Removed 2017 data from timetable as the data is submitted in “Initial Year of Data Submission”:
File Type
Due Date
Incurred YR
Claims Paid Date Cutoff
Sample
07/15/2018
2017
06/30/2018
Production
09/15/2018
2017
06/30/2018
On Page 92:
Added footer to Exhibit A- Certification of Claims Form 4200-0007 in Submission Guide.
On Pages 93 through 97
Added footer to Exhibit B- Data Contribution Agreement Form 4200-0008 in Submission Guide
