Direct Data Submission (DDS) 2015 Report Year Insurance...

Direct Data Submission (DDS) 2015 Report Year Insurance Coverage

Data Field Specifications & Codes

Why is submitting accurate insurance data important? The insurance coverage code and member ID number are required fields in the direct data submission (DDS) process. Submitting accurate data is important and can benefit your clinic. It is used in several ways including:

1. Identifying health plans: Mapping the insurance plan member ID to the insurance product category (e.g., Commercial/Private insurance, Medicare, Minnesota Health Care Programs).

2. Minnesota Department of Health: Risk adjustment of statewide data by product. 3. MN Community Measurement (MNCM) Health Care Disparities Report: Segmenting results and makes

comparisons by product. 4. Payment incentives: MN Bridges to Excellence (BTE) purchasers use counts to calculate incentive

payments for clinics.

What insurance data is collected and submitted? Insurance Coverage Code: Enter one of the designated insurance codes (see Table 1) in the Insurance Coverage Code field of the DDS data file. The insurance code must reflect the name of the insurance payer as seen on the patient’s insurance card. This can be identified through the logo or company name on the card. The code and patient’s insurance plan 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. Insurance Plan Member ID: Enter the insurance plan member ID of the patient.

What insurance data is not collected or submitted? Group numbers or Social Security Numbers

Examples of health plan names shown on a patient’s card Enter the following code (See Table 1 for more codes)

Blue Cross Blue Shield of Minnesota [1] – BCBS of MN HealthPartners (Medicare managed care plan) [3] – HealthPartners Medica (Minnesota Health Care Programs managed by health plan) [4] – Medica Medicare Health Insurance [8] – Medicare fee-for-service Minnesota Department of Human Services [13] – MN DHS, Medicaid fee-for-service UCare [7] – UCare

XYZ Health Insurance Co. Health Plan Product Patient Name Group Number 12345 Member ID Number 123456789

Use the insurance payer name and logo on the patient’s

insurance card to identify the correct code to submit

Find the Member ID on the patient’s insurance card; enter

this ID in the DDS data file

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Data Field Specifications & Codes Field Specifications for Patient Insurance Coverage Data Below are the field specifications and codes for reporting patient insurance coverage information for DDS.

Field Name Notes Excel Format

Example

Insurance Coverage Code

Using the list of codes in Table 1, enter the code that corresponds with the patient’s insurance payer at the most recent encounter on or prior to the last day of the measurement period:

• Cycle A Measures O Optimal Diabetes Care and Optimal Vascular Care: 12/31/2014 O Depression Care: 05/31/2014 (file 1)

09/30/2014 (file 2) 01/31/2015 (file 3)

• Cycle B Measures O Total Knee Replacement and Spinal Surgery: Functional Status and

Quality of Life Outcome Measures: 03/31/2015 O Pediatric Preventive Care: Adolescent Mental Health and/or Depression

Screening and Pediatric Preventive Care: Overweight Counseling: 12/31/2014

• Cycle C Measures O Optimal Asthma Care, Colorectal Cancer Screening, Maternity Care:

Primary C-section: 06/30/2015 If the insurance payer name does not correspond to one of the codes listed in Table 1, enter “99” and the name of the insurance payer in the Insurance Coverage “Other” Description field. Blank values will create an ERROR upon submission. Quality Check: Verify each cell has an accepted code.

Number

1




Data Field Specifications & Codes Insurance Coverage “Other” Description

If code 99 was entered in the Insurance Coverage Code field (above field), enter the name of the insurance payer. If Insurance Coverage Code (above field) is not 99, leave blank. Quality Check: Verify each cell has text in it if 99 is listed in the Insurance Coverage Code field.

Text Assurant Health

Insurance Plan Member ID

Enter the patient's insurance plan member ID. IMPORTANT: Format Excel field as TEXT in the spreadsheet. Always work in the Excel file (do not work in a .csv file as this will alter the format of the data). • Do NOT enter Group numbers or Social Security Numbers (e.g., code 8,

Medicare Fee-for-Service product), enter “999.” • Include leading zeros (e.g., 000123456789). • Do NOT enter hyphens or spaces. • Leave BLANK if:

O Patient does not use or have insurance (self-pay or uninsured) or O Code 37 is used in the “Insurance Coverage Code” field

• Note the member ID formatting tips for in Table 1. • Refer to card examples in Appendix A to assist in identifying the insurance plan

member ID. Quality Check: Verify no Social Security Numbers are entered.

Text FBOXZ79269




Data Field Specifications & Codes Table 1: Codes for Patient Insurance Coverage Information Code Insurance Payer Name Notes

18 Aetna 33 Allina Partners Care 27 America’s PPO 22 American Family

1 Blue Cross Blue Shield of Minnesota

Including, but not limited to, Aware Gold, Blue Plus, Options Blue, Preferred Gold, Simply Blue, PMAP, MinnesotaCare, MSHO and Medicare managed care products. Please see Appendix A for examples of Blue Cross Blue Shield of Minnesota insurance cards. Note:

O Commercial insurance plan member IDs always start with a three character prefix followed an “XZ” followed by nine digits.

O Public program insurance plan member IDs always start with the three character prefix “XZG” followed by nine digits that begin with the number eight.

O Federal employee insurance plan member IDs always start with an R followed by eight digits.

15 Blue Cross Blue Shield (not Minnesota)

Anthem, etc.

17 Cigna Including, but not limited to, Great West. 23 Comprehensive Care

Services

32 HealthEOS 3 HealthPartners Including, but not limited to, individual or group plans, PMAP,

MinnesotaCare, MSHO and Medicare managed care products. Note: Insurance plan member IDs are always numeric.

37 HITECH Act Only use this code if patient requested restriction per the HITECH Act. A description must be included in “Insurance Coverage ‘Other’ Description” field to indicate which insurance payer type the patient has using one of the following descriptions:

O Commercial O Medicare O MHCP

Note: • If patient is covered by Medicare fee-for-Service, enter code 8. • If patient is self-pay, enter code 16. • If patient is uninsured, enter code 29. • Leave insurance plan member ID blank.




Data Field Specifications & Codes Code Insurance Payer Name Notes

14 Humana

21 Indian Health Services

11 Itasca Medical Care Including, but not limited to, PMAP, MinnesotaCare, MSHO and 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 and Medicare managed care products.

13 Minnesota Department of Human Services (DHS)

Medicaid Fee-For-Service.

20 Medicaid (not Minnesota)

8 Medicare Health Insurance (Fee-for-Service and supplemental plans)

Including, but not limited to, Pyramid Life, Tricare (including TriWest), Unicare, ZMedicare. Note: Insurance plan member IDs are typically SSNs, therefore enter the code (8) and enter “999” for the insurance plan member ID.

5 Metropolitan Health Plan (MHP)

Including ,but not limited to, PMAP, MinnesotaCare, MSHO and Medicare managed care products.

30 MMSI (Mayo Management Services Inc.)

6 Preferred One Member IDs are always 11 digits, typically starting with the number 8.

10 PrimeWest Including, but not limited to, PMAP, MinnesotaCare, MSHO and 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 patients using a sliding fee payment system.

9 South Country Health Alliance (SCHA)

Including, but not limited to, PMAP, MinnesotaCare and MSHO.

24 State Farm

26 Travelers Insurance




Data Field Specifications & Codes Code Insurance Payer Name Notes

7 UCare Including, but not limited to, PMAP, MinnesotaCare, MSHO and Medicare managed care products. Note: Insurance plan member ID format is typically “000######00” where # is a numeric digit.

28 UMR (formerly Wausau)

29 Uninsured Patient does not have health insurance.

31 United Health Care

19 Veterans Administration (VA, CHAMPVA)

Note: Insurance plan member IDs are typically SSNs, therefore, enter “999” for the insurance plan member ID.

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 insurance 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)

Identify the insurance payer that manages the patient’s coverage and enter the appropriate code. If you are unable to identify the insurance payer but know that the coverage is MHCP, enter code 36. Note: It benefits your clinic to accurately identify the insurance payer. The information is used for a variety the purposes, including pay-for-performance programs (e.g. health plans, MN Bridges to Excellence).

Motor vehicle insurance 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. Sage (breast and cervical cancer

screening coverage)

Workers Compensation

Insurance coverage code not listed (Other)

If the insurance payer is not one of the codes listed above, enter code 99 and enter in the name of the insurance payer in the Insurance Coverage “Other” Description field.





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

Federal Employee Member Insurance Card

State Public Program Member Insurance Card




Data Field Specifications & Codes 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




Data Field Specifications & Codes 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




Data Field Specifications & Codes 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





PreferredOne 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

Helpline 612-746-4522 | E-mail [email protected] | MNCM Data Portal https://data.mncm.org/login

© MN Community Measurement, 2014. All rights reserved.



Data Field Specifications & Codes PreferredOne Administrative Services Card 1

PreferredOne Administrative Services Card 2




Data Field Specifications & Codes PreferredOne Community Health Plan Card 1

PreferredOne Community Health Plan Card 2



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