| (a) Payors must submit the data files required by subsection
(c) of this section to the Center according to the schedule provided
in §21.5405 of this title (relating to Timing and Frequency of
Data Submissions). Payors are responsible for submitting or arranging
to submit all applicable data under this subchapter, including data
with respect to benefits that are administered or adjudicated by another
contracted or delegated entity, such as carved-out behavioral health
benefits or pharmacy benefits administered by a pharmacy benefit manager.
Payors may arrange for a third-party administrator or delegated or
contracted entity to submit data on behalf of the payor, but may not
submit data that duplicates data submitted by a third party.
(1) The Texas Health and Human Services Commission
may submit data on behalf of all applicable payors participating in
a plan or program identified in §21.5401(b)(17) - (b)(20) of
this title (relating to Applicability).
(2) A payor that acts as an administrator on behalf
of a health benefit plan or dental plan for which reporting is optional
per Insurance Code §38.407, concerning Certain Entities Not Required
to Submit Data, may ask the plan sponsor whether it elects or declines
to participate in or submit data to the Center and may include data
for such plans within the payor's data submission. Both the inquiry
to and response from the plan sponsor should be in writing.
(3) A payor providing Medicare Supplement benefit plans
may elect to submit Medicare Supplement benefit plan data to the Center.
(b) Payors or their designees must register with the
Center each year to submit data, consistent with the instructions
and procedures contained in the submission guide. Payors must communicate
any changes to registration information by contacting the Center within
30 days using the contact information provided in the submission guide.
Upon registration, the Center will assign a unique payor code and
submitter code to be used in naming the data files and provide the
credentials and information required to submit data files.
(c) Payors must submit the following files, consistent
with the requirements of the Texas APCD CDL:
(1) enrollment and eligibility data files;
(2) medical claims data files;
(3) pharmacy claims data files;
(4) dental claims data files; and
(5) provider files.
(d) Payors must package all files being submitted into
zip files that are encrypted according to the standard provided in
the submission guide. Payors must submit the encrypted zip files to
the Center using one of the following file submission methods:
(1) save the files on a Universal Serial Bus (USB)
flash drive and use a secure courier to deliver the USB drive to the
database according to delivery instructions provided in the submission
guide;
(2) transmit the files to the Center's Managed File
Transfer servers using the Secure File Transport Protocol (SFTP) and
the credentials and transmittal information provided upon registration;
(3) upload files from an internet browser using the
Hypertext Transfer Protocol Secure (HTTPS) protocol and the credentials
and transmittal information provided upon registration; or
(4) transmit the files using a subsequent electronic
method as provided in the data submission guide.
(e) Payors must name data files and zip files consistent
with the file naming conventions specified by the Center in the submission
guide.
(f) Payors must format all data files as standard 8-bit
UCS Transformation Format (UTF-8) encoded text files with a ".txt"
file extension and adhere to the following standards:
(1) use a single line per record and do not include
carriage returns or line feed characters within the record;
(2) records must be delimited by the carriage return
and line feed character combination;
(3) all data fields are variable field length, subject
to the constraints identified in the Texas APCD CDL, and must be delimited
using the pipe (|) character (ASCII=124), which must not appear in
the data itself;
(4) text fields must not be demarcated or enclosed
in single or double quotes;
(5) the first row of each data file must contain the
names of data columns as specified by the Texas APCD CDL;
(6) numerical fields (e.g., ID numbers, account numbers,
etc.) must not contain spaces, hyphens, or other punctuation marks,
or be padded with leading or trailing zeroes;
(7) currency and unit fields must contain decimal points
when appropriate;
(8) if a data field is not to be populated, a null
value must be used, consisting of an empty set of consecutive pipe
delimiters (||) with no content between them.
(g) Data files must include information consistent
with the Texas APCD CDL that enables the data to be analyzed based
on the market category, product category, coverage type, and other
factors relevant for distinguishing types of plans.
(h) Payors must include data in medical, pharmacy,
and dental claims data files for a given reporting period based on
the date the claim is adjudicated, not the date of service associated
with the claim. For example, a service provided in March, but adjudicated
in April, would be included in the April data report. Likewise, any
claim adjustments must be included in the appropriate data file based
on the date the adjustment was made and include a reference that links
the original claim to all subsequent actions associated with that
claim. Payors must report medical, pharmacy, and dental claims data
at the visit, service, or prescription level. Payors must also include
claims for capitated services with all medical, pharmacy, and dental
claims data file submissions.
(i) Payors must include all payment fields specified
as required in the Texas APCD CDL. With respect to medical, pharmacy,
and dental claims data file submissions, payors must also:
(1) include coinsurance and copayment data in two separate
fields;
(2) clearly identify claims where multiple parties
have financial responsibility by including a Coordination of Benefits,
or COB, notation; and
(3) include specified types of denied claims and identify
a denied claim either by a denied notation or assigning eligible,
allowed, and payment amounts of zero. The data submission guide will
specify the types of denied claims that must be included on the basis
of the claim adjustment reason code associated with the denial. In
general, denied claims are not required when the reason for the denial
was incomplete claim coding or duplicative claims. Denied claims are
required when they accurately reflect care that was delivered to an
eligible member but not covered by a plan due to contractual terms,
such as benefit maximums, place of service, provider type, or care
deemed not medically necessary or experimental or investigational.
Payors are not required to include data for rejected claims or claims
that are denied because the patient was not an eligible member.
(j) Every data file submission must include a control
report that specifies the count of records and, as applicable, the
total allowed amount and total paid amount.
(k) Unless otherwise specified, payors must use the
code sources listed and described in the Texas APCD CDL within the
member eligibility and enrollment data file and medical, pharmacy,
and dental claims data file and provider file submissions. When standardized
values for data fields are available and stated within the Texas APCD
CDL, a payor may not submit data that uses a unique coding system.
(l) Payors must use the member's social security number
as a unique member identifier (ID) or assign an alternative unique
member ID as provided in this subsection.
(1) If a payor collects the social security number
for the subscriber only, the payor must assign a discrete two-digit
suffix for each member under the subscriber's contract.
(2) If a payor does not collect the subscriber's social
security number, the payor must assign a unique member ID to the subscriber
and the member in its place. The payor must also use a discrete two-digit
suffix with the unique member ID to associate members under the same
contract with the subscriber.
(3) A payor must use the same unique member ID for
the member's entire period of coverage under a particular plan. If
a change in the unique member ID or the use of two different unique
member IDs for the same individual is unavoidable, the payor must
provide documentation, if available, linking the member IDs in the
form and method provided by the Center.
(m) When standardized values for data variables are
available and stated within the Texas APCD CDL, no specific or unique
coding systems will be permitted as part of the health care claims
data set submission.
(n) Within the enrollment and eligibility data files,
payors must report member enrollment and eligibility information at
the individual member level. If a member is covered as both a subscriber
and a dependent on two different policies during the same month, the
payor must submit two member enrollment and eligibility records. If
a member has two different policies for two different coverage types,
the payor must submit two member enrollment and eligibility records.
(o) Payors must include a header and trailer record
in each data file submission according to the formats described in
the Texas APCD CDL. The header record is the first record of each
separate file submission, and the trailer record is the last.
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