Maine Frequently Asked Questions (FAQs) for the Collection of Commercial Claims Data

  1. Why do we have to send this data to you?
    To be in compliance with the State of Maine Rule 90-590 Chapter 243: Maine Health Data Organization, Uniform Reporting System for Health Care Claims Data Sets. A copy of this Rule should have been supplied to you; however, if you do not have a copy of this document for your use please contact info@mhdpc.org to have a copy delivered to you.


  2. Do we have to use the asterisk (*) as the field separator in the files? What it a text value contains an (*) within it?
    The use of the asterisk (*) as the field separator is a HIPPA and Maine Health Data Organization Rule Specification and MUST be used to separate each field within the required files. Although, not specifically stated in the rule, it is perfectly valid to enclosed any or all text/alpha fields within double quotes - ex: "abc". If a text value that is required actually contains an (*) as one of the characters then that field MUST have double quotes around the entire value - ex: "ab*cd".


  3. Are claims filed for vision coverage considered a reportable health care claim for purposes of this Act?
    Yes, vision coverage is included under Chapter 243 and should be submitted in the claims layout. This would include visits to an Optician or Ophthalmologist for routine eye exams, surgeries, etc. but would not include claims for eye glasses and/or other corrective products services.


  4. Whom do I contact if I am having Upload problems?
    For general transmission questions or for Web Upload questions please contact webadmin@mhdpc.org What is the transmission time frame for the data? According to the rule, the data must be filed by the last day of the month for the previous month's activity. Therefore, on January 31 data for December of the previous year must be submitted.


  5. How is the Pharmacy Benefit Code, ME019, to be coded in view of some of the Prescription Coverage Mandates in the State of ME?
    If you cover an Employer group in the State and they opt out of any Pharmacy coverage rider, but you still have to provide benefits for items like diabetic supplies or certain injectable products, then, even though this data would come to us in the Pharmacy file transmission you would load a ""NO"" value for the member(s) in this employer group.


  6. What if our system uses "Home Grown" claim processing/CPT codes to pay certain types of claims? What do you want us to do if these codes are longer than the 5 digits that are defined in the file layout?
    Following HIPAA standards, eventually all "Home Grown" processing codes should be eliminated from your systems. Until that point in time we suggest that you do the following: Since the file format that you will be sending to us is a delimited ASCII file you can send us the full length value of this field in the correct data element. As part of our validation check we will verify the longest length value in this element and make sure that the Data Warehouse can accommodate the whole value. You must submit an Excel spreadsheet with all local codes and their descriptions to meinfo@ncdms.org before submitting your medical claims data or your submission may fail.


  7. Why did my file fail with an "invalid relationship code" error?
    One of the frequent problems that we found in many payers was with the coding of individual relationship code fields (ME012, MC011, PC011, DC011). These code values are different between file types for the same member because of HIPAA coding specifications that were followed. Please pay close attention to any of the coded fields.


  8. Why did my file fail with an "invalid product code" error?
    Product is sometimes misinterpreted as the type of business you, as the payer, see yourself doing. Actually, the value in the product field (ME003, MC003, DC003, PC003) should reflect the type of product that a subscriber/member is covered under instead of what type of insurance company the payer considers itself. There were many payers using the code of CI - Commercial for every member to say that they are a commercial insurer, yet the members were covered by products that would be considered a POS product ('PS' in the eligibility file or '13' in the medical, dental, or prescription claims files) or PPO product ('PR' in the eligibility file or '12' in the medical, dental, or prescription claims files) or IND product ('IN' in the eligibility file or '15' in the medical, dental, or prescription claims files).