Direct Data Submission (DDS) 2013 Report Year Insurance Coverage Data Field Specifications & Codes

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

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?

Insurance Coverage Code. Enter one of the designated insurance codes (see page 3) into the Insurance Coverage 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, 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: Enter the following code:

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 payer name and logo on the patient’s insurance card to identify the correct code to enter

in the DDS data file

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Field Specifications for Patient Insurance Coverage Data

Below are the field specifications and codes for reporting patient insurance coverage information for DDS.

Summary of Changes Member ID: Social Security Number

If the member ID is a social security number, enter “999” – do not enter the patient’s social security number.

Field Name Notes Excel

Format

Example Insurance Coverage

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: 12/31/2012

 Depression Care: 05/31/2012 (file 1)

09/30/2012 (file 2)

01/31/2013 (file 3)

 Optimal Asthma Care, Colorectal Cancer Screening, Maternity Care: Primary C-section: 06/30/2013

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 Insurance Coverage “Other” Description field.

Blank values will create an ERROR upon submission.

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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.

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Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login 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., 000123456789)

 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.

 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

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Codes for Patient Insurance Coverage 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

 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.

15 Blue Cross Blue Shield (not Minnesota)

 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

14 Humana

21 Indian Health Services

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)

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Code Payer Name Notes

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: Member IDs are typically SSNs, therefore enter the code (8) but leave the Member ID field blank.

5 Metropolitan Health Plan (MHP)

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

30 MMSI (Mayo

Management Services Inc.)

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)

 Including but not limited to PMAP, MinnesotaCare, MSHO

24 State Farm

26 Travelers Insurance

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

31 United Health Care 19 Veterans Administration

(VA, CHAMPVA)

99 Other If “99” is entered, description on plan must be included in “Insurance

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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)

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

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)

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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

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HealthPartners

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

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Medica

Below are examples of Medica insurance cards. Please use these examples to assist in determining the patient’s insurance plan member ID.

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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

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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

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PreferredOne Administrative Services Card 1

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Hotline: 612-746-4522 | E-mail: [email protected] | Data Portal: https://data.mncm.org/login PreferredOne Community Health Plan Card 1