Wholly denied claims are not required to be included in HCCD submissions; although they can be included voluntarily. Wholly denied claims refer to claims in which all lines are denied.

However, if a claim is only partially denied (i.e. some claim lines are paid), then the entire claim must be submitted to the HCCD – including the denied lines. For this reason, Table B.1.F Claim Status of the DSG has been revised to include additional valid values. Information on partially-denied claims will assist in analyses of performed services and assist in claims versioning efforts.

All files submitted to the HCDD must be formatted as standard text files and must follow the format guidelines found in Section 5.1 of the DSG.

There are three sections for all four HCCD file types: the header, “detail”, and trailer sections. All three sections should be submitted in a single file, and all three sections should contain the name of the data column, delimited using the pipe character, followed by the row(s) of information, also delimited using the pipe character. Below is an abridged example of how a member eligibility file should be submitted to the HCCD. The example below is for a data submitter who only has two enrolled members during the reporting period (for example purposes only). The example below also has the section names underlined; these section names SHOULD NOT appear in the actual submission and are included for clarification purposes only.

Header Record Example

HD001 ǀ HD002 ǀ HD003 ǀ HD004 ǀ HD005 ǀ HD006

ME ǀ DE100 ǀ SubmitterName ǀ 010318 ǀ 310318 ǀ 3500

Detail Example

ME001 ǀ ME002 ǀ ME003 ǀ ME004 ǀ ME005 ǀ ME006 ǀ ME007…….

DE100 ǀ SubmitterName ǀ MM ǀ 2018 ǀ 03 ǀ 12092284 ǀ IND

DE100 ǀ SubmitterName ǀ MM ǀ 2018 ǀ 03 ǀ 13462537 ǀ FAM

Trailer Record Example

TR001 ǀ TR002 ǀ TR003 ǀ TR004 ǀ TR005 ǀ TR006

ME ǀ DE100 ǀ SubmitterName ǀ 010318 ǀ 310318 ǀ 140418

There is no prescribed format for the historic data Summary Report. The total number of members in each month of historic data can be provided to DHIN in whatever format is preferable for the Data Submitter (e.g. email, Excel document via sFTP, etc.).

As outlined in the Data Collection Regulation, dental claims are currently not required to be submitted to the HCCD. As such, all dental claim-related fields (such as ME020) are denoted as voluntary lines of business (“V”) in the Data Submission Guide. Behavioral health claims, however, fall under the definition of “Medical Claims” as per 16 Del.C. §10312(8), and therefore must be included in data submissions to the HCCD.

The Data Submission Guide applies to both Mandatory Reporting Entities and to Voluntary Reporting Entities. Some data elements pertain only to voluntary lines of business and are marked with a “(V)” in the “Required” column

For the most part, Employer Tax ID and Employer Group Name pertain to lines of business which are not required for HCCD submission (e.g. large group plans). Therefore, they are marked as (V).

However, these two fields do apply to State Group Health Insurance plans which are required to be submitted to the HCCD. In these cases, the assumption of DHIN is that coverage for state employees and retirees will flow through a separate data feed and will have a distinct plan ID, separate from the other lines of business. If that is correct, then ME032 and ME044 would in fact also be voluntary data elements. If that is not correct, and state employee/retiree data will be submitted in the same submission as all other lines of business, then ME032 and ME044 is a required data element.

There are currently five data elements marked as “TH” in the Data Submission Guide: MC107, PC019, MP013, MP014, and MP015. This is an error and will be corrected in the next version of the DSG. All data elements marked as “TH” should instead be marked as Required (“R”), and populated at the required threshold percentage.  

The Provider File should include information on all of the billing providers and rendering service providers with associated medical claims during the reporting period. That being said, DHIN understands that payers will not always have complete information on out-of-network providers and therefore, ask that as much information as possible be included for out-of-network providers, and all information be provided for in-network providers.

In instances where a single provider has more than one “entry” in a data submitters database (e.g. they serve as both billing and performing providers, they have multiple NPIs, etc.), the data submitter should report each provider entry separately.