Healthcare Claims Database

Claims previously reported to the HCCD as paid and subsequently adjudicated as a wholly denied claim must be reported to the HCCD. Otherwise, wholly denied claims are not required to be included in HCCD submissions and may be included voluntarily. Wholly denied claims refer to claims in which all lines are denied. For partially denied (i.e., some claim lines are paid), the entire claim must be submitted to the HCCD including the denied lines. For this reason, Table B.1.F Claim Status of the Data Submission Guide (DSG) has been revised to include additional valid values. Information on partially denied claims will assist in analyses of performed services and assist in claim-versioning efforts.

All files submitted to the HCCD 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 records 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 has only two enrolled members during the reporting period and is for illustrative 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

Record Type | Reporting Entity Code | Reporting Entity Name | Beginning Month | Ending Month | Record Count

ME | DE100 | SubmitterName | 202403 | 202403 | 2

Detail example

Reporting Entity Code | Reporting Entity Name | Insurance Type Code/Product | Year | Month | Insured Group or Policy Number | Coverage Level Code…

DE100 | SubmitterName | MM | 2024 | 03 | 12092284 | IND

DE100 | SubmitterName | MM | 2024 | 03 | 13462537 | FAM

Trailer record example

Record Type | Reporting Entity Code | Reporting Entity Name | Beginning Month | Ending Month | Extraction Date

ME | DE100 | SubmitterName | 202403 | 202403 | 20240430

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 (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. Behavioral-health claims, however, fall under the definition of “Medical Claims” as per 16 Del.C. Section 10312(8), and therefore must be included in data submissions to the HCCD.

The Employer Tax ID and Employer Group Name are required when submitting records for the State Group Health Insurance plans, and individual policies (e.g., Medicare Advantage plan) must be reported as “IND.” Reporting on any other plans is optional.

The Provider File should include information on all of the billing providers, rendering-service providers, prescribing providers and pharmacies with associated medical and pharmacy 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, asks 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. In the event the same provider delivered and was reimbursed for services rendered from two different physical locations, then the provider-data file shall contain two separate records for that same provider reflecting each of those physical locations. One record shall be provided for each unique physical location for a provider.

The historical files can be submitted in DSG Version 3.0 format.

For further guidance, contact Mike Mariano at mmariano@freedmanhealthcare.com.

Metallic levels are the plan categories assigned to Marketplace Plans. This field is required for small-group and nongroup (individual) plans sold inside or outside the Marketplace. Plan categories are listed on the exchange as gold, silver, bronze, platinum and catastrophic. The Catastrophic Plan category, previously omitted for the DSG, was added to Version 4.0 Rev. DSG.

Yes, the placeholder field ME108 was replaced with a new data element: High-Deductible Plan Indicator.