- Pin
- 31786-00190
- Kind
- RFP
- Doc Id
- RFP 31786-00190 Digital Submission Instructions Cost Proposal Appendix 7.1 Appendix 7.2 Appendix 7.3 Appendix 7.4 Appendix 7.5 Appendix 7.6 Appendix 7.7 Appendix 7.8 Appendix 7.9 Appendix 7.10 Appendix 7.11 Appendix 7.12 Appendix 7.13 Appendix 7.14 Appendix 7.15 Appendix 7.16 Appendix 7.17 Appendix 7.18
- Title
- Third Party Administrator Services for the State's Public Sector Health Plans
- Due Date
- Dec 18, 2026
- Pdf Text
- Version CY2024.1
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DISCOUNT DATA SPECIFICATIONS
The Uniform Discount and Data Specification (UDS) workgroup was created to develop a standardized
data specification in order to simplify the data development process for carriers. The workgroup is only
focused on what data elements should be included in the submission. No discussion of use is permitted
at any UDS meeting. Any discussion about data use should take place directly between data submitters
and data receivers.
Time Period
Include all medical claims incurred 7/1/2023-12/31/2024 and paid through 2/28/2025. Please
note that for Inpatient claims, admission date should be considered the incurred date.
Data Content
Include Group claims only
o Private exchange business should be included
Include all claims from all providers except as noted in exclusions below
o Include claims for both contracted and non-contracted providers
o Include high-cost claims - do not exclude any claim because of high dollar amounts
o Include all claims for services covered under medical benefits, regardless of the discount
percentage amount
o Include claims that are paid through networks that your organization rents if these rental
networks are normally part of the product offering you make to your customers
o Include all other provider payments not already included in the claims data in the Other
Provider Payments portion of Appendix A. All types of payments that are applicable to
medical coverage that would not be included in a self-insured admin fee should be
captured. These types of payments should be included both if they are passed back to the
employer or are not directly passed back to the employer. These payments should be
included both if they relate to self-insured or fully insured business. Examples of these
payments (but not an exclusive list) include: withholds, pay for performance payments,
risk settlements, bonus payments, pre-payments, provider incentives due to risk sharing
arrangements, care collaboration fees, and provider fees to fund administrative functions.
o Include Minnesota provider tax payments in both the 'Eligible Billed $' and 'Allowed $'
fields.
All adjudication adjustments for a claim should be applied to that claim before the claim is
summarized
Exclude the following:
o Claims for members age 65 or older where age is measured as the difference between the
date of service and member’s birth date rounded down to the integer
o All Medicare Supplement, Medicare Advantage and Individual claims
o All Medicare and Medicaid claims
o All claims with COB where your organization is the secondary payer
o All mail order prescription drug, retail prescription drug, dental and vision hardware
claims not covered under medical benefits
o Payments for interest expense, regulatory fees and prompt pay penalties
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o Claims paid through custom network arrangements established for specific customers that
are not generally available to other groups
In these instances, only claims paid through the custom network arrangements for
those specific customer and provider combinations should be excluded.
Further, if a customer has a custom network with a provider for only a subset of
services, only the subset of claims paid under the custom network for those
specific customer + provider combinations for which the custom network
arrangement applies should be excluded.
Additionally, the custom network must be in place at the time of the incurred
experience period defined in the Time Period at the beginning of these
specifications.
o Claim lines that include ineligible services and related charges as defined below in “Data
Layout”
o All capitation paid as well as any claim lines and/or encounter data associated with or
paid through capitated arrangements
o All surcharges and covered life assessments such as NYCHRA
o All network access fees including access fees for rental networks
o All members in the following group types:
Prison groups (prisoners, not prison employees)
Railroad groups
o All denied and pended claims and claim lines.
o All claims for medical provider customers that have an SIC code of 8062
Only applies to customers with a physician group that accounts for at least 5% of
professional spend or an acute care hospital.
o All claims incurred at an Indian Health Services (IHS) facility. IHS facilities should be
identified by either Place of Service code (05-08) or by the list in Appendix N.
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DATA AGGREGATION METHODOLOGY
All terminology shown in italics will be further defined in the “Data Layout” section of this document
1. Data should be separated into one of the following three groups based on type of service:
A. Inpatient Facility (facility charges only; does not include associated professional charges)
B. Outpatient Facility (facility charges only; does not include associated professional charges)
C. Professional and Other services (including professional charges associated with facility
claims)
2. Service lines should be summarized into an Event. An Event is defined according to the type of
service it is associated with:
A. Inpatient Facility Event = Admission
If a patient is transferred to a different facility, a new admission record should be created
B. Outpatient Facility Event = “Case” or “Procedure”
Determining whether an Outpatient Event should be reported as either a Case or Procedure
is based on the Revenue Codes and logic shown in Appendix C of this document
If the Event type is a Case, make sure the Case includes all service lines incurred in a
facility by the claimant in one day
If the Event type is not “Case” and there are multiple dates of service on the claim, assume
all claim lines are incurred on the minimum service date (i.e., first day of service) listed on
the claim
C. Professional and Other Services Event = “Procedure”
For Inpatient and Outpatient Facility Events, there are situations where Emergency Room visits turn
into Inpatient Admissions. In addition, it is also possible that an Emergency Room visit could have
an Outpatient Surgery related to it. As such, a hierarchy to define types of Events is needed:
If any portion of an Event occurs in an Inpatient setting, then the claim and all charges
associated with it should be classified as Inpatient
If an Event is not an Inpatient Admission and has any Revenue Codes that indicate
Emergency Room services, it should be classified as an Emergency Room case
If an Event is not an Inpatient Admission or Emergency Room case and has any Revenue
Codes that indicate Outpatient Surgery, the entire claim shall be considered Outpatient
Surgery
When summarizing service lines associated with admissions and cases to the Event level, a claim
identification number or similar field should be used to identify all service lines that should be
included in the Event.
3. Each Event should be assigned a Hierarchical Pricing Code, Network Status Indicator and Pay as
Billed Provider Indicator as defined below in the “Data Layout” section
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4. Each Inpatient Event should also be assigned a Catastrophic Indicator based on the Total Allowed
Amount level of the Event. If the Total Allowed Amount for the Inpatient Event equals or exceeds
$150,000, the Event is considered a catastrophic claim. There are two categories of catastrophic
claims: one for claims with Total Allowed Amounts between $150,000.00 and $299,999.99 and a
second for claims equal to or exceeding $300,000.
5. Events are then aggregated as specified in the layout and output in different records according to
“Group By” categories specified in Appendix A of this document
Specific instructions on how to categorize Events as well as a list of fields and definitions are provided
below.
DATA SUBMISSION TIMING
Organizations providing data understand that in order for the data to be of the best value, it must be
submitted in a timely fashion when compared to the service period. With this in mind, all organizations
submitting data should do so by the end of September of the following year (i.e., September 30, 2025 for
this submission).
DATA LAYOUT
DATA SUBMISSION FILE FORMATS
Files should be submitted in text format. All fields requested in this document are summarized in
Appendix A.
FIELD DEFINITIONS
The information presented in this section applies to all types of claims (Inpatient, Outpatient and
Professional/Other). After this section, there is a definition and instruction section that addresses
additional instructions and fields by claim type (Inpatient, Outpatient and Professional/Other claims).
All indicators in the data should be mutually exclusive. That is, when aggregating amounts on any
given field, the sum of data for charge and utilization fields will be the actual total for that field
(i.e., no double counting).
Organization Name
Name of organization providing data.
Service Period
Dates of service represented by data submission in format MMDDYY-MMDDYY. First date should be
the start date and second date should be end date. As an example, for the CY2024 data submission, this
field would be populated as 070123-123124. If period is not equal to 18 months, it should be disclosed
on the actuarial certification.
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3 Digit Patient Zip Code
All of the records in this data submission should include the patient’s residential 3-digit Zip Code. If the
patient’s residential zip code is not available, the zip code of the employee to which the member is
related should be used. If there is no patient or employee zip code available, a dummy zip code of
“ZZZ” should be submitted.
Product Indicator
The “Product Indicator” will be used to identify and differentiate submitted data for each product a
carrier would potentially offer an employer group. Data should be aggregated separately for each
unique product a carrier wishes to submit for evaluation.
Positions 1 through 3 of the Product Indicator should indicate the product type (PPO, HMO, POS, EPO,
TRA) and positions 4 and 5 should be used as a suffix (e.g., 01, 02, 03) in case a carrier submits more
than one product of the given type. Please note that no formal naming convention is prescribed for the
remaining positions in this submission. This should allow carriers flexibility in providing product
indicators that most appropriately reflect their product portfolio. It is expected that each carrier will
provide a translation table or key for the “Product Indicator” field in their data submission. The format
under which a carrier should submit this information is provided as Appendix G of this document. This
key should allow users to easily identify products. It is recommended that both the product’s marketing
name and description be supplied along with the “Product Indicator” on this key.
For purpose of illustration, examples of characteristics that could cause reimbursement to vary among
products are shown below. This is neither an all-inclusive list nor are the items shown intended to be
addressed by all carriers. Also, there are other examples that may require product differentiation. As
stated above, it is expected that each carrier will appropriately identify key characteristics that
differentiate products in their portfolio and provide Product Indicators reflecting these differences.
Product type: PPO vs. Open Access POS vs. Gatekeeper POS vs. EPO etc.
Group’s Funding Arrangement: Fully Insured vs. Self-Insured
Multiple Networks available in the same area
Product with Multiple In-Network Benefit Levels vs. Open Access PPO
New Business vs Existing Business
Please note above that unique products should be identified based on three factors:
- Network size
- Provider contracts
- Benefit Tiers (1 vs 2+ tiers)
Products that differ in any of these three areas should be submitted under different Product Indicators.
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6-Month Indicator
The “6-month Indicator” will be used to identify the half year in which the submitted data was incurred.
The table below shows the values that should be entered in the column and the corresponding dates for
the submission.
6-month Indicator Time Period for CY2024 Submission
H1 July 2023 – December 2023
H2 January 2024 – June 2024
H3 July 2024 – December 2024
Hierarchical Pricing Code
The Hierarchical Pricing Codes listed below serve as a replacement for the Benefit/Contract Status
indicator from prior submissions. This list is meant to encompass different pricing arrangements that
may be in place. As evident in the name, the list is hierarchical meaning if an arrangement can be
categorized under Code 1, then it should be categorized as such; otherwise, move on to Code 2.
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Code Description Notes
1 Direct Carrier Contract
This is defined as a written contract between the carrier
and the provider, which covers these services at that
provider for this network. If a carrier does not have any
direct carrier contracts in a geographic area and instead
rents a network, the primary rental network can be
categorized in code 1. Any additional/supplemental wrap
networks should be considered code 3.
2 Claims subject to surprise billing
rules
All claims subject to surprise billing rules should be
included, regardless of how the payment amount was
determined (QPA-level, through arbitration, or other
methods). This includes both the federal surprise billing
rules
(https://www.federalregister.gov/documents/2022/08/26/2
022-18202/requirements-related-to-surprise-billing), and
state-specific surprise billing rules. Only claims subject to
these surprise billing rules should be included in pricing
code 2.
3 Third Party Wrap Network
A Third Party Wrap Network is a third party that the
carrier contracts with, where the third party has direct
provider contracts.
Individual Claim Negotiation
This is an isolated negotiated price for a claim, which
would not necessarily apply to any other claims incurred
at this provider. This would include claims negotiated
either internally or by a third party; claims negotiated
either on a one-off basis or a batch all at the same time
qualify to be in this bucket.
5 Reference Based Pricing Schedule
This is when the carrier or a third-party pays the claim
using a Reference pricing table (e.g. Data iSight, FAIR
Health, % of Medicare).
6 Percentage of billed Charges Claims paid at 100% of billed charges belong in this
bucket.
7 All Others
There may be some facility admissions where the Hierarchical Pricing Code for a facility changes
during the admission. In these cases, the admission should be classified with the Hierarchical Pricing
Code in effect for the facility on the first day of the admission.
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Network Status Indicator
This indicator, set to either “I” for “In-Network” or “O” for “Out-of-Network”, corresponds to the
method of adjudication of member benefits.
Noncontracted Savings Indicator for Negotiated Savings with Noncontracted Providers
Default value is “N”. The Noncontracted Savings Indicator should be set to “Y” for claims where:
A carrier is able to negotiate a contracted savings with the noncontracted provider and
The provider cannot balance bill the member for the contracted savings.
Please note that all claims submitted should be coded with an indicator for this field and that this field
should not be left blank.
Arrangement Indicator
The “Arrangement Indicator” groups data based on Funding Arrangement between Fully Insured and
Self-insured groups.
Pay as Billed Provider Indicator
Claims that a carrier requests be considered for Pay as Billed status should be indicated with a “Y” in
this field. Carriers should be prepared to substantiate this classification at the provider level with proof
that the provider either routinely files claims with Submitted Charges = Allowed Charges or the provider
does not file Submitted Charges. If the overall discount for a provider is greater than 2.0%, the claims
filed by that provider may not be classified as Pay as Billed. Explanation for all claims coded as “Pay as
Billed” should be provided in the actuarial certification provided with the data.
Eligible billed charges are not allowed to be adjusted for pay as billed claims, except in the following
instance: If a carrier and/or data submitter separately receives a report of billed charges at the claim level
from providers who routinely file claims on a pay as billed basis, the separately reported billed charges
may be submitted as Actual eligible billed dollars. In those instances, the Pay as Billed Indicator should
be ‘N’.
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Financial Data
The definitions provided below are intended to standardize terminology as it relates to this claim charge
data submission for Provider Reimbursement Analysis.
Submitted Charges All charges submitted by the provider for payment
Ineligible Charges Sometimes referred to as "Non-covered Charges". These are charges
not covered due to denial of services, claim duplication, medical
policy, ineligible members or the plan of benefits. Detailed
descriptions of types of Submitted Charges that are considered
Ineligible are provided below.
Eligible Billed Charges Sometimes referred to as "Covered Charges". Eligible Billed Charges
= (Submitted Charges less Ineligible Charges) before application of fee
schedules, contractual reimbursement provisions, and R&C cutbacks
Negotiated Savings Sometimes referred to as "Provider Discount". Savings resulting from
fee schedules or contractual reimbursement provisions. Reductions
that could result in member balance billing should not be included as
Negotiated Savings
Reasonable & Customary Cutback
Amount
Any difference between Submitted Charges and Allowed Amount that
is not accounted for in Ineligible Charges.
Allowed Amount Allowed Amount = (Eligible Billed Charges less Negotiated Savings
resulting from fee schedules or contractual reimbursement provisions,
OR R&C cutbacks) prior to member cost sharing.
Paid Amount Sometimes referred to as “Plan Paid Amount”. This is the Allowed
Amount reduced for member cost sharing. It represents the actual
amount paid by the health plan.
Member Cost Sharing This is the portion of the Allowed amount that is the member’s
responsibility to pay. This includes deductibles, copays, and
coinsurance. Member cost sharing, as defined here, should reflect the
appropriate balance billing arrangement.
Allowed Amount = Submitted Charges
Minus
Ineligible Charges
Minus
(Negotiated Savings
OR
R&C cutbacks (if applicable))
Paid Amount = Allowed Amount
Minus
Member Cost Sharing Amounts
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Ineligible Charges
These are charges for services not considered eligible for payment under the plan. Examples include:
Duplicate bills
Pending or denied claims
A type of service that is not covered by the plan of benefits:
o For example, if cosmetic surgery is not covered under the plan and a claim is submitted that
includes cosmetic procedures, the charges for these procedures would be considered
ineligible charges
o Claim lines with the non-covered cosmetic procedure above would be excluded from this
data submission
Services incurred in excess of plan limits
o For example, if the plan imposes a 40 visit annual limit on outpatient mental health visits and
a claim is submitted for a 41st visit, the charges for this visit would be considered ineligible
o Another example is a plan that covers up to 5 inpatient days for a certain diagnosis and a
claim is submitted for 6 days, the charges for the 6th day would be considered ineligible
o The visits/days and associated charges not covered in the examples above would be excluded
from all Claim data in this data submission
o Should only exclude services that are not covered due to the plan limit
Claims denied due to medical management/medical necessity decisions such as length of stay
cutbacks and medical claim review
Pre-Existing Condition Exclusions
As illustrated in the examples above, all claim lines, units and Submitted Charges associated with
Ineligible Charges should be excluded prior to summarizing data into the Events described above in
“Data Aggregation Methodology”.
All claim lines and related Submitted Charges for services which are covered by a plan but are
“bundled” through business rules/edits in a carrier’s claim processing system should be included as
Eligible Billed Charges. These amounts should not be treated as denied claims.
Actual, Adjusted and Projected Data
In order to provide accurate historical information as well as projections for future periods, data is to be
provided in three categories as outlined below. Please note that values should be provided for all actual,
adjusted and projected fields regardless of whether a carrier is making adjustments or projections. To
aid users of the data, two fields are provided that should be used to indicate if adjusted data different
than actual is submitted or if projected data different than adjusted is submitted:
The field “AdjCopyof Actual” should be coded as “Y” for all records if Adjusted is always a
copy of Actual. If Adjusted is always or sometimes different than Actual, this field should be
populated as “N” for all records.
The field “ProCopyof Adj” should be coded as “Y” for all records if Projected is always a copy
of Adjusted. If Projected is always or sometimes different than Adjusted, this field should be
populated as “N” for all records.
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Retroactive recoveries (such as fraud, waste, and abuse programs) which are received after the ending
paid date of the Time Period are not permitted to be included in Actual, Adjusted, or Projected data
fields.
Neither Actual, Adjusted, or Projected data can reflect expected changes in provider mix for any reason,
including, but not limited to, the following:
Providers who were out of the network in at least part of the Time Period, but will be joining the
network at a later date
Providers who have significantly different discounts than others in the area
Specifically prohibited are the following:
Modifying data to estimate claims shifting between providers
Removing claims at any provider simply due to abnormal discounts
A - Actual: Historical claims incurred and paid in the requested time period with no adjustments. All
data submissions require an actuarial certification that confirms that no adjustments have been made to
the historical data included in the “Actual” fields. “Actual” data should be reported for all utilization
data (admissions, days, cases and procedures) and financial data (Eligible Billed Charges, Negotiated
Savings and Allowed Amount).
B - Adjusted: “Adjusted” data is historical data that has been changed or modified to more accurately
reflect a carrier’s actual discounts. Examples of when the “Adjusted” fields might be used:
A carrier has access to a new network in a specific area due to acquisition or merger
A carrier changes rental network partners used in an area
A carrier has little or no experience in a new product and uses “Actual Allowed Amount” data
from an established product with “adjustments” for provider contract differences to represent the
new product’s “Adjusted Allowed Amount”
A carrier cannot explicitly remove access fees from their data and instead uses an
assumption/adjustment method to remove access fees
It is expected that a product for which “Adjusted Allowed Amount” data is provided would be based on
the “Actual Allowed Amount” data of a similar product or network. In the case of new networks from
acquisition/merger or changes in rental network partners, it is possible that the “Adjusted” data is simply
“Actual” data from the new network (before merger or selection as a partner) to be substituted for the
carriers “Actual” data.
For all claim types, “Adjusted” data should be reported for all utilization data (admissions, days, cases
and procedures) and financial data (Eligible Billed Charges, Negotiated Savings, Allowed Amount, and
Paid Amount), even if only one of the fields is affected by the network change. All methods used to
create “Adjusted” data should be disclosed in the Actuarial Certification (Appendix I) and the impact of
these adjustments should be itemized in the Appendix I Supplement - Adjustment Impact Schedule (see
excel file with Appendices).
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When reflecting adjusted data for items in the list above:
Only adjustments for discounts can be made; no adjustments for additional cost of care savings
or other points can be made
(M&A Only): The discount for any single provider cannot be adjusted higher than the highest
discount of the merged companies
(Rental Partner Change Only): the rental partner agreement must be executed and effective by no
later than six months after the end of the incurred period
(M&A or Rental Partner Changes): Once the merger and/or rental partner change is in place for
the entire historical experience period, adjustments can no longer be made
C – Projected: Includes any adjustments to the data file that are based on finalized future changes to
provider discounts for which historical data is not representative of future discount results based on
finalized contract changes. The most common reason for supplying “Projected” data is recognition of
recent changes in provider discounts that have yet to be recognized in the “Actual” or “Adjusted” data
provided. Projections should also be used to recognize the impact of contractual fee escalators and/or
multi-year guarantees a carrier has with providers. Appendix H gives other examples of situations
where “Projected” data would be submitted. Carriers should only project discounts for providers for
whom a change in discount will occur.
“Projected” data is different from “Adjusted” data as “Adjusted” data is intended to reflect the same
time period as “Actual” data while “Projected” data is intended to reflect claims in a future period.
The following presents additional guidance around submission of “Projected” data:
o Appendix H must be completed and submitted for all geographic areas where “Projected” data
is provided.
o In all cases, “Projected” data should only be provided for contracts or changes that have
been negotiated and finalized. Projections should not be based on negotiation targets or
situations that are “likely” to occur.
o Projections should be submitted for any 3-digit zip code where a change will occur and should
include all known changes in that 3 digit zip code, not just discount improvements. Both
discount improvements and deterioration should be reflected in “Projected” data.
o Discount changes in any 3-digit zip code should be calculated such that the overall “Projected
Discount” for that zip code reflects the percentage of claims serviced by providers affected by
the event justifying the projection
o “Projected Discounts” should only be calculated for providers affected by the event
justifying the projection
o Provider specific ”Actual/Adjusted Discounts” should be used for claims serviced by
providers that are not affected by the event justifying the projection
o The overall “Projected Discount” for a 3-digit zip code should represent a blend of the
“Projected Discount” for providers affected by the event justifying the projection and the
“Actual/Adjusted Discounts” of those providers not affected by the event
o The discount changes submitted on Appendix H should reflect the discount change over
all providers and claims in the 3-digit zip code.
o An example of this calculation is shown on page 14.
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For each data submission, the timeframe of the submission and effective dates of claims that drive the
“Projected” data must be recognized. For this data submission, a projection period of 1/1/2025 –
12/31/2025 should be used. All “Projected” changes that are effective after 1/1/2025 should be pro-
rated for the number of months it will impact discounts in 2025. In this way, the projected discount will
represent the expected discount over the period 1/1/2025-12/31/2025. Only contracts executed by
March 31, 2025 (3 months after the ending incurred date for this submission) for future effective dates
should be considered for projections.
“Projected” amounts should only differ from the “Actual”/“Adjusted” data it is based upon for
Negotiated Savings and Allowed Amounts. While “Projected” fields for all utilization (admissions, days,
cases and procedures) and Eligible Billed Charge data should not differ from the “Actual”/”Adjusted”
data, we require that “Projected” amounts for all fields be provided to ensure that the intended discount
amount is determined.
“Projected” Allowed Amounts should be calculated such that the discount off of 1/1/2024-12/31/2024
Eligible Billed Charges is the discount that is expected to be achieved in the prospective period
(1/1/2025-12/31/2025). In order to complete this calculation, a standardized billed charge trend should
be used. The billed charge trends for this data submission are included in Appendix B. These trends
should be assumed for all discount projections regardless of geographical area. Milliman has also
provided appropriate caveats and disclosures for the use of these billed charge trends that should be
communicated to field staff.
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An illustration of how the projection should be calculated and reported is shown on the next page using
a projection period of 1/1/2025 – 12/31/2025 and a historical period of 1/1/2024 – 12/31/2024. Please
note that data outside of CY2024 (i.e. H1 – July 2023 to December 2023) should not be projected
and therefore all projected columns should be populated with $0. In addition to this example, two
examples of how the Expected Change in Allowed Amount and Discount Projection are calculated for
contracts where all or a portion of the reimbursement is based on a Percentage of Billed Charge method
are also provided below.
Projections when Reimbursed as Percentage of Billed Charges - Example 1
A provider is reimbursed at 50% of billed charges for OP services. No change in the percentage of
charges reimbursed for OP Services occurs in the projection period (it remains 50%). While the
percentage of billed charges does not change, the amount reimbursed will increase by the same rate as
billed charges. In this situation, the Expected Change in Allowed Amount is expected to increase by the
prescribed billed trend of 4.0%.
Projections when Reimbursed as Percentage of Billed Charges - Example 2
A provider is reimbursed 50% of billed charges for OP services. A contract change occurs where OP
services are now reimbursed at 52% of billed charges. The Expected Change in the Negotiated Savings
Amount should be calculated as:
((1 + Prescribed Billed Trend)
Multiplied by
(1 - New Percentage of Billed Charge Reimbursement)
Divided by
(1 - Prior Percentage of Billed Charge Reimbursement))
Minus 1
OR
(1.065 * (1 - 0.52) / (1 - 0.50)) – 1 = 1.8%
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FIELDS FOR INPATIENT FACILITY CLAIMS
All admissions and claims, including high cost claims, should be included
When coding inpatient facility claims, use coding system MS-DRG v41.1
Data should be included for all discharges, including due to death of the patient
This is for facility claims only. No professional fees associated with facility services should be
included
Include data for all inpatient facility types (hospital, rehabilitation center, skilled nursing facility
and mental health hospitals)
Exclude utilization and charge data for any unpaid, non-covered days associated with ineligible
charges as defined below
Incurred dates for Inpatient Claims should be represented by the date of admission.
There may be some admissions where the Hierarchical Pricing Code for a facility changes during
the admission. In these cases, the admission should be classified with the Hierarchical Pricing
Code in effect for the facility on the first day of the admission.
Catastrophic Indicator
Indicator set to “0” for Inpatient Events (admissions) with between $150,000 and $299,999.99 of total
Actual Allowed Amount. The indicator should be set to “1” for Inpatient Events (admissions) with total
Actual Allowed Amount equal to or exceeding $300,000. Utilization and claim charges submitted with a
Catastrophic Indicator = “0” or “1” should include all utilization and claim amounts associated with the
Inpatient Event, not just excess portion of the Inpatient Event that exceeds the high cost threshold.
As an example, if a 25 covered day inpatient event with $300,000 in Actual Allowed amounts occur, the
entire claim ($300,000 in Actual Allowed amount and all 25 covered days) should be summarized into
one event and included with a catastrophic indicator of “1”.
All charges and utilization for claims coded with a Catastrophic Indicator of “0” or “1” should be
excluded from the aggregation of non-catastrophic claims (Catastrophic Indicator = “N”) so that double
counting is avoided.
DRG
Based on the discharge DRG. For this submission, use coding system MS-DRG v41.1. Carriers should
ensure one DRG version is used for all inpatient data and should not submit data with a mix of DRG
versions.
If a carrier must submit data based on a version other than MS-DRG v41.1, it is important that the
carrier ensure that all inpatient claims are based on this alternate version and that there is not a mix of
data where some claims are coded as MS-DRG v41.1.
DRG Version Indicator
Indicates DRG version submitted in the data. Appendix J shows coding to be used for this field. This
field should be coded for all records submitted in the Inpatient claims data file.
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MDC
Use standard MDC definitions. Include data for all MDCs. Some claims can be mapped to more than
one MDC. Admissions at Skilled Nursing Facilities should be coded as MDC 95. For all admissions
where the MDC is unknown or ungroupable, MDC 99 should be used.
Number of Admissions
If a patient is transferred to a different facility, a new admission record should be created. Please ensure
that your admission counts are net of any reversals (negative adjustments). Reversals should offset
admission counts and financial data in your dataset and should not be counted as additional admissions.
# of Covered Days
Total number of covered inpatient days related to the admissions defined above. All non-covered days
should be excluded from the day count. For claims where the admission and discharge date are the
same, Number of Covered days should be set to 1. There should be no IP claims with 0 days. Please
ensure that your day counts are net of any reversals (negative adjustments). Reversals should offset day
counts and financial data in your dataset and should not be counted as additional days.
FIELDS FOR OUTPATIENT FACILITY CLAIMS
For Inpatient and Outpatient Facility Events, there are situations where Emergency Room visits turn into
Inpatient Admissions. In addition, it is also possible that an Emergency Room visit could have an
Outpatient Surgery related to it. As such, a hierarchy to define types of Events is needed. Please refer
to page 2 of this document for classification of facility events into Inpatient and Outpatient categories.
All claims should be included
This is for facility claims only. No professional fees associated with facility services should be
included.
If a carrier is unable to separate the facility and professional components of a claim, all lines of
the claim should be included as Outpatient Facility events (use Appendix C to determine if the
event type should be summarized into a Case or included by Procedure). For these events, a
modifier of “GF” (Global Fee) should be used to indicate that the facility and professional
components of the claim are both included in Outpatient Facility.
Carriers should use the actuarial certification to disclose the number of Outpatient Facility events
and associated Eligible Billed charges where the following occur:
o Facility and professional utilization and/or charges cannot be separated and
o a CPT Code Modifier of “GF” is not used (see definition of CPT Code Modifier below)
Include data for all outpatient facility types (hospital, independent/freestanding labs and centers,
ambulatory surgery centers, rehabilitation center, and mental health hospitals)
Any Professional claims with Revenue Codes and/or CPT/HCPCS codes in the ranges defined as
“Ancillary” Outpatient Facility claims (see Appendix C) should be excluded from Professional
claims and included as Outpatient Facility “Ancillary” claims
For claim lines coded with Revenue Codes 960-989, the following criteria should be used to
determine if the claim line should be included in Outpatient Facility or Professional claims:
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o If the claim line has a Revenue Code between 960 and 989 AND has a CPT/HCPCS code
coded on the claim line, the claim line should be included as a Professional claim and the
CPT/HCPCS code should be reported as prescribed for Professional claims
o Otherwise, the claim should be categorized as an Outpatient Facility claims
Exclude utilization and charge data for any unpaid, non-covered services associated with
ineligible charges as defined above
For the most part, Outpatient Facility Claims use the same definitions as Inpatient Facility Claims.
Several Inpatient Facility Claim fields are not collected for Outpatient Facility Claims. They are:
Catastrophic Indicator, DRG, MDC, Number of Admissions and Number of Covered Days.
Outpatient Facility Claim fields that are different than fields for other claim types and their related
definitions are as follows:
Outpatient Type of Service
There are seven types of services for outpatient facility claims. Appendix C defines the types of services
for outpatient facility claims and also describes how to count the number of services for each category.
CPT Code and CPT Code Modifiers
For Radiology and Pathology services, there are situations where a service will have both a Revenue
Code and CPT code. In order to ensure consistent collection and treatment of data among carriers, this
data submission requires that the combination of CPT Code and Modifier (as defined in Appendix E of
this document) be submitted as aggregation variables for any Outpatient Facility Radiology or Pathology
services coded with both a Revenue Code and CPT code.
Number of Services
The requested counting methods for each Outpatient Type of Service are shown in Appendix C. Please
ensure that your numbers of service counts are net of any reversals (negative adjustments). Reversals
should offset service counts and financial data in your dataset and should not be counted as additional
services.
FIELDS FOR PROFESSIONAL CLAIMS
All claims should be included
This is for professional claims only. For claims where there is a facility (technical) and
professional component, only the professional component should be included.
If a carrier is unable to separate the facility and professional components of a claim, all lines of
the claim should be included as Outpatient Facility events (see page 9 for coding of these claims)
Any Professional claims with Revenue Codes and/or CPT/HCPCS codes in the ranges defined as
“Ancillary” Outpatient Facility claims should be excluded from Professional claims and included
as Outpatient Facility “Ancillary” claims (see Appendix C for these codes)
For claim lines coded with Revenue Codes 960-989, the following criteria should be used to
determine if the claim line should be
- Start Date
- Sep 15, 2026
- Due Date Raw
- Dec 18, 2026
- Pdf Enriched
- Yes
- Start Date Raw
- Sep 15, 2026
Tennessee Central Procurement Office (CPO)Issuing agency·Tennessee·via a public procurement portal