New Mexico Register / Volume XXXIV, Issue 8 / April
25, 2023
This is an amendment
to 7.1.31 NMAC, Section
9, effective 4/25/2023.
7.1.31.9 SUBMISSION
OF CLAIMS DATA TO DATABASE:
A. All-payer claims database data
providers:
(1) Data providers
must submit all available data and health information
with necessary identifiers to the database as described in the APCD-Common
Data Layout (APCD-CDLTM, Version [1.1] 2.1 with errata, Copyright [2018-2020] 2021 by APCD Council, National Association
of Health Data Organizations, the University of New Hampshire) within the time
frames in this rule and in accordance with procedures established herein.
(2) Any data provider used by an
entity that participates in the database such as a third-party administrator or
pharmacy benefit manager must provide claims data
to the department or the data vendor upon request of the entity.
(3) The
following plans or entities may voluntarily provide claims data to the database
within the time frames and in accordance with procedures established by the
department:
(a) Employer
sponsored plans subject to the Employee Retirement Income Security Act of 1974;
and
(b) any governmental
or tribal program or facility that provides health care services to American
Indians and Alaska Natives.
(4) Health insurance carriers that only
offer the following excepted benefit coverages are not required to report:
(a) specific
disease;
(b) accident or
injury;
(c) hospital
indemnity and other fixed indemnity;
(d) disability;
(e) long-term
care; and
(f) vision
coverage.
(5) [Centennial care] Medicaid managed care organizations provide claims data to the
New Mexico human services division (HSD), and who will then submit that data to
the department of health.
(6) Health insurance carriers
covering less than 500 individuals are not required to submit files to the database
but are required
to report the number of individuals with coverage during
the previous year on March 1st.
B. Data submission procedures:
(1) The department
shall:
(a) utilize
an internet-based user interface (or similar technology) that allows for secure
submission and acceptance of data submissions;
(b) perform
quality assurance and validation of all submitted data and provide feedback to
the data providers; and
(c) provide
data submissions procedures to data providers in a data submission guide that
is based on a current version of the APCD-Common Data Layout.
(2) Data
submission frequency: data shall be submitted at least monthly.
(3) Data
providers shall make every effort to initially submit complete, accurate, and
valid data in the APCD-Common Data Layout and shall correct all identified
errors within the timelines established by the department or its designee.
(4) An initial test submission of data
may be required.
(5) Data dating to January 1, [2019]
2020 must be submitted initially.
(6) The department may sanction data
providers who do not comply with this rule.
(7) Data shall be submitted beginning
January 1, [2022] 2023.
[7.1.31.9 NMAC - N,
04/20/2021; A, 4/25/2023]