Health Insurers: Health Care Claims Reports

Introduction

An insurer authorized to write accident and health insurance in this State, a corporation organized pursuant to Insurance Law Article 43, or a health maintenance organization certified pursuant to Public Health Law Article 44 (an issuer) must report to the Superintendent quarterly and annually on health care claims payment performance for comprehensive health insurance coverage.

Issuers must submit the report using the Health Care Claims Report template.

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Frequently Asked Questions

Should affiliated companies with separate NAIC Company Codes submit one combined report or separate reports?

A separate report should be submitted for each NAIC Company Code.

What “lines of business” are included on this report?

Commercial coverage, Medicaid Managed care, Essential Plan, and Child Health Plus lines of business are included on this report. Medicaid Managed Care does not include HARP (Health and Recovery Plans), SNPs (Special Needs Plans), MLTCs (Managed Long Term Care), or Medicare Advantage plans. Each line of business is reported separately on different worksheets. The Aggregate worksheet totals the lines of business worksheets automatically.

Should claims from stand-alone dental or vision insurance be included on the report?

No. The report should include claims under comprehensive health insurance coverage only.

What is the definition of “claim” for this report?

A claim is defined at the unique number level with all the claims lines supporting it.

How should claims received be counted for this report?

All claims received during the reporting period should be counted under the number of claims received during the current reporting period. If a claim was received but then adjusted or corrected and resubmitted again later, it should be counted each time it was received.

Are claims received counted during the reporting period based on date of service or date the claim was submitted for received claims?

Claims received are counted using the date the claim is submitted.

Are claims from pharmacy benefit managers included in this reporting?

Each issuer should include data from pharmacy benefit managers or other vendors that adjudicate claims (i.e., they receive, process and make determinations on claims) on their behalf on a single report by NAIC Company Code.

How should claims rejected by the issuer be counted for the report?

Rejected claims are claims that are received by the issuer but then rejected as incomplete or for some other error or issue before the claim is adjudicated. Rejected claims include but are not limited to pharmacy point of sale claims. Any claims rejected during the reporting period should be counted under the number of claims rejected during the current reporting period. However, claims rejected by a clearinghouse would not be included in the issuer’s report if the claims were not received by the issuer.

How should pended claims be counted for the report?

Claims received by the issuer but not yet adjudicated (paid or denied) as of the end of the reporting period should be counted under the number of pended claims. Pended claims include open claims and claims pended due to a request for information. The number of pended claims may include claims received during a prior reporting period.

How should claims denied, claims paid, or claims paid in part and denied in part be counted for the report?

All claim determinations (denied, paid, or denied or paid in part) made during the reporting period should be counted under their respective items. The number of claims denied, claims paid, or claims paid in part and denied in part may include claims received during a prior reporting period, but the determination on the claim was made during the current reporting period.

How is a claim that is paid in part and denied in part counted?

A claim that is paid in part and denied in part will be counted on line 14. The dollar value for a claim paid in part and denied in part is reflected by the amount partially paid and amount partially denied, using either the allowed amount or billed charges for the claim (lines 15-18).

Some comprehensive health insurance policies provide benefits for dental or vision services. What provider type should these claims be counted under?

Claims for dentists or optometrists should be counted under the category “Other Health Care Professionals.”

How is “physician” defined for the provider category?

A physician means a health care professional licensed as a physician (a Doctor of Medicine or Doctor of Osteopathic Medicine) pursuant to Education Law Title 8 or a physician comparably licensed, registered, or certified by another state.

How is “health care professional” defined for the provider category?

A health care professional means an appropriately licensed, registered or certified health care professional pursuant to Education Law Title 8 or a health care professional comparably licensed, registered, or certified by another state.

Should emergency room services be counted under “Hospital – Inpatient” or “Hospital – Outpatient”?

Emergency room services should be counted under “Hospital – Outpatient”.

Should inpatient rehabilitation services and skilled nursing facilities be classified as “Hospital – Inpatient” or Other Facilities”?

Inpatient rehabilitation services and skilled nursing facilities should be classified under “Other Facilities.”

What provider types would be in the “Other” category?

Any health care provider that does not fit under the specifically designated categories would be in the “Other” category. Examples include durable medical equipment or medical supplies vendors.

What denial reasons would be in the “Other” category?

Any denial reason that does not fit under the specifically designated categories would be in the “Other” category. All claim denials during the reporting period should be accounted for on Table 3.

Claims may have more than one denial reason due to the different denial reasons for claim lines. If a claim has different claim line denial reasons, is the claim denial be reported under one denial reason or counted under all applicable denial reasons?

Claims should be counted only under one denial reason on Table 3. If any one of the denial reasons is “not medically necessary,” the claim should be counted there. For all other denial reasons, the issuer should determine the primary reason and count the claim denial once.

Are appeals received limited to appeals for claims denied during that reporting period?

Appeals received should reflect any appeals received during that reporting period and are not limited to claims denied during that reporting period.

Does this report include appeals of post-service denials only (i.e., claim denials) or should appeals for pre-service denials (i.e., preauthorization denials) be included?

Appeals of post-service denials (i.e., claims) should be counted on the report. Appeals of pre-services denials should not be counted.

If an appeal overturned a claim denial, is the original claim still included in the number of claim denials on Table 1, or is it removed since it was ultimately approved?

A claim that is denied during the reporting period should be counted on lines 11 or 13 even if the claim was subsequently overturned on appeal during that reporting period. A claim that is overturned upon appeal during the reporting period should be accounted for on Table 2.

Does appeals received include appeals submitted by providers and insureds?

Yes. Appeals received includes appeals submitted by providers and insureds.

Are provider appeals that are submitted based on a contractual appeal right counted?

Yes. Appeals accounted for on Table 2 include any first level appeal, including utilization review appeals pursuant to Insurance Law § 4904, grievances, and provider appeals due to contractual rights.

Are second level appeals and external appeals counted on the report?

No, only first level appeals should be counted on the report.

Are step therapy denial reason and the non-formulary drug denial reason limited to pharmacy claims?

Yes.

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Table 1: Claim Data

Line	Variable	Definition
1	# of Claims Pended at the end of the Prior Reporting Period	Claims not yet adjudicated (paid or denied) as of the end of the prior reporting period.
2 3	$ Value of Claims Pended at the end of the Prior Reporting Period	The dollar value for claims pended as of the end of the prior reporting period. Issuers may report either the billed charge (line 2), allowed amount (line 3), or both, but should do so consistently throughout the report.
4	# of Claims Received during the Current Reporting Period	The total number of claims received during the current reporting period. A claim is defined at the unique number level with all the claims lines supporting it.
5 6	$ Value of Claims Received during the Current Reporting Period	The total billed charges for claims received during the reporting period. Issuers may report either the billed charge (line 5), allowed amount (line 6), or both, but should do so consistently throughout the report.
7	# of Claims Rejected during the Current Reporting Period	The total number of claims rejected during the reporting period.
8	# of Claims Paid in Full during the Current Reporting Period	The total number of claims paid in full during the reporting period.
9 10	$ Value of Claims Paid in Full during the Current Reporting Period	The dollar value for claims paid in full during the reporting period. Issuers may report either the billed charge (line 9), allowed amount (line 10), or both, but should do so consistently throughout the report.
11	# of Claims Denied in Full during the Current Reporting Period	The total number of claims denied in full during the reporting period.
12 13	$ Value of Claims Denied in Full during the Current Reporting Period	The dollar value for claims denied in full during the reporting period. Issuers may report either the billed charge (line 12), allowed amount (line 13), or if available, both.
14	# of Claims Paid in Part and Denied in Part during the Current Reporting Period	The number of claims (at the unique claim number level) paid in part and denied in part during the reporting period.
15 16	$ Value of Claims Partially Paid during the Current Reporting Period	The dollar value of claims paid in part during the reporting period. Issuers may report either the billed charge (line 15), allowed amount (line 16), or both, but should do so consistently throughout the report.
17 18	$ Value of Claims Partially Denied during the Current Reporting Period	The dollar value for claims denied in part during the reporting period. Issuers may report either the billed charge (line 17), allowed amount (line 18), or both, but should do so consistently throughout the report.
19	# of Claims Pended at the end of the Current Reporting Period	*Do not enter information on this line. Values are auto calculated.*
20 21	$ Value of Claims Pended at the end of the Current Reporting Period	*Do not enter information on these lines. Values are auto calculated.*
22 23 24	% # of Claims Denied during the Current Reporting Period % $ Value of Claims Denied during the Current Reporting Period (Billed Charges) % $ Value of Claims Denied during the Current Reporting Period (Allowed Amount)	*Do not enter information on these lines. Values are auto calculated.*

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Table 2: Appeals Data

Line	Variable	Definition
25	# of First Level Appeals Pending at the end of the Prior Reporting Period	The total number of appeals pending at the end of the prior reporting period.
26 27	$ Value of Claims Initially Denied in Full or in Part that were pending First Level Appeal at the end of the Prior Reporting Period	The total dollar values of denied claims that were pending first level appeals as of the end of the prior reporting period. Issuers may report either billed charges (line 26), allowed amount (line 27), or both, but should do so consistently throughout the report.
28	# of First Level Appeals Received during the Current Reporting Period	The total number of appeals received during the reporting period.
29 30	$ Value of Claims Initially Denied in Full or in Part that were submitted for First Level Appeal during the Current Reporting Period	The total dollar values for claim denials upheld on first level appeal in full or in part during the report period. Issuers may report either billed charges (line 29), allowed amount (line 30), or both, but should do so consistently throughout the report.
31	# of First Level Appeals Overturned in Full during the Current Reporting Period	The total number of first level appeals overturned in full during the reporting period.
32	# of First Level Appeals Overturned in Part during the Current Reporting Period	The total number of first level appeals overturned in part during the reporting period.
33 34	$ Value of Claims Paid in Full or in Part upon First Level Appeal during the Current Reporting Period	The total dollar values for claims paid for first level appeals either overturned in full or in part during the reporting period. Issuers may report either billed charges (line 33), allowed amount (line 34), or both, but should do so consistently throughout the report.
35	# of First Level Appeals Upheld during the Current Reporting Period	The total number of first level appeals upheld in full during the reporting period.
36 37	$ Value of Claims Denied in Full or in Part upon First Level Appeal during the Current Reporting Period	The dollar value for claims denied upheld upon first level appeal in full or in part during the reporting period. Issuers may report either billed charges (line 36), allowed amount (line 37), or both, but should do so consistently throughout the report..
38	# of First Level Appeals Pending at the end of the Current Reporting Period	*Do not enter information on this line. Values are auto calculated.*
39 40	$ Value of Claims Initially Denied in Full or in Part that were Pending First Level Appeal at the end of the Current Reporting Period	*Do not enter information on these lines. Values are auto calculated.*
41 42 43	% # of First Level Appeals Upheld in Full during the Current Reporting Period % $ Value of First Level Appeals Upheld in Full or in Part during the Current Reporting Period (Billed Charges) % $ Value of First Level Appeals Upheld in Full or in Part during the Current Reporting Period (Allowed Amount)	*Do not enter information in this column. Values are auto calculated.*

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Table 3: Denial Reasons by Provider Types

Variable	Definition
# of Claims Denied in Full or in Part	The total number of claims denied in full or in part during the reporting period by denial reason and provider type. Claims should be counted only under one denial reason. If any one of the denial reasons is “not medically necessary,” the claim should be counted there. For all other denial reasons, the issuer should determine the primary reason and count the claim denial once.
$ Value of Denied Claims (Billed Charges)	The total billed charges for claims denied in full or in part during the reporting period. Issuers may report either the billed amount, allowed amount, or both, but should do so consistently throughout the report.
$ Value of Denied Claims (Allowed Amount)	The total allowed amount for claims denied in full or in part during the reporting period. Issuers may report either the billed amount, allowed amount, or both, but should do so consistently throughout the report..

Variable

Definition

# of Claims Denied in Full or in Part

The total number of claims denied in full or in part during the reporting period by denial reason and provider type.

Claims should be counted only under one denial reason. If any one of the denial reasons is “not medically necessary,” the claim should be counted there. For all other denial reasons, the issuer should determine the primary reason and count the claim denial once.

$ Value of Denied Claims (Billed Charges)

The total billed charges for claims denied in full or in part during the reporting period. Issuers may report either the billed amount, allowed amount, or both, but should do so consistently throughout the report.

$ Value of Denied Claims
(Allowed Amount)

The total allowed amount for claims denied in full or in part during the reporting period. Issuers may report either the billed amount, allowed amount, or both, but should do so consistently throughout the report..

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