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 (.xls)
Submit completed reports via SERFF using the filing type "Health Care Claims Report". The file should be named using the format [COMPANY_NAME]_[REPORTING PERIOD]".
Questions?
If you have questions, do not have access to SERFF, or need assistance from DFS email [email protected].
Claim Data for Health Care Claims Reporting
| 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. |
Appeals Data for Health Care Claims Reporting
| 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. |
Denial Reasons by Provider Type
| 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.. |