90-590 C.M.R. ch. 247 – Uniform Reporting System for Non-Claims-Based Payments and Other Supplemental Health Care Data Sets

90-590 MAINE HEALTH DATA ORGANIZATION
1. CHAPTER 247: UNIFORM REPORTING SYSTEM FOR NON-CLAIMS-BASED PAYMENTS AND OTHER SUPPLEMENTAL HEALTH CARE DATA SETS

SUMMARY: This Chapter contains the provisions for filing supplemental health care data sets, including non-claims-based payments; aggregated, claims-based payments; and prescription drug rebate data.

1. Definitions
1. Unless the context indicates otherwise, the following words and phrases shall have the following meanings:

1. Behavioral Health Care. "Behavioral health care (BH)" means services to address mental health and substance use conditions. 24-A MRSA §6903, sub-§1-A. For examples of BH providers see Appendix C.
2. Capitation Payments. “Capitation payments” means per capita payments to providers to provide services needed by designated patients over a defined period.
3. Care Management/Care Coordination/Population Health Payments. “Care management/care coordination/population health payments” means payments to fund a care manager, care coordinator, or other traditionally non-billing practice team members (e.g., practice coaches, patient educators, patient navigators, or nurse care managers) who help providers organize clinics to function better and help patients take charge of their health.
4. Carrier. "Carrier" means an insurance company licensed in accordance with 24-A M.R.S., including a health maintenance organization, a multiple employer welfare arrangement licensed pursuant to 24-A M.R.S., chapter 81, a preferred provider organization, a fraternal benefit society, or a nonprofit hospital or medical service organization or health plan licensed pursuant to 24 M.R.S. An employer exempted from the applicability of 24-A M.R.S., chapter 56-A under the federal Employee Retirement Income Security Act of 1974, 29 United States Code, Sections 1001 to 1461 (1988) (“ERISA”) is not considered a carrier.
5. Designee. "Designee" means an entity with which the MHDO has entered into an agreement under which the entity performs data collection, validation and management functions for the MHDO and is strictly prohibited from releasing information obtained in such a capacity.
6. Electronic Health Records/Health Information Technology Infrastructure/Other Data Analytics Payments. “Electronic health records/health information technology infrastructure and other data analytics payments” means payments to help providers adopt and utilize health information technology, such as electronic medical records and health information exchanges, software that enables practices to analyze quality and/or costs outside of the electronic health records and/or the cost of a data analyst to support practices.
7. Global Budget Payments. “Global budget payments” means payments made to providers for either a comprehensive set of services for a designated patient population or a more narrowly defined set of services where certain services such as behavioral health or pharmacy are carved out. Services typically include primary care clinician services, specialty care physician services, inpatient hospital services, and outpatient hospital services, at a minimum. Hospitals and health systems are typically the provider types that would operate under a global budget, though this is not widespread.
8. Medicare Health Plan Sponsor. “Medicare health plan sponsor” means a health insurance carrier or other private company authorized by the United States Department of Health and Human Services, Centers for Medicare and Medicaid Services to administer Medicare Part C and Part D benefits under a health plan or prescription drug plan.
9. Medication Reconciliation. “Medication reconciliation” means payments to fund the cost of a pharmacist to help practices with medication reconciliation for poly-pharmacy patients.
10. MHDO. "MHDO" means the Maine Health Data Organization.
11. M.R.S. “M.R.S.” means Maine Revised Statutes.
12. Non-Claims Based Payments. “Non-claims-based” means payments that are for something other than a fee-for-service claim. These payments include but are not limited to Capitation Payments, Care Management/Care Coordination/Population Health Payments, Electronic Health Records/Health Information Technology Infrastructure/Other Data Analytics Payments, Global Budget Payments, Patient-centered Medical Home Payments, Pay-for-performance Payments, Pay-for-reporting Payments, Primary Care and Behavioral Health Integration Payments, Prospective Case Rate Payments, Prospective Episode-based Payments, Provider Salary Payments, Retrospective/Prospective Incentive Payments, Risk-based Payments, Shared-risk Recoupments, Shared-savings Distributions.
13. Patient-centered Medical Home Payments. “Patient-centered medical home payments” means Practice-level payments such as payments to Patient-Centered Medical Homes (PCMH), Health Homes for provision of comprehensive services; payments based upon PCMH recognition; or payments for participation in proprietary or other multi-payor medical -home or specialty care practice initiative.
14. Pay-for-performance Payments. “Pay-for-performance payments” means payments to reward providers for achieving a set target (absolute, relative, or improvement-based) for quality or efficiency metrics. Payments could include the return of a withhold if not attached to a claim payment.
15. Pay-for-reporting Payments. “Pay-for-reporting payments” means payments to providers for reporting on a set of quality or efficiency metrics, usually to build capacity for future pay-for-performance incentives.
16. Payor. "Payor" means a carrier, third-party payor, third-party administrator, Medicare health plan sponsor or Medicaid.
17. Pharmacy Benefits Manager. "Pharmacy benefits manager" means an entity that performs pharmacy benefits management as defined in 24-A M.R.S. §4347, sub-section 17.

Pharmacy Benefits Manager Compensation. “Pharmacy benefits manager compensation” means the difference between:
1. the value of payments made by a carrier to its pharmacy benefits manager; and
2. the value of payments made by the pharmacy benefits manager to dispensing pharmacies for the provision of prescription drugs or pharmacy services with regard to pharmacy benefits covered by the carrier.
Primary Care. "Primary care" means regular check-ups, wellness and general health care provided by a provider (see Appendix A) with whom a patient has initial contact for a health issue, not including an urgent care or emergency health issue, and by whom the patient may be referred to a specialist.
Primary Care and Behavioral Health Integration Payments: “Primary care and behavioral health integration payments” means payments that promote the appropriate integration of primary care and behavioral health care that are not reimbursable through claims (e.g., funding behavioral health services not traditionally covered with a discrete payment when provided in a primary care setting), such as: a) substance abuse or depression screening; b) performing assessment, referral, and warm hand-off to a behavioral health clinician; and/or c) supporting health behavior change, such as diet and exercise for managing prediabetes risk). This excludes payments for mental health or substance use counseling.
Prospective Case Rate Payments. “Prospective case rate payments” means payments received by providers in a given provider organization for a patient receiving a defined set of services for a specific period.
Prospective Episode-based Payments. “Prospective episode-based payments” means payments received by providers (which can span multiple provider organizations) for a patient receiving a defined set of services for a specific condition across a continuum of care by multiple providers, including providers, or care for a specific condition over a specific time.
Provider. "Provider" means a health care facility, health care practitioner, health product manufacturer or health product vendor but does not include a retail pharmacy.
Provider Salary Payments. “Provider salary payments” means payments for salaries of providers who provide care. This category may only be applicable for closed health systems.
Rebate. “Rebate” means a discount, chargeback, or other price concession that affects the price of a prescription drug product, regardless of whether conferred through regular aggregate payments, on a claim-by-claim basis at the point-of-sale, as part of retrospective financial reconciliations (including reconciliations that also reflect other contractual arrangements), or by any other method. “Rebate” does not mean a “bona fide service fee”, as such term is defined in Section 447.502 of Title 42 of the Code of Federal Regulations, published October 1, 2019.
Recoveries. “Recoveries” means payments received by a provider from a payor and then later recouped due to a review, audit, or investigation. Recoveries not reported in claims payments should be netted out of the total non-claims-based payments reported.
Retrospective/Prospective Incentive Payments. “Retrospective/prospective incentive payments” means payments to reward providers for achieving quality and/or efficiency goals. The two main subcategories of incentive payments are pay-for-performance and pay-for-reporting.
Risk-based Payments. “Risk-based payments” means payments received by providers (or recouped from providers) based on performance relative to a defined spending target. Risk-based payment methodologies can be applied to different types of budgets, including but not limited to episode of care and total cost of care. The two main subcategories of risk-based payments are shared savings and shared risk.
Shared-risk Recoupments. “Shared-risk recoupments” means payments payors recoup from providers if costs of services are above a predetermined, risk-adjusted target. Shared-risk arrangements are typically calculated on a total cost of care basis and typically exclude high-cost outliers. Recoupment should be netted out of the total non-claims-based payments reported.
Shared-savings Distributions. “Shared-savings distributions” means payments received by providers if costs of services are below a predetermined and risk-adjusted target. The amount of savings the provider can receive is often linked to performance on quality measures.
Substance Use Disorder (SUD). “SUD means a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems such as impaired control, social impairment, risky use, and pharmacological tolerance and withdrawal, excluding tobacco/nicotine or caffeine use.
Supplemental Health Care Data Sets. “Supplemental health care data sets” means data files specific to payments for primary care, behavioral health, or other health care services. Supplemental health care data sets may include aggregated, non-claims-based payment information, or aggregated or non-aggregated, SUD claims-based payment information.
Third-party Administrator. “Third-party administrator” means any person licensed by the Maine Bureau of Insurance under 24-A M.R.S., chapter 18 who, on behalf of a plan sponsor, health care service plan, nonprofit hospital or medical service organization, health maintenance organization or insurer, receives or collects charges, contributions or premiums for, or adjusts or settles claims on residents of this State.
Third-party Payor. "Third-party payor" means a state agency that pays for health care services or a health insurer, carrier, including a carrier that provides only administrative services for plan sponsors, nonprofit hospital, medical services organization, or managed care organization licensed in the State.

2. Non-Claims-Based Payments and Other Supplemental Health Care Data Set Filing Description

General Requirements
Payors that: i) provide medical and pharmacy benefits to Maine residents; and ii) are not excluded from submitting health care claims data sets under 90-590 C.M.R. Chapter 243 Sec 2(A)(9)(a-b); and iii) reimburse providers by means other than a Fee-for-Service model shall submit to the MHDO or its designee the following complete data sets, if applicable.
Types and descriptions of data sets and supporting information files
1. Non-claims-based (NC) data sets consist of aggregated NC payment information regarding payments from payors to providers for the prior calendar year, which is defined as the performance period. NC files must contain the most recent information available at the time of file generation with a minimum of 3 months of run-out. Payors shall report NC payments for Medicare and non-Medicare Advantage (commercially insured) populations separately, combining plans as needed within those populations. It may be necessary to estimate portions of NC payments by population if amounts are paid to provider systems for plans that include both populations. Population counts encompass all eligible members, not just those associated with providers who received NC payments.
2. Aggregated, SUD claims-based (AC) data sets consist of AC payment information regarding payments from payors to providers. The performance period is retrospective and defined to include claims incurred during the prior calendar year (no limitation on paid date). AC files must contain the most recent information available at the time of file generation with a minimum of 3 months of run-out. Payors shall aggregate SUD claims payments by the product codes identified in Section 2(B), data element AC003 and report totals for each product code. The total members and total member months in the AC file include all members eligible for the product code in the performance period, not just those with SUD claims.
3. Prescription drug rebate (DR) data sets consist of aggregated prescription drug payment and rebate information. The performance period is retrospective and defined to include claims incurred during the prior calendar year with no limitation on paid date or rebate received date. DR files must contain the most recent information available at the time of file generation with a minimum of 3 months of run-out.
4. All data set types shall be accompanied by appropriate supporting information files (NS and AS). Samples are found at https://mhdo.maine.gov/portal.
  1. NS the supporting information file for an NC payment data set must describe the methods used to reimburse behavioral health care providers.
  2. AS, the supporting information file for an AC payment data set must detail the methods used to identify the substance use disorder claims, the specific code lists that are used for procedure codes, revenue codes and diagnosis codes, provider types and any other detail on the claim that is required to select the substance use disorder claim.
The payors specified in section (1) shall indicate the data set types that are applicable to all plans or certify that these are not applicable via the annual registration update at https://mhdo.maine.gov/portal by February 28^thof each year. It is the responsibility of the payor to amend the information, as needed, and to have an authorized user electronically sign to confirm/attest that the information provided is complete and accurate.
The payor(s) that administer(s) health insurance for State of Maine employees and the Maine Education Association Benefits Trust to pay for behavioral health care shall also submit separate data sets and supporting information for these two groups.
Each payor is responsible for the submission of all applicable data sets and supporting information made by any sub-contractor on its behalf.
Any self-funded employee benefit plan regulated by ERISA that submits claims data under 90-590 C.M.R. Chapter 243 Section 5 shall submit completed, applicable data sets for Maine residents and supporting information in accordance with the provisions of this rule. Any such data shall be subject to the same laws and regulations as other MHDO data.
Data Elements and Attributes by Header Record, Trailer Record and File Type

Header Record (for All File Types)

Data Element #	Data Element Name	Type	Maximum Length	Definition/Description

HD001	Record Type	Text	2	HD

HD002	Submitter	Text	8	MHDO-assigned identifier of payor submitting data. Do not leave blank.

HD003	Payor	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage

HD004	Type of File	Text	2	AC Aggregated, SUD Claims-Based Payments DR Prescription Drug Rebates NC Non-Claims-Based Payments

HD005	Period Beginning Date	Text	6	CCYYMM
				Beginning of paid period for payments

HD006	Period Ending Date	Text	6	CCYYMM
				End of paid period

HD007	Record Count	Number	10	Total number of records submitted in this file
				Exclude header record in count

HD008	Comments	Text	80	Submitter may use to document this submission by assigning a filename, system source, etc.

Trailer Record (for All File Types)

Data Element #	Data Element Name	Type	Maximum Length	Definition/Description

TR001	Record Type	Text	2	TR

TR002	Submitter	Text	8	MHDO-assigned identifier of payor submitting data. Do not leave blank.

TR003	Payor	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage

TR004	Type of File	Text	2	AC Aggregated, SUD Claims-Based Payments DR Prescription Drug Rebates NC Non-Claims-Based Payments
TR005	Period Beginning Date	Text	6	CCYYMM
				Beginning of paid period for payments

TR006	Period Ending Date	Text	6	CCYYMM
				End of paid period

TR007	Date Processed	Text	8	CCYYMMDD
				Date file was created

File Type NC – Non-Claims-Based Payments

Data Element #	Data Element Name	Type	Maximum Length	Definition/Description

NC001	Submitter	Text	8	MHDO-assigned identifier of payor submitting data. Do not leave blank.

NC002	Payor	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage

NC003	Placeholder	N/A	0	Leave blank.

NC004	Performance Period Start Date	Text	6	CCYYMM Effective date of performance period. Performance period refers to payment date.

NC005	Performance Period End Date	Text	6	CCYYMM End date of performance period. Performance period refers to payment date.

NC006	Total Number of Members	Number	10	The count of individual members with any eligibility in the performance period in the population identified in NC012. No decimal places; round to nearest integer. Example: 12345

NC007	Total Member Months	Number	10	The total number of member months of eligibility in the performance period in the population identified in NC012. No decimal places; round to nearest integer. Example: 12345

NC008	Total Dollars Non-Claims-Based Payments	Number	10	No decimal places; round to nearest integer. Example: 12345


NC009	Total Dollars Non-Claims-Based Payments (Primary Care Only Portion)	Number	10	No decimal places; round to nearest integer. Example: 12345 See definition of Primary Care above (1Q) for reporting Primary Care Only.
NC010	Total Dollars Non-Claims-Based Payments (BH/SUD Only Portion)	Number	10	No decimal places; round to nearest integer. Example: 12345 See definition of Behavioral Health/Substance Use Disorder above (1A) and Appendix C for examples for reporting BH/SUD Only.

NC011	Total Dollars Non-Claims-Based Payments (non-PC/non-BH/SUD)	Number	10	No decimal places; round to nearest integer. Example: 12345

NC012	Population	Text	2	Population to which the payments apply. CI Commercially Insured (non-Medicare Advantage) MA Medicare Advantage MC MaineCare
NC013	Payor Notes	Text	320	Clarification about the population to which the payments apply, limitations in ability to report the measure, and/or explanation of why the data is not reported.

File Type AC – Aggregated SUD Claims-Based Payments

Data Element #	Data Element Name	Type	Maximum Length	Definition/Description

AC001	Submitter	Text	8	MHDO-assigned identifier of payor submitting data. Do not leave blank.

AC002	Payor	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage
AC003	Insurance Type/Product Code	Text	2	Code identifying the type of insurance policy within a specific insurance program. Refer to Appendix B for standard code list. Coding should match MHDO Rule Chapter 243 Data Element ME003.

AC004	Performance Period Start Date	Text	6	CCYYMM Effective date of performance period for reported Insurance Type/Product Code. Performance period refers to incurred date on redacted claims.

AC005	Performance Period End Date	Text	6	CCYYMM End date of performance period for reported Insurance Type/Product Code. Performance period refers to incurred date on redacted claims.

AC006	Total Number of Members	Number	10	The count of individual members with any eligibility in the performance period in the product code identified in AC003. No decimal places; round to nearest integer Example: 12345

AC007	Total Member Months	Number	10	The total number of member months of eligibility in the performance period in the product code identified in AC003. No decimal places; round to nearest integer Example: 12345

AC008	Total Plan-Paid Dollars SUD Claims-Based Payments Not Reported to MHDO	Number	10	The amount on claims that were not submitted to the MHDO under MHDO Rule Chapter 243. No decimal places; round to nearest integer. Example: 12345

AC009	Total Plan-Paid Dollars on Claims/Claim Lines Sent to MHDO where SUD Codes Were Removed	Number	10	Indicates the amount paid on claims where SUD codes were removed before the claims were submitted to MHDO under MHDO Rule Chapter 243. No decimal places; round to nearest integer. Example: 12345
AC010	Coverage Type	Text	2	Type of coverage with which payments are associated. 01 Medical 02 Pharmacy
AC011	Payor Notes	Text	320	Clarification about the population to which the payments apply, limitations in ability to report the measure, and/or explanation of why the data is not reported.
AC012	Total Plan-Paid Dollars SUD Claims-Based Payments Related to Primary Care	Number	10	No decimal places; round to nearest integer. See Appendix A for PC provider definition. Example: 12345

File Type DR – Prescription Drug Rebates

Data Element #	Data Element Name	Type	Maximum Length	Definition/Description

DR001	Submitter	Text	8	MHDO-assigned identifier of payor submitting data. Do not leave blank.

DR002	Payor	Text	8	MHDO-assigned code of the insurer/ underwriter in the case of premiums-based coverage, or of the administrator in the case of self-funded coverage

DR003	Placeholder	N/A	0	Leave blank.

DR004A	Performance Period Start Date	Text	6	CCYYMM Effective date of performance period. Performance period refers to date of fill.
DR004B	Performance Period End Date	Text	6	CCYYMM Effective date of performance period. Performance period refers to date of fill.

DR005	Drug Code	Text	11	NDC Code

DR006	Drug Name	Text	80	Text name of drug

DR007	Generic Drug Indicator	Text	1	N No, branded drug Y Yes, generic drug

DR008	Specialty Drug Indicator	Text	1	Drug defined as a specialty drug under the terms of a payor’s contract with its PBM. N No Y Yes

DR009	Total Count of Prescriptions Filled	Number	15	Total count of all prescriptions filled by members. No decimal places; round to nearest integer Example: 12345

DR010	Total Quantity Dispensed	Number	15	Total Number of metric units of medication dispensed. No decimal places; round to nearest integer Example: 12345
DR011	Total Pharmacy Expenditure Amount	Number	15	The sum of all incurred claim allowed payment amounts to pharmacies for the drug as defined by the payor’s prescription drug benefit. This amount shall include member cost sharing amounts. This shall also include all incurred claims for individuals included in the member population regardless of where the prescription drugs are dispensed (i.e., includes claims from in-state and out-of-state providers). (Allowed amount should include direct drug costs and exclude non-claim costs. This amount will not reflect prescription drug rebates or pharmacy benefit manager compensation in any way). No decimal places; round to nearest integer Example: 12345

DR012	Total Manufacturer Prescription Drug Rebates	Number	15	Total prescription drug rebates remitted by or on behalf of a pharmaceutical manufacturer, directly or indirectly, to a payor, or to a pharmacy benefits manager under contract with a payor. The total manufacturer prescription drug rebate amount should not be included in the total pharmacy expenditure amount. No decimal places; round to nearest integer Example: 12345

DR013	Total Pharmacy Prescription Drug Rebates	Number	15	Total prescription drug rebates (including direct or indirect remuneration) remitted by or on behalf of a pharmacy, directly or indirectly, to a payor, or to a pharmacy benefits manager under contract with a payor. The total pharmacy prescription drug rebate amount should not be included in the total pharmacy expenditure amount. No decimal places; round to nearest integer Example: 12345
DR014	Percent Rebate Retained by PBM	Number	5	The percent of total prescription drug rebates retained by a pharmacy benefits manager under contract with a payor. Do not code decimal point. Two decimal places implied.

DR015	Total PBM Compensation Amount	Number	15	The total value of payments made by the payor to its pharmacy benefits manager that is not paid to the pharmacy. The pharmacy benefits manager compensation amount should not be included in the total pharmacy expenditure amount. PBM compensation does not include any compensation paid by a manufacturer, developer, or labeler for the performance of services. No decimal places; round to nearest integer. Example: 12345

DR016	Payor Notes	Text	1000	Additional information related to the data submitted for this drug product.

File-Level Specifications
File Formats.
1. 1. 1. Each data file submission shall be an encrypted (AES-256) ASCII file, variable field length, and asterisk delimited. It shall contain a header record and a trailer record. The header record is the first record of each separate file submission, and the trailer record is the last. Each record shall be terminated with a carriage return (ASCII 13), or a carriage return line feed (ASCII 13, ASCII 10).
    2. Each supporting information file shall be a Microsoft Excel^®-compatible spreadsheet.
Filled Fields. All required fields shall be filled where applicable. Non-required text and number fields shall be left blank when unavailable.
Position. All text fields are to be left justified. All numeric fields are to be right justified.
Signs. Positive values are assumed and need not be indicated as such. Negative values must be indicated with a minus sign and must appear in the left-most position of all numeric fields.

3. Submission Requirements

File Organization. Each file shall be submitted to the MHDO or its designee separately.
Filing Method. Data files and supporting information must be submitted to the MHDO’s Payor Data Portal via secure FTP or secure web upload interface at https://mhdo.maine.gov/portal. E-mail attachments shall not be accepted.
Testing of Files. File testing shall be completed within one hundred and eighty days of the adoption of any changes to the data element content or format of the files described in Section 2(B) or at least sixty days prior to the initial submission of production files.
Rejection of Files. Failure to conform to the requirements subsections
A, B, or C of this Section shall result in the rejection of the applicable data file(s). All rejected files must be resubmitted in the appropriate, corrected form to the MHDO or its designee within 15 days.
Filing Period. The annual filing for each submission shall cover the previous completed calendar year and shall be due by August 31.
Update/Replacement of Data. A payor may update or replace a data file submission up to one year after its original due date. Any updates or replacements after this period must be approved by the MHDO.

4. Data Validation; Notification; Response

Attestation. The MHDO or its designee shall require an authorized user for each payor to electronically sign an attestation that the payor is compliant with the requirements outlined in this rule. The annual attestation shall be due by August 31.
Notification. Within 15 days, the MHDO or its designee will complete the evaluation of any data file submissions and notify any payors whose data submissions for any filing period do not satisfy the requirements of Section 2(B). This notification will identify the specific file(s) and the data elements within the file(s) that do not satisfy the requirements.
Response. Each payor notified under subsection 4(B) shall respond in writing within 15 days of notification and make the necessary changes within 30 days to satisfy the requirements.

5. Public Access
1. Information collected, processed and/or analyzed under this rule shall be subject to release to the public or retained as confidential information in accordance with 22 M.R.S. Chapter 1683 and Code of Maine Rules 90-590, Chapter 120, unless prohibited by state or federal law.
2. 6. Extensions or Waivers to Data Submission Requirements
  If a payor, due to circumstances beyond its control, is temporarily unable to meet the terms and conditions of this rule, a written request must be made within 30 days of the filing deadline of August 31 to the Compliance Officer of the MHDO. The written request shall include: the specific requirement to be extended or waived; an explanation of the cause; the methodology proposed to eliminate the necessity of the extension or waiver; and the time frame required to come into compliance. If the Compliance Officer does not approve the requested extension or waiver, the payor may submit a written request appealing the decision to the MHDO Board. The appeal shall be heard by the MHDO Board at the next regularly scheduled meeting following receipt of the request at the MHDO.
3. 7. Compliance
  The failure to file, report, or correct non-claims-based payment data sets when required under the provisions of this rule may be considered a violation under 22 M.R.S. Sec. 8705-A and Code of Maine Rules 90-590, Chapter 100: Enforcement Procedures.

STATUTORY AUTHORITY: 22 M.R.S. §§ 8703(1); 8704(1) & (4); and 24-A M.R.S, §6951

EFFECTIVE DATE: December 12, 2021
AMENDED: December 20, 2022
AMENDED: December 17, 2023 – 2023-250
AMENDED: May 31, 2026 – filing 2026-122

Appendix A

Primary Care Provider Type Taxonomy Codes and Description

Primary Care
261QF0400X	Federally Qualified Health Center
261QP2300X	Primary Care Clinic
261QR1300X	Rural Health Clinic
207Q00000X	Physician, Family Medicine
207R00000X	Physician, General Internal Medicine
175F00000X	Naturopathic Medicine
208000000X	Physician, Pediatrics
208D00000X	Physician, General Practice
363L00000X	Nurse Practitioner
363LA2200X	Nurse Practitioner, Adult Health
363LF0000X	Nurse Practitioner, Family
363LP0200X	Nurse Practitioner, Pediatrics
363LP2300X	Nurse Practitioner, Primary Care
363A00000X	Physician Assistants
363AM0700X	Physician Assistants, Medical
207RG0300X	Physician, Geriatric Medicine
207QG0300X	Family Practice Geriatrics
207QA0505X	Family Practice Adult
207QA0000X	Family Practice Adolescent
175L00000X	Homeopathic Medicine
2083P0500X	Physician, Preventive Medicine
364S00000X	Certified Clinical Nurse Specialist
163W00000X	Registered Nurse, Non-Practitioner
OB/GYN Codes
207V00000X	Physician, Obstetrics and Gynecology
207VG0400X	Physician, Gynecology
363LW0102X	Nurse Practitioner, Women’s Health
363LX0001X	Nurse Practitioner, Obstetrics and Gynecology

Appendix B

Maine Health Data Organization

Source Codes

General Note: The MHDO leverages a wide range of source lists. Many of these lists come from standards development organizations, a few are homegrown (MHDO-created) lists, and a small number of lists combine list values across sources. In addition, where noted, we adopt the standard recommended by the APCD Common Data Layout (APCD-CDL™), which seeks to harmonize data collection efforts across states by advancing recommended lists for common data elements. In situations where the CDL references a field from the ASC X12, values from versions later than 005010 may be used even if the CDL specifies an earlier version.

APCD Common Data Layout (APCD-CDL™)

APCD Council, National Association of Health Data Organizations, The University of New Hampshire

(MHDO Data Element: AC003)

SOURCE: APCD Common Data Layout, Version 4.0.1

AVAILABLE FROM :

https://www.apcdcouncil.org/common-data-layout

APCD Council

965 E Center St

Provo, UT 84606

ABSTRACT: The purpose of the All-Payer Claims Databases (APCD) Common Data Layout (CDL) is to standardize member eligibility and healthcare payment data across states. As part of these efforts, the CDL also advances recommendations for validation source lists to further harmonize data collection. Where indicated above, MHDO data elements will utilize the CDL source list, which leverages codes from the ASC X12 and other sources.

Accredited Standards Committee (ASC)ASC X12 Directories

(MHDO Data Element: AC003 )

SOURCE: Complete ASC X12 005010 Standard. NOTE: while the initial mapping in this document is based on the 005010 standard, list values from equivalent mappings from later versions of this standard may be used.

AVAILABLE FROM:

https://www.nex12.org/

Data Interchange Standards Association, Inc. (DISA)

7600 Leesburg Pike Ste 430

Falls Church, VA 22043

ABSTRACT: The complete standard includes design rules and guidelines, control standards, transaction set tables, data element dictionary, segment directory and code sources. The data element dictionary contains the format and descriptions of data elements used to construct X12 segments. It also contains code lists associated with these data elements. The segment directory contains the format and definitions of the data segments used to construct X12 transaction sets.

Several Definitions are adapted from the Milbank Memorial Fund Report, available from:

https://www.milbank.org/wp-content/uploads/2021/04/Measuring_Non-Claims_7-1.pdf

National Uniform Claim Committee

Healthcare Provider Taxonomy Code Set

(MHDO Data Element: NC010; Tables in Appendices A and C)

SOURCE: https://taxonomy.nucc.org/

ABSTRACT: The Healthcare Provider Taxonomy Code Set is a hierarchical code set that consists of codes, descriptions, and definitions. Healthcare Provider Taxonomy Codes are designed to categorize the type, classification, and/or specialization of health care providers. The Code Set consists of two sections: Individuals and Groups of Individuals, and Non-Individual.

Appendix C

Examples of Behavioral Health Provider Type Taxonomy Codes and Descriptions

Taxonomy Code	Taxonomy Description
Taxonomy Code	Classification	Specialization
101Y00000X	Behavioral Health & Social Service Providers	Counselor
101YA0400X	Behavioral Health & Social Service Providers	Addiction (Substance Use Disorder)
101YM0800X	Behavioral Health & Social Service Providers	Mental Health
101YP1600X	Behavioral Health & Social Service Providers	Pastoral Behavioral Health & Social Service Providers
101YP2500X	Behavioral Health & Social Service Providers	Professional
101YS0200X	Behavioral Health & Social Service Providers	BH & Social Service Providers, School
103T00000X	Psychologist, Clinical	Assistant Behavior Analyst
103TA0400X	Psychologist, Clinical	Behavior Technician
103TA0700X	Psychologist, Clinical	Behavioral Health & Social Service Providers/Psychologist, Adult Development & Aging
103TB0200X	Psychologist, Clinical	Behavioral Health & Social Service Providers/Psychologist, Cognitive & Behavioral
103TC0700X	Psychologist, Clinical	Behavioral Health & Social Service Providers/Psychologist, Clinical
103TC1900X	Psychologist, Clinical	Behavioral Health & Social Service Providers/Psychologist, Counseling
103TF0000X	Psychologist, Clinical	Behavioral Health & Social Service Providers/Psychologist, Family
103TH0100	Psychologist	Health Service
103TP0016X	Psychologist, Clinical	Behavioral Health & Social Service Providers/Psychologist, Prescribing (Medical)
103TP0814X	Psychologist, Clinical	Behavioral Health & Social Service Providers/Psychologist, Psychoanalysis
103TP2701X	Psychologist, Clinical	Behavioral Health & Social Service Providers/Psychologist, Group Psychotherapy
104100000X	Behavioral Health & Social Service Providers	Social Worker
1041C0700X	Behavioral Health & Social Service Providers	Behavioral Health & Social Service Providers
1041S0200X	Behavioral Health & Social Service Providers	School
106E00000X	Assistant Behavior Analyst	Behavior-analytic services
106H00000X	Behavioral Health & Social Service Providers	Marriage and Family Therapist
133VN1006X	Registered Dietitian or Nutrition Professional	Dietary & Nutritional Service Providers/Dietician, Registered, Nutrition, Metabolic
163WA0400X	Registered Nurse	Addiction (Substance Use Disorder)
163WP0807X	Registered Nurse	Psychiatric/Mental Health, Child & Adolescent
163WP0808X	Registered Nurse	Psychiatric/Mental Health
163WP0809X	Registered Nurse	Psychiatric/Mental Health, Adult
172V00000X	Community Health Worker	Patient Navigator, Health Educator, or Promoter
175T00000X	Peer Specialist	Peer Specialist
207PP0204X	Emergency Medicine	Pediatric Emergency Medicine
207QA0401X	Physician/Addiction Medicine	Allopathic & Osteopathic Physicians/Family Medicine, Addiction Medicine
2083A0300X	Preventive Medicine	Addiction Medicine
2084A0401X	Physician/Addiction Medicine	Allopathic & Osteopathic Physicians/Psychiatry & Neurology, Addiction Medicine
2084F0202X	Physician/Neuropsychiatry	Allopathic & Osteopathic Physicians/ Psychiatry & Neurology, Forensic Psychiatry
2084P0015X	Physician/Neuropsychiatry	Allopathic & Osteopathic Physicians/ Psychiatry & Neurology, Psychosomatic Medicine
2084P0800X	Physician/Psychiatry	Allopathic & Osteopathic Physicians/Psychiatry
2084P0802X	Physician/Neuropsychiatry	Allopathic & Osteopathic Physicians/ Psychiatry & Neurology, Addiction Psychiatry
2084P0804X	Physician/Neuropsychiatry	Allopathic & Osteopathic Physicians/ Psychiatry & Neurology, Child & Adolescent Psychiatry
2084P0805X	Physician/Neuropsychiatry	Allopathic & Osteopathic Physicians/ Psychiatry & Neurology, Geriatric Psychiatry
221700000X	Art Therapist	Trauma, Oncology, Addiction, Autism, or Expressive Arts
222Q00000X	Developmental Therapist	Developmental Therapist
225500000X	Specialist/Technologist	Respiratory, Developmental, Rehabilitative and Restorative Specialist
225600000X	Dance Therapist	Dance Therapist
225700000X	Massage Therapist	Chronic Pain
251K00000X	Public Health or Welfare	Social & Behavioral Sciences
251S00000X	Agencies	Community/Behavioral Health
251V00000X	Voluntary Health or Charitable Agency	Agencies/Voluntary or Charitable
261QC1500X	Clinic/Center	Community Health
261QM0801X	Community Mental Health Center	Ambulatory Health Care Facilities/Clinic/Center, Mental Health
261QM0850X	Ambulatory Health Care Facilities	Adult Mental Health
261QM0855X	Ambulatory Health Care Facilities	Adolescent And Children Mental Health Care Facilities
261QM2800X	Clinic/Center	Methadone
261QR0405X	Clinic/Center	Rehabilitation, Substance Use Disorder
273R00000X	Psychiatric Unit	Addiction, Forensic, Neuropsychiatry
276400000X	Hospital Units	Rehabilitation, Substance Use Disorder Unit
283Q00000X	Hospital-Psychiatric (PPS excluded)	Hospitals/Psychiatric Hospital
3104A0625X	Assisted Living Facility	Assisted Living, Mental Illness
310500000X	Nursing & Custodial Care Facilities	Intermediate Care Facility, Mental Illness
311Z00000X	Custodial Care Facility	Custodial Care Facility
320600000X	Residential Treatment Facilities	Residential Treatment Facility, Mental Retardation And/Or Developmental Disabilities
320800000X	Residential Treatment Facilities	Community Based Mental Illness
322D00000X	Residential Treatment Facilities	Residential Treatment Facility, Emotionally Disturbed Children
323P00000X	Residential Treatment Facilities	Psychiatric Residential Treatment Facility
324500000X	Residential Treatment Facilities	Substance Abuse Rehabilitation Facility
3245S0500X	Residential Treatment Facilities	Substance Abuse Treatment, Children
363LP0808X	Nurse Practitioner	Physician Assistants & Advanced Practice Nursing Providers/Nurse Practitioner, Psychiatric/Mental Health
364S00000X	Certified Clinical Nurse Specialist	Physician Assistants & Advanced Practice Nursing Providers/Clinical Nurse Specialist
364SP0807X	Certified Clinical Nurse Specialist	Physician Assistants & Advanced Practice Nursing Providers/Clinical Nurse Specialist, Psychiatric/Mental Health, Child & Adolescent
364SP0808X	Certified Clinical Nurse Specialist	Physician Assistants & Advanced Practice Nursing Providers/Clinical Nurse Specialist, Psychiatric/Mental Health
364SC1501X	Clinical Nurse Specialist	Community Health/Public Health
364SF0001X	Clinical Nurse Specialist	Family Health
364SP0809X	Certified Clinical Nurse Specialist	Physician Assistants & Advanced Practice Nursing Providers/Clinical Nurse Specialist, Psychiatric/Mental Health, Adult
405300000X	Prevention Professional	Prevention Professional