Mo. Code Regs. Ann. tit. 19, § 10-5.010
PURPOSE: This rule establishes the procedures for health maintenance organizations to collect and submit data to the Department of Health pursuant to section 192.068, RSMo.
(1) The following definitions shall be used in the interpretation and enforcement of this rule:
(2) Starting in 1998, commercial health care plans shall submit annually to the department, member satisfaction survey data—
(3) Starting in 1998, health care plans shall provide annually to the department, audited quality indicator data—
(4) Starting in 1998, all commercial health care plans shall submit annually to the department enrollee data for linkage with department data to produce quality indicators—
(6) A health care plan demonstrates continual or substantial failure to comply with the provisions of this rule when the health care plan has been notified by the department that it fails to comply with the provisions of section 192.068, RSMo and this rule and the health care plan—
| City | Name of enrollee city of residence | |
|---|---|---|
| State | Enrollee state of residence, either as two digit FIPS or two character | |
| postal abbreviation. | Example: Missouri=29 or MO | |
| Zip Code | Five digit postal code. Should crosscheck with city and state. | |
| Example: if zip is 63011, city should be ‘Ballwin’, not ‘St. Louis’ | ||
| Enrollee Birth Date | Birth mother’s date of birth in format MMDDYYYY with leading zero(s) | |
| retained for month and/or day. Example 010176 | ||
| Continuous Enrollment** | 1=meets criteria | 2=does not meet criteria |
| Birth Hospital Name | Full name of birth hospital | |
| Hospital Federal Tax I.D. | Nine digit tax identification number of the birth hospital. Do not enter a dash. | |
| Hospital Admit Date | Date birth mother was admitted to hospital, in format MMDDYYYY with leading zero(s) retained for month | |
| and/or day. Example 010199 |
| justified with leading zeroes retained. If SSN unknown, insert unique Plan ID. | |
|---|---|
| Enrollee ID | Mother’s SSN in the format XXXXXXXXX (no dashes). Field should be left |
| justified with leading zeroes retained. If SSN unknown, insert unique Plan ID. | |
| First Name | First Name of Birth Mother, preferably as given on birth record |
| Middle Initial | Middle initial of birth mother |
| Last Name | Last name of birth mother, preferably as given on birth record |
| Enrollee Maiden Name | Birth Mother’s Maiden Name |
| Address1 | House number and Street Name |
| Address2 | Apartment, lot number, etc. |
| Geocode* | Enrollee city of residence, represented as a four digit Missouri city code, |
| including leading zero(s) Example: Blue Springs = 0425 |
| Field Name | Field Values | ||
|---|---|---|---|
| Health Care Plan ID | Five digit code issued by Dept. of Insurance (NAICID) | ||
| If none issued, use any unique 7 char string | |||
| Plan Type | 1=HMO | 2=POS | 3=Other |
| Financial Class Type | 1=Commercial | 2=Medicare 3=Medicaid | |
| Type of Coverage | 1=Single | 2=Family | |
| Relationship Code | Relationship of Birth Mother to Subscriber | ||
| 01= Subscriber (self) | |||
| 02= Spouse of Subscriber | |||
| 03= Child of Subscriber | |||
| 04= Disabled Dependent |
AUTHORITY: section 192.068, RSMo Supp. 1999.* Emergency rule filed Jan. 16, 1998, effective Jan. 26, 1998, terminated April 15, 1998. Original rule filed Jan. 16, 1998, effective Aug. 30, 1998. Amended: Filed Oct. 30, 1998, effective May 30, 1999. Amended: Filed Dec. 20, 1999, effective May 30, 2000. *Original authority: 192.068, RSMo 1997. of Data to Monitor Health Maintenance Organizations Table B Quality Indicator Data Specifications Reporting Period: CY1999 Data reported for each of the indicators listed below shall conform to the NCQA HEDIS Data Submission Tool and all other HEDIS technical specifications for indicator descriptions and calculations. An “X” in the table below indicates data are to be reported for this quality indicator if the health care plan offers this product line to Missouri residents. Indicator Commercial Medicaid Medicare Childhood Immunization Status Adolescent Immunization Status Breast Cancer Screening* Cervical Cancer Screening* Beta Blocker Treatment After Heart Attack Comprehensive Diabetes Care Antidepressant Medication Management Annual Dental Visit ___________________________________________________________________________ *The plan may elect to use the prior year’s data when the indicator is subject to rotation and is off-cycle for NCQA reporting. File Content For each of the quality indicators listed above, the plans shall report the following elements from the NCQA HEDIS Data Submission Tool: 1. Data collection methodology (Administrative or Hybrid.) 2. Eligible member population (i.e., members who meet all denominator criteria.) 3. Minimum required sample size (MRSS) or other sample size 4. Number of original sample records excluded because of valid data errors. 5. Number of records excluded because of contraindications identified through administrative data. 6. Number of records excluded because of contraindications identified through medical record review. 7. Additional records added from the auxiliary list. 8. Denominator 9. Numerator events by administrative data 10. Numerator events by medical record 11. Reported rate 12. Lower 95% confidence interval 13. Upper 95% confidence interval All data elements above shall conform to the HEDIS technical specifications, as outlined in the NCQA-published technical manuals. Applicable to: X X X X X X 19 CSR 10-5 X X X X X X X X Table B Quality Indicator Data Specifications Reporting Period: CY1999 (continued) File format and media The quality indicator data shall be submitted hardcopy as well as electronically, in a data file format to be specified by the Department. The file format will be provided to the plans for the option of data entry on diskette using Microsoft Excel or Access software, or on-line data entry to the Department via the Internet. All other data specifications shall conform to those required by NCQA for submission of the audited quality indicator data. File Consistency Plans that elect to submit separate files for sub-groups of their enrollment population must consistently do so for all data submission categories required by this rule. Health care plans that contract with the Division of Medical Services to provide coverage in more than one Medicaid region, shall submit separate quality indicator data for the enrollees in each region. of Data to Monitor Health Maintenance Organizations 19 CSR 10-5 Table C Health Care Plan Data for Birth-Related Indicators File Specifications Record Filtering This file contains records for female enrollees of the health care plan who delivered a live birth during the reporting year, including those who resided or gave birth outside Missouri. Separate enrollee records shall be submitted for each delivery. (E.g., An enrollee who has two deliveries in the same reporting year would require two separate records.) File Media Enrollee data shall be submitted to the Department electronically as PC ANSI or ASCII files. File Consistency Plans that elect to submit separate files for sub-groups of their enrollment population must consistently do so for all data submission categories required by this rule. Health Care Plan Data for Birth-Related Indicators LAYOUT FOR HEADER RECORD Field Name Plan Name LAYOUT FOR ENROLLEE LEVEL RECORDS Field Name Health Care Plan ID Plan Type Financial Class Type Type of Coverage Relationship Code Subscriber ID Enrollee ID First Name Middle Initial Last Name Enrollee Maiden Name Address1 Address2 Geocode City State Zip Code Enrollee Birth Date Continuous Enrollment Birth Hospital Name Hospital Federal Tax I.D. Hospital Admit Date
* Both month and year. See “Description of File Contents” on the page following for example. Table C Record Layout Columns Field Length Begin End 1 46 Columns Field Length Begin End 1 5 6 6 7 7 8 8 9 10 11 21 22 32 33 46 47 47 48 62 63 77 78 107 108 121 122 125 126 145 146 147 148 152 153 160 161 161 162 181 182 190 191 198 Data Type Justify 46 C Data Type Justify 5 C 1 N 1 N 1 N 2 C 11 C 11 C 14 C 1 C 15 C 15 C 30 C 14 C 4 C 20 C 2 C 5 C 8 C 1 N 20 C 9 N 8 C Fill w/ leading zeroes L Fill w/ leading zeroes L -- -- -- -- L L L -- L L L L -- L L L -- -- L R -- -- Y Y Y Y* Y* of Data to Monitor Health Maintenance Organizations 19 CSR 10-5 Table C Health Care Plan Data for Birth-Related Indicators Description of File Contents Subscriber ID Subscriber’s SSN in the format XXXXXXXXX (no dashes). Field should be left * Data file of geocodes is available for download from the Department, via the Internet at http://www.health.state.mo.us/ResourceMaterial ** Continuous enrollment shall be figured in accordance with the current HEDIS specifications for PreNatal Care in the First Trimester. Table D Managed Health Care Services File Specifications Responses to the following questions must be submitted electronically, in a data file format specified by the Department. The file format will be provided to the plans for the option of data entry on diskette using Microsoft Access software, or on-line data entry to the Department via the Internet. Table D must be completed for each managed care product line (Commercial, Medicaid, or Medicare) offered by each licensed health care plan. Responses should be based on activity or status during the reporting period, within each product line (payor). Survey questions in Table D shall apply except where otherwise noted, only to fully insured (ERISA exempt) enrollments. of Data to Monitor Health Maintenance Organizations I. HEALTH PLAN INFORMATION Instructions: Submit one set of Table D information, Parts I and II, for each product line (i.e. type of payor) offered by your organization. 1.) Product Line (CHECK ONE): 2.) Missouri Department of Insurance Licensed Plan Name: ___________________________________ 3.) NAIC Identification Number (5-digit): __ __ __ __ __ 4.) Name as marketed to your members (for Buyer’s Guide display purposes): ____________________________________________________________________________ 5.) List the following for each of your products within this product line: Marketed a.) Product Name ___________________ ___________________ 6.) Through what organization was your managed care organization accredited as of: a.) January 1, 1999? Accrediting organization: ( ) NCQA Level of Accreditation: b.) December 31, 1999? Accrediting organization: ( ) NCQA Level of Accreditation: 7.) What is the Disenrollment Rate* of this product line? Numerator: = Rate_____ 8.) Managed Care Organization Contact Person for Table D Information: a.) Name: _______________________________ b.) Title: __________________________ c.) Phone: _______________ d.) Fax: ________________ e.) E-mail: __________________ * Disenrollment Rate: The percent of members enrolled on Dec. 31, 1998, who were not enrolled as of December 31, 1999. Changes in product type or payee type, or any gaps in enrollment during 1999 should not be counted as disenrolled. Table D Managed Health Care Services Reporting Period: CY 1999 ( ) Commercial ( ) Medicare ( ) Medicaid Dba (if applicable): ______________________ b.) HMO/POS c.) Customer Service ________ ________ ( ) URAC _________ _________ ( ) URAC _________ _________ Denominator:____________ 19 CSR 10-5 ————Phone Numbers——————- d.) RN Hotline ______________ ___________ ______________ ___________ ( ) JCAHO ( ) None _________ ( ) JCAHO ( ) None _________ II. HEALTH PLAN SERVICES 1.) Please indicate for each of the following high risk conditions/diseases, if your managed care plan (A) has screening mechanisms, (B) provides case management, and (C) provides specific educational materials to persons-at-risk: Screening High Risk Conditions/Diseases Mechanisms Asthma Stroke/Cardiovascular Disease Breast Cancer Cervical Cancer Ovarian Cancer Congestive Heart Failure (CHF) Chronic Obstructive Pulmonary Disease Diabetes Depression HIV Sickle Cell Anemia High Risk Pregnancy Obesity Tobacco Use Multiple Illnesses Chronic Diseases Other _____________________ (PLEASE SPECIFY) 2.) Please indicate if your managed care plan provides any of the following: a.) Routine distribution of educational materials on general health promotion, disease prevention and wellness b.) Information sent to all plan enrollees which addresses some or all of the high-risk conditions/ diseases listed in Question 1. c.) Distribution of preand post-surgical information to enrollees Table D Managed Health Care Services Reporting Period: CY 1999 (A) Management ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) YES ( ) YES ( ) YES (B) Case ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) (CHECK ALL THAT APPLY) (C) Education for Persons-at-risk ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) NO ( ) NO ( ) NO of Data to Monitor Health Maintenance Organizations Note: The term reminder/recall in Questions 3a – 4b refers to notices intended to insure timely scheduling of the specific preventive screening/test or service indicated. General education materials or notices tied to anniversary dates, such as birthdays or enrollment dates, do not meet this definition. 3a.) Commercial or Medicaid only (If completing for a Medicare plan, skip to Question 3b) Do you send reminder/recall letters and/or make telephone calls from your managed care plan office to your members to ensure usage of the following preventive services? Mammograms Immunizations Pap smears Diabetic Screens/Tests 3b.) Medicare only Do you send reminder/recall letters and/or make telephone calls from your managed care plan office to your members to ensure usage of the following preventive services? Mammograms Immunizations Well-woman checks Diabetic Screens/Tests 4a.) Commercial or Medicaid only (If completing for a Medicare plan, skip to Question 4b) Do you provide reminder/recall letters for your providers to use to notify your enrollees of the following preventive services? Mammograms Immunizations Pap smears Diabetic Screens/Tests 4b.) Medicare only Do you provide reminder/recall letters for your providers to use to notify your enrollees of the following preventive services? Mammograms Immunizations Well-woman checks Diabetic Screens/Tests ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES ( ) YES 19 CSR 10-5 ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO ( ) NO 5.) Does your plan routinely conduct continuing education sessions with your providers to improve their knowledge on current clinical practice recommendations? 6.) Does your managed care plan provide a RN hotline for your members? ( ) YES, for all products ( ) YES, for some products 7.) During the reporting period, did your plan provide coverage to your non-ASO members for the following health benefits? Please indicate if the benefit item was offered as standard coverage for all non-ASO products within the product line (commercial, Medicaid or Medicare), as standard coverage only for some non-ASO products in the product line, offered only by rider clause, or not covered at all. (CHECK ONLY ONE FOR EACH BENEFIT LISTED) Products Rx coverage of prenatal vitamins, including folic acid................................. Contraceptives: Birth control pills.............. IUDs............................. Norplant......................... Depo Provera................... Annual eye exam for refractive errors.................. Autologous bone marrow transplants........................ Stem cell rescue for breast cancer............................. Access to chiropractic services Access to podiatric services.... Unrestricted approval for annual flu shots.................. Smoking cessation classes or cessation medications....... Routine physical exams......... Pap smears........................ Conduct wellness surveys...... ( ) YES ( ) NO Non-ASO Product Only All Some Offered only Products by rider clause ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) NO Not Offered ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) of Data to Monitor Health Maintenance Organizations 8.) During the reporting period, did your plan manage the following health services for your ASO group contracts? For each of the health services listed below, please indicate if it was elected as a covered benefit in all the ASO contracts with your plan, in some of the ASO contracts, or in none of the ASO contracts. (CHECK ONE COLUMN ONLY) Also indicate the proportion of your total ASO member enrollment who have coverage for the health service. Contracts Immunizations.................... Mammograms..................... Pap Smear.......................... 9.) For each preventive service listed below, please indicate if, during the reporting year, your plan (A) requires physicians to provide you their practice profile or (B) provides the individual practice profiles to the physicians. In column (C) indicate if you sent comparative profile information to the physicians. Childhood Immunizations................... Adolescent Immunizations.................. Breast Cancer Screenings................... Pap Smears.................................... Beta Blocker Treatment After Heart Attack.......................... Comprehensive Diabetic Care: Hemoglobin Testing........................ Retinal Disease Eye Exam................ LDL-C (Lipids) Testing................... Nephropathy Screenings................... Annual Flu Shots for Older Adults........ Tobacco Cessation Counseling............. Other (Please specify)______________ Selected Covered Benefits: All Contracts ( ) ( ) ( ) ASO Contracts Some None of the Contracts ( ) ( ) ( ) (CHECK “A” OR “B”) || (CIRCLE Y or N) (A) Physicians Provide Profiles ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ASO Enrollment ( ) ( ) ( ) (B) Plan Provides Profiles ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) 19 CSR 10-5 Percent of Covered _______ _______ _______ (C) Plan Sends Comparative Profile Data Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N 10.) Please indicate the administrative policies for your plan, as they applied to your non-ASO members during the reporting year. (CHECK A RESPONSE FOR EACH POLICY LISTED) a.) Allow access to OB/GYNs other than the once per year visit without referral b.) Patient must see PCP for referral to any specialist c.) PCP must contact HMO or its agency for referral to any specialist d.) Members can access non-OB/GYN innetwork specialist without referral or prior authorization e.) Allow specialists other than OB/GYN to be designated as PCP for patients with chronic disease 11.) For each procedure category listed below, please provide the hospital identifier information and the number of procedures performed on your plan members during the reporting period for the facilities in your plan network. Use additional data entry lines, as necessary. Procedure/ICD9-CM Code a.) Cardiac Catheterization (37.21-37.23) Products Hospital Name 1._______________________________|___________|___ 2._______________________________|___________|___ 3._______________________________|___________|___ 4._______________________________|___________|___ 5._______________________________|___________|___ 6._______________________________|___________|___ 7._______________________________|___________|___ 8._______________________________|___________|___ 9._______________________________|___________|___ 10. ______________________________|___________|___ YES All ( ) ( ) ( ) ( ) ( ) Federal YES Some Products ( ) ( ) ( ) ( ) ( ) Px ID # | # NO No Plan Products ( ) ( ) ( ) ( ) ( ) of Data to Monitor Health Maintenance Organizations Procedure/ICD9-CM Code b.) Cardiac Angiography (88.55-88.57) c.) Coronary Artery Bypass Graft (36.1, 36.2) d.) Total Hip Replacement (81.51, 81.53) 19 CSR 10-5 Federal Px Hospital Name ID # | # 1._______________________________|___________|___ 2._______________________________|___________|___ 3._______________________________|___________|___ 4._______________________________|___________|___ 5._______________________________|___________|___ 6._______________________________|___________|___ 7._______________________________|___________|___ 8._______________________________|___________|___ 9._______________________________|___________|___ 10. ______________________________|___________|___ 1._______________________________|___________|___ 2._______________________________|___________|___ 3._______________________________|___________|___ 4._______________________________|___________|___ 5._______________________________|___________|___ 6._______________________________|___________|___ 7._______________________________|___________|___ 8._______________________________|___________|___ 9._______________________________|___________|___ 10. ______________________________|___________|___ 1._______________________________|___________|___ 2._______________________________|___________|___ 3._______________________________|___________|___ 4._______________________________|___________|___ 5._______________________________|___________|___ Procedure/ICD9-CM Code d.) Total Hip Replacement (continued) e.) Prostatectomy (60.21, 60.29, 60.3-60.5 60.61, 60.62, 60.69) Federal Px Hospital Name | ID # | # 6._______________________________|___________|___ 7._______________________________|___________|___ 8._______________________________|___________|___ 9._______________________________|___________|___ 10._______________________________|___________|___ 1._______________________________|___________|___ 2._______________________________|___________|___ 3._______________________________|___________|___ 4._______________________________|___________|___ 5._______________________________|___________|___ 6._______________________________|___________|___ 7._______________________________|___________|___ 8._______________________________|___________|___ 9._______________________________|___________|___ 10. ______________________________|___________|___