Frequently Asked Questions
This is a list of frequently asked questions from payer–submitters and the MHDO responses. It will be updated on an ongoing basis, as needed.
Question: Will the new MHDO Data Warehouse submissions replace all file transfers to OnPoint CDM?
Answer: Yes. All future data submissions will be made to the new MHDO Data Warehouse.
Question: Are we required to submit the same files to the MHDO Data Warehouse as the OnPoint CDM?
Answer: Yes. The requirements for claims data submissions remain the same.
Question: What if some of the data being required is not available within our data warehouse?
Answer: In general, all data elements that can have an appropriate blank/null value have been identified in the layouts for the individual files. However, it is understood that there are limitations within different processing and data warehouse structures. The new system gives users significant control over how to deal with this by overriding validation issues and providing reasons for not being able to meet the threshold.
Question: It was our understanding that coding changes would not be necessary in the transition to the new system for how we populate the data itself outside of not encrypting on a field level.
Answer: Your understanding is accurate – there are no coding changes required.
Question: Can the compliance officer stop getting emails when files are submitted?
Answer: The compliance officer receives all emails related to compliance within the MHDO portal. New file submissions fall under that purview. To stop receiving emails, the user must be removed as the compliance contact.
Question: Will the changes to the validation rules for claims data submissions to the Maine Data Warehouse Portal require payer testing?
Answer: Changes to the validation rules in early May, 2014 will not require payer testing, but HSRI will perform internal system testing.
Question: Why didn't I receive an email confirmation that my file passed after I resolved all of the validation errors?
Answer: The MHDO Portal will email users after a file has been submitted. If the file has no validation errors, the email is a notice that the file has passed. If the file has validation issues, the email is a notice that the file has failed. At this point, the MHDO Portal will not push out an email confirming the file’s passed state if the failures are resolved manually (i.e. through profile, ad hoc, or exemption level validations).
Question: Where can I find more information on the 2014 changes to Chapter 243?
Answer: Information about the changes can be found on the MHDO website https://mhdo.maine.gov/rules.htm
Question: Where can I find information on recent changes to the website?
Answer: The Release Notes page has relevant details about major changes made to the Data Warehouse Portal website and related functionality.
Question: I have multiple subentities in my company. Do I have to use the same Administrative Contact for each?
Answer: No, in the Portal, accounts are initially setup with one Administrative Contact that has the ability to add or invite additional users, who can then be granted Administrative permissions. You can setup as many Administrative Contacts as necessary for your company’s processes.
Question: How do I register multiple subentities that will submit data under my company’s account?
Answer: If the subentities are essentially part of your company you can add users as Member Eligibility, Medical, Dental, or Pharmacy Contact and designate them as data users. If the subentity is an entirely different company you can add them as a Third Party Submitter.
Question: I’m a TPA with multiple employer sponsored plans. Do I need to register them all as Third Party Submitters?
Answer: No. The contracted TPA is the only entity that is legally responsible for the submission of healthcare claims processed for self-insured plans/plan sponsors/employer groups.
Question: What is the difference between the Third Party Submitters and On-Behalf Submissions?
Answer: Registering a Third Party Submitter with your company authorizes them to submit data for your company. On-Behalf Submissions are submissions your company makes for another company. These relationships must be setup in the MHDO Portal Registration to ensure that data submissions pass the validation rules and are properly credited in your Compliance Report.
Here is an example of several relationships and how they should be reflected in each company’s Registration in the Portal.
Company A submits a portion of their own data but the rest is submitted by Company B. Company C submits a portion of their own data but the rest is submitted by Company A.
Company A Registration
Third Party Submitters
• Company B
• Company C
Company B Registration
Third Party Submitters
• Company A
Company C Registration
Third Party Submitters
• Company A
Question: How do I drop or add a submitter ID associated with my company?
Answer: A request to add or drop a submitter ID needs to be approved by MHDO. Please send an email to Compliance Officer, Philippe Bonneau with your request.
Reporting and Submission Requirements
Question: Who should I contact if I have questions about the reporting requirements and compliance?
Answer: Please contact Philippe Bonneau, Compliance Officer, Maine Health Data Organization at firstname.lastname@example.org or 207-287-6743.
Question: I did not have any claims activity during the last period (month or quarter). Do I still need to submit a file?
Answer: Yes, please submit a file with a header and trailer record count of 0.
Question: For the field- MC070 (Service Provider Country Code) can we use ’OT’, when we do not have a country name in the data?
Answer: Please leave the field blank when the country is not known.
Question: For MC038, DC031, and PC025, Claim Status, three of the current valid values are 01 – Processed as Primary, 02 – Processed as Secondary, and 03 – Processed as Tertiary; the 835 implementation guide, specified as the basis for the revised mapping, lists these three conditions as 1, 2, and 3, without the leading zero. Is this material? Will your systems accept both 01 and 1 or should we make a modification to include the leading zero?
Answer: The system will be able to accept both formats (with and without a leading zero).
Question: MC003, DC003, and PC003, Insurance Type/Product code now maps off of the 835 transaction set and there is an option to distinguish Dental Maintenance Organization business while the field ME003, Insurance Type/Product Code, which now maps off of the 271 code set, does not have an equivalent mapping option. This may cause a disconnect between the product typing across the member and claims files. I just wanted to point this out.
Answer: In consultation with payers, the MHDO has had to add values to these code sets in the past. If the need arises, we may have to do so again.
Question: The relationship codes I submitted are failing. Why?
Answer: Under the 5010 standard the codes “34 – Other Adult” and “76 – Dependent” are no longer acceptable for MC011, DC011, and ME012. These fields should be recoded with “G8 – Other Relationship” so the file will pass the validation.
Question: If I am submitting older data (prior to November 2014), should I submit it in the new Chapter 243 format or the old Chapter 243 format?
Answer: All data submissions regardless of data period must be submitted in the new format.
Data Submission/Transfer Process
Question: Will the new compression/encryption process use a different field encryption methodology or will the file have to be field encrypted (through the web portal) before transmission to the FTP Server?
Answer: Sensitive information within files will no longer be protected using field-level encryption; instead, file-level encryption will be used. Submitters will use commercially available, payer-approved file compression and encryption software, rather than proprietary software created and distributed by the vendor.
Question: If we choose to submit files via SFTP are the files required to be zipped/encrypted prior to sending?
Answer: Yes. Submitters will use commercially available, payer-approved file compression and encryption software, rather than proprietary software created and distributed by the vendor. Specifications and instructions for file compression and encryption can be found in the User Guide.
Question: How will I find out if my submission failed?
Answer: All files will be validated within 24 hours of submission. Once the validation process has completed you will receive a notification email. Any validation issues found can be viewed and resolved on the Portal.
Question: Whom do I contact if I am having upload problems either via the Portal or SFTP?
Answer: The Portal Help Desk is available for any technical/system issues that a user may encounter. Customers of the Portal should expect support during regular business hours (8am-5pm EDT, Monday – Friday) within two hours of request. Below is the contact information for the Help Desk:
Toll-free Phone Number: (866) 315-7125
Email Address: email@example.com
Question: When we submit the encrypted files to the MHDO Data Warehouse for validation (through the portal or by SFTP), are the files landed on a National Opinion Research Center (NORC) server for the validation process, or, are the files validated outside of the NORC environment and moved to the NORC environment after validation?
Answer: The files are either uploaded or SFTP'd to NORC-controlled servers. They are then validated and stored entirely within NORC's secure data enclave.
Question: Can I submit test files?
Answer: Yes, you may submit test files but they need to be named as such so they are not included in the data warehouse. In order to name them you must follow the naming conventions specified in the user guide using “TEST” as the payer ID. You can number the files if needed (i.e. TEST1, TEST2). The test file will be live until the evening site maintenance at 11:59 pm of the same day.
Question: We had submitted our files via SFTP but they aren’t showing up on the submission history screen on the MHDO portal page.
Answer: If files are submitted via SFTP that are not properly compressed and encrypted (example: .txt file), they will not show up on the submission history screens.
Question: I am trying to submit a file (C0756_201212ME1v1.txt). The portal is telling me my file is improperly named. Why?
Answer: Leading zeroes must be used in the Sequence and Version number. The proper naming of the file is: C0756_201212ME01v01.txt.
Question: Where does the MHDO Data Warehouse reside? Describe what protections are in place for system security.
The MHDO Data Warehouse systems reside within the National Opinion Research Center (NORC) secure facilities. These facilities have strictly controlled physical access and maintain boundary protection utilizing network firewalls, Intrusion Prevention System (IPS) and security monitoring using a unified situational platform. The IT environment is thoroughly documented and is compliant with NIST 800-53 Rev.3 standards. Security provisions are established and maintained to include:
- Managed firewall and IPS
- Configuration management baselines: FDCC\USGCB for laptops, Center for Internet Security (CIS) benchmarks for network and server systems
- Least privilege access to system boundary
- Continuous physical and system security monitoring
- Managed security policies using domain group policies for complex passwords and mandatory renewal
- Domain-managed virus protection
- Access control procedures for data and systems
- Virus and spam filtering of email
- Encryption, FIPS 140-2 Level 2 – laptops (Full Disk), VPN connection (2-factor authentication), Encrypted backups tapes
In NORC’s Data Enclave environment, which houses MHDO systems,- users are logically separated within their work area and unable to remove any information without prior authorization from MHDO. Any inbound or outbound files are managed and audited by the NORC Data Custodians.
Annual security tests are conducted by a third party IT security auditor. This auditor conducts a design-level review of controls that support the security of the Enclave using NIST Special Publications 800-53 (Moderate-Impact assets) as the security standard, and an analysis of risks to electronic protected health information (ePHI) in the Enclave as a result of any potential gaps., which are immediately addressed. The auditor evaluates the design and implementation of the following aspects of the NORC System Security Plan (SSP) through:
- Stating roles and responsibilities for ownership and stewardship of the SSP,
- Stating the risk assessment, methodologies, processes and documents,
- The certification and authorization of acquired and developed systems,
- Operational controls, including contingency and incident response plans and maintenance plans,
- Considerations of personnel management and facilities and physical security management,
- The integrity of information and the integrity of communications (network) systems,
- The control of access controls, including authentication of access accounts and the approved movement of data to zones of varying degrees of security,
- The appropriate selection of controls from the NIST 800-53 catalog of controls (as a result of FIPS 199 classification and the Risk Assessment), and
- The policies and process documentation (standards, procedures, guidelines and audit records, where applicable) for the selected controls from NIST 800-53.
In addition, these annual security tests include penetration testing and simulated denial-of-service attacks. The NORC Data Enclave was recently awarded a federal Authorization to Operate by USDA’s Economic Research Service.
The NORC Data Enclave complies with the following federal compliance guidance:
- NIST Special Publication (SP) 800-55, Security Metrics Guide for Information Technology Systems
- NIST SP 800-53, Recommended Security Controls for Federal Information Systems
- NIST SP 800-51, Use of the Common Vulnerabilities and Exposures (CVE) Vulnerability Naming Scheme
- NIST SP 800-37, Guide for the Security Certification and Accreditation of Federal Information Systems
- NIST SP 800-34, Contingency Planning Guide for Information Technology Systems
- NIST SP 800-26, Security Self-Assessment Guide for Information Technology Systems
- NIST SP 800-18, Guide for Developing Security Plans for Information Technology Systems
- Health Insurance Portability and Accountability Act (HIPAA) of 1996
- FIPS 200, Minimum Security Requirements for Federal Information and Information Systems
- FIPS 199, Standards for Security Categorization of Federal Information and Information Systems
- FIPS 191, Guideline for the Analysis of Local Area Network Security
- IEEE Std 829-1998, IEEE Standard for Software Test Documentation
The NORC Data Enclave IT Security Plan is fully compliant with the Federal Information Security Management Act, provisions of mandatory Federal Information Processing Standards (FIPS), and meets all of NIST’s IT, data, system and physical security requirements.
In addition to internal NORC confidentiality and ethics statements, all NORC Data Enclave employees must sign project specific Nondisclosure Agreements as specified in Commerce Acquisition Regulation (CAR) 1352.209-72, Restrictions against Disclosures.
NORC is in compliance with DOC IT Security Program Policy, section 4.5 and the NIST IT Security Management Handbook, including section 8.3 regarding policy on rules of behavior. The NIST Policy on IT Resources Access and Use must be followed for rules of behavior for this system.
The NORC Data Enclave is subject to the DoC IT Security Program Policy and Minimum Implementation Standards along with the IT security laws and federal regulations including:
- Public Law 107-347 E-Government Act of 2002 (FISMA included), Title V:
- Confidentiality Information Protection and Statistical Efficiency Act (CIPSEA).
- Public Law 200-253 Computer Security Act of 1987
- OMB Circular No. A-130 , Appendix III, Security of Automated Information Resources
- Department of Commerce Administrative Orders and
- NIST Administrative Manual Chapter 11.02 and the NIST IT Security
Question: Can the MHDO Portal can now handle files with 0 records?
Answer: Yes, however the header and trailer information must be included.
This is what the whole file should look like;
HD/TR = Header/Trailer
C12345 = Submitter/Payer code
DC = File type (Dental Claim)
201212*201212 = Date (December 2012)
Remember that empty fields still need quote mark text qualifiers.
Question: Do my files have to be named a certain way for data submission?
Answer: Yes, there is a standard naming convention outlined in the Naming Files Before Compression and Encryption section of the User Manual. Following it helps the system identify what is being submitted and by whom. If a file does not follow this naming convention it will cause a structural validation issue. All files, regardless of reporting frequency, should be named using: Payer ID [including suffix, if appropriate], underscore, Period Ending Date, File Type, Sequence Number, Version Number, and file extension (.txt, .zip, .7z, etc). The Payer ID should correspond to the Payer ID in the header of the file. An underscore (“_”) should be used after the Payer ID. The Period Ending Date (CCYYMM) in the file name should correspond to the Period Ending Date in the header and trailer of the file. Quarterly data submissions should use the end date for the last month of the quarter. For example, the first quarter of 2014 would use 201403.
Question: I am a new MHDO user and my group is required to upload historical files. Can I upload all of them to the MHDO Portal within a single zip file?
Answer: Please upload all historical files in the same way you upload current files. For example, if you are a monthly submitter, please submit the historical files within monthly uploads to the portal. Including more than one file in an uploaded zip file will result in a validation error.
Question: How do I know what values to use in Header/Trailer rows?
Answer: Please see Chapter 243 Appendix B-1 and B-2 for definitions of HD and TR fields.
Question: My file has structural and profile, ad hoc, or exemption level issues. Which should I clear first?
Answer: Structural validation issues should always be resolved first because they cannot be overridden through the portal. The only way to clear a structural issue is to resubmit a corrected file. When a file contains structural issues (i.e. a field is too long) subsequent validations may be inaccurate. By resolving structural errors first, other validations can be successfully performed and may clear up issues for you.
Question: My file has a structural issue saying the row is too long. Why?
Answer: Do not include an extra asterisk (*) at the end of a row or the validation system will detect it as an extra field and cause a structural failure on the file. Do not submit anything longer than required field length or it will cause a validation issue.
Question: My file is getting validation issues for some codes that I believe are correct.
Answer: If the codes in question are numbers confirm whether or not the standard requires a leading zero to be included. If the code does not match the standard exactly it will not be accepted. The one exception is for MC038, DC031, and PC025 for which codes with leading zeros and without leading zeros will be accepted.
Question: Is the validation rules list in the MHDO Data Warehouse Portal final as of 8/29/2013?
Answer: At close of business on 8/29/2013 the descriptions of the validations will be final for the first data submission period. However, we will be refining the validation logic and supporting code sets up to the go live date (September 12th). MHDO will periodically be updating their validation rules.
Question: Will one of the validation processes be to match each claim product to a member eligibility record?
Answer: We are not matching claims to their member eligibility record for this first data submission period. That will be a validation included in a future release.
Question: My company has previously submitted validation or code lists (often referred to as “homegrown” codes) to MHDO to validate my files. Do I need to resubmit?
Answer: No. We will be loading the previously submitted and approved payer validation lists into the Data Warehouse.
Question: My company has a new validation or code list to submit. Where do I send it?
Answer: Please send all payer specific code lists to the Help Desk firstname.lastname@example.org.
Question: Will old validation exemptions be transferred over to the new system?
Answer: No. As we are approaching the annual review of all exemptions, we are using the transition to the new system as an opportunity to refresh all validation exemptions. The new system gives the user significant control over validations. Users will be able to review all of the validation rules in the portal at any time. Users will also be able to override Profile-level validations and request Exemption-level validations at any time. It is recommended, between the time that the system opens and when you submit files in late September, that you set Profile and request Exemption overrides.
Question: There seems to have been a misunderstanding of how the payer groups control their profile validations. We thought there would be functionality for us to set our % levels for preset validations thresholds we are unable to meet. From Beta testing, we’ve learned we would only be able to set overrides and bypass the validation altogether versus us setting our threshold %. This was a concern because we would be bypassing quite a few profile validations.
Answer: In the new system, requesting an override will exempt your data submission from a validation and will not require changing percentages. We will be monitoring the quality of data received under this new process and future modifications may be made based on results. As we have discussed, metadata is going to be very important in our new system.
Question: Is there a one-to-one correspondence with the company suffixes and their collection of submitter codes? How will you know which Validation Profile to use to validate my files?
Answer: Every file submitted has a header record with one payer ID. The payer ID includes the suffix, null or other. The system will look at that record and select the corresponding Validation Profile to use.
Question: Will my company’s suffixes be preloaded into the portal?
Answer: Yes, they will be preloaded into the portal. Any changes going forward will need to be communicated to and approved by MHDO.
Question: Can thresholds be lowered so my file passes?
Answer: The validation rules and thresholds were assessed and updated in early May 2014. This included the lowering of thresholds where appropriate. If a file is still failing a validation rule, users can override the issue.
Question: Why is the denominator different across different validation rules within a single file?
Answer: The denominators vary due to the validation rule criteria. While the majority of rules look at all records within a file, some have a condition that only look at a subset of applicable records. For example, some rules only evaluate inpatient records. If a condition is present it will be described in the Validity Criteria of a given rule.
Question: My failed due to Duplicate File Name structural issue. How do I fix this?
Answer: This failure was caused by submitting a file with the exact same name as a previously submitted file. You need to resubmit the file with a new file name with a new version or sequence number. This is explained in the Naming Files Before Compression and Encryption section of the User Manual.
Sequence number: This is used to differentiate files with otherwise identical file names (for example, when two medical files are submitted during the same submission period). It’s expressed as a two-digit number, starting with 01. You must include the leading zero. The sequence numbering starts over with each new submission period.
Version number: This is used to differentiate multiple submissions of the same file. This will be important if a file needs to be resubmitted to resolve an issue such as a validation failure. The letter v should be used, followed by two digits, starting with v01. You must include the leading zero. Original submissions of all files should be labeled v01.
Question: If there are no issues remaining on the Validation Issues screen, does that mean that the files have passed?
Answer: Yes. When there are no remaining validation issues, your file is then considered passed. If the status of your file does not update to show a passed status and still shows no validation issues, please contact the Help Desk.
Question: I requested an exemption for my file, but it is still showing up as failing and there is still an issue for that validation rule. What happened?
Answer: The date range in the exemption request form now covers the data date, not the submission date. For example, when submitting January MC files in February and a user needs to request an exemption, they must select a start date of January. If February is selected, then exemption will not be activated until the next month’s MC file is submitted.
Question: I am submitting older data, why isn’t it passing?
Answer: Submission periods are locked for data periods already released to end users (data are released every quarter). When submitters try to submit data for a locked period, a Submission Period Locked structural validation issue occurs. This issue must be resolved before all other validation issues. If the data are less than a year old, the validation issue will be cleared as soon as the information is provided by the user. Submissions of data older than one year will require approval from MHDO before the issue will be cleared.
Question: When will Profile and Exemption-Level Overrides be reset?
Answer: All existing profile and exemption-level overrides will expire as of February 1, 2015. Submissions that occur after this reset (January 2015 data) will be evaluated against all validation rules. New profile and exemption-level overrides will have to be requested as needed. MHDO will do this reset each year to encourage payers to review whether their data quality has improved.
Question: Will I be able to view my terminated Profile and Exemption-Level Override history?
Answer: Yes, when creating a new Profile or Exemption Override after the reset, or at any time by clicking “View Override” on an overridden field, you will be able to see a record of past overrides for that field including both the reason for the override and any notes as to why the override was terminated. You can also view the history of how your data have performed against the validation rules across all your submissions in the Validation Report.
Question: Are default SSN values accepted in submitted data?
Answer: All data submission SSN Validation Rules will cross-reference a list of invalid SSN values including those listed by the Social Security Administration. Using these values in submitted data will result in a failed status on the file.
Question: What common issues cause the Decryption Failed message?
Answer: 1. No password was used when zipping 2. The wrong password was used when zipping 3. The zip contains more than one file
Question: How should we determine which claims should contain ICD-9 versus ICD-10 codes?
Answer: Date of Service (MC059) on or before September 30, 2015 should be coded as ICD-9. Date of Service (MC059) on or after October 1, 2015 should be coded as ICD-10.
Question: Where can we find more information about ICD-10 codes and the challenges involved in the transition from ICD-9?
Answer: Three helpful sites with extensive information are: Centers for Medicare and Medicaid Services(CMS), Centers for Disease Control and Prevention(CDC), and the World Health Organization(WHO).
Question: A field (Reason for Visit) exists on the 837; however, it is not down-streamed to our source systems. How should this be handled?
Answer: If a payer does not capture and is not able to report data as defined and mapped, then the conditions or limitations on the data should be documented as completely and clearly as possible in the justification required for a profile override or an exemption request. The MHDO does not want fields duplicated from values in similar fields or other workarounds aimed at meeting thresholds rather than accurate reporting. If there is ever a concern about what you will be able to provide you are welcome to contact the Help Desk or the MHDO Compliance Officer with questions.