Sheet 1: Contents

	
	
	

		
This workbook contains the following tabs:
		


	
	

		


		


	
	

		
Tab Name
		
Contents
	
	

		
Mandatory Questions
		
Payer Data Entry: Overview of File and Data Verification
	
	

		
HD-TME
		
Insurer Data Entry for Header Record
	
	

		
Spending Data
		
Insurer Data Entry by Business Category Code
	
	

		
Definitions
		
Definitions for payers to reference when completing templates
	
	

		
Reference Tables
		
Reference Tables for Various Fields
	
	

		
Version Updates
		
Changes made to the template for 2019 and 2020 data collection
	



Sheet 2: Mandatory Questions

	
	
	
	
	

		
Delaware Insurer TME Data Specifications
Mandatory Questions
		
	

		


		


		


		


	
	

		


		


		


		


	
	

		


		
I verify that the information in this workbook is accurate.
		


		


	
	

		
Insurer:
		


		
[Select an option from the drop down]
		


	
	

		
Contact Email:
		


		
[Input Required]
		


	
	

		
Data Year:
		


		
[Select a calendar year option from the drop down]
		


	
	

		


		


		


		


	
	

		


		
All questions in this tab must be answered.
		


		


	
	

		


		
Mandatory Questions
		
	

		


		
Questions
		
Response
		
Comments
	
	

		


		
Does the health status adjustment tool correspond to the Line of Business Category Codes?
		


		


	
	

		


		
Do the health status adjustment scores reflect only Delaware residents for each Business Category code?
		


		


	
	

		


		
Does the health status adjustment tool use concurrent modeling?
		


		


	
	

		


		
Does the health status adjustment tool use truncation?
		


		


	
	

		


		
Is the health status adjustment tool based on all-encounter diagnosis-based inputs?
		


		


	
	

		


		
Is pharmacy data an input in your health status adjustment tool?
		


		


	
	

		


		
Is the health status adjustment tool the same as that used to report the 2017-18 baseline data?
		


		


	
	

		


		
Is the spending reported in a manner consistent with the service category definitions outlined in Version 3.0 of the Implementation Manual?
		


		


	
	

		


		
Does the TME data include Delaware residents only?
		


		


	
	

		


		
Do the data represent members who receive, at a minimum, medical benefits?
		


		


	
	

		


		
Are the data limited only to members for whom the insurer is primary on the claim?
		


		


	
	

		


		
Are members attributed to provider organizations consistent with each contract?
		


		


	
	

		


		
Do the TME data include allowed amounts?
		


		


	
	

		


		
Does the TME include services provided by providers, regardless of location of provider?
		


		


	
	

		


		
Does the TME include services provided by providers, regardless of the situs of the member's plan?
		


		


	
	

		


		
Do the TME data include all data for all attributed members for each month a member was attributed?
		


		


	
	

		


		
How long was the claims runout period?
		


		


	
	

		


		
How long was the non-claims runout period for non-claims payments?
		


		


	
	

		


		
Are IBNR/IBNP factors applied to the TME data?
		


		


	
	

		


		
Is pharmacy rebate data estimated?  If yes, how?
		


		


	
	

		


		
What carved-out services are estimated?  If estimations were made, did DHCC approve your methodology for estimating?
		


		


	
	

		


		
Is there anything else you would like us to know about the data you submitted?
		


		


	



Sheet 3: HD-TME

	
	
	
	
	
	

		
Delaware Health Care Commission
		


		


		


		


		


		


	
	

		
Header Record File
		


		


		


		


		


		


	
	

		
Data Year: CY
		


		


		


		


		


		


	
	

		
Insurer: 
		


		


		


		


		


		


	
	

		
Blue = Payer-reported data 
		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


	
	

		
Insurer Org ID
		
Period Beginning Date
		
Period Ending Date
		
Comments
		
Health Status Adjustment Tool
		
Health Status Adjustment Version
		
"Doing Business As"