Current requirements for quarterly claims data effective January 1, 2021
File layouts and rules effective January 1, 2022
Current requirements for annual payment arrangement file (PAF)
Requirements for annual submission of Appendices 1 and 2 are detailed below. Submission occurs through the Human Services Research Institute portal. The file layouts, rules (including definitions), memorandum and training information may also be useful when submitting Exhibit L as required by contract for CCOs.
Effective September 2, 2021
Voluntary submission of hospital indicator in the Payment Arrangement File
APAC is happy to support the Value-Based Payment (VBP) Compact by accepting the
voluntary submission of a hospital indicator in the Payment Arrangement File (Appendix 1) starting with the submission due September 30, 2021.
See more information on the VBP Compact.
APAC has opened a previously unused data element (PRAPM201) to collect the hospital indicator on a voluntary basis. HSRI is prepared to accept the data in PRAPM201, currently marked 'For future implementation.' Specific information for submission:
The data can also be submitted using the
updated excel template. This template can be used with or without the inclusion of the hospital indicator. Thank you for supporting the Value Based Payments Compact with these data.
Requesting waivers, extensions and field-specific exemptions
Waivers
Waivers are requested using the
APAC-1a form and must be requested by December 2 for the following year. Waivers must be requested if an organization is identified as a mandatory reporter and believes it will not have data to report. This can occur if:
- Number of covered lives in Oregon falls below 5,000 for carriers and third-party administrators after excluding ERISA-reported covered lives. A
mandatory attestation form may be required to document ERISA-reported and non-ERISA-reported counts.
- All lines of business are excluded from APAC reporting; see OAR 409-025-0110 for excluded lines of business
- All lines of business are for federal entities or sovereign tribal groups that are not reporting voluntarily
- For pharmacy benefit managers and others not limited by the 5,000 covered lives, the organization believes the burden of reporting outweighs the benefits of receiving the data. This is discretionary for the program to approve.
Waivers may also be requested for specific files. This is common for third party administrators who do not bill for subscriber-level premiums. Please review the chart below (Files required by mandatory reporter type) before submitting a waiver.
Waivers are approved for one calendar year only as many of the reasons for approving the waiver are subject to change over the course of a year (rules, lines of business, number of covered lives).
Extensions
Extensions are requested when a mandatory reporter or a data submitter acting on their behalf cannot submit an acceptable file by the required submission date. Under Oregon Administrative Rule, extensions must be submitted no later than 14 calendar days prior to the submission date. Extensions can be submitted either by submitting the
APAC-1b form by email or directly within the HSRI portal through the functionality described in the
user manual.
Exemptions
Exemptions for validations to specific data elements are requested within the HSRI portal after the file has failed the validation rules. Exemption requests are filed for each rule failure. Each request must include detail on the reason the exemption is requested and mitigation plans to meet the validation requirements in future submissions.
See here for instructions on submitting exemptions.
Mandatory
Reporters and Reportable Lines of Business
The Oregon Health Authority identifies mandatory reporters based on the type of the organization, the number of lives it covers in Oregon and the lines of business it operates:
Mandatory reporters by type of organization and number of covered lives
Mandatory reporters are identified in ORS 442.372 and OAR 409-025-0110 as:
- Insurance carriers and fraternal benefit societies with more than 5,000 covered lives as residents of Oregon
- Third party administrators with more than 5,000 covered lives as residents of Oregon
- All pharmacy benefits managers
- All coordinated care organizations
- All insurers providing benefits under Medicare Part A, B, or D
- All insurers providing benefits for dual eligible (Medicare and Medicaid)
- All insurers offering a plan in Oregon’s health insurance exchange and
- All insurers providing group health insurance to PEBB or OEBB
Reportable lines of business
Reportable lines of business are set by OAR 409-025-0110 as:
- Medicare Advantage Part C and Medicare Part D
- Medicaid
- Individual health insurance
- Small employer health insurance
- Large group health insurance
- Health insurance provided through associations and trusts
- PEBB and OEBB group health insurance plans
- Self-insured plans not subject to ERISA and
- Dental insurance
Files required by type of mandatory reporter
Quarterly submission of claims data
Annual submission of payment arrangement file
Additional Resources
APAC Program email:
apac.admin@dhsoha.state.or.us
Technical Assistance at HSRI
Help desk email at HSRI:
APAChelp@hsri.org
HSRI APAC Data Submission and Quality Portal:
User Manual
HSRI APAC Data Submission and Quality Portal:
FAQs
Detailed information on Validation Rule application to files is available within the submission portal under Guides > Validation Rules.
Rules
Oregon Administrative Rules (OARs)
- 413.032(2) Creation of all payer claims database
- 442.372 Definitions for PRS 442.372 and 442.373
- 442.363 Health care data reporting by health insurers
- 442.993 Civil penalties for failure to report health care data of health insurers