Filing Instructions For The 2015 Mlr Reporting Year - Centers For Medicare & Medicaid Services (Cms) Page 23
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578. Provision of electronic health records, patient portals, and tools to facilitate patient
self-management.
Exclude costs associated with establishing or maintaining a claims adjudication system,
including costs directly related to upgrades in HIT that are designed primarily or solely to
improve claims payment capabilities or to meet regulatory requirements for processing claims
(for example, costs of implementing new administrative simplification standards and code sets
adopted pursuant to the Health Insurance Portability and Accountability Act (HIPAA), 42
U.S.C. §1320d-2, as amended, including all expenditures related to ICD-10 which should be
reported in Lines 4.6 and 5.8.
Line 4.6 – Allowable ICD-10 Implementation Expenses
Include:
ICD-10 conversion costs incurred in the MLR reporting year up to 0.3% of earned
premium in the relevant State market.
Exclude: ICD-10 maintenance costs, as well as ICD-10 implementation expenses in excess
of 0.3% of earned premium.
Section 5 – Non-Claims Costs
Line 5.1 – Cost containment expenses not included in quality improvement expenses
Include:
Expenses that serve to actually reduce the number of health services provided or
the cost of such services.
This category can include costs only if they result in reduced costs or services such as:
• Post- and concurrent- claim case management activities associated with past or
ongoing care
• Pre-service utilization review
• Detection and prevention of payment for fraudulent requests for reimbursement
(including amounts reported in Part 2, Line 2.17a)
• Expenses for internal and external appeals
• Network access fees to preferred provider organizations and other network-based
health plans (including prescription drug networks) and allocated internal salaries and
related costs associated with network development and/or provider contracting
Exclude: Cost-containment expenses that improve the quality of health care reported in Part
1, Section 4.
Line 5.2 – All other claims adjustment expenses
Include any expenses for administrative services that do not constitute adjustments to premium
revenue, reimbursement for clinical services to enrollees or expenditures on quality
improvement activities or cost containment expenses.
This category can include such costs as:
• Estimating the amount of losses and disbursing loss payments
• Maintaining records, general clerical and secretarial costs
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