Frequently asked questions CMS Annual Statutory Return Submission Specification 1 April 2015

Yearofsubmission Yearofsubmission is 2014 for this return. Financialyear may be 2013 or 2014 as we collect data for those 2 years. Section 3.1 of the CMS Technical Guide Data Spec V3.2 corrected to read as follows: Year of submission refers to the year for which the return is prepared. For the 2014 Healthcare Utilisation Annual Statutory Return, the Year of Submission (YearofSubmission) will be 2014.

Consistency of Utilisation data with the financials data As stated earlier; data is being submitted in two separate sections; old system – Financials; new system - utilisation Schemes are advised that it is important that there is consistency of certain data fields in these two systems, areas of special emphasis are Membership – the number of members should be the same on both submissions Total Benefits – the total benefits paid between the two systems should be consistent. Some schemes raised the point that the will be minor difference; such variation would be acceptable Managed Care benefits – Total expenditure towards managed care on the two systems should also be consistent.

Reversals How do schemes treat reversals? In the normal course of business of a medical scheme, it may be necessary to reverse claims for what ever reason. When report the financial amounts and utilisation please ensure you do not include claims which have been reversed. The scheme should identify the reversed claim with negative payment and the initial claim – positive payment and exclude both for reporting purposes.

Ex-gratia Scheme/administrator systems handle ex-gratia claims in different ways. It is however important to note that ex-gratia claim amounts should not be double counted. For example if a claim was partly settled from “normal benefits” with the remainder being paid ex-gratia then the ex-gratia portion should be shown here with the “normal benefit” amount being shown in the relevant area of the submission. If a scheme cannot separate ex-gratia amounts from the “normal benefits” paid, then zero (0) must be reported for ex-gratia in Table B.11.

How are we submitting the old Financials section? The financial section of the previous system should be submitted as in previous years. (Parts 1.1 up to 2.4 and Parts 4.1 up to Part 11) The portal will be open and available for these sections only. The submission for the utilisation section only (Parts 2.5 up to 3.9) is covered by the new system.  11/20/2018

Is this submission based on payment year or service year? Previously, the claims data used to calculate utilisation statistics was based on service date.  The use of service dates would require schemes to wait until April following the reporting year before the data may be extracted (in order to allow for claims to be run-off and minimise the impact of IBNR claims). The industry comments indicated that it is not practical for schemes to prepare the submission at such a late date. Therefore the claims extract should be based on payment date.  11/20/2018

Are we submitting data at scheme or option level? Schemes will submit data at option level.

Are we are only working off the data tables now? Yes, schemes will submit data table from now onwards. CMS will generate return a return for the schemes to sign off. CMS will make available the code/calculations used to generate such returns.

Is the identification of beneficiaries with a CDL condition based on chronic disease programme registration and not checking claims? Registration on a chronic disease management programme for CDL conditions must be used to identify beneficiaries with a CDL condition in all data tables requiring CDL information. The only exception is in table A.7 where E&V must be used

If a patient has more than 1 CDL, must the line be counted more than once? If a beneficiary is registered for multiple chronic conditions then the beneficiary should be counted for each of the conditions specified. It is therefore possible to have multiple records for such beneficiaries. The only exception is in table A.7 where E&V must be used.

Appendix A [App.1] has not been updated, do we continue as we have in the past or do we only include codes from this list? At the time of publishing this document Appendix A has not been updated and is the same version that was previously published as part of version 1.3 of the specification. A more structured process will be setup in order to finalise and maintain the lists in consultation with the industry.

Do schemes report on claims with Zero amount paid? In a majority of the cases, the use of payment date implies the claims will have a non zero amount claimed. However, there are some cases where the claim will not be paid – hence amount paid will be zero. For this submission such claim should not be included in the utilisation section particularly B1. We are trying to match utilisation section financials as far as possible. In future submissions we will include an additional line item to capture such claims

Will CMS require schemes to report on the efficiency discount options? Schemes must report on registered benefit options only. Efficiency discount options must be rolled up to their parent option.

What is a visit – table B1? All claim lines relating to a specific beneficiary, on a specific service date to a specific provider would constitute a single visit per consultation code. We will provide a list of consultation codes (may not be exhaustive).

Do amounts per discipline exclude medication – table B1? Amounts per discipline reported in Table B.1 must not include claims for medicines. Amounts for medicines must be reported in Table B.2

Must hospital admissions for a beneficiary with a chronic condition include all admissions for this beneficiary or only admissions relating to the specific condition? Table B.5 should contain data for all-cause admissions. This table is completed by using a file on beneficiaries registered on the chronic disease management programme for CDL conditions as well as claim lines associated with these beneficiaries.

Hospital admissions What is an admission? What is a re-admission? A day case defined is an admission where Discharge date = Admission date. An inpatient admission is an admission where Discharge date ≥ Admission date. An overnight admission in a day clinic will therefore be categorised as an inpatient admission. Transfers between hospital should not be counted as re-admissions

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