Health plan issuers and administrators are required to submit information about certain claims from health care providers (not facilities) to FAIR Health’s benchmarking database.
Why is this information needed?
State law requires that a benchmarking database be used in medical billing arbitration cases between out-of-network health care providers and health plans.
The claims data required from health plans is needed to validate data and create necessary benchmarks.
What claim information must be submitted?
- Providers’ billed charges
- Date of service
- Payors’ allowed amounts
- Place of service name and address
- Patient’s age and gender
- Provider’s specialty
- Full schedule of official CPT, HCPCS, and ANE procedure codes
- Other data elements as needed to validate the accuracy of the data
Data contributors can get more information about all the required data elements by contacting FAIR Health’s Director of Data Management Eric Okurowski at 212-257-2385 or eokurowski@fairhealth.org.
What type of claims do not need to be submitted?
- Dental services
- Facility services
- Prescription data (This does not include specialty drugs on a medical claim, which should be submitted.)
- Medicare or Medicaid services
Questions?
- For questions about the FAIR Health data contribution program or relevant licensing agreement, contact:
- Chief Operating Officer Tom Swift at tswift@fairhealth.org.
- Executive Director of Business Development Donna Smith at dsmith@fairhealth.org.
- Learn more about the benchmarking database by watching the recorded webinar for health plans. The recording is available after you fill out the registration form.
- For questions about the arbitration process, email IDR@tdi.texas.gov.