File Submission Requirements

Requirements for file submissions.

The following requirements must be met for coding gap files generated by payer systems:

• File Naming Convention: The payer-generated file must align to the risk coding file naming convention and have the word risk in the file. The file naming convention must be unique; that is, no two files can have the same file name. For example, a correct file naming convention with a file extension .gz in NDJASON format would be: risk-gaps-inbound-oracle-11070922.ndjson.gz.
• File Structure: The payer file should align with the following file format requirements:
  • Maximum File Size: Each file size is restricted to 5GB.
  • Data Mapping: Payers are expected to report the following member demographic information because the demographic information is used to derive the internal member identifier:
    • First Name
    • Last Name
    • Middle Name/Initial (Optional)
    • Date of Birth
    • Gender
    • Address (Optional): Address1, Address2, City, State, and ZIP
• File Submission Frequency: One file per week. Payers are expected to keep sending gaps in every file for all members until the gap is closed in the payer system. Any gap that was reported by the payer and is not surfaced in the subsequent gap data file is considered closed in the payer system. The difference in gap status is reconciled between the payer system and the EHR, and the gap status is adjusted in the EHR.