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An Introduction to CMS data
Joe Brenner Office of the Actuary
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Claims data Who provides service?
Providers – Institutional providers who are ‘certified’ based upon conditions of participation such as Hospitals, Skilled Nursing Homes Physicians Suppliers/Others – Includes non-physician practitioners, group practices, labs, ambulance, DME suppliers Approximately 1.2 million providers, physicians, suppliers & others serve Medicare
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Claims data The Medicare claims process
Using information returned from CWF, FI/Carrier process claim for payment or denial. CWF host sites transmit claims data to CMS daily. CMS processes the transmitted claims through the CWF Medicare Quality Assurance System (MQAS) prior to loading data into the National Claims History (NCH) Repository and the National Medicare Utilization Database (NMUD)
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Claims data Data dictionary
Basic information on all fields in a claim record General description of field Location, length, format Description Alias Source code tables Mainframe CLIST: G:\PUBLIC\LSD\Data Streamlining\DESY\Version I data dictionary\ Description – free form Alias – std field name used in OIS, elsewhere Source tables - appendix
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Claims data General claim layout info
Fixed portion Common to all files Many fields exist across all files Demographics Claim total dollars Trailers Vary in length, content Count in fixed portion Loop processes each segment Specific to claim type Revenue centers / Line items
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Claims data National Claims History (NCH) Source for all claims
Fed by Common Working File (CWF) CWF is raw claims submitted by providers Some processing is done as claim moves to NCH Not final action processed
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Claims data Standard Analytical Files (SAFs)
Extracted from NCH and split by type Inpatient Outpatient Skilled Nursing Facilities (SNF) Home Health Agencies (HHA) Hospice Durable Medical Equipment (DME) Final action processed applied Place of service determines file place of service determines file (Mollie’s quest) – if HHA, claim is in HHA regardless of service provided
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Claims data Physician/Supplier Contacts One for each state
Too voluminous to fit in a single file Contacts CMS internal users: Marvella Bunch – ) Outside CMS: Judy Reinecke –
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Other claims files 5% Sample
MEDPAR - Medicare Provider Analysis and Review Extended hospital/SNF stay synthesized to a single record Gives full view of a bene’s experience in single record 5% Sample Exists for all claim types (inlcuding Physcian/Supplier) Based on bene’s HIC (SSN) Proven reliability at high level PS/DME – all iterations as in CWF Medpar – single stay
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Enrollment data Enrollment database (EDB) All enrollees over time
Some information comes from SSA Multiple segments must be consolidated to determine a bene’s status
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Denominator Derived from Enrollment Database (EDB)
Created each year at the end of March Summary information on all benes who received service during previous year Basic demographic info (including DOD) Entitlement ESRD Buy-in HMO ESRD flag – Eugenea?
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Drug data Housed in Integrated Data repository (IDR) only
IDR is source for all claims and enrollment data Built on Teradata platform
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NCH / NMUD Derived from CWF Original repository for all claims
All iterations of single claim Derived from CWF per slide 3 Iteration = adjustment; cite examples
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SAS claims input statements
Input statements exist for all claim types Also exist for each version See B1G4.DESY.CNTL for all types Contact for access
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Integrated Data Repository (IDR)
Relational database Contains Part A, B and D claims Risk scores Enrollment Provider
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IDR Data Flow Diagram IDR SSA EDB CWF NCH MARx HPMS CMEM BD PDFS DDPS
Denominator EDB CWF NCH MARx HPMS CMEM BD PDFS DDPS HCPCS CPT Rev. Center DRG BETOS NDC NPI POS UPIN NCPDP OSCAR PIN Procedure Provider
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Enterprise Architecture Example
Teradata Platform Desktop Computer Business Intelligence Mainframe Channel Network Channel Business Intelligence Mainframe The Teradata platform can consist from one to many powerful computers to create a massively parallel architecture. The system can be accessed by many different avenues including, - Desktop applications - Business Intelligence networks - Mainframe channels This is in contrast to our old paradigm of using cartridge tapes to store large amounts of data, which can only be accessed using the mainframe. Many avenues of data access
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Oh No!!! Don’t make me use the mainframe!
The mainframe is probably the most feared technology at CMS It’s nothing more than a server on steroids. It has it’s quirks, but doesn’t everything? It’s as easy to use as the PC once you get used to it.
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Getting to the mainframe
Host on Demand (HOD) URL
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HOD
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CMS Data Center
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Application selection screen
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Main menu
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Dataset list utility
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Dataset list utility
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Dataset list utility
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Dataset list utility
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PF Keys
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PF keys
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Split screen mode
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Use PF 9 to swap
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Use PF 9 to swap
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Edit panel
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Member selection list
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Edit member
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IOF
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IOF
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