Minnesota Health Care Claims Reporting System Stakeholder Meeting 1/29/09, 1-4 p.m. Presented by: Maine Health Information Center 1
Meeting Agenda About Maine Health Information Center Introduction to National Claims Data Management System Data element recommendations Key dates Q&A 2
Maine Health Information Center (MHIC) 3
MHIC Project Team Janice Bourgault Director of Data & Application Services Jim Harrison CEO Jonathan Harvell VP of Information Technology & Administration Suanne Singer Senior Consultant 4
About MHIC Independent, nonprofit health data management and research organization Established in 1976 Provide health data services to a wide range of clients with the goal of promoting informed decision making 5
MHIC Staff 35 Staff members researchers, statisticians, project managers, data processing professionals and IS analysts Staff located in 3 offices central Maine, southern Maine and central New Hampshire 6
MHIC Related Experience Aggregating and analyzing healthcare data for 30 years Hospital discharge data Proprietary claims data Workers compensation claims data Statewide claims data commercial, Medicaid, Medicare 7
MHIC Claims Experience 1988 State of Maine as an employer (40,000 covered lives 1 reporter) 1993 Maine Health Management Coalition (200,000 covered lives 15 reporters) 1997 Maine Medicaid (250,000 covered lives 1 reporter) 8
National Claims Data Management System (NCDMS) The System Developed by MHIC Web-based application Secure data submission Quality edits Reporting Communication tool 9
National Claims Data Management System (NCDMS) The People Data operations / client support staff Initial reporter approval process Ongoing reporter support compliance, troubleshooting Technical support staff NCDMS development, maintenance Infrastructure management Data quality assurance 10
Clients Using NCDMS 2002 Maine Health Data Organization (750,000 covered lives, 140 payers, Medicaid, Medicare) 2005 NH Department of Health and Human Services (500,000 lives, 40 payers, Medicaid) 11
Clients Using NCDMS 2007 Massachusetts Health Care Quality and Cost Council (3.5 million covered lives, 30 payers) 2008 Vermont Department of Banking, Insurance, Securities and Health Administration (350,000 covered lives, 50 payers) 12
Massachusetts Time Line 09/21/2007 10/16/2007 11/6/2007 11/15/2007 11/21/2007 12/1/2007 Data collection rule MHIC contract Reporter kick off NCDMS ready for MA Statistical plan Historical data due 13
Massachusetts Data Set Completeness Month Eligibility Medical Pharmacy 12/07 0% 0% 0% 1/08 9% 6% 2% 2/08 87% 17% 91% 3/08 87% 85% 97% 4/08 94% 97% 100% Records: 60M 144M 45M 14
National Claims Data Management System 15
www.ncdms.org 16
About NCDMS Non-secure web site (as communication medium) Information on state initiatives that use claims data management system, including individual data collection and release rules Information on frequently asked questions by data submitters Process for data submitters to register for data submission 17
About NCDMS Secure web portal (as an application for registered users) Access to the file encryption application Secure file submission upload utility Data submission and data quality reports 18
About NCDMS Secure web portal (as an application for registered users) Aggregate metadata reporting for submitters, NCDMS staff and state regulatory agencies Integrates with robust relational database structure and customizable reporting tools to meet needs of participating submitters, NCDMS staff and contracting agencies 19
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Encryption Algorithm Secretary of Commerce has issued a National Institute of Standards and Technology (NIST) standard including SHA-512 as part of Secure Hash Signature (SHS) standard Documentation of this standard can be found as part of Federal Information Processing Standards Publications (FIPS PUB 180-2). This standard has defined the SHA-512 hash algorithm as secure based on computationally infeasibility of Breaking the encrypted message Altering the encrypted message 22
Encryption Process Based on defined record layout specific data elements are encrypted in place in file on data submitter desktop Encrypted files are then zipped and renamed with relevant submitter id, file type and date conventions 23
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Unencrypted File Encrypted File 25
File Upload Only available to members who are logged in to secure website Secure Sockets Layer (SSL) 128-bit encryption run on secure website User selects previously encrypted and zipped file and uploads through a basic file upload application 26
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Reports Reporter status # of overdue or failed submissions Status and history of file submissions Detail on passed and failed data elements Comparison of data elements to state thresholds and/or payer specific thresholds Report on additional data quality edits Example: % of records without patient zip 30
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Data Element Recommendations 40
Recommendations Data sets Data elements Specifications and formats HIPAA transaction set data elements (ASC 12N 270/271 eligibility, 835 remittance, 837 claims) HIPAA coding standards National harmonization effort 41
Data Sets Eligibility Pages 3-9 Medical claims Pages 10-27 Pharmacy claims Pages 28-39 42
Data Set Documentation Recommended data elements Threshold % Payers meeting threshold Composite rate National standards mapping Data dictionary Code values 43
Information Not Collected Services provided to uninsured Fully denied claims Workers compensation bills Premium information Administrative fees Test results from lab work, imaging, etc. 44
Elements Necessary to Create De-Identified Data Set Plan specific contract number (encrypted) Subscriber name (encrypted) Member name (encrypted) Date of birth (encrypted) Gender Relationship to subscriber City, state, and zip code of residence 45
Elements Needed to Create De-Identified Data Set Data elements run through linkage software to create a de-identified number for each member De-Identified member number Links eligibility to claims Links medical and pharmacy claims to one member Tracks member across data reporters for longitudinal studies and for accurate reporting in situations of primary and secondary coverage 46
Eligibility Why? Understand population demographics: age, gender, poverty levels (Medicaid distribution), geographic distribution Calculate utilization rates per 1000 to compare to national, regional & state rates Eligibility periods for HEDIS measures and for preventive measures such as mammograms 47
Eligibility What? One record for each covered member for each month eligible for services A family of four with coverage for the period January 2008 through June 2008 will have 24 eligibility records (4x6) Type of coverage Medical or prescription drug indicator 48
Eligibility Demographic information Gender Relationship to subscriber Date of birth (to calculate age) City, state and zip code of residence (to assign geographic area) De-identified member number 49
Eligibility Demographic information Insurance indicator (primary or secondary) Insurance product type Coverage level Medical home 50
Medical Claims Why? Disease prevalence Utilization patterns Resource consumption Payment information 51
Medical Claims What? One record for each service Patient demographics Diagnosis and treatment Inpatient hospital detail Service dates Provider information Financial information 52
Medical Claims Patient demographics Gender Relationship to subscriber Date of birth City, state and zip code of residence Insurance product type De-identified member number 53
Medical Claims Diagnosis and treatment Diagnoses Admitting E-code Principal Other (12) Procedures Revenue code CPT/HCPC and modifier(s) ICD-9-CM 54
Medical Claims Inpatient hospital detail Admission date Admission source Admission type Discharge date and discharge hour Discharge status 55
Medical Claims Service dates Date of service from Date of service thru 56
Medical Claims Provider information Servicing provider Provider number assigned by data reporter Provider tax ID National service provider ID (NPI) Name Specialty City, state, zip code and country 57
Medical Claims Provider information Billing provider Provider number assigned by data reporter National billing provider ID (NPI) Name 58
Medical Claims Provider information Referring provider Provider number assigned by data reporter Provider tax ID National referring provider ID (NPI) Name 59
Medical Claims Financial information Charge amount Paid amount Prepaid amount Member responsibility Co-pay amount Coinsurance amount Deductible amount 60
Pharmacy Claims Why? Treatment patterns Resource consumption Payment information 61
Pharmacy Claims What? One record for each filled prescription Patient demographics Pharmaceutical information Service date Provider information Financial information 62
Pharmacy Claims Patient demographics Gender Relationship to subscriber Date of birth City, state and zip code of residence Insurance product type De-identified member number 63
Pharmacy Claims Pharmaceutical information NDC (National Drug Classification code) Drug name New or refill indicator Generic drug indicator Dispense as written indicator Compound drug indicator 64
Pharmacy Claims Financial information Charge amount Paid amount Member responsibility Co-pay amount Coinsurance amount Deductible amount 65
Pharmacy Claims Financial information Ingredient cost Postage amount claimed Dispensing fee Service dates Date prescription filled 66
Pharmacy Claims Provider information Prescribing provider DEA (Drug Enforcement Administration) number National prescribing provider ID (NPI) Name 67
Summary Eligibility data One record for each member for each covered month whether services were received that month or not Medical claims One record for each billed service eligible for payment by data reporter or member through co-pay, coinsurance or deductible Pharmacy claims One record for each filled prescription eligible for payment by data reporter or member through co-pay, coinsurance or deductible 68
Key Dates 1/29/09 Stakeholder meeting 2/03/09 Stakeholder conf call 2-3 p.m. CST 2/10/09 Public comments due 2/11/09 Final data recommendations May 09 Data reporter meeting 6/01/09 NCDMS ready 7/01/09 Reporters must begin submitting data 69
Questions? Contact info: Janice Bourgault Maine Health Information Center jbourgault@mhic.org 207/430-0684 70