Скачать презентацию An Introduction to CMS data Joe Brenner Office Скачать презентацию An Introduction to CMS data Joe Brenner Office

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An Introduction to CMS data Joe Brenner Office of the Actuary Joseph. Brenner@cms. hhs. An Introduction to CMS data Joe Brenner Office of the Actuary Joseph. Brenner@cms. hhs. gov 410 -786 -6262

Claims data Who provides service? Providers – Institutional providers who are ‘certified’ based upon Claims data Who provides service? Providers – Institutional providers who are ‘certified’ based upon conditions of participation such as Hospitals, Skilled Nursing Homes l Physicians l Suppliers/Others – Includes non-physician practitioners, group practices, labs, ambulance, DME suppliers l Approximately 1. 2 million providers, physicians, suppliers & others serve Medicare l

Claims data The Medicare claims process Using information returned from CWF, FI/Carrier process claim Claims data The Medicare claims process Using information returned from CWF, FI/Carrier process claim for payment or denial. l CWF host sites transmit claims data to CMS daily. l 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) l

Claims data Data dictionary l Basic information on all fields in a claim record Claims data Data dictionary l Basic information on all fields in a claim record General description of field Location, length, format Description Alias Source code tables Mainframe CLIST: MV 00. @BEB 3002. CLIST(RIF) l G: PUBLICLSDData StreamliningDESYVersion I data dictionary l http: //www. cms. hhs. gov/Identifiable. Data. Files/02_Standard. Analytical. Files. asp l l l

Claims data General claim layout info l Fixed portion l l l Common to Claims data General claim layout info l Fixed portion l l l Common to all files Many fields exist across all files Demographics Claim total dollars Trailers l l l Vary in length, content Count in fixed portion Loop processes each segment Specific to claim type Revenue centers / Line items

Claims data l National l Source Claims History (NCH) for all claims l Fed Claims data l National l Source Claims History (NCH) for all claims l Fed by Common Working File (CWF) l CWF is raw claims submitted by providers l Some processing is done as claim moves to NCH l Not final action processed

Claims data Standard Analytical Files (SAFs) l Extracted from NCH and split by type Claims data Standard Analytical Files (SAFs) l Extracted from NCH and split by type l Inpatient l Outpatient l Skilled Nursing Facilities (SNF) l Home Health Agencies (HHA) l Hospice l Durable Medical Equipment (DME) l Final action processed applied l Place of service determines file l

Claims data l Physician/Supplier l One for each state l Too voluminous to fit Claims data l Physician/Supplier l One for each state l Too voluminous to fit in a single file l Contacts l CMS internal users: l Marvella Bunch (marvella. bunch@cms. hhs. gov – 410 -786 -1885) l Outside l Judy CMS: Reinecke (judith. reinecke@cms. hhs. gov – 410 -786 -9264

Other claims files l MEDPAR - Medicare Provider Analysis and Review Extended hospital/SNF stay Other claims files l MEDPAR - Medicare Provider Analysis and Review Extended hospital/SNF stay synthesized to a single record l Gives full view of a bene’s experience in single record l l 5% Sample l Exists for all claim types (inlcuding Physcian/Supplier) l Based on bene’s HIC (SSN) l Proven reliability at high level

Enrollment data l Enrollment l All database (EDB) enrollees over time l Some information Enrollment data l Enrollment l All database (EDB) enrollees over time l Some information comes from SSA l Multiple segments must be consolidated to determine a bene’s status

Denominator l Derived from Enrollment Database (EDB) l Created each year at the end Denominator l Derived from Enrollment Database (EDB) l Created each year at the end of March l Summary information on all benes who received service during previous year l Basic demographic info (including DOD) l Entitlement l ESRD l Buy-in l HMO

Drug data l Housed in Integrated Data repository (IDR) only l IDR is source Drug data l Housed in Integrated Data repository (IDR) only l IDR is source for all claims and enrollment data l Built on Teradata platform

NCH / NMUD l Derived from CWF l Original repository for all claims l NCH / NMUD l Derived from CWF l Original repository for all claims l All iterations of single claim

SAS claims input statements l Input statements exist for all claim types l Also SAS claims input statements l Input statements exist for all claim types l Also exist for each version l See B 1 G 4. DESY. CNTL for all types l Contact Joseph. Brenner@CMS. HHS. GOV for access

Integrated Data Repository (IDR) l Relational database l Contains l Part A, B and Integrated Data Repository (IDR) l Relational database l Contains l Part A, B and D claims l Risk scores l Enrollment l Provider

IDR Data Flow Diagram Procedure Denominator HCPCS EDB CWF CMEM BD NCH CPT NDC IDR Data Flow Diagram Procedure Denominator HCPCS EDB CWF CMEM BD NCH CPT NDC BETOS SSA DRG Rev. Center Provider IDR NPI POS HPMS MARx PDFS NCPDP PIN OSCAR UPIN DDPS

Enterprise Architecture Example Teradata Platform l Desktop Computer l Business Intelligence l Mainframe Channel Enterprise Architecture Example Teradata Platform l Desktop Computer l Business Intelligence l Mainframe Channel l Channel Network Mainframe Business Intelligence Many avenues of data access

Oh No!!! Don’t make me use the mainframe! l The mainframe is probably the Oh No!!! Don’t make me use the mainframe! l The mainframe is probably the most feared technology at CMS l It’s nothing more than a server on steroids. l It has it’s quirks, but doesn’t everything? l It’s as easy to use as the PC once you get used to it.

Getting to the mainframe l Host on Demand (HOD) URL https: //158. 73. 207. Getting to the mainframe l Host on Demand (HOD) URL https: //158. 73. 207. 36/cms/tn 3270. html. ascii

HOD HOD

CMS Data Center CMS Data Center

Application selection screen Application selection screen

Main menu Main menu

Dataset list utility Dataset list utility

Dataset list utility Dataset list utility

Dataset list utility Dataset list utility

Dataset list utility Dataset list utility

PF Keys PF Keys

PF keys PF keys

Split screen mode Split screen mode

Use PF 9 to swap Use PF 9 to swap

Use PF 9 to swap Use PF 9 to swap

Edit panel Edit panel

Member selection list Member selection list

Edit member Edit member

IOF IOF

IOF IOF