APAC 101 1
Overview OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 2
What is APAC? The Oregon All Payer All Claims Database (APAC) is a large database that houses administrative health care data for Oregon’s insured populations. Specifically, APAC includes medical and pharmacy claims, enrollment data, premium information, and provider information for Oregonians who receive coverage through commercial insurers as well as through public payers such as Medicaid and Medicare. OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 3
What is APAC? APCDs Across the Country The Oregon All Payer All Claims Database (APAC) is a large database that houses administrative health care data for Oregon’s insured . APAC is one of 13 state-led All Payer Claims Databases (APCDs) populations. Specifically, APAC includes medical and pharmacy claims, in the country, with four more in active development. States use these enrollment data, premium information, and provider information for initiatives in much the same way as Oregon: to inform new policies and Oregonians who receive coverage through commercial insurers as well innovations for health care cost containment, quality improvement, and as through public payers such as Medicaid and Medicare. health access; to evaluate programs; and to bring transparency to the health care system. OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 4
Data Collection OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 5
OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 6
What Data Is Included? Medical and Pharmacy Claims Includes patient diagnoses, procedures performed by provider, and amount payer and patient will pay for services and prescription drugs Member Enrollment Information Includes type of insurance, and member age, gender, and geography APAC Provider Information Includes provider identifier, location, and specialty Premium Information Includes total premium amounts billed for each month of coverage OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 7
What Data Is Included? Medical and Pharmacy Claims Includes patient diagnoses, procedures performed by provider, and amount payer and patient will pay for services and prescription drugs What is a claim? Member Enrollment Information Includes type of insurance, and member age, gender, and geography APAC A claim is a request for payment that a medical Provider Information Includes provider identifier, location, and specialty provider sends to a payer (i.e. a health insurance company or health care program) for services rendered by the provider. A claim Premium Information includes information about the patient’s diagnoses, the procedure(s) Includes total premium amounts billed for each month of coverage performed by the provider, the amount the payer and patient will pay for the service(s) under a health insurance plan, and–in the case of paid claims–the final amount paid for the treatment or service. OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 8
What Data Is Included? Medical and Pharmacy Claims Includes patient diagnoses, procedures performed by provider, and amount payer and patient will pay for services and prescription drugs Member Enrollment Information Includes type of insurance, and member age, gender, and geography Provider Information APAC Includes provider identifier, location, and specialty Premium Information Includes total premium amounts billed for each month of coverage Non-Claims Payment Information (APMs) New! Includes health care payments made to providers that are non-claims based—such as capitation, pay-for-performance, global budget, etc. OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 9
What Data is Not Included? APAC does not include the following: • Data from commercial health plans with fewer than 5,000 covered lives; • Data on individuals insured through federal programs including Tricare, Federal Employees Health Benefits Program, Department of Veterans Affairs, and the Indian Health Service; • Data on uninsured populations and other individuals who pay out of pocket; • Data for other types of insurance such as workers’ compensation and stand-alone dental or vision policies; and • Claims related to alcohol and drug treatment. OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 10
Data Submitters ≥ 5,000 lives All OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 11
Who does not submit to APAC TRICARE Veterans Administration Indian Health Service Coverage for active duty Coverage for people who Provides federal health military service members, served in the active services for American National Guard and military Indians and Alaska Reserve Members, and Natives their families Some types of commercial coverage Accident policies, dental-only insurance, disability policies, hospital indemnity policies, long-term care insurance, Medicare supplemental insurance, specific disease policies, stop-loss plans, student health insurance, vision-only insurance, workers compensation, and coverage from carriers and TPAs with fewer than 5,000 enrollees in Oregon OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 12
Data Files Submitted to APAC Member Eligibility File Medical Claims File (Appendix B) (Appendix A) Pharmacy Claims File Medical Provider File (Appendix D) (Appendix C) Control File: Billed and Control File: Medical and Paid Amounts Pharmacy Member Months (Appendix E) (Appendix E) APM File and Control File Coming Premium File (Appendices G and H) Soon! (Appendix F) 13
Data Submissions Schedule Incurred Month, 2015 Incurred Month, 2016 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Due date* 01/31/2016 05/01/2016 07/31/2016 10/31/2016 Incurred Month, 2016 Incurred Month, 2017 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Due date* 01/31/2017 05/01/2017 07/31/2017 10/31/2017 Incurred Month, 2017 Incurred Month, 2018 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Due date* 01/31/2018 05/01/2018 07/31/2018 10/31/2018 OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 14
Data Submissions Schedule Incurred Month, 2015 Incurred Month, 2016 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Due date* 01/31/2016 05/01/2016 Why require multiple 07/31/2016 10/31/2016 resubmissions of the same incurred months? Incurred Month, 2016 Incurred Month, 2017 When a medical or pharmacy visit takes place, the provider submits a claim to the patient’s insurer to bill for the Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Due date* service. 01/31/2017 05/01/2017 The insurer receives the claim, processes it, and pays it. This period of time is referred to as “claims lag” and can vary 07/31/2017 depending on the type of payer and provider. While some claims are paid within two months of the date of service, others can 10/31/2017 take up to 12 months or more. Furthermore, some claims require adjustments after they have been paid; for example, if the payer discovers an error in the claim. Incurred Month, 2017 Incurred Month, 2018 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Once the claim is paid, the payer submits it to APAC during its next quarterly submission. However, OHA set up the Due date* 01/31/2018 rolling 12-month submission schedule to try to capture as many claims as possible—those that take longer to 05/01/2018 process as well as claims that have been adjusted. 07/31/2018 10/31/2018 OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 15
Timeline for Claims Data Submitted to APAC OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 16
Data Validation OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 17
Validation Levels 1-3 (Milliman-led) Level 3: Level 4 Level 5 Level 2: Level 1: Annual Data Audit Quarterly Data Audit sent to Automated File, Field and Quality 2-year, processed data look-back submitters before processing Checks (within 24 hrs. of data submission) (60 days after full years’ data (within 15 days of data submission) submission) OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 18
Validation Levels 4 and 5 (OHA-led) Level 1 Level 2 Level 3 Level 5: Level 4: Public Facing Reports Annual Interagency Validation Comparing APAC to other data sources OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 19
Additional validation work • OHA will study the claims of particular interest to DCBS • The primary objective will be to identify payer-specific algorithms to de-duplicate and further clean the claims data • OHA may seek feedback from individual payers regarding their own claims data • OHA will recommend claims data cleaning and de-duplication algorithms for implementation by DCBS (Enter) DEPARTMENT (ALL CAPS) (Enter) Division or Office (Mixed Case) 20
APAC Functions OFFICE OF HEALTH ANALYTICS Health Policy and Analytics Division 21
Recommend
More recommend
