The Centers for Medicare and Medicaid Services (CMS) is developing a standards-based Application Programming Interface (API) to provide PDP sponsors with Medicare Parts A and B claims data for their enrollees. Consistent with CMS’ Final Rule to implement Section 50354 of the Bipartisan Budget Act of 2018, CMS is providing standalone Medicare Part D plan (PDP) sponsors the opportunity to request access to Medicare claims data. Access to Medicare claims data for their enrollees will help plans promote the appropriate use of medications and improve health outcomes, among other benefits.
PDP sponsors may request Medicare claims data via the Claims Data Attestation module in the Health Plan Management System (HPMS). This attestation process ensures that PDP sponsors are aware of how they may or may not use the Medicare claims data, including the limitations associated with the reuse and redisclosure of the data. Visit HPMS
For documentation on our sandbox, go here.
To learn more about our data, go here.
Frequently Asked Questions
As CMS continues to gather feedback from PDP sponsors on sharing Parts A & B claims data, we anticipate adding more FAQs to this page. If you have a question that is not listed below, please ask in the AB2D Google Group.
- Why is CMS making claims data available to PDP sponsors?
In February 2018, the Bipartisan Budget Act of 2018 (BBA) was signed into law and included a provision requiring the development of a process to share Medicare fee-for-services claims data with PDP sponsors. Section 50354 of the BBA specifically provides that the Secretary of Health and Human Services shall establish a process under which PDP sponsors may request, beginning in plan year 2020, that the Secretary provide on a periodic basis and in an electronic format standardized extracts of Medicare claims data about its plan enrollees. Such extracts would contain a subset of Medicare Parts A and B claims data as determined by the Secretary and would be as current as practicable.
- What is the Final Rule?
In response to the Bipartisan Budget Act of 2018 (BBA), CMS published a Final Rule to implement section 50354 of the BBA, which outlines the manner in which CMS proposes to implement this requirement.
- Who is eligible to request Medicare Claims data under this process?
Standalone Medicare Part D plan (PDP) sponsors.
- When can PDP sponsors begin requesting data?
The Health Plan Management System (HPMS) Claims Data Attestation module can be used by PDP Sponsors to submit a request for Medicare claims data (by contract) beginning January 1, 2020. The HPMS attestation process ensures PDP sponsors are aware of how Medicare claims data may and may not be used, including limitations associated with reuse and redisclosure of the data. To submit a request, visit HPMS.
- What is Claims Data Attestation?
Attestation performed through the Health Plan Management System (HPMS) Claims Data Attestation module affirms adherence to the permitted uses and limitations for Medicare claims data that is listed in § 423.153 of the Final Rule.
What is the permitted use of the data?
Section § 423.153(c) of the Final Rule specifies that PDP sponsors receiving Medicare claims data for their corresponding PDP plan enrollees may use the data for:
(i) Optimizing therapeutic outcomes through improved medication use;
(ii) improving care coordination so as to prevent adverse healthcare outcomes;
(iii) for any other purpose described in the first or second paragraph of “health care operations” under 45 CFR 164.501, or that qualify as “fraud and abuse detection or compliance activities” under 45 CFR 164.506(c)(4).
What use of the data is not permitted?
Section § 423.153(c) of the Final Rule specifies that PDP sponsors receiving Medicare Parts A and B claims data for their PDP plan enrollees may not use the data for the following purposes:
(i) To inform coverage determinations under Part D;
(ii) To conduct retroactive reviews of medically accepted indications determinations;
(iii) To facilitate enrollment changes to a different prescription drug plan or an MA-PD plan offered by the same parent organization; or
(iv) To inform marketing of benefits.
- How do PDP sponsors access the data?
PDP sponsors will be able to access the data by leveraging an Application Programming Interface (API).
- What is the format of the data extract?
The data will be provided via API in Fast Healthcare Interoperability Resources (FHIR) format.
The AB2D API will leverage the Bulk FHIR Specification
- What are the data elements that will be accessible through the API?
Medicare Parts A and B claims data elements (fields) in the standardized extract as specified in the rule:
- An enrollee identifier
- Diagnosis and procedure codes (for example, ICD-10 diagnosis and Healthcare Common Procedure Coding System (HCPCS) codes)
- Dates of service
- Place of service
- Provider numbers (for example, NPI)
- Claim processing and linking identifiers/codes (for example, claim ID, and claim type code)
As the API is developed, a full list of the data elements will be shared.
- Can a PDP sponsor request historical data?
Section 1860D-4(c)(6)(D) of the Act provides that the Secretary shall make standardized extracts available to PDP sponsors with data that is the most current as practicable. While we understand that historical data may assist PDP sponsors, we must adhere to the statutory language. As this program matures, PDP sponsors will amass historical data.
- What is the lag time for getting claims data?
CMS is working on providing data as current as practicable. There are a number of factors impacting the lag time, we will monitor the lag time as we build out the API.
- How can we get more data elements in addition to what’s listed in the Final Rule?
CMS will continue to evaluate the data elements provided to PDP sponsors to determine if data elements should be added or removed based on the information needed to carry out the permitted uses of the data. Any proposed changes would be established through rulemaking.
- What are the data sources and how often is the data updated?
The AB2D API will leverage the Beneficiary FHIR Data server, which gets the data from the Chronic Condition Warehouse (CCW). The data is refreshed weekly.
- I’ve already attested, when will I get access to the data?
We are planning to provide a sandbox for the PDP sponsors to test the API using synthetic data in the Spring of 2020.
The production API with beneficiary claims data will be available later this year.