Support

Only active, stand-alone Medicare Prescription Drug Plan (PDP) sponsors are eligible to use the AB2D API. This excludes PACE and MAPD. PDP sponsors, also known as Part D sponsors, are private insurers that provide prescription drug benefits to Medicare enrollees.

Medicare Parts A and B data elements (fields) in the standardized extract include:

• an enrollee identifier
• diagnosis and procedure codes (e.g., ICD-10 diagnosis and Healthcare Common)

Healthcare Common Procedure Coding System (HCPCS) codes:

• dates of service
• places of service
• National Provider Identifier Standard (NPI) numbers for providers
• claim processing and linking identifiers/codes (e.g., claim ID and claim type code)

AB2D receives data upstream from the Chronic Conditions Warehouse (CCW).

The final rule specifies that data may be used for:

• Optimizing therapeutic outcomes through improved medication use
• Improving care coordination
• Other purposes [that qualify] as “fraud and abuse detection or compliance activities”

The following uses are not permitted:

1. Inform coverage determinations under Part D;
2. Conduct retroactive reviews of medically accepted indication(s) determinations;
3. Facilitate enrollment changes to a different prescription drug plan or an MA-PD plan offered by the same parent organization; or
4. Inform marketing of benefits

Learn more about permitted uses of the data.

What is the final rule?

AB2D evaluates the data elements provided to PDP sponsors based on how well they support the permitted uses. Any proposed changes would be established through rulemaking. If you have any feedback, please email ab2d@cms.hhs.gov.

PDP sponsors must have an active Attestor at all times to access claims data. Your organization will not receive data during periods without an active Attestor. If your organization only has 1 Attestor, and they leave without a replacement, then your organization will lose access to the API until another active CEO, CFO, or COO attests.

Re-attestation will restore access to the API, including historical claims data that was not accessible during the lapse in active attestation. It’s strongly encouraged to add multiple Attestors to reduce the risk of gaps in data access.

PDP sponsors have access to AB2D as long as they have an active Attestor.

The “final” query code indicates a final bill for payment. This doesn’t necessarily mean the claim is finalized and complete. For example, it’s possible for a claim object with a “final” query code to be cancelled and resubmitted under a new claim ID.

Every time you pull the data, you will get the latest version of a claim. Claim objects have a lastUpdated field, which represents when the data was last refreshed by the API. This shows when AB2D received the update, not when the update was submitted to Medicare. Learn how to use lastUpdated and claim ID to identify a unique instance of a claim.