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Frequently Asked Questions
Why is CMS making claims data available to PDP sponsors?expand_more
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?expand_more
Who is eligible to request Medicare Claims data under this process?expand_more
Stand-alone Medicare Part D Plan (PDP) sponsors.
How do standalone Medicare Part D Plan (PDP) sponsors access the Medicare Parts A and B claims data as mandated by the BBA and Final Rule?expand_more
PDP sponsors will be able to access the Medicare Parts A and B claims data by leveraging the AB2D Application Programming Interface (API).
I'm a Standalone Medicare Part D Plan (PDP) sponsor. How does my organization receive Medicare Parts A and B claims information using the AB2D API?expand_more
A standalone Medicare Part D Plan (PDP) sponsor must first complete the attestation process for each of their participating Part D contracts. After attesting, the AB2D team will work directly with the “AB2D Data Operations Specialist” and the Attestor to ensure that the (PDP) is able to retrieve Medicare Parts A and B claims data. Learn more about accessing AB2D claims data.
What is Claims Data Attestation?expand_more
Attestation is a process to ensure PDP sponsors are aware of how the Medicare claims data provided by AB2D may and may not be used, including limitations associated with reuse and redisclosure of data. Attestation performed through the Health Plan Management System (HPMS) Claims Data Attestation module affirms adherence to these permitted uses and limitations of this claims data as listed in § 423.153 of the Final Rule . To attest, visit HPMS
Who within my organization can Attest?expand_more
Attestation must be performed by a Medicare Part D Plan (PDP) Sponsor CEO, CFO, or COO. The Attestor must hold an active CEO, CFO, or COO role within their organization. Part D Plan (PDP) sponsors are allowed to have multiple executives attest to each participating contract.
What happens if an Attestor leaves my company?expand_more
Participating Part D Plan (PDP) sponsors must have an active Attestor at all times and will not receive data during periods where the (PDP) sponsor does not have an active Attestor. If your organization has a single Attestor and they leave without a replacement, then your organization will lose access to new data until another active CEO, CFO, or COO attests. Re-attestation will restore access to new claims data and provide historical claims data that was not accessible during the lapse in active attestation. Having multiple Attestors reduces the risk of data gaps due to workplace attrition and is strongly encouraged.
What is the permitted use of the data?expand_more
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?expand_more
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.
When can PDP sponsors begin requesting data?expand_more
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.
What is the format of the data extract?expand_more
What are the data elements that will be accessible through the API?expand_more
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
- 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)
Can a PDP sponsor request historical data?expand_more
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.
How can we get more data elements in addition to what’s listed in the Final Rule?expand_more
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?expand_more
The AB2D API will leverage the Beneficiary FHIR Data (BFD) server, which receives data from the Chronic Condition Warehouse (CCW). The majority of the BFD data is refreshed weekly with a few data elements being loaded monthly.