CLAIMS AND UTILIZATION DATA

INTRODUCTION

Processing claims for Medicare health insurance benefits is fundamental to the operation of the Medicare program. CMS (previously HCFA) is responsible for ensuring that payments are made for medically appropriate and covered services. CMS also ensures that these services are rendered to eligible beneficiaries by qualified providers. Extensive records are generated for and by this administrative function. The detailed claims records submitted for Medicare covered services provide a unique source of information on health care utilization and costs. From these records, numerous analytic files are created by CMS to support Medicare program and policy development and evaluation, health care analyses, and clinical and epidemiological research.

The data for claims and utilization files originate with a claim submitted by a physician, hospital, or other provider. In the last few years, the process by which claims are submitted and paid has undergone changes that have significantly improved data availability and quality.

The Claims and Utilization Data files contain extensive utilization information at various levels of summarization for a variety of providers and services. Depending on the level of summarization, the unit of analysis for a given file of claims records might be the claim, hospital stay, or procedure. Some files contain data from a single type of provider, such as a hospice, while others contain data from more than one type of Medicare provider.

The Claims and Utilization Data chapter consists of five file groups:

• National Claims History (NCH) Files
• Standard Analytic Files (SAFs)
• Stay Records Files
• Part B Medicare Files
• Other Utilization Files

The NCH Files contain claim records for both institutional (Inpatient/SNF/Outpatient, HHA and Hospice) and non-institutional (Physician/Supplier & DME) data. The SAFs contain claims records in final action form, with all adjustments resolved. The Stay Records File group summarizes all inpatient services rendered to a beneficiary from admission to a hospital through discharge, or from admission to a Skilled Nursing Facility (SNF) (beneficiary may still be a patient in the SNF). The Part B Medicare Files group discusses the historic Part B Medicare Annual Data (BMAD) Files and their successors which contain data on the utilization and prices of physician services and certain other medical services, equipment, and supplies covered by the Medicare Supplementary Medical Insurance (SMI) plan. Finally, the Other Utilization Files group contains claims and utilization files that

pre-date the advent of the Common Working File (CWF) (as do the historic BMAD files and the Stay Records Files).

Each of these file groups and the files within them are discussed in detail following background information on the creation of claims and utilization files.

The Creation of Claims and Utilization Files

The CWF is a Medicare Part A and Part B benefit coordination and claims validation system. Under CWF, the country is divided into nine distinct processing sectors. Each sector has a designated contractor "host" site and a number of Fiscal Intermediary (FI) or carrier processing contractors. Each beneficiary is assigned to one and only one sector. The host site maintains an entitlement and utilization database that includes all Part A and Part B utilization data for each Medicare beneficiary in its sector. FIs and carriers do not send claims directly to CMS. Instead, they interact with the host site. FIs and carriers process claims submitted by providers, submit claims to the host site for prepayment review and authorization, and then act on host site authorization to pay claims. Further information about CWF claims processing can be found in the Overview of the Health Care Financing Administration chapter in the Orientation Section.

Prior to the CWF, claims were referred to as bills and CMS stored institutional utilization and physician/supplier services data in separate files. The institutional utilization data were stored in five bill files: inpatient, Home Health Agency (HHA), hospice, outpatient, and SNF. The bill files were used to create other files such as the Medicare Provider Analysis and Review (MEDPAR) File. To supplement its physician/supplier utilization data, CMS required all carriers to submit BMAD Files. BMAD Files contained sample and summary physician/supplier claims data, including claim line item detail for a sample of beneficiaries. More information on the BMAD Files can be found in the Part B Medicare Files group discussion in this chapter.

Under the CWF, CMS (previously HCFA) maintains claim level data for both institutional and non-institutional services. Carriers no longer submit payment records or BMAD Files. Physician/supplier claims data contain line item detail for every service listed on the claim. CWF claims records are the data source for most claims and utilization files.

The following table shows the type of claims data contained in each claims and utilization file. The "Institutional and Non-institutional" column lists files that include data from both institutional and physician/supplier claims. The "Inpatient/SNF," "Outpatient," "HHA," and "Hospice" columns list the files that contain data only from each of those types of institutional claims. The last column presents files created from non-institutional claims data only. More information on each file in the table is provided in the individual file discussions.

Files containing claims data that are discussed in other chapters of the guide such as the Medicare Current Beneficiary Survey (MCBS) File and the Continuous Medicare History Sample (CMHS) File, are not included in this table.

Please see:

• NCH Files
• Standard Analytical Files
• Stay Records Files
• Part B Files
• Other Utilization Files