Data Organization

DATA ORGANIZATION

The Data section of the Reference Guide contains database and file information. The databases and files are divided into data chapters and file groups. Organizing and grouping the data in this manner throughout the Reference Guide enables the reader to easily locate specific file information and to relate it to the CMS (previously HCFA) data processing environment.

Data Chapters

Claims and Utilization Data

Enrollment and Eligibility Data

Combined Claims and Enrollment DataProvider of Services Data

Provider Cost Report Data

Special Programs Data

Medicaid Data

Reference/Resource Data

Public Use Files Data

Beneficiary Encrypted Files Data

The Claims and Utilization Data chapter discusses numerous analytic files that were created by CMS to support Medicare program and policy evaluation and development. These files contain detailed records of Medicare claims submitted for payment as well as summarized claims data. As such, they provide a unique source of information on the utilization of health care.

Accurate and up-to-date records of each Medicare enrollee are required by CMS for Medicare program administration. Eligibility of the individual receiving services and the status of beneficiary entitlement must be established each time a claim is submitted. CMSoperates an extensive enrollment data system to meet the information requirements of this administrative function. The Enrollment and Eligibility Data chapter describes files derived from the enrollment data system.

The Combined Claims and Enrollment Data file contains linked enrollment and utilization data. The file in this chapter contains beneficiary characteristics data and annual utilization data for a sample of Medicare beneficiaries. The file contains a history of annual utilization, regardless of utilization activity within a particular year.

The Provider of Services Data chapter describes three files. Two of the files contain information on institutional provider characteristics. One of these files contains data that are collected during the Medicare and Medicaid institutional provider certification process. The other file contains data used to calculate payments for all Medicare Prospective Payment System (PPS) hospitals. The remaining file contains summary information for physicians.

The Provider Cost Report Data chapter describes files containing data from cost reports that are submitted to CMS by Medicare-certified facilities. The files contain specific financial and statistical cost report data such as facility characteristics and costs and charges by cost center.

The Special Programs Data chapter consists of files containing information collected for a particular group of Medicare beneficiaries or providers. This chapter discusses the End Stage Renal Disease (ESRD) Program Management and Medical Information System (PMMIS) Database and the Medicare Current Beneficiary Survey (MCBS) Files.

The files discussed in the Medicaid Data chapter contain Medicaid eligibility, expenditure, and recipient data. Also included are state Medicaid program characteristic data, and Medicaid drug utilization and product description data.

The Reference/Resource Data chapter presents a collection of utility files used by CMS in conjunction with administrative and analytic files. The files contain various indices, standards, and coding systems.

The Public Use Files Data chapter describes files that have been edited and stripped of all information that could be used to identify individuals. These files are the primary source of data for federal agencies outside of CMS, government contractors, academic researchers, and commercial enterprises that are not permitted access to individual identification information.

The Beneficiary Encrypted Files (BEFs) Data chapter includes files that have been encrypted, ranged or blanked. BEFs require a signed Data Use Agreement (DUA) before the data can be released. These files are another source of data for customers (federal agencies outside of CMS government contractors, academic researchers, and commercial enterprises) who are not permitted access to individual identification information, but have projects determined to be in the government’s interest and projects that require a level of detail not available in the PUFs.

File Groups

The files within five of the data chapters are further divided into file groups that organize the files by system or function. The file groups are presented below, under the corresponding data chapter. In other data chapters where no file groups exist, there were no logical groupings of the files, or there were too few files to establish subgroups.

Claims and Utilization Data

Enrollment and Eligibility Data

Enrollment Database Files
Other Enrollment Files

Medicaid Data

Medicaid Eligibles, Claims, and Utilization Files
Medicaid Drug Rebate Files
Medicaid and Children’s Health Insurance Budget and Expenditure Files

Public Use Files Data

Cost Limits - Cost Reports
Enrollment
Payment Rates Institutional Providers
Payment Rates Non-Institutional Providers
Providers
Utilities/Miscellaneous
Utilization
Medicaid

Beneficiary Encrypted Files Data

Enrollment
Standard Analytical Files (SAFs)
Expanded Modified MEDPAR
Hospital (National) File
Expanded Modified MEDPAR
Hospital (State) File
Expanded Modified MEDPAR
Skilled Nursing Facility
Physician Sample File (Formerly BMAD Provider File)
5% Sample Durable Medical Equipment (DME)