MEDICAID ELIGIBLES, CLAIMS, AND UTILIZATION FILES

The Medicaid Eligibles, Claims, and Utilization Files group includes the following data files:

• Medicaid Valid Tapes Files
• Personal Summary Record File
• State Medicaid Research Files
• HCFA Form 2082 Totals File

States submit annual Medicaid program statistics to CMS (previously HCFA) on standard CMS forms. One such form required from states is the HCFA Form 2082 which contains state-level summary counts for Medicaid recipients and services, categorized by types of service and demographic characteristics. Such information enables CMS to determine state and national trends in Medicaid enrollment and utilization. States have the option to submit the hard copy Form 2082 or to provide eligibility and claims data to CMs.

CMS manages the Medicaid Statistical Information System (MSIS), to collect raw Medicaid eligibility and claims data from states. When a state elects to participate in the MSIS project, it provides a copy of its eligibility and claims data to CMS on tape. The MSIS processes and edits the data received from the state, and the data are used by CMS to produce a HCFA Form 2082 for the state. The data provided by the state must pass MSIS edits for a consecutive number of quarters so that a valid Form 2082 is produced from the data submitted. When a valid and acceptable HCFA Form 2082 report is produced, that state is exempt from submitting a hard copy HCFA Form 2082. Until an acceptable Form 2082 report is produced using MSIS data, the state must continue submitting a completed hard copy form in addition to providing the data on tape.

While not all states elected to participate in MSIS prior to 1999, the number of available participants allowed CMS to build a significant data source for analysis of Medicaid utilization patterns. The Balanced Budget Act (BBA) of 1997 mandated that all states participate in MSIS beginning in 1999.

Medicaid Valid Tapes Files

The Medicaid Valid Tapes Files include the Eligible, Inpatient Claims (Claim-IP), Long-term Care Claims (Claim-LT), and Other Claims (Claim-OT) Files. These files are created from data submitted by states to CMS as part of the MSIS project. Once submitted, the state tape files are validated by CMS and become the Valid Tapes Files.

File Creation

Each quarter, states participating in the MSIS project provide CMS with a tape file that contains information for all persons eligible for Medicaid in their state. This file is called the Eligible File. Participating states also provide quarterly tape files containing all adjudicated claims for medical services reimbursed with Medicaid funds during that quarter. There are three types of claims files, depending on the type of service reported: Claim-IP, Claim-LT, or Claim-OT. CMS conducts QA edits to ensure that data are within acceptable error tolerance levels. Acceptable data are then recorded in the Valid Tapes Files. For some states, these files are available beginning as early as fiscal year 1985, but the data elements and years of available data vary by state.

The data contained in the Valid Tapes Files are limited to MSIS participating states and may vary because of varying state programs. The differences in the state programs complicate analysis of the data across states. As more states comply with MSIS participation, the amount of beneficiary and claim level data available will increase. As of 1998, 32 states were participating in the MSIS project:

File Maintenance

When the new quarterly Valid Tapes Files are created by CMS, existing files are updated with corrections. As the files are created and updated, basic edits are performed to ensure data quality. The edits performed on the eligible and claims files fall into four categories:

• Tests for numeric fields that contain non-numeric data
• Tests for 8- and 9-filling of fields, which indicate that a field was not applicable
• Tests for values outside established allowable ranges
• Relational tests for inconsistencies between two or more data elements

MSIS evaluates the first 500 records in each state's eligible tape to ensure that the current quarter records fall within the reported quarter. If more than 50 percent do not fall within the current quarter, the file is rejected and returned to the state without further evaluation.

MSIS also evaluates the first 600 records of a state's claim tape file for inconsistencies in payment date. If more than 50 percent of the current quarter claims have a payment date that is not consistent with the reporting quarter, the file is rejected without further evaluation. States are required to sort their tape files by beneficiary. Improperly sorted eligible and claims files are also returned to the state.

Documented error tolerance levels for each data element in the eligible and claims files describe the maximum allowable percentage of records that may have missing, unknown, or invalid code combinations. Error rates in excess of the error tolerance level for any field cause the entire file to be rejected.

File Structure and Usage

States submit eligible and claims files each quarter. The Valid Tapes Eligible File contains one record for each person who was eligible for Medicaid for at least one day during the reporting quarter, one record for each individual who was determined to be eligible during the reporting quarter for a previous quarter, and records that correct previously submitted records.

The Medicaid Valid Tapes claims files contain several record types such as current claims for medical services, adjustments to previously paid claims, premium payments, and dummy claims. Dummy claims simulate claims that would have been generated for Health Maintenance Organization (HMO)/Prepaid Health Plan (PHP) patients if they were billed on a fee-for-service basis. Additionally, some states use zero-dollar claims for special purposes such as tracking individual services covered in a lump sum billing.

Three distinct claims files are created each quarter: the Claim-IP, Claim-LT, and Claim-OT. Each file reports detailed information for a different group of services. The Claim-IP File contains records for inpatient hospital services claims. The Claim-LT File contains records of claims for long-term care received in an institution. Long-term care includes services rendered in SNFs, ICFs for persons who are mentally retarded, psychiatric hospitals, and independent (free-standing) psychiatric wings of acute care hospitals.

The Claim-OT File contains all Medicaid claims not included in either the Claim-IP File or the Claim-LT File. These claims include the following:

• Provider payments for all non-institutional Medicaid services
• Provider claims for all services received in hospitals, SNFs, or ICFs that are not billed as part of long term or inpatient care such as physician visits and prescription drugs (Beginning in 1999, prescription drugs are submitted in a separate claim RX file.)
• HMO/PHP premium payments
• Claims for medical and non-medical services received under an approved Medicaid plan

The claims files are used for health care research and evaluation activities, program utilization and expenditure forecasts, analyses of policy alternatives, program management support at both the Federal and state levels, responses to Congressional inquiries, and longitudinal tracking of enrollees and services.

Because participation in the MSIS project was voluntary until January 1999, the data maintained in the Valid Tapes Files are limited to participating states, and vary from state to state.

Data Structure and Usage

The Valid Tapes Files are stored at the HDC. The Eligible File contains personal characteristics information and monthly enrollment data for each Medicaid recipient. The monthly enrollment data are present for each month of the reporting quarter in which the individual is eligible for Medicaid. Each fixed length record contains approximately 20 data elements including general demographic information such as date of death, date of birth, sex, race, and county code as well as information regarding basis of eligibility and maintenance assistance status. The 1994 Valid Tapes Eligible File contains approximately 62 million records.

The claims files contain data elements that describe dates and place of service, payment amounts, and primary diagnosis. The Claim-IP File contains claims for inpatient hospital services. There are approximately 30 data elements on each fixed length record, including beneficiary identification, admission and discharge date, and procedure code data. The 1994 Claim-IP File contains approximately five million records.

The Claim-LT File contains claims for long-term care services received in an institution. The fixed length records have approximately 20 data elements that include beneficiary identification, diagnosis, and number of days of care. The 1994 Claim-LT File contains approximately 15 million records.

The Claim-OT File contains all Medicaid claims not included in either the Claim-IP File or the Claim-LT File. The fixed length records have approximately 20 data elements including number of units of service, state-specific service, and drug codes. The 1994 Claim-OT File contains approximately 540 million records.

Migration of Data

The Medicaid Valid Tapes Files have not been affected by the changing CMS data processing environment.

List of Data Elements

A list of data elements contained in the Eligible File, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov. The data elements for the claims files are divided as follows: data elements in all claims files, data elements in both the Claim-IP and Claim-LT Files, data elements in the Claim-IP File only, data elements in the Claim-LT File only, and data elements in the Claim-OT File only.

Medicaid Personal Summary Record File

The Medicaid Personal Summary Record File was designed to provide a single source of data for Medicaid eligibles by state and fiscal year and to facilitate efficient analysis of state supplied eligible, recipient, and paid claims data. The file summarizes paid Medicaid claims data at the person level.

File Creation

The Personal Summary Record File is created only for states that submit data through MSIS. A list of participating states is contained in File Creation in the Medicaid Valid Tapes Files discussion. As more states participate in the project, more person-level data will be available. The Personal Summary Record File is created using quarterly validated eligible and claims files, any prior year fourth quarter Personal Summary Record File, and the prior quarter of the current year Personal Summary Record File. These files are merged to create a new quarterly year-to-date Personal Summary Record File. The Personal Summary Record File is available for some states beginning as early as fiscal year 1985.

When claims data are summarized for an individual who was eligible during the prior year but not the current year, the individual's demographic information is derived from the prior year Personal Summary Record File. Claims that cannot be linked to eligible data records are assigned a "dummy" MSIS identification number. All claims associated with a dummy MSIS identification number are summarized into a single record. Attempts are made to link these records to eligibility information obtained in future processing quarters.

File Maintenance

The Personal Summary Record File is updated quarterly throughout the fiscal year as described under File Creation. The annual file is a fourth quarter year-to-date file. Validated eligible and claims files used to populate the Personal Summary Record File may contain data errors that are identified as a result of QA checks. Flags indicating the presence of these errors are coded within each eligible and claim file. Error flags can be assigned for incorrect data type, format, or logical relationship. These flags identify data that should not be included in the summarization of claims records into a Personal Summary Record File.

File Structure and Usage

The Personal Summary Record File contains one summary record for each person participating in a state Medicaid program. The MSIS eligibility and claims data are summarized to provide eligibility and utilization information by individual. Each Personal Summary Record File contains one record for each unique MSIS identification number assigned to a Medicaid recipient. The records are sorted by identification number within a state.

As with the Valid Tapes Files, the Personal Summary Record File contains information for only those states participating in the MSIS project and years in which the state submitted tape data. The file can be used to study Medicaid utilization at the person-level.

Data Structure and Usage

The data contained in the Personal Summary Record File include eligibility and utilization data summarized at the person-level. The data are used to analyze Medicaid utilization (e.g., cost by age group within states and services rendered to subsets of recipients) and are also used for program and policy evaluations. The 1994 file contains approximately 16 million fixed length records. Each record contains approximately 75 data elements including demographic information such as date of birth, age group, date of death, sex, and county code, basis of eligibility and maintenance assistance status; claims data such as total number of claims, total dollars paid for claims, and coinsurance flag; and type of coverage at the person-level. The file is available for some states as early as 1985.

Methods of Access

HDC users may access the Personal Summary Record File data directly through the menu-driven M204 Medicaid User Interface (MUI) Subsystem.

Migration of Data

The Personal Summary Record File has not been affected by the changing CMS data processing environment.

List of Data Elements

A list of data elements contained in the Personal Summary Record File, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov.

State Medicaid Research Files (SMRF)

The State Medicaid Research Files (SMRF) are the Medicaid Eligibles, Claims, and Utilization files reformatted into file structures requested by researchers to facilitate the use of Medicaid data. The files are sorted by calendar year and by date of service. Adjustments have been applied, and new type of service and eligibility codes have been added. The Inpatient file contains stay records with maternal and neonatal claims separated where possible. A separate drug file has been created that includes injectables. The specific SMRFs are listed below:

• Drug Claims Files
• Inpatient Claims Files
• Long Term Care Claims Files
• Other (Ambulatory) Claims Files
• Person Summary Files

File Creation

The SMRF data are created nine months after the end of the calendar year. The MSIS eligibility data for each state from the study year plus two quarters of the following year are processed to create a base eligibility record for the SMRF Person Summary File. This record is updated as each claim file is processed so that the Person Summary File is completed when the last claim file is processed.

The SMRF Drug, Ambulatory, Inpatient, and Long Term Care files are created separately for the MSIS Claims data. Adjustments are applied and some additional variables are created.

File Maintenance

SMRFs are created from the quarterly MSIS Valid Tapes. Because the MSIS files are by date of payment and because of payment lag time, SMRFs are created using seven quarters of MSIS data - the four quarters of the calendar being created and three quarters of the following year.

After the file has been created, the data are given a "preliminary review," which searches for programming errors and obvious data errors. Data dumps and SAS distributions are reviewed. The processing of adjustment records and the crosswalking to new data fields are scrutinized. Significant problems are corrected and the data files are recreated. Smaller problems and/or uncorrectable problems do not cause the files to be recreated but are noted in the data documentation.

The data are further reviewed in the Data Verification Phase and analyzed in depth using a number of statistical tools. Any anomalies and data quality problems are documented. The data summaries, distributions, and statistics are saved for researchers who need to perform further analysis of data patterns.

File Structure and Usage

While the data is essentially the same as the MSIS data, the file structure has been changed to accommodate researchers. The files are sorted by calendar year and by date of service with adjustments applied.

The MSIS Other (OT) files have been divided into Ambulatory and Drugs. The Drug file contains all drugs including injectables.

The MSIS Inpatient (IP) claims have been combined to form Stay records in the SMRF IP files. Maternal and neonatal are kept separate, if possible. States report these claims in various ways.

With the exception of adjustments, the MSIS and SMRF Long Term Care (LT) files should be virtually identical.

Data Structure and Usage

The SMRF Files mirror the MSIS Valid Tapes Files except they are consolidated based on date of service rather than date of payment. Furthermore, the following data are added:

• Neonate Indicator
• Delivery Indicator
• Additional Types of Service
• Additional Eligibility Codes

Migration of Data

The development of Medicaid SMRF files for calendar years 1996, 1997 and 1998 was delayed by Y2K priorities in CMS. These files are now in production. Changes in MSIS reporting requirements were implemented for Medicaid agencies in fiscal year 1997 and 1998. Then, the BBA mandated reporting by all states beginning in 1999. As the BBA was mandated, additional changes in MSIS reporting requirements were implemented for fiscal year 1999. Each round of changes had an impact on selected SMRF data elements and their code values. Beginning in November 1999, new specifications for the 1996, 1997 and 1998 SMRF files were being developed.

List of Data Elements

A list of data elements contained in the SMRF Files, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov. The data elements for the claims files are divided as follows: data elements in all claims files; data elements in both the Claim-IP and Claim-LT Files; data elements in the Claim-IP File only; data elements in the Claim-LT File only; and data elements in the Claim-OT File only.

Medicaid HCFA Form 2082 Totals File

The Medicaid HCFA Form 2082 Totals File contains summarized eligible, recipient, and claim expenditure information similar to the information provided by the HCFA Form 2082 report.

File Creation

The HCFA Form 2082 Totals File contains summary counts of Medicaid recipients and services, categorized by type of service within states. The Medicaid HCFA Form 2082 Totals File is created from both hard-copy Form 2082 reports and MSIS data. The process by which these reports are submitted by the states or prepared by CMS is described in the introduction to this file group. As more states participate in the MSIS program, and thus eventually become exempt from submitting hard-copy forms, the source of data for the HCFA Form 2082 Totals File will shift to the MSIS files submitted by states.

Each annual HCFA Form 2082 Totals File covers one fiscal year and is usually available in May of the following year. A HCFA Form 2082 Totals File is available for each fiscal year beginning in 1987.

File Maintenance

Preliminary versions of the HCFA Form 2082 Totals File are available almost immediately after the file is updated. A final version of the file is generally available in May of the following fiscal year. HCFA Form 2082 data are subjected to a series of arithmetic checks to ensure data accuracy and consistency. MSIS data are subjected to the verification process described in File Creation in the Medicaid Valid Tapes Files discussion.

File Structure and Usage

The HCFA Form 2082 Totals File contains total dollars expended or number of patients treated by Medicaid covered services; the file does not contain claim- or recipient-level data. The data are used to determine trends in Medicaid coverage and utilization at the state and national level. The HCFA Form 2082 Totals File data are limited to what is reported by states in the HCFA Form 2082 report. The HCFA Form 2082 was supplemented in 1987 and 1989 to cover additional Medicaid eligible groups created by legislation. Subsequent changes in 1997 modified the eligibility categories, and in 1998, the service categories were updated.

Data Structure and Usage

The HCFA Form 2082 Totals File is an annual statistical abstract of state Medicaid program characteristics. The file consists of a SAS table with approximately 7,000 data cells that include information on payment amounts, numbers of individuals enrolled and served, and service units. These cells are categorized by basis of eligibility, maintenance assistance status, demographic characteristics, and type of service. The data contained in the table correspond to the hard copy Form 2082 reports submitted by states. General state and national trends in Medicaid enrollment and utilization can be tracked with the data contained in this file. The years of data available vary by state, starting in 1987.

Methods of Access

The HCFA Form 2082 Totals File is available in hard copy or on diskette. Tables are created from the file and are available at the state or national level. The national level tables are available as a PUF. The summarized MSIS data used to create the file can be accessed through the menu-driven M204 MUI Subsystem. Additional information about the PUF is provided in the Public Use Files Data chapter. An online version of the HCFA Form 2082 Totals File that contains data only for MSIS participating states is also maintained.

Migration of Data

The HCFA Form 2082 Totals File has not been modified as a result of the changing CMS data processing environment.

List of Data Elements

A list of data fields contained in the HCFA Form 2082 Totals File, along with brief definitions and coding schemes, will be included in the future on the CMS web site at www.cms.hhs.gov.

Medicaid Data | Eligibles, Claims, and Utilization Files | Drug Rebate Files |Budget and Expenditure Files