1. An Introduction to CMS data
Joe Brenner
Office of the Actuary

2. Claims data Who provides service?
Providers – Institutional providers who are ‘certified’ based upon conditions of participation such as Hospitals, Skilled Nursing Homes
Physicians
Suppliers/Others – Includes non-physician practitioners, group practices, labs, ambulance, DME suppliers
Approximately 1.2 million providers, physicians, suppliers & others serve Medicare

3. Claims data The Medicare claims process
Using information returned from CWF, FI/Carrier process claim for payment or denial.
CWF host sites transmit claims data to CMS daily.
CMS processes the transmitted claims through the CWF Medicare Quality Assurance System (MQAS) prior to loading data into the National Claims History (NCH) Repository and the National Medicare Utilization Database (NMUD)

4. Claims data Data dictionary
Basic information on all fields in a claim record
General description of field
Location, length, format
Description
Alias
Source code tables
Mainframe CLIST:
G:\PUBLIC\LSD\Data Streamlining\DESY\Version I data dictionary\
Description – free form
Alias – std field name used in OIS, elsewhere
Source tables - appendix

5. Claims data General claim layout info
Fixed portion
Common to all files
Many fields exist across all files
Demographics
Claim total dollars
Trailers
Vary in length, content
Count in fixed portion
Loop processes each segment
Specific to claim type
Revenue centers / Line items

6. Claims data National Claims History (NCH) Source for all claims
Fed by Common Working File (CWF)
CWF is raw claims submitted by providers
Some processing is done as claim moves to NCH
Not final action processed

7. Claims data Standard Analytical Files (SAFs)
Extracted from NCH and split by type
Inpatient
Outpatient
Skilled Nursing Facilities (SNF)
Home Health Agencies (HHA)
Hospice
Durable Medical Equipment (DME)
Final action processed applied
Place of service determines file
place of service determines file (Mollie’s quest) – if HHA, claim is in HHA regardless of service provided

8. Claims data Physician/Supplier Contacts One for each state
Too voluminous to fit in a single file
Contacts
CMS internal users:
Marvella Bunch – )
Outside CMS:
Judy Reinecke –

9. Other claims files 5% Sample
MEDPAR - Medicare Provider Analysis and Review
Extended hospital/SNF stay synthesized to a single record
Gives full view of a bene’s experience in single record
5% Sample
Exists for all claim types (inlcuding Physcian/Supplier)
Based on bene’s HIC (SSN)
Proven reliability at high level
PS/DME – all iterations as in CWF
Medpar – single stay

10. Enrollment data Enrollment database (EDB) All enrollees over time
Some information comes from SSA
Multiple segments must be consolidated to determine a bene’s status

11. Denominator Derived from Enrollment Database (EDB)
Created each year at the end of March
Summary information on all benes who received service during previous year
Basic demographic info (including DOD)
Entitlement
ESRD
Buy-in
HMO
ESRD flag – Eugenea?

12. Drug data Housed in Integrated Data repository (IDR) only
IDR is source for all claims and enrollment data
Built on Teradata platform

13. NCH / NMUD Derived from CWF Original repository for all claims
All iterations of single claim
Derived from CWF per slide 3
Iteration = adjustment; cite examples

14. SAS claims input statements
Input statements exist for all claim types
Also exist for each version
See B1G4.DESY.CNTL for all types
Contact for access

15. Integrated Data Repository (IDR)
Relational database
Contains
Part A, B and D claims
Risk scores
Enrollment
Provider

16. IDR Data Flow Diagram IDR SSA EDB CWF NCH MARx HPMS CMEM BD PDFS DDPS
Denominator
EDB
CWF
NCH
MARx
HPMS
CMEM BD
PDFS
DDPS
HCPCS
CPT
Rev. Center
DRG
BETOS
NDC
NPI
POS
UPIN
NCPDP
OSCAR
PIN
Procedure
Provider

17. Enterprise Architecture Example
Teradata Platform
Desktop Computer
Business Intelligence
Mainframe Channel
Network
Channel
Business Intelligence
Mainframe
The Teradata platform can consist from one to many powerful computers to create a massively parallel architecture.
The system can be accessed by many different avenues including,
- Desktop applications
- Business Intelligence networks
- Mainframe channels
This is in contrast to our old paradigm of using cartridge tapes to store large amounts of data, which can only be accessed using the mainframe.
Many avenues of data access

18. Oh No!!! Don’t make me use the mainframe!
The mainframe is probably the most feared technology at CMS
It’s nothing more than a server on steroids.
It has it’s quirks, but doesn’t everything?
It’s as easy to use as the PC once you get used to it.

19. Getting to the mainframe
Host on Demand (HOD) URL

20. HOD

21. CMS Data Center

22. Application selection screen

23. Main menu

24. Dataset list utility

25. Dataset list utility

26. Dataset list utility

27. Dataset list utility

28. PF Keys

29. PF keys

30. Split screen mode

31. Use PF 9 to swap

32. Use PF 9 to swap

33. Edit panel

34. Member selection list

35. Edit member

36. IOF

37. IOF