SF30 - 05GA0A24Q0025 Amend 0002.pdf

5/14/2024

Statement of Work Private Health Insurance Claims Data Service

April 23, 2024

REVISED MAY 10, 2024

Statement of Work: Private Health Insurance Claims Data Service

Section 1: Background

The Government Accountability Office (GAO) is an independent agency that carries out audit, evaluative and investigative assignments in addition to providing legal analyses to Congress. GAO performs work at the request of Congress and under the Comptroller General’s authority. In carrying out its work, GAO analyzes and evaluates executive branch agency programs.

GAO often needs large database resources to provide documentary or quantitative evidence to support analytic findings. Examples of these analytic findings are found on the agency’s web site: https://www.gao.gov.

Section 2: Purpose

GAO requires a data service on commercial health insurance claims in the United States to support a congressionally mandated study.

Section 3: Requirements

The data service must be a commercially available online product with data, services, and support for eight user accounts as described below.

A. Data

The data service must cover commercial health insurance claims for self-funded and fully insured employer-based health insurance group plans, for all 50 states and the District of Columbia. The data must represent multiple insurers, with claims covering at least 20 million lives per year. The data must cover all of 2019–2022 inclusive and at least the first six months of 2023. The data service must include the following data elements:

1. Procedure Code – five-character coding that describes the medical procedure that was performed for the claim.

2. Place of service – American Medical Association (AMA) place of service code.

3. Provider category – provider category code that indicates the specialty of the health care professional.

4. Service from Date – start date for the service or event.

5. Date of Last Service – end date for the service, event, or confinement being billed by the provider.

6. In-/Out-of-Network Indicator – indicator that designates whether the provider or facility is in or out of the insurer’s network for the particular service and member.

7. Business Line – identifies the insurer’s book of business.

8. Allowed Amount – the amount paid by the insurer for the service or item (also known as the negotiated rate).

9. Provider Geographic Indicator – the zip code, MSA, CBSA, county, or state in which the provider is located.

10. Beneficiary Geographic Indicator – the zip code, MSA, CBSA, county, or state in which the beneficiary resides.

11. National Provider Identification (NPI) – NPI code for the provider of the service, either actual or encrypted.

B. Services and Tools

1. The vendor must provide access to claim-line-level data through an online platform which users can access via individual username/password login.

2. Exports from the vendor’s platform must meet either requirement 1A or requirement 1B as described below.

Data Export Requirement

Data Aggregation Level Other Considerations

Requirement 1A Line-level data N/A Requirement 1B Data aggregated to the provider NPI, network status, procedure code, and beneficiary geographic area

The vendor’s platform must accommodate in-platform use of SAS and Stata, and the vendor must provide a means to export outputs, logs, and code from the platform in addition to aggregated data

3. The vendor must provide a means to export data from the platform in formats compatible with SAS and Stata.

4. Exports from the vendor’s platform must be transmitted as direct downloads from the platform or via an ODBC interface.

C. Support

1. Technical support must be available by videoconference and email from 9am to 5pm Eastern time to troubleshoot technical problems of access, downloading, and use of data service.

2. Analytic support must be available by videoconference and email from 9am to 5pm Eastern time to advise GAO on best methods to obtain needed data and to discuss data sources and data quality assurance steps.

3. Vendor must provide access to record layouts, the data dictionary or data dictionaries which cover the required data elements, the codebook, and the users’ guide.

D. Permissions for Usage and Publication

1. The vendor must allow GAO to publish or present summary statistics from statistical models that include the data.

2. The vendor must allow GAO to publish or present graphics based on the data.

3. The vendor must allow GAO to cite to the data source in the methodology section of any publicly released report which relies on analyses of this data. Discussion of the data source in the methodology section may include a broad description of the data, how it relates to the overall commercial insurance market, and any findings regarding the data’s reliability that are relevant to the report.

4. The vendor must allow GAO to share the findings based on the data in GAO publications and in testimonies before Congress.

5. The vendor must allow GAO to store all exports from the vendor’s platform in GAO’s records management system for audit purposes.

Section 4: Deliverables

In addition to the data recipients, the deliverables must be sent to the Contracting Officer Representative (COR), the Contracting Officer (CO), and the Contract Specialist (CS). The CO and CS will not need the user accounts but will need to ensure all deliverables are met in a timely manner.

Description Frequency Format Date Completed

Provide access to the data service platform.

As requested 8 accounts Within 5 business days after contract award and upon request

Provide initial account start up support

As requested Email or videoconference consultation as needed

Within 10 business days after contract award and upon request

Provide technical and customer support as needed

As requested Email or videoconference consultation as needed

From date of award through end of period of performance

Provide product documentation (record layouts, the data dictionary or data dictionaries which cover the required data elements, the codebook, and the users’ guide)

As requested Paper, pdf copies, web sites, or database as needed

Within 15 business days after contract award, and as needed