10th SOW Attach J-5a Revised.docx

Attachment J-5 Data Supplied by CMS - Amendment #2 as of May 6, 2011

Section J, Attachment J-5

A. Updated Monthly on QualityNet Warehouse

(1) Beneficiary data - from CMS’s Enrollment Data Base (EDB). Contains information for beneficiaries, both alive and expired, who were alive as of 1997. Beneficiaries who expired prior to 1997 are not included in this warehouse. Additions and updates are added monthly as of the previous month’s EDB. The data includes Parts A, B and D, beneficiary demographic information, entitlement reason, cross reference and coverage.

(2) Health Service Encounters - from CMS’s National Claims History (NCH) repository. This includes all inpatient encounters in raw, interim, and final action/stay record form, and ambulatory surgery center (ASC) records in raw and final action form. ASC services are billed by both intermediaries and carriers, so the data exists in two formats; outpatient and physician/supplier.

(3) Inpatient Standard Analytic Table (ISAT) - Each QIO database can be populated with raw and interim inpatient records for providers in that state in the standard ad hoc Part A base format, if the QIO loads the monthly ISAT file. QIOs can also run a monthly final action/stay procedure after loading the monthly ISAT file to their local database.

(3) Medicare Advantage (HMO) and Prescription Drug Plan (PDP) tables contain information from the Managed Care Health Plan Management System (HPMS).

(4) Provider Tables - includes all provider facility categories except CLIA Labs.

(5) Physician Tables –includes new or updated records since the prior month’s merge. Can have multiple practice settings per NPI, deactive and active. UPINs ceased being assigned in June 2007. CMS maintains an NPI Registry to cross reference a UPIN to an NPI.

(6) Reference Tables/Lookup tables (dictionaries/definitions) - updated annually or as new codes become operational.

DRG, Diagnostic and Procedure Codes from the Medicare Code Editor (3M) (annually around October 1),HCPCS code table supplied from CHPPS/OIS (annually around January 1), Revenue Center Codes, Condition Codes, Occurrence Codes, Span codes, Payer codes, Value codes and other code tables made available from the CMS files or CMS’s corporate data dictionary

B. Updated Quarterly on QualityNet Warehouse

CMS Denominator File – Each year, a denominator file is built to contain live beneficiaries as of the beginning of that year. Quarterly updates add new beneficiaries into the file, but do not remove deceased beneficiaries until the next year’s file is built. Yearly Denominator Files have been maintained since 2000 and are limited to Part A, B and Managed Care coverage. The CMS Denominator table is a rolled-up, flattened version of the CMS EDB relational tables with one record per year for each Medicare beneficiary.

C. Available on Clinical Data Warehouse

The Clinical Data Warehouse contains data uploaded from hospitals across the nation and abstracted data for surveillance cases for the national topics, used to calculate surveillance rates for the Scope of Work. Rates are calculated by quarter, as soon as all data for the sample have been submitted successfully into the warehouse. Quarterly rates are available by state by topic in standard reports (i.e. PPR Reports, etc.).

D. Ad Hoc as requested by QIOs to support CMS approved projects

(7) Durable Medical Equipment (Non-institutional/Part B)

E. Outpatient Data Analytic File -This analytic file will be provided based on 10th SoW measures.

Opportunities File -This file is supplied on a requested basis from the QIO for each completed quarter and contains Part A Outpatient and Part B data for any claim that had at least one qualifying physician evaluation and management (E&M) HCPC or revenue center code. For the detailed list of qualifying E&M codes please refer to SDPS Memo #02-405-PO found on QIOnet at: http://qionet.sdps.org/sdps_memos/sdps_memos_2002/02405po.htm.

These data can be used by QIOs to perform internal beneficiary-physician linkage based on individual QIO needs. Data can be used to identify and research the various providers and beneficiaries submitting E&M claims as well as all billed services that appear on the E&M claim record. The data fields contained within this file are based on recommendations from the July 2001 analytic joint application development session and subsequent QIO feedback. You may need to perform additional filtering based on your project needs. The only filtering criteria applied by default are as follows:

· bene_state_cd values specified on the ad hoc data request form

· hse_claim thru_dt values within the time period specified on the ad hoc data request form Requesting QIOs will receive two SAS datasets (one for Part A and one for Part B). QIOs will not have to perform any joins or merges between base and detail data as that has been incorporated t into the SAS datasets.

F. Nursing Home Data

· Facility Specific Quality Measures File – a quarterly file, placed on each QIO’s server, which contains the publicly reported quality measures for every facility in their state.

· Resident Level Data File – a quarterly file, placed on each QIO’s database server, which contains quality measure information on all of the nursing home residents in their state. The file contains information on whether each resident was counted in the calculation of each publicly reported quality measure as well as identifier information, date of assessment, and reason for assessment.

G. Other Information, Data and Reports

· Reports – information and progress on QIO achievement on improvement required within the 10th SOW. To be made available on the QIONet as reports are created and released.