1_AttachmentJ-5.doc

Attachment J-5 Data Supplied by CMS

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.

(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. 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) HMO tables – full flat file data dump from Plan Information Control System (PICS)

(4) Provider Tables - from an OSCAR extract, includes all provider facility categories except CLIA Labs.

(5) Physician Tables – extracted from UPIN Repository files, includes new or updated records since the prior month’s merge. Can have multiple practice settings per UPIN, deactive and active.

(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

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.

C.

Provided as available on QualityNet Warehouse

Area Resource File (ARF)

D.

Available on Clinical Data Warehouse

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 has been submitted successfully into the warehouse. Quarterly rates are available by state by topic within PRS as well as in standard reports (i.e., Dashboard Reports, PPR Management Reports, etc.).

E.

Ad Hoc as requested by QIOs to support CMS approved projects

(1) Inpatient > 3 years old (Institutional/Part A)

(2) Outpatient (Institutional/Part A/Part B)

(3) Skilled Nursing Facility (Institutional/Part A)

(4) Home Health Agency (Institutional/Part A)

(5) Hospice (Institutional/Part A)

(6) Physician-Supplier (Non-institutional/Part B)

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

F.

Outpatient Data in support of the Task 1D projects

· Task 1D Analytic File This analytic file contains one record for eligible beneficiaries for the specified age group for the Mammography and Diabetes topics. The beneficiary-level record contains the topic quality indicator flags along with the various segmentation and demographic information typically included in the OD QIOSC reports. Also included for reference is the UPIN assigned based on the CMS Task 1d linkage algorithm, if applicable, along with the corresponding UPIN specialty code. This file will allow the QIO to examine characteristics of the Diabetes and Mammography eligible populations related to the receipt (or lack thereof) of Diabetes and Breast Cancer Screening services.

The following files are only supplied on a requested basis from the QIO for each completed quarter.

· Combined Topic All Ages Analytic File This analytic file contains one record for eligible beneficiaries of all ages for the Mammography and Diabetes topics. The beneficiary-level record contains the topic quality indicator flags along with the various segmentation and demographic information typically included in the OD QIOSC reports. Also included for reference is the UPIN assigned based on the CMS Task 1d linkage algorithm, if applicable, along with the corresponding UPIN specialty code. This file will allow the QIO to examine characteristics of the Diabetes and Mammography eligible populations related to the receipt (or lack thereof) of Diabetes and Breast Cancer Screening services.

· Opportunities File

This file 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.

This data is the underlying raw data source used for the CMS Task 1d beneficiary-PCP linkage algorithm. QIOs can use these data 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.

· Qualifying UPIN Visits File This file originates from the physician opportunities Part A Outpatient and Part B claims and contains summary information for qualifying visits for every beneficiary-UPIN combination within the Breast Cancer and Diabetes topic cohorts (but expanded to include all ages).

This rolled-up visits file contains the claims data that are summarized prior to the final one-to-one beneficiary-primary care provider (PCP) assignment for the CMS task 1d linkage algorithm. QIOs can use these data to identify all qualifying providers (i.e., those with qualifying specialties or those targeted by the QIO for Task 1d) who had qualifying visits with a beneficiary of any age in the Diabetes or Breast Cancer cohort, not just the PCP assigned as per the CMS Task 1d linkage algorithm.

Fields will be included to allow you to identify the number of qualifying visits and the latest service date for each beneficiary-UPIN combination along with a flag indicating if the UPIN was the assigned provider based on the CMS task 1d linkage algorithm.

· Mammography Services File This beneficiary level file contains the latest Part A Outpatient and Part B mammography services record during the measurement period for each mammography eligible beneficiary of any age that received a mammogram (as per the CMS performance measure criteria). This file is similar to the analytic data files previously released to QIOs by the CMS Kansas City Regional Office, except these files are in SAS format.

G.

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.

· Standard Analytic Report (SAR) – This data is delivered quarterly to the QIO via QualityNet Exchange to assist in their state’s nursing home quality improvement work. The SAR contains text, tables, graphs, SAS code, spreadsheets for each quality measure, and six SAS datasets containing numerator, denominator, quality measure rates, OSCAR survey deficiency information, and state and national quality measure rates for their state. Also included is a tracking tool that creates a state level report.

H. Home Health Data

· Each Quality Improvement Organization (QIO) has access to their quality of care measure rates of improvement for identified participant Home Health Agency’s (HHA’s) through the Quality Improvement and Evaluation System (QIES) via QIONet. QIES allows each state to run monthly analytic reports to monitor outcome-bases improvement for each HHA facility.

· QIO’s also have access to the Outcome-Based Quality Improvement Rollup Summary Reports on QIES.

I. Other Information, Data and Reports

· Dashboard Reports – information and progress on QIO achievement on improvement required under the tasks and subtasks within the 8SOW. To be made available on the QIONet as reports are created and released.

· Access to HCIS (Health Care Information System)

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