Category of health care payers. (e.g., Medicare, TRICARE, Commercial Managed Care - PPO)
Submitted By: Joel Andress
/ Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality (CCSQ)
Data Element Information
Use Case Description(s)
Use Case Description
Insurance type information is used by providers (e.g., hospitals, clinicians) for data for billing. This patient-level information provides context for how healthcare benefits are covered for a patient. This information is vital for administrative purposes (billing) and also important for quality measurement to help define target populations and to assess quality differences among patients with differing insurance coverage.
Estimated number of stakeholders capturing, accessing using or exchanging
More than 4,000 hospitals and 1 million providers currently capture, access and exchange this insurer type information. This information is currently electronically submitted by providers (hospitals, clinicians) to CMS with every eCQM submitted for measurement. It is also necessary information for CMS, and insurer reimbursement.
eCQI resource center, includes measure specifications for CMS program eCQMs- payer information submitted along with all patient-level data for each measure: https://ecqi.healthit.gov/ecqms
Data exchange of insurer information is also critical for clinical care. Providers need to be aware of insurance type in order to recommend the most optimal services for their patients at point of care and thereafter, and facilitate care coordination. This information is also necessary for billing and reimbursement purposes.
Estimated number of stakeholders capturing, accessing using or exchanging
All hospitals/providers should have this administrative information available for billing purposes.
Healthcare Aims
Improving patient experience of care (quality and/or satisfaction)
Improving the health of populations
Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Number of organizations/individuals with which this data element has been electronically exchanged
5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts
Payer information is electronically exchanged from organization’s EHR systems to CMS for reporting and payment quality measurement programs, via QRDA files and other architectures. This insurer type element has been tested for reliability and validity of capture during the development of CMS eCQMs and can be feasibly exchanged. Ongoing testing for exchanging these data for measurement as part of supplemental data in FHIR standards via HL7 Connectathons.
This information has also been electronically exchanged with external organizations via C-CDA. https://ecqi.healthit.gov/qrda http://www.hl7.org/implement/standards/product_brief.cfm?product_id=7 https://confluence.hl7.org/display/FHIR/2020-09+Clinical+Reasoning
Restrictions on Standardization (e.g. proprietary code)
No challenges anticipated. This data is available in standard terminology that can be publicly access via the VSAC and HL7.
Restrictions on Use (e.g. licensing, user fees)
We are not aware of any restrictions.
Privacy and Security Concerns
This data, like any patient data should be exchanged securely. Current processes exist, governed by CMS and ONC, to securely transfer this data element.
Estimate of Overall Burden
Payer data is regularly captured by a broad range of healthcare providers, and should not cause burden to implement. This data is already regularly exchanged and available in standardized fields and terminology, and necessary for all administrative billing purposes.
Given that the health insurance information is used specifically for filing claims or checking eligibility, consistency with the X12 EDI standards on insurance is recommended.
Exchange of data element: The Multiple Chronic Conditions eCare Plan project successfully tested this element at the Sep 2020 and Jan 2021 FHIR connectathons and has implemented it at the OHSU testing site.
Additional Use Cases: MedMorph: https://www.cdc.gov/csels/phio/making-ehr-data-more-available.html
Central Cancer Registry Reporting: https://www.cdc.gov/cancer/npcr/
Health Care Surveys: https://www.cdc.gov/nchs/dhcs/nhcs_registry_landing.htm
PCORnet: https://pcornet.org/
Birth Reporting: https://www.cdc.gov/nchs/nvss/births.htm
Multiple Chronic Conditions eCare Pan: https://confluence.hl7.org/display/PC/Multiple+Chronic+Conditions+%28MCC%29+eCare+Plan
This element is used by CMS Quality Reporting and is marked Required or MustSupport in the FHIR QI Core IG
Submitted by marti.velezis on 2022-05-01
Use of X12 EDI Standards
Given that the health insurance information is used specifically for filing claims or checking eligibility, consistency with the X12 EDI standards on insurance is recommended.