|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.|
|Estimate the breadth of applicability of the use case(s) for this data element||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
|Link to use case project page||https://ecqi.healthit.gov/ecqms|
|Use Case Description||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.|
|Estimate the breadth of applicability of the use case(s) for this data element||All hospitals/providers should have this administrative information available for billing purposes.|
|Maturity of Use and Technical Specifications for Data Element|
|Applicable Standard(s)||SOP (example, value set OID: 2.16.840.1.114220.127.116.1191)
|Additional Specifications||HL7 QI-Core Implementation Guide: STU 4 (v4.0.0 for FHIR 4.0.1), Coverage http://hl7.org/fhir/us/qicore/profiles.html
CMS Quality Data Model (QDM) version 5.5 Guidance (https://ecqi.healthit.gov/sites/default/files/QDM-v5.5-Guidance-Update-May-2020-508.pdf)
HL7 C-CDA Release 2.0 (http://www.hl7.org/implement/standards/product_brief.cfm?product_id=492)
|Current Use||This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders|
Insurance type is routinely captured in EHR systems used by hospitals and providers. These EHR data is submitted by providers to CMS from hospitals, providers, health IT vendors for eCQM public reporting in CMS IQR, QPP, and Promoting Interoperability programs. CMS requires the submission of patient and encounter based data -for quality measurement for eligible hospitals/CAHs and clinicians using ONC Certified Health Electronic Record Technology (CEHRT).
Available in EHR systems:
|Extent of exchange||5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.|
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.
|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.|
|Other Implementation Challenges||N/A|
Data related to an individual’s insurance coverage for health care.
Category of health care payers. (e.g., Medicare, TRICARE, Commercial Managed Care - PPO)