Description (*Please confirm or update this field for the new USCDI version*)
Category of healthcare payers, insurance products, or benefits.
Examples include but are not limited to Medicaid, commercial, HMO, Medicare Part D, and dental.
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
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.
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
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.
NCQA again recommends that ONC adjust the current coverage type element and adopt a hierarchical structure for coverage type to allow for complete information related to the type of coverage a person has, and allow for utility of the data. The structure should include:
Because there are not multiple data elements in which to store this information, one individual could fall into several categories in Coverage Type. For example, an organization might classify members as enrolled in an HMO, but under the current element, stakeholders would be unable to distinguish if the HMO is a commercial product.
In NCQA’s HEDIS reporting structure, we mitigate this challenge by asking organizations to submit multiple records to indicate if a member is in multiple Coverage Type categories. For example, one member enrolled in a commercial HMO with a drug benefit has three sets of records: one indicating commercial enrollment dates, one indicating HMO enrollment dates, one indicating drug benefit enrollment dates. It would be more efficient to have one set of records indicating that the member is in Product line: Commercial; Product: HMO; Benefit: Drug. We encourage ONC to consider how to make this data element more granular.
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.
Submitted by NCQA on
NCQA Comment on Coverage Type: for USCDI v5
NCQA again recommends that ONC adjust the current coverage type element and adopt a hierarchical structure for coverage type to allow for complete information related to the type of coverage a person has, and allow for utility of the data. The structure should include:
Product Line: Commercial, Medicare, Medicaid, Exchange
Product: HMO, POS, PPO, EPO
Benefit: Drug benefit, Mental health benefit
Because there are not multiple data elements in which to store this information, one individual could fall into several categories in Coverage Type. For example, an organization might classify members as enrolled in an HMO, but under the current element, stakeholders would be unable to distinguish if the HMO is a commercial product.
In NCQA’s HEDIS reporting structure, we mitigate this challenge by asking organizations to submit multiple records to indicate if a member is in multiple Coverage Type categories. For example, one member enrolled in a commercial HMO with a drug benefit has three sets of records: one indicating commercial enrollment dates, one indicating HMO enrollment dates, one indicating drug benefit enrollment dates. It would be more efficient to have one set of records indicating that the member is in Product line: Commercial; Product: HMO; Benefit: Drug. We encourage ONC to consider how to make this data element more granular.