Data related to an individual’s insurance coverage for health care.

Data Element
Coverage Type
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
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.
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
Applicable Standard(s) SOP (example, value set OID: 2.16.840.1.114222.4.11.3591)
https://vsac.nlm.nih.gov/valueset/expansions?pr=ecqm
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
Supporting Artifacts 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:
https://fhir.cerner.com/millennium/r4/financial/coverage/
https://mydata.athenahealth.com/fhirapidoc
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs
https://ecqi.healthit.gov/ecqms

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Programs
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.
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


https://ecqi.healthit.gov/qrda
Potential Challenges
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

Comment

Submitted by NCQA on

NCQA Comment on Coverage Type: for USCDI v5

  1. Coverage Type:

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.

Submitted by marti.velezis on

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. 

Submitted by nedragarrett_CDC on

Unified Comment from CDC

  • 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.
     
  • Applicable Standard:  http://hl7.org/fhir/R4/valueset-coverage-type.html
     
  • 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

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