What to Expect with Claims Data

A previous query defined the different nuances encompassed under the term “data quality” to help shed light on the myriad factors that can impact the output from the Colorado All Payer Claims Database (CO APCD). This piece will outline some baseline expectations for users who are new to claims data.

Claims Data is Administrative Data

When the purpose of a health care claim is considered, it becomes clear what kind of data it will contain – it is chiefly designed for provider reimbursement, so all information will be related to the services rendered and the associated payments or costs. Since certain things are not required for billing, like height, weight, blood pressure, or test results, they are not included in a claim. Diagnoses, procedures or treatments, and length of visit are included because insurance companies use the information to process (or adjudicate) claims and determine who should be paid, and for what amount.

Here is a breakdown of what information is submitted to the CO APCD by claim type (medical, professional, pharmacy, or dental).

Claims data in the CO APCD will always be retrospective. By its nature, claims data cannot be released in real time because of the many steps associated with generating and adjudicating a claim:

1. Patient visits provider
2. Provider (or their staff/service) codes and submits the claim
3. Health insurance company processes the claim (note, this process can be lengthy, and not all claims are paid initially and some are denied)
4. If the claim is processed (adjudicated), it is submitted to the CO APCD in a large batch by health insurance companies and public plans such as Medicaid and Medicare
5. CIVHC data managers receive the claims data, and ensures they are submitted correctly, and pass numerous validity/quality checks
6. If the claims data passes CIVHC intake, they make it to the CO APCD data warehouse

The time between the patient visit and the claim’s incorporation into the CO APCD can be as short as three months, or it can take longer based on a delay at any of the steps listed above.

CIVHC maintains a process to regularly update the CO APCD. Payers provide CIVHC with data monthly, and every two months we incorporate that data in a data warehouse refresh and re-process the entire CO APCD to fix or correct irregularities that may have existed with previous submissions. This ensures all data in the CO APCD is consistent and processed using the same rules.

CIVHC regularly posts information about what months have been added to the CO APCD following each refresh on the Data User Resources page on civhc.org.

What Can You Do with Claims Data?

By considering the information included in a claim, it is possible to start to see what type of analyses are possible with an APCD. Some important examples include:

• Since they are predominately for billing/payment, they are a natural source for cost analysis. They reveal not only what providers and facilities charged, but also the actual amounts paid by both insurers and patients. With the type of facilities and services/treatments listed, it is possible to study utilization to understand where people are going for different services (and how cost varies by location)
• Chronic conditions can be explored given the indication of diagnosis.
• Claims data can also illuminate health care use and access as the claim indicates that an encounter took place and includes age and gender, which allows a deeper dive into whether certain populations are receiving care as recommended.
• The types of tests and services are listed with the diagnosis can also shed light on the quality of care provided, and whether the care received aligns with clinical guidelines on specific protocols for certain conditions.

The combination of the data elements in a claim can lead to nearly infinite topics of study and it can become daunting to try to narrow down a project to something manageable. There are also multiple nuances about what is possible with the CO APCD. CIVHC has resources available to help navigate the possibilities of using CO APCD data. The Change Agent Index is a sortable list of projects using CO APCD data to improve lives in Colorado and across the country. Additionally, CIVHC has hosted a webinars discussing use cases of the CO APCD and highlighting how Change Agents have utilized the database to make decisions to improve lives in Colorado and across the country.

If you have questions about a potential project using CO APCD claims data, please contact us at info@civhc.org.