Medicare Enrollment Data
The Denominator File contains demographic and enrollment information about each Medicare beneficiary during a calendar year. The information in the Denominator File is 'frozen' in March of the following calendar year. This file includes only information about beneficiaries’ Part A and B entitlement. This file was later incorporated into the Master Beneficiary Summary File.
The Beneficiary Annual Summary File is a beneficiary level file that contains demographic, enrollment, CCW chronic condition flags, and summarized service utilization and payment. This file includes the following segments: (1) A/B; (2) Chronic Conditions (CC); and (3) Cost & Utilization (CU). This file was later incorporated into the Master Beneficiary Summary File (MBSF).
The Master Beneficiary Summary File includes several segments.Base (A/B/C/D) segment includes beneficiary enrollment information, such as the beneficiary unique identifier, state and county codes, zip code, date of birth, date of death, sex, race, age, monthly entitlement and enrollment information (A/B/C/D) and plan information for Medicare Advantage (Part C) and the Prescription Drug Program (Part D).
This MBSF segment includes summarized information about the service utilization and Medicare payment amounts by file type.
This MBSF segment includes 27 chronic condition data warehouse flags called CCW Flags. This includes 6 new chronic conditions in addition to the 21 chronic conditions previously defined.
The Other Chronic or Potentially Disabling Conditions segment of the MBSF flags beneficiary records for the presence of 35 chronic or potentially disabling conditions not included in the original list of 27 conditions.
This segment includes cause of death information from death certificates provided through linkage with the National Death Index (NDI). It includes the date of death, cause of death and underlying conditions for cause of death.
Medicare Facility Claims Utilization Data
The Medicare Provider and Analysis Review (MedPAR) Files contain inpatient hospital and/or skilled nursing facility (SNF) final action stay records for all Medicare beneficiaries. MedPAR files contain the following information: procedures, diagnoses, and DRGs, length of stay, beneficiary and Medicare payment amounts, summarized revenue center charge amounts.
The Inpatient file contains final action fee-for-service claims data submitted by inpatient hospital providers for reimbursement of facility charges. The charge amount can be broken out for specific Revenue Center Codes, such as those for emergency room or emergency department charges. Additionally, this file includes revenue center information. The Revenue Center Codes provide details on charges, such as those for emergency room/emergency department charges. Emergency Room ER and Emergency Department facility costs, charges are available in this file.
The Skilled Nursing Facility (SNF) file contains final action, fee-for-service, claims data submitted by SNF providers. Medicare Institutional provider numbers are not encrypted; however, physician identifiers, e.g. NPIs or UPINs are encrypted. This file includes: diagnosis (ICD-9 diagnosis), and procedure (ICD-9 procedure code), dates of service, reimbursement amount, SNF provider number, and beneficiary demographic information.
The Outpatient Utilization File presents information on common outpatient services provided to Medicare fee-for-service beneficiaries. It presents information on utilization, payment, and estimated hospital-specific charges for select Ambulatory Payment Classification (APC) Groups paid under the Medicare Outpatient Prospective Payment System. Examples of institutional outpatient providers include hospital outpatient departments, rural health clinics, renal dialysis facilities, outpatient rehabilitation facilities, comprehensive outpatient rehabilitation facilities, and community mental health centers.
Medicare Provider Claims Utilization Data
The Carrier file (also known as the Physician/Supplier Part B claims file) contains final action fee-for-service claims submitted on a CMS-1500 claim form. Most of the claims are from non-institutional providers, such as physicians, physician assistants, clinical social workers, nurse practitioners. Claims for other providers, such as free-standing facilities are also found in the Carrier file. Examples include independent clinical laboratories, ambulance providers, and free-standing ambulatory surgical centers. This file includes: diagnosis and procedure (ICD-9 diagnosis, CMS Common Procedure Coding System (HCPCS) codes), dates of service, reimbursement amounts, and beneficiary demographic information.
The Hospice file contains final action claims submitted by Hospice providers. Once a beneficiary elects Hospice, all Hospice related claims will be found in this file, regardless if the beneficiary is in Medicare fee-for-service or in a Medicare managed care plan. This file includes: the level of hospice care received (e.g., routine home care, inpatient respite care), terminal diagnosis (ICD-9 diagnosis), the dates of service, reimbursement amounts, Hospice provider number, and beneficiary demographic information.
The Home Health Agency Utilization file presents information on services provided to Medicare beneficiaries by home health agencies. It contains information on utilization, payment (Medicare payment and standard payment), submitted charges, and demographic and chronic condition indicators organized by CMS Certification Number (6-digit provider identification number), Home Health Resource Group (HHRG), and state of service.
The Durable Medical Equipment (DME) file contains final action, fee-for-service claims submitted by Durable Medical Equipment suppliers.
Medicare Prescription Drug Data
The Part D Denominator File contains demographic and enrollment information about each Medicare beneficiary enrolled in the Part D program during a calendar year. This file is not available after March of 2010. This file was incorporated into the Beneficiary Summary File. This file includes: beneficiary unique identifier, state and county codes, zip code, date of birth, date of death, sex, race/ethnicity, and monthly Part D entitlement indicators.
The PDE data contain prescription drug costs and payment data that enable CMS to make payments to the plans and otherwise administer the Part D benefit. When a beneficiary fills a prescription under Medicare Part D, a prescription drug plan sponsor must submit a record to CMS. The PDE data are not the same as individual drug claim transactions but are extracts using CMS-defined standard fields.
The Plan Characteristics file contains plan information for all Medicare Advantage (Part C) plans and all stand-alone Part D Prescription (PDP) Plans. The data are released in 6 separate files (all of which come standard with the file). Plan identifiers are encrypted in the data, so researchers must use this file to find out more information about the plan.
The Prescriber Characteristics file contains information about the practitioner who prescribed the drug. Prescriber identifiers are encrypted in the Part D data, so researchers must link this file with the Prescriber id in order to obtain more information about the prescriber. Data fields include: prescriber taxonomy (simliar to specialty), practice state, and academic/professional credentials.
The drug characteristics file is a supplemental set of variables that are appended to the Part D Event data. The drug characteristics file contains four variables from the First DataBank® (FDB) reference file. The variables include: brand name, generic name, strength, and form of the drug.
The pharmacy characteristics file provides information about the type of pharmacy (e.g., community/retail pharmacy, mail order, institutional pharmacy), the location of the pharmacy (i.e., state), and whether the pharmacy has a relationship with a common parent organization. Pharmacy identifiers are encrypted in the data, so researchers must use this file to find out more information about the pharmacy.
CMS has developed a Part D formulary file that can be linked to the RIF PDE data that contains formulary details for each plan including National Drug Codes (NDCs), cost share tier level, and indicators for step therapy, quantity limits, and prior authorization. The file contains an encrypted formulary ID that will allow researchers using the RIF Part D data to obtain formulary information. This file will only be useful to researchers who are using the Part D event data. It cannot be used as a standalone file like the Prescription Drug Plan Formulary, Pharmacy Network, and Pricing Information.
Medicare Survey Data
Designed to provide quick access to MCBS data and related findings to users, the MCBS Access to Care are multipurpose, nationally representative of the Medicare population and comprehensive (e.g. include MA and FFS, community and facility, disabled and aged populations).
The MCBS Cost & Use files are a unique data resource, compiling survey and administrative data sources on Medicare covered and non-covered health care costs, utilization, and insurance coverage.
The Medicare Current Beneficiary Survey (MCBS) is a continuous, multipurpose survey of a nationally representative sample of the Medicare population. The survey file includes: Demographics: household characteristics, information on income and assets Health care: access, satisfaction, usual source of care, preventive service Health status: medical conditions, health behaviors Timeline data: health insurance, residence Facility characteristics for non-community dwelling beneficiaries
This file is truly a supplement file and must be merged with the Survey File to complete analysis. Data included in the Cost Supplement File: Health care cost: data on expenditure and payment, source of payment, supplementary insurance costs Health care utilization: services received including those not paid by Medicare, Fee-for-Service claims data. Supports analyses not possible solely with survey or claims data.
The Long Term Care Minimum Data Set (MDS) 3.0 is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents (regardless of payer) of long-term care facilities certified to participate in Medicare or Medicaid.
CMS develops, implements and administers several different patient experience surveys. These surveys ask patients (or in some cases their families) about their experiences with, and ratings of, their health care providers and plans, including hospitals, home health care agencies, doctors, and health and drug plans, among others. The surveys focus on matters that patients themselves say are important to them and for which patients are the best and/or only source of information.
Medicare ACO Data
CMS has created a set of standard analytical files that contain data from the Shared Savings Program (SSP). One of these is the SSP Beneficiary-Level Research Identifiable File (RIF), the second is the SSP Provider-Level RIF. SSP RIFs do not include Pioneer, Next Generation ACO or Comprehensive End Stage Dialysis Care Organizations (ESCO) data. The Provider-Level RIF contains a record for each institutional and individual provider that participated in the Shared Savings Program. Variables include but are not limited to: National Provider Identifier (NPI), Legal Business Name (LBN), CMS Certification Number (CCN) facility type, and provider specialty type.
CMS has created a set of standard analytical files that contain data from the Shared Savings Program (SSP). One of these is the SSP Beneficiary-Level Research Identifiable File (RIF), the second is the SSP Provider-Level RIF. SSP RIFs do not include Pioneer, Next Generation ACO or Comprehensive End Stage Dialysis Care Organizations (ESCO) data. The Bene-level file contains a record for each individual.
The MD-PPAS file assigns Medicare providers to medical practices based on the tax identification numbers and elaborates on the Centers for Medicare & Medicaid Services (CMS) provider specialty classification. This provider-level dataset is built around two identifiers: the national provider identifier (NPI) and the tax identification number (TIN).
CMS has created a set of standard analytical files that contain Pioneer Accountable Care Organizations. Includes: provider-level RIF that contains a record for each individual provider that participated in the Pioneer ACO Model, beneficiary-level RIF that contains a record for each individual beneficiary that was aligned to a Pioneer ACO, pioneer ACO Settlement File.
CMS has created a set of standard analytical files that contain Pioneer Accountable Care Organizations. Includes provider level information.