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All-Payer Claims Database Submission – Common Data Layout and PACDR X12

As we strike out into 2018, the implementation of All-Payer Claims Databases (APCD) across states remains variable and dynamic. Massachusetts maintains a comprehensive implementation, aggregating data feeds from over 80 public and private payers.  Massachusetts has leveraged their APCD to create a state-specific risk adjustment model to meet the ACA provision which balances funds from healthier populations to higher risk pools. Late in 2016, Minnesota concluded a feasibility study which determined their APCD could significantly improve risk adjustment vs. the federal model.

On the other hand, West Virginia and Tennessee have put APCD development on hold. California payers optionally submit claims and encounters to a public benefit corporation. Legal, fiscal and political concerns guarantee a fluid situation for insurers.

This blog post is focused on the technical obstacles that health plans face in states requiring APCD submission. Since these databases have phased in over the last decade through both voluntary and legislated mechanisms, the features and requirements of APCDs are distinct. Early in the movement to begin aggregating payer data, industry stakeholders recognized the need for standards in the data submission formats.

Most APCD submission guides define these categories:

  • Medical Claims (Institutional and Professional)
  • Pharmacy Claims
  • Dental Claims
  • Member Eligibility
  • Provider File (Physician and Facility)

For most states, these categories are implemented as delimited text files of up to 200 columns. These formats arose from the APCD Council’s harmonization effort to define a Common Data Layout (CDL). The data in the CDL files are scored for importance based on state requirements, which allow for the development of validation and acceptance/rejection criteria.

Most APCD data points originate from the HIPAA X12 transactions received from providers. Therefore, health plans submitting adjudication data to their state APCD will operate most successfully with a platform that combines EDI management with a rules framework and database persistence. T-Connect simplifies the translation and mapping of 837 files to CDL transmissions, promoting rapid development and customization.

In parallel to the definition of the delimited CDL files, ASC X12 approved guidelines in 2012 for reporting post-adjudicated claim data to state APCDs. These transactions, referred to as Post Adjudicated Claims Data Reporting (PACDR), track closely to 837 formats but contain enough variances to render 837 translation engines incompatible. T-Connect contains PACDR-specific translation capabilities to parse and store the following transactions in a database:

  • 005010X298 – 837 Post-Adjudicated Claims Data Reporting: Professional
  • 005010X299 – 837 Post-Adjudicated Claims Data Reporting: Institutional
  • 005010X300 – 837 Post-Adjudicated Claims Data Reporting: Dental

New York is in the final stages of rolling out their APCD, which requires claim submission in the PACDR format. It remains to be seen how broadly the post-adjudicated X12 transactions will be adopted vs. the CDL ASCII format. The following chart contrasts strengths and weaknesses of the two:

PACDR Comparison

CDL vs. PACDR

Ultimately, payers and TPAs must adhere to the format defined by their state. Tallan assists health plans in developing efficient frameworks for submitting APCD information with T-Connect. Contact us today to begin a conversation about our experience in streamlining encounter and eligibility reporting with the CDL and PACDR formats.

 

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