Purchased Care Data (TED-I & TED-NI) - PowerPoint Presentation

1. Purchased Care Data (TED-I & TED-NI)Veronika PavKennell & Associates, Inc.

2. ObjectivesUnderstand the relationship between DHA, the Managed Care Support Contractors, Civilian Health Care Providers, and BeneficiariesDescribe the characteristics of the Institutional, Non-Institutional, and Provider purchased care data tablesApply appropriate filters to separate out inpatient professional, outpatient professional, pharmacy, Prime and TRICARE For Life2

3. Purchased Care SynonymsPurchased Care is referred to in a variety of ways:Claims DataDowntownPrivate Sector or PSCNetwork Managed Care LeakageTED Data (TED-NI, TED-I, TED-PR)3

4. Common Terms4National Provider ID Tmt DMIS IDHIPAA Taxonomy Code MEPRS CodeICD Dx Code ICD Px CodeCPT/HCPCS Code CCS Category MDC MS-DRG APC Service DatesBasic Workload Weighted WorkloadPerson IDs DemographicsBencat & Bencat Common HCDPs, Enrollment GroupPCM ID Enrollment SiteEnrollment MEPRS Code Eligibility GroupDeployment Information Raw vs Total Geography Record ID

5. MCSCs are required to establish networks of providers who have agreed to take TRICARE patients and who are paid under negotiated agreements5Purchased Care ContractsManaged Care Support Contractors (MCSC)

6. RegionContractor NameContractor Number (T17)EastHumana 12WestHealth Net136Purchased Care ContractsManaged Care Support Contractors (MCSC)

7. RegionContractor NameContractor Number (Tnex/T3)WestTriWest/United 62/08SouthHumana63/05NorthHealth Net64/047Purchased Care ContractsManaged Care Support Contractors (MCSC)

8. Other Purchased Care ContractorsAcronymContract NameContractor NumberTOPTRICARE Overseas Program15/10TPharmTRICARE Pharmacy70/73TDEFICTRICARE Dual Eligible Fiscal Intermediary Contract71/748

9. Claims Payment ProcessClaimHealth Care EventMCSCDEERS Eligibility CheckPaymentDHATED databaseTED-ITED-NITED-PR9

10. Two Different Claim Types & One Provider Record10Institutional (TED-I)Contains claims submitted by institutionsInpatient Care and Inst-based Home Health(Does not contain ER or Hosp Outpat Dept)Non-institutional (TED-NI)Contains all other claimsSometimes called “Professional” claimsProfessional Care, Supplies, Services, Outpatient Facilities, PrescriptionsPurchased Care ProvidersRecords of providers authorized to bill TRICARE

11. MERHCF FlagMERHCF is “Medicare Eligible Retiree Health Care Fund” Medicare Eligible Flag is ‘T’ or ‘U’TRICARE is second payer, except for care that Medicare does not coverNo requirement for matching Provider record11‘T’ is Medicare Elig ≥ 65, ‘U’ is Medicare Elig < 65

12. MERHCF FlagDHP is “Defense Health Program”Flag is ‘N’ or ‘A’TRICARE is usually first payerT-U-N-ADHP and MERHCF represent funding, they are NOT identifications of programs12‘A’ is Active Duty and Active Duty Family Members, ‘N’ is all other <65 care

13. Institutional & Non-Institutionalat Record LevelFor Institutional Data, one record for range of dates at one institution for one beneficiary on one bill. Use Record ID for “atomic” level dataFor Non-Institutional Data, each record represents one procedure code for one date or a range of datesMultiple procedure codes may be present on one Non-Institutional claim as line itemsTherefore, Line Item No. must be used in conjunction with the Record ID to capture all records. Use Record ID and line item no. for “atomic” level data There is a concatenated field called “Record ID/Line Item No” (TEDNO + LINUM) that does this for you in TED-NI.13

14. Record IDsFor TEDI:For non-acute care: Ted Number (TEDNO)For acute care: Admitting TEDNO (ADMTEDNO) **For TED-NI:“Record ID +Line Item No” (TEDNO || LINUM)14

15. Non-InstitutionalUse Line Item Number15Adding Line Item No to this query shows that there are 4 records for this one Non-Institutional claimNote: use Raw values instead of Total values for individual claims and line items

16. Geography Related Data Elements on TEDsBased on where beneficiary lives:Beneficiary Zip CodeCatchment Area: 40 mile inpat MTF onlyMTF Service Area: 40 mile, inpat + amb MTFPRISM Area: 20 mile, inpat + amb MTFPrime Service Area: Y/N flag indicating whether in Prime Service Area or notTPR Flag: Y/N flag indicating whether in TRICARE Prime Remote Area or notMarket Area ID: Prime Service Area sub-classifications as defined in MCSC contractsBeneficiary Region and Beneficiary HSSC Region16

17. Geography Related Data Elements on TEDsBased on where care is provided:Provider ZipProvider State/Country CodeProvider Catchment Area: 40 mile inpat onlyProvider Market Area ID: Prime Service Area sub-classifications as defined in MCS contractsProvider PRISM Area: 20 mile, inpat + ambProvider Catchment Area MSMA: Multi-Service Market Area (MSM) and Enhanced Multi-Service Market Areas (eMSM)Provider Catchment HSSC Region (Tnex Region)17Note: Important for Demand/Supply Questions

18. DEERS Data in TEDsWhen a claim is processed by the MCSC there is a query sent to DEERS to determine the status of the beneficiary. The resulting DEERS fields are added to the TED recordWhen the claim is added to MDR, and then M2, several weeks later, it is matched to the most current DEERS extract file for that date of careThe timing difference can lead to differences between what is reported on the TED and DEERS fields added at the time of MDR processing 18

19. Enrollment Related DataFrom MCSC Eligibility CheckFrom MDR/M2 Merge with DEERS ExtractBen Cat Common of RecordBen Cat CommonEnrollment Site of RecordEnrollment SiteEnrollment StatusACV, ACV Group19

20. Enrollment Status – TEDI and TEDNI FY 2017 - Number of Records Enrollment StatusDescriptionInstNon-InstFSTRICARE for Life475,94982,417,782PSTRICARE Senior Pharmacy 43,602,336V Extra108,19042,469,756U Prime, Civilian PCM115,73632,419,213Z Prime, Military PCM87,63925,749,530T Standard47,51312,704,725 All Others20,5006,615,588SRSupplemental25,3196,146,18520

21. Relative Weighted Data in TEDsRVU: Relative Value UnitMeasures relative complexity or resources used for a procedure or serviceTED-NI APC Weights: Ambulatory Payment ClassificationRepresents the relative resource intensity from a facility perspective of the reported procedure. Only applicable to procedures and facility that are paid by APC.TED-NIMS-DRG RWP: Relative Weighted ProductMeasures relative complexity and resources used for inpatient facilitiesBased on MS-DRG codesTED-IAcute Care Only21

22. Completeness of DataCompletion estimates are made for almost all measures“,Raw” means what has been reported to date; the actual data for a record“,Total” means what we expect to report when all records have been processed; represents records that haven’t been processed – recalculated every month22

23. TED-I Completion Factor by Month as of 10/25/201723

24. Provider Information on Inst and Non-Inst RecordsNPI: National Provider Identifiera unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).Provider Specialty, HIPAA 10-byte specialty codeIf there is no NPI, then use the Purchased Care Provider Table24

25. Non-Institutional Data25

26. Non-Institutional DataEach record is a billed procedure code (line item)Includes:Professional Services (provider bills), both inpatient and outpatientPharmacyDurable Medical EquipmentServices (like ambulance)ER and other ambulatory, or outpatient, facility billsLaboratory and Radiology (outpatient)26

27. Non-Institutional DataPharmacy ClaimsPharmacy claims are in two locations in M2:Purchased Care Non-InstitutionalPDTS27Usually better to use PDTS for analyses of prescription usageNote: foreign Rx in TED-NI only

28. Non-Institutional DataPharmacy ClaimsTo exclude pharmacy claims from non-institutional analyses use Program Ind Code (PIC) Not Equal to ‘D’28

29. Non-Institutional DataService Type CodeFor inpatient professional care, select Service Type Code I (contains some outpatient with global codes pre-op and post-op)Can also use PLACE OF SERVICE (PLACE) = 2129

30. Non-Institutional DataPlace of Service CodeWhere care was renderedPlace of Service (PLACE)Examples:Urgent Care = 20 (does not include all UC)Inpatient Hospital = 21Outpat Hosp = 22 (and 19 starting 1/1/2016)Emergency Room = 23Office = 11MTF = 26Pharmacy = 0130

31. Non-Institutional DataPlace of Service Code FY 2016CodePlace of ServiceRecords% Total11Office86,547,02334%01Pharmacy79,024,57231%22Hospital Outpatient Department35,085,79114%12Home12,296,2655%23Emergency Room12,247,6805%21Inpatient Hospital10,751,3854%81Outpatient Lab9,680,9064% All Others8,692,8243%31As of 10/25/2017

32. Non-Institutional DataService NatureService NatureIndicates the clinical nature of care reported on the claime.g. medical care (1), radiology (4), lab (5), and mental health (H)Used to distinguish between TRICARE Mail Order Pharmacy (M) and Retail Pharmacy (B) 32

33. Non-Institutional DataVisits33 VisitsEvaluative VisitsDefinitionMixed definition - Evaluative, care management and assessments Treatment services Examples:Physical therapy ImmunizationsAllergen therapy  Evaluative, care management and assessments only.  Limited to encounters involving history, exam or decision making which is not included in a separately coded procedure.  TerminologyVisitEvaluative Visit More appropriately reflects the type of care captured and minimizes misuse or confusion.FY2014 Count of Visits104,889,55246,129,655#HCPCS/CPT Included in AlgorithmApproximately 900 – static list.Approximately 300 – updated each year to accommodate code additions and deletions.

34. Non-Institutional DataBuilding EpisodesNo good way to discern ‘encounters’.Depending on the type of care, can apply logic:Per person per provider per day(e.g. office visits – dermatologist, PCM, etc.)Per person per day (e.g. Same day surgeries) 34

35. Non-Institutional DataLinked Referral and ClaimsReferral File Added Network Referral Indicator: 0/1 flag. 1 means that the referral was used in a claims adjudication process (US only). 0 means it was not.0s could be MTF referrals, unused network referrals or unnecessary referrals.Derived by matching to a claims adjudication file from the MCSCs. This information is not available in CHCS alone.Jan 15+35MHS-wide Referrals for FY2016FM 1 – FM 10

36. Non-Institutional DataLinked Referral and ClaimsReferral objectsMTF-MCSC Referral FlagReferring MTF and HierarchyUINReferral Begin Date Referral End Date Referral FY/FM36Referring Provider ID/EDIPN/NPIReferring MTF MEPRS CodeMTF Referral Access to Care CategoryInitial MTF Referred Visit Flag

37. Non-Institutional DataLinked Referral and ClaimsNote the matching UINs.This referral generated 5 office visit anesthesiologist encounters, for $547. Referred from Family Practice Medical Home.MEPRS Code FCC = CHAMPUS Beneficiary Support (caution, not always used with network referrals)Access to Care Category = Specialty.Access Standard (<28 days) was met.37Note: United (MCSC) only links the earliest line item associated with a referral with the UIN. Using rules coordinated with the Referral Management Workgroup, the MDR linking logic incorporates additional line items.

38. Non-Institutional DataKey FieldsDemographic Patient InformationPatient Enrollment Information (PCM, Enrollment Site, etc.)MDC1 Procedure (CPT) + 2 Modifiers + Units of Service (SVCS)5 DiagnosesFacility Claims/ChargesProvider Specialty = 99Provider Information (NPI, Specialty, location) 38

39. Institutional Data39

40. Institutional ClaimsIncludes institutional bills forInpatient CareAcute Care: HospitalsNon-Acute: SNF, RTC, Rehab, HospiceHome Health CareOutpatient HospiceSome records represent parts of a stayCalled Interim BillsAllows providers to get paid for care, prior to patient dischargeCan adjust initial TED or be separate TED record (sequential dates and same Person ID)Admitting TED Number available in M2/MDR, for Acute Care only40

41. Additional Records for a ClaimRecord IDPerson IDAdmission DateBegin Date Of CareEnd Date Of CareDischarge Status111111111AAA10/31/201610/31/201611/30/201630222222222AAA10/31/201612/1/201612/31/201630333333333AAA10/31/20171/1/20171/31/20173041Institutional Claims in sequence for same patient for same hospital stayPayments occur over many monthNew record created each monthDischarge status = 30, Still a PatientAdmitting TED Number will be the same but TED Number (TEDNO) will be different

42. Institutional ClaimsAcute Care Hospital IndicatorIndicates whether care is delivered in an acute care facility1 = Acute Care, 0 = Not Acute CareAll Direct Care MTFs are Acute CareNon Acute Care cannot be done by the MTFNot ‘recapturable’ 42

43. Admitting TED Number (ADMTEDNO)Used to group Inst and Non-Inst records into episodes of careOnly available for acute care claims Added to both Inst and Non-Inst records during MDR/M2 processingCollects all records associated with an acute care institutional stay43

44. Example of Inpatient EpisodeData ElementValuePerson ID------849MS-DRG (Description)C / Section w no complicationsAdmission Date2/27/2016Begin Date2/27/2016End Date3/1/2016Record ID2016072CA 96736 1905065Admitting TED Number2016072CA 96736 1905065Amount Paid4,546.96Bed Days344From TED-I. Note admitting TED Number

45. Example of Inpatient EpisodeData ElementClaim 1Claim 2Claim 3Person ID------849------849------849Begin Date Of Care2/28/20162/28/20162/28/2016End Date Of Care2/28/20162/28/20162/28/2016Place Of Service21 - Inpatient21 - Inpatient21 - InpatientProvider Specialty Code05Anesthesiology16Obstetrics22PathologyAmount Paid, Raw$255.36 $1,123.20 $38.37 Overall RVU, Raw021.271.01Procedure Code01961595148830545Use Admitting TED Number to get matching records from TED-N

46. Institutional ClaimsInstitution Type for FY 2015 AcuteCareInst TypeDescriptionFY 2015% Total110General medical and surgical586,66567%076Skilled Nursing Facility126,66914%191Sole community/Critical Access53,4906%022Psychiatric hospital42,4335%070Home Health Care Agency or unit20,5402%All Others51,1916%46

47. Institutional ClaimsDischarge StatusIndicates how patient left the institutionValues for routine discharge, death, transfer, etcValue of “still a patient” (30) indicates more bills are to follow to cover remainder of stay10.0% of records overall0.15% for acute care*Remove “still a patient” when doing average LOS, average cost, case mix47* Many of these are low birth weight newborns

48. Institutional ClaimsKey FieldsPatient Demographic InformationPatient Enrollment InformationReferral Information (if the stay was a result of a referral from the MTF)MDCMS-DRG12 Diagnoses6 ProceduresAdmission Source / Discharge StatusICU flagIndicates if patient stayed in an ICU for at least some of the stayOR FlagIndicates if patient used the operating room during the stay48

49. Institutional ClaimsMeasuresNumber of Claims Set to 1 for all recordsNumber of AdmissionsAdmission credit only given to admitting record, in case of interim claimsBed Days / Authorized DaysNumber of days in hospital / Number of days for which TRICARE will payNote that Home Health Agencies (Inst Type 70) are reporting bed days, so take care to remove themRelative Weighted Product (MS-DRG RWP)Only for acute care hospitals49

50. 50Purchased Care Providers Table

51. Purchased Care Providers TableContains a record for anyone who may bill TRICAREException: Provider record not required for TDEFIC claimsThis is where you would find a provider’s name, city and state51

52. Purchased Care Providers Table52

53. Purchased Care Provider TableProvider Identifier KeyProvider Tax IDMultiple Provider IDProvider ZipFive digit ZIP codeProvider Specialty/Institution Type(same fields as on Provider table)Use concatenated field:“Prov Tax ID/ZIP/Multi ID/Specialty”53Note: One provider may have several records

54. Purchased Care Provider TableProvider Identifier KeyProv NameProv CityProv StateProv Tax IDMulti Prov ID Prov ZipHUBER,JAMES,DCONYERSGAAAAAAAAAAA00630012HUBER,JAMES,DCONYERSGAAAAAAAAAAA00730207HUBER,JAMES,DCONYERSGAAAAAAAAAAB01230012HUBER,JAMES,DLITHONIAGABBBBBBBBB00003005854

55. Institution Type / Provider SpecialtyInstitution TypeType of institution (e.g. 91 = Sole Community/Critical Access)Blank for non-institutional providersProvider SpecialtyTwo character provider major specialty group (e.g. 26 = Psychiatry)Blank for institutional providersProvider records are de-duped on Institution Type/Provider Specialty55

56. Other Provider FieldsProvider NameProvider CityProvider State or CountryTwo character state code, or Three character country code if foreign56

57. Purchased CareSummaryPurchased Care uses Managed Care Support Contractors (MCSC) to create networks of civilian providers and to process claimsMCSC send TED records to TRICARE: Institutional (buildings), Non-Institutional (professionals, services, supplies, facilities, drugs), Provider (name and city)Institutional records are either acute care or non-acute, usually categorized by MS-DRGNon-Institutional records are based on the Procedure Code (CPT/HCPCS), they are individual line itemsNon-Institutional inpatient professional (Service Type Code I) is care provided to a patient admitted to an institution57

58. Questions? 58vpav@kennellinc.com