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Frequently Asked Questions related to Claims data to part D Sponsors API
Guidance for Frequently Asked Questions related to Claims data to part D Sponsors API web page
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: January 01, 2020
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Why is CMS making claims data available to PDP sponsors?
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In February 2018, the Bipartisan Budget Act of 2018 (BBA) was signed into law and included a provision
requiring the development of a process to share Medicare fee-for-services claims data with PDP sponsors.
Section 50354 of the BBA specifically provides that the Secretary of Health and Human Services shall
establish a process under which PDP sponsors may request, beginning in plan year 2020, that the
Secretary provide on a periodic basis and in an electronic format standardized extracts of Medicare claims
data about its plan enrollees. Such extracts would contain a subset of Medicare Parts A and B claims data
as determined by the Secretary and would be as current as practicable.
What is the Final Rule?
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In response to the Bipartisan Budget Act of 2018 (BBA) , CMS published a
Final Rule to implement section
50354 of the BBA, which outlines the manner in which CMS proposes to implement this requirement.
Who is eligible to request Medicare Claims data under this process?
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Stand-alone Medicare Part D Plan (PDP) sponsors.
How do standalone Medicare Part D Plan (PDP) sponsors access the Medicare Parts A and B claims data as
mandated by the BBA and Final Rule?
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PDP sponsors will be able to access the Medicare Parts A and B claims data by leveraging the AB2D
Application Programming Interface (API).
I'm a Standalone Medicare Part D Plan (PDP) sponsor. How does my organization receive Medicare Parts
A and B claims information using the AB2D API?
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A standalone Medicare Part D Plan (PDP) sponsor must first complete the attestation process for each of
their participating Part D contracts. After attesting, the AB2D team will work directly with the “AB2D Data
Operations Specialist” and the Attestor to ensure that the (PDP) is able to retrieve Medicare Parts A and B
claims data. Learn more about accessing AB2D claims data.
What is Claims Data Attestation?
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Attestation is a process to ensure PDP sponsors are aware of how the Medicare claims data provided by
AB2D may and may not be used, including limitations associated with reuse and redisclosure of data.
Attestation performed through the Health Plan Management System (HPMS) Claims Data Attestation
module affirms adherence to these permitted uses and limitations of this claims data as listed in
§ 423.153 of the Final Rule . To attest, visit
HPMS
Who within my organization can Attest?
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Attestation must be performed by a Medicare Part D Plan (PDP) Sponsor CEO, CFO, or COO. The Attestor
must hold an active CEO, CFO, or COO role within their organization. Part D Plan (PDP) sponsors are
allowed to have multiple executives attest to each participating contract.
What happens if an Attestor leaves my company?
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Participating Part D Plan (PDP) sponsors must have an active Attestor at all times and will not receive data
during periods where the (PDP) sponsor does not have an active Attestor.
If your organization has a single Attestor and they leave without a replacement, then your organization
will lose access to new data until another active CEO, CFO, or COO attests. Re-attestation will restore
access to new claims data and provide historical claims data that was not accessible during the lapse in
active attestation.
Having multiple Attestors reduces the risk of data gaps due to workplace attrition and is strongly
encouraged.
What is the permitted use of the data?
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Section § 423.153(c) of the Final Rule specifies that PDP sponsors receiving Medicare claims data for their
corresponding PDP plan enrollees may use the data for:
(i) Optimizing therapeutic outcomes through improved medication use;
(ii) improving care coordination so as to prevent adverse healthcare outcomes;
(iii) for any other purpose described in the first or second paragraph of “health care operations” under 45
CFR 164.501, or that qualify as “fraud and abuse detection or compliance activities” under 45 CFR
164.506(c)(4).
What use of the data is not permitted?
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Section § 423.153(c) of the Final Rule
specifies that PDP sponsors receiving Medicare Parts A and B claims
data for their PDP plan enrollees may not use the data for the following purposes:
(i) To inform coverage determinations under Part D;
(ii) To conduct retroactive reviews of medically accepted indications determinations;
(iii) To facilitate enrollment changes to a different prescription drug plan or an MA-PD plan offered by the
same parent organization; or
(iv) To inform marketing of benefits.
When can PDP sponsors begin requesting data?
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The Health Plan Management System (HPMS) Claims Data Attestation module can be used by PDP
Sponsors to submit a request for Medicare claims data (by contract) beginning January 1, 2020.
What is the format of the data extract?
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The AB2D API leverages the Bulk FHIR Specification
which uses the file format: NDJSON, New Line Delimited JSON . An NDJSON file provides a single record on each line, which makes it
easy for various tools to look at and process one record at a time before moving on to the next one.
What are the data elements that will be accessible through the API?
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Medicare Parts A and B claims data elements (fields) in the standardized extract as specified in the rule:
An enrollee identifier
Diagnosis and procedure codes (for example, ICD-10 diagnosis and Healthcare Common
Procedure Coding System (HCPCS) codes)
Dates of service
Place of service
Provider numbers (for example, NPI)
Claim processing and linking identifiers/codes (for example, claim ID, and claim type code)
Can a PDP sponsor request historical data?
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Section 1860D-4(c)(6)(D) of the Act provides that the Secretary shall make standardized extracts available
to PDP sponsors with data that is the most current as practicable. While we understand that historical
data may assist PDP sponsors, we must adhere to the statutory language. As this program matures, PDP
sponsors will amass historical data.
How can we get more data elements in addition to what’s listed in the Final Rule?
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CMS will continue to evaluate the data elements provided to PDP sponsors to determine if data elements
should be added or removed based on the information needed to carry out the permitted uses of the
data. Any proposed changes would be established through rulemaking.
What are the data sources and how often is the data updated?
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The AB2D API will leverage the Beneficiary FHIR Data (BFD) server, which receives data from the Chronic
Condition Warehouse (CCW). The majority of the BFD data is refreshed weekly with a few data elements
being loaded monthly.
HHS is committed to making its websites and documents accessible to the widest possible audience,
including individuals with disabilities. We are in the process of retroactively making some documents accessible.
If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.
DISCLAIMER: The contents of this database lack the force and effect of law, except as
authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically
incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted
on the guidance repository, except to establish historical facts.
