healthcare edi software Caliber Health

APCD Claims Database Submission Guidelines

APCD implementation by state remains variable and dynamic. Massachusetts maintains a comprehensive All-Payer Claims Databases (APCD) 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 ACPD 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 via their EDI Gateway to a public benefit corporation. Legal, fiscal and political concerns guarantee a fluid situation for insurers.

These databases contain claims data and eligibility information used for cost analysis, gathering quality information, and benefits usage. Most of the data is service-level information such as charges, payments, and the provider information, along with patient treatment information. Patient identifiers are hidden or encrypted for privacy.

Technical Obstacles Health Plans Face

Today we’ll focus on the technical obstacles in states requiring APCD submission  hat health plans face. 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 EDI healthcare data reporting 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)

APCD Data Submission Guidelines

For most states, these categories are implemented as delimited text files of up to 200 columns according to APCD data submission guidelines . 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 such as the EDI 834 . Therefore, health plans submitting adjudication data to their state APCD will operate most successfully with an  EDI Gateway  that combines a rules framework and EDI database persistence. T-Connect simplifies the translation and mapping of EDI 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 X12 transactions in a EDI Database Solution:

  • 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

Caliber Health is an EDI company that assists health plans in developing efficient EDI Software for submitting APCD information. Begin a conversation with our EDI integration experts to streamline encounters and set up 270/271 real time eligibility services.

Leave a Reply

Your email address will not be published. Required fields are marked *