Medicare

Medicare is a health insurance program, administered by the United States government, for people who are aged 65 and over; to those who are under 65 and are permanently physically disabled or who have a congenital physical disability; or to those who meet other special criteria like the End Stage Renal Disease program (ESRD).

Part D Pharmacy Characteristics File

The Part D Pharmacy Characteristics file provides information about the pharmacy identified as the source of the drug for each Part D Event (PDE) prescription fill record.

What does this file include? (variable highlights)

  • Pharmacy type
  • Pharmacy dispenser type code
  • Pharmacy primary taxonomy code
  • DME service
  • Walk-in service
  • Linking variable to the PDE file:
    • CCW Pharmacy ID

Why do researchers request this file?

  • Evaluate medication possession rates by pharmacy type
  • Assess the effect of pharmacy type on clinical outcomes

Special considerations

  • Beginning with the CY 2014 file, it is possible to request an unencrypted pharmacy identifier.
  • Researchers who request and are approved by CMS for unencrypted variables will be able to link to third party data for pharmacy characteristics.

Part D Prescriber Characteristics File

The Medicare Part D Prescriber Characteristics file contains descriptive information for the prescriber identified on a Part D Event file record.

What does this file include? (variable highlights)

  • Primary Taxonomy Code
  • Practice location (state)
  • Academic or Professional Credential for the prescriber
  • Linkage variables to the PDE file:
    • CCW Prescriber Identifier

Why do researchers request this file?

  • Studies describing prescribing patterns based on prescriber specialty
  • Evaluation of clinical outcome based on prescriber characteristics

Special considerations

  • Prior to CY2014 data, the prescriber ID is the encrypted CCW Prescriber ID, which cannot be linked to external, non-CMS Part D data sources.

Part D Drug Characteristics File

The Medicare Part D Drug Characteristics file refers to a set of variables that are appended to the Medicare Part D Event file (PDE). Researchers need to request the specific variables required for their study and CMS must approve the release.

What does this file include? (variable highlights)

  • Product ID (NDC) used to link Drug Characteristics to PDE file
  • Brand name
  • Generic name
  • Strength
  • Form of the drug

Why do researchers request this file?

  • Researchers who do not have access to a proprietary NDC database use this file to identify specific drugs, strengths and formulation
  • Studies assessing pharmaceutical treatment that compare strengths and/or formulations of prescription drugs
  • Studies evaluating drug utilization under the Medicare Part D program

Special considerations

  • Requests for any Part D data file require selection and justification for each requested variable.
  • This file does not include drug class or any other taxonomy variables.
  • The Part D Drug Characteristics file is not released as a freestanding file. Requested variables are appended to the requested PDE file. The structure is a flat file.
  •  
    • Product ID (NDC) used to link Drug Characteristics to PDE file
    • Brand name,
    • Generic name,
    • Strength
    • Form of the drug

Carrier (Fee-for-Service)

The Carrier File includes fee-for-service claims submitted by professional providers, including physicians, physician assistants, clinical social workers, nurse practitioners.

Claims for some organizational providers, such as free-standing facilities are also found in the Carrier Claims File.  Examples include independent clinical laboratories, ambulance providers, free-standing ambulatory surgical centers and free-standing radiology centers.

Researchers rarely use this file alone.

This file is based on information from the CMS claim form 1500.

What does this file include? (variable highlights)

  • Diagnosis (ICD diagnosis)
  • Procedure (CPT code)
  • Dates of service
  • Charges
  • Allowed amounts
  • Reimbursement amount
  • Provider NPI number

Durable Medical Equipment (Fee-for-Service)

The Durable Medical Equipment (DME) file contains fee-for-service claims submitted by Durable Medical Equipment suppliers to the DME Medicare Administrative Contractor (MAC).

What does this file include? (variable highlights)

  • Diagnosis, (ICD diagnosis code)
  • Services provided (CMS Common Procedure Coding System (HCPCS) codes)
  • Dates of service
  • Charge
  • Reimbursement amounts
  • Supplier provider number
  • Supplier NPI

Home Health Agency (Fee-for-Service)

The Medicare Fee-For-Service (FFS) Home Health Agency (HHA) containd FFS claims submitted by Medicare home health agency providers for reimbursement of home health covered services. 

This file is based on information from the CMS form 1450 (UB04).

What does this file include? (variable highlights)

  • Type of visit (eg: skilled care, home health aide, physical therapy)
  • Quantity of services
  • Diagnosis (ICD diagnosis),
  • Dates of service
  • Reimbursement amount
  • Home health agency provider number 

Hospice (Fee-for-Service)

The Hospice file contains claims submitted by Medicare hospice providers. Records are included in the file regardless of whether the beneficiary is enrolled in fee-for-service (FFS) Medicare or Medicare Advantage (Medicare managed care.) 

This file is based on information from the CMS form 1450 (UB04).

What does this file include? (variable highlights)

  • The level of hospice care received (e.g., home health aide, skilled nursing care)
  • Diagnosis (ICD diagnosis codes)
  • The dates of service
  • Submitted charges
  • Reimbursement amounts
  • Hospice provider number

Inpatient (Fee-for-Service)

The Medicare Fee-For-Service Inpatient (IP) Claim File contains fee-for-service (FFS) claims submitted by inpatient hospital providers for reimbursement of facility costs. These claim records represent covered stays (Medicare paid FFS bills).

This file is based on information from the CMS form 1450 (UB04).

What does this file include? (variable highlights)

  • Admission, discharge dates
  • Diagnosis (ICD diagnosis)
  • Procedure (ICD procedure code)
  • FFS reimbursement amount
  • Hospital provider number

Outpatient (Fee-for-Service)

The Outpatient file contains fee-for-service (FFS) claims submitted by institutional outpatient providers. Examples of institutional outpatient providers include hospital outpatient departments, rural health clinics, renal dialysis facilities, outpatient rehabilitation facilities, comprehensive outpatient rehabilitation facilities, Federally Qualified Health Centers and community mental health centers. The file includes facility charge amounts.

This file is based on information from the CMS form 1450 (UB04).

What does this file include? (variable highlights)

  • Diagnosis (ICD diagnosis)
  • Procedure (ICD procedure code)
  • Healthcare Common Procedure Coding System (HCPCS) codes, including CPT codes
  • Dates of service
  • Medicare FFS reimbursement amount
  • Outpatient facility provider number 

Skilled Nursing Facility (Fee-for-Service)

The Medicare Fee-for-Service  Skilled Nursing Facility (SNF) claim file contains information from paid bills submitted by SNF institutional facility providers. Skilled nursing care is the only level of nursing home care that is covered by the Medicare program.

The information on the file records is based on the CMS form 1450 (UB04).

What does this file include? (variable highlights)

  • Diagnosis codes (ICD diagnosis)
  • Procedure codes (ICD procedure)
  • Admission/discharge dates
  • FFS Reimbursement amount
  • SNF provider number