Download Pharmetrics Plus Data Dictionary Jan 2013

IMS HEALTH PharMetrics Plus Data Dictionary IMS LifeLink © IMS HEALTH INCORPORATED OR ITS AFFILIATES. ALL RIGHTS RESERVED. CONFIDENTIAL AND PROPRIETARY
Table of Contents
Section I: PharMetrics Plus Overview
This section provides general information about PharMetrics Plus, its source, and
information about many of the highlights and attributes of claims data.
Section II: File Details and Inventory
This section contains a complete listing of all file fields and a brief description of
their contents.
A standard extract from Pharmetrics Plus consists of the following files:

Claims detail (Claims)
Patient level file of claim specific elements are from the detail record lines for all
claims submitted to the health plan for payment, whether on a HCFA-1500,
UB04, via a pharmacy claims system or PBM, or any other source. The file is
sorted by patient id and date.

Enrollment (Enroll)
Patient level file of key demographics and eligibility information for patients in a
dataset. The file consists of one record per member.

Extended Enrollment (Enroll2)
Patient level file of Benefit level indicators in a month to month format such as
product and payer type; there are up to eight string formatted records per
enrollee.
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Section III: Appendices to Pharmetrics Plus Files
This section contains tables of names, codes and/or descriptions of standard or
custom variables in the data.
There are eight tables in this section:

Admit Source Codes

Admit Type Codes

Dispensed as Written Codes

Enrollee Relationship Codes

Place of Service Codes

Plan Payer Types

Plan Product Types

Provider Specialty
Section IV: Clinical Code Reference Files

NDC Reference – Reference information for all the NDC codes found in the
extract.

Diagnosis Reference – Reference information for all the ICD-9-CM diagnosis
codes found in the extract.

Procedure Code Reference – Reference information for all the CPT-4, HCPCS
and ICD-9 procedure codes found in the extract.
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Section 1: PharMetrics Plus Overview
IMS’ collaboration with Health Intelligence Company, which operates as Blue Health
Intelligence, allows IMS’ bio-pharmaceutical clients sole access to one of the largest US
health plan claims databases. The PharMetrics Plus claims database is comprised of
adjudicated claims for more than 150 million unique patients across the United States,
with approximately 40 million active in the most recent calendar year, 2011 with both
pharmacy and medical coverage. Data are available from 2006 onwards; with a typical
3-4 month service date lag due to claims adjudication.
PharMetrics Plus data has diverse representation of geography, employers, payers,
providers and therapy areas. Patients in each 3-digit zip code and every Metropolitan
Statistical Area of the US are included, with coverage of data from 90% of US hospitals,
80% of all US doctors, and representation from 85% of the Fortune 100 companies.
In addition to standard fields such as inpatient and outpatient diagnoses and
procedures, retail and mail order prescription records, PharMetrics Plus has detailed
information on the pharmacy and medical benefit (copay/coinsurance amount,
deductible), the inpatient stay (admission type and source, discharge status) and
provider details (specialty, zip code, attending, referring, rendering, prescribing,
primary care provider). All 3-digit zip codes in the US are covered and reported allowing
more granular patient segmentation and comparisons by geography.
Amounts allowed and paid by health plans are available for services rendered, as well
as dates of service for all claims. Other data elements include demographic variables
(age, gender, and geographic region), product type (e.g., HMO, PPO), payer type (e.g.,
commercial, Medicare-Risk), and start and stop dates of health-plan enrollment.
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Due to the broad reach of the data, records in the PharMetrics Plus database are
representative of the national, commercially insured population in terms of age and
gender. The data are also longitudinal, with approximately 20 million patients who have
both medical and pharmacy coverage with 3 or more years of continuous enrollment.
Data contributions are subjected to a series of quality checks to ensure a standardized
format and to minimize error rates. All data are HIPAA compliant to protect patient
privacy.
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Section 2: File Details and Inventory
PharMetrics Plus CLAIMS File Inventory
Data Variable
Description
Data
Variable
Field
Name
Data Variable Definition
adm_sc
The source of admission identifies the place where
the patient was identified as needing admission to
a facility. Please refer to Appendices Section.
Restrictions apply.
*
Admit Type Code
adm_tc
Priority of the inpatient admission. Information
located on For example, an admission type of
elective indicates that the patient's condition
permitted time for medical services to be
scheduled. Please refer to Appendices Section.
Restrictions apply.
*
Allowed Amount
allowed
The contracted reimbursable amount for covered
medical services or supplies that the health plan
agrees to pay to service providers.
Attending
Provider ID
att_id
When populated, NPI where available, else Plan
Specific Provider ID will be on the claim.
New
att_spec
Specialty of the Attending Provider. The attending
provider’s primary specialty For physicians, this
usually represents his/her board registered
specialty. For non-physicians, specialty reflects
the type of provider/facility.
New
bill_id
When populated on medical and facility claims,
NPI where available, else Plan Specific Provider
ID. When populated on retail pharmacy records,
NPI/NCPDP where available.
New
bill_spec
The billing provider’s primary specialty. For
physicians, this usually represents his/her board
registered specialty. For non-physicians, specialty
reflects the type of provider/facility.
New
Admit Source
Code
Attending
Provider Specialty
Code
Billing Provider ID
Billing Provider
Specialty Code
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PharMetrics Plus CLAIMS File Inventory
Data Variable
Description
Data
Variable
Field
Name
Data Variable Definition
Bill Type
billtype
The bill type code indicates the status (complete
bill, interim bill) of the facility bill. This field is not
available for professional and pharmacy claims.
Charge Amount
charge
This is the amount charged/billed for services
provided by the servicing provider or facility.
Claim Number
claimno
Claim line number assigned by the health plan
adjudication system for internal tracking
purposes. If a claim number is not submitted by
the contributor, the field will be blank.
New
Coordination of
Benefit Amount
(COB Amount)
cobamt
The reduction in the amount paid to the provider
to reflect adjustments as a secondary payer.
New
Medical
Coinsurance
Amount
coinsamt
Confinement
Number
conf_num
Copayment
copay
The amount the insured individual pays, as a set
percentage of the cost of covered medical
services, as an out-of-pocket payment to the
provider. Example: Insured pays 20% and the
insurer pays 80%.
The confinement is constructed by using the
‘frm_dt’ on the first room and board record and
the ‘thru_dt’ on the last facility record in a series
of facility records that have the same provider id
and overlapping or contiguous dates. The
confinement number is then assigned to all
records that fall within that time frame.
Confinement number is not unique within an
extract. You must use pat_id and conf_num for
uniqueness.
Amount an insured individual pays directly to a
provider at the time the services or supplies are
rendered. Usually, copay will be a fixed amount
per service, such as $15.00 per office visit.
Amounts should include any sanction/penalty or
copay form of insured noncompliance such as lack
of prior authorizations. Also includes any amount
paid as copayment or coinsurance for prescription
medications.
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PharMetrics Plus CLAIMS File Inventory
Data Variable
Description
Data
Variable
Field
Name
Data Variable Definition
CPT Modifier
cpt_mod
Modifiers represent special circumstances related
to the performance of the service.
New
Dispensed as
Written
daw
Code indicating whether or not the prescriber's
instructions regarding generic substitution were
followed. Refer to Appendices Section.
New
Days Supplied
dayssup
Estimated number of days the prescription will
last or was prescribed.
deductible
The portion of this service that the member must
pay which is applied to the total period deductible.
Deductibles are usually applied over a specific
time period, such as per calendar year, per benefit
period, or per episode of illness.
Admitting
Diagnosis
diag_admit
Also considered the primary diagnosis code. ICD9-CM diagnosis code describing the condition
chiefly responsible for a patient's admission to a
facility. It may be different from the principal
diagnosis, which is the diagnosis assigned after
evaluation.
Diagnosis Code
diag1 diag11
Each record may include up to 11 ICD-9
(International Classification of Diseases, 9th
revision). These codes describe the patient's
condition or diagnosis.
Deductible
Dispensing Fee
dispense_fee
The dispensing fee paid. This amount is included
in the Total Amount Paid. Represents a sum of
any of one or more of the following: Ingredient
Cost Paid, Dispensing Fee Paid, Flat Sales Tax
Amount Paid, Percentage Sales Tax Amount Paid,
Incentive Amount Paid, Professional Service Fee
Paid, Other Amount Paid, less Patient Pay Amount
and Other Payer Amount Recognized.
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PharMetrics Plus CLAIMS File Inventory
Data Variable
Description
Data
Variable
Field
Name
Data Variable Definition
Formulary
Indicator
formulary
At the claim record level, value indicated whether
the prescription drug was paid as included in the
plan's formulary at the record level.
Valid values are:
F Formulary
N Non-Formulary
From Date
from_dt
Date on which services began for inpatient
services or date of service for same day services,
office visits, outpatient services, etc.
ICD9 Procedure
Code (Primary)
icd9prc1
Principal medical procedure a patient received
during inpatient stay. Current coding methods
include: International Classification of Diseases
Surgical Procedures (ICD-9).
New
ICD9 Procedure
Code (Secondary)
icd9prc2 icd9prc6
Additional ICD-9 procedure codes assigned to the
inpatient claim.
New
Line Number
linenum
Line identification number that usually represents
the number assigned in a source system for
identification and processing.
New
National Drug
Code (NDC)
ndc
The NDC is an eleven digit number that identifies
the manufacturer, product name, and package
size of each approved or repackaged prescription
drug. These codes are assigned by the FDA.
Paid Amount
paid
The dollar amount actually paid by the health plan
to a provider for services rendered.
Claim Paid Date
paid_dt
The date the claim was paid.
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PharMetrics Plus CLAIMS File Inventory
Data Variable
Description
Data
Variable
Field
Name
Data Variable Definition
Patient ID
pat_id
Encrypted unique patient identifier.
Discharge Status
patstat
Patient’s status as of the discharge date for an
facility stay. Patient status is only available for
inpatient claims.
New
Primary Care
Physician (PCP)
ID
pcp_id
When populated NPI where available, else Plan
Specific Provider ID on the claim.
New
Primary Care
Physician (PCP)
Specialty
pcp_spec
Specialty of the Primary Care Physician.
New
Claim Payment
Status
Place Of Service
Procedure Code
pmt_st_cd
pos
proc_cde
Indicates whether the claim was paid or denied.
P - Paid
D - Denied
New
A HCFA standard variable identifying the location,
or place, where medical services were rendered.
Refer to Appendices Section.
Procedure Code: A unique code identifying each
procedure. These are either:
CPT-4 Codes: AMA developed codes that describe
medical, surgical, and diagnostic services
performed by clinicians.
HCPCS Codes: Codes developed by HCFA to
describe the provision of supplies, injections,
materials, services, durable medical equipment,
and non-physician procedures.
Revenue Center Codes: These codes are used to
associate certain costs with specific revenue
centers in a facility. Revenue codes will be
present in the proc_cde field only when a HCPCS
or CPT code was not present on the claim.
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PharMetrics Plus CLAIMS File Inventory
Data Variable
Description
Place Of Service
Procedure Code
Data
Variable
Field
Name
pos
proc_cde
Data Variable Definition
A HCFA standard variable identifying the location,
or place, where medical services were rendered.
Refer to Appendices Section.
Procedure Code: A unique code identifying each
procedure. These are either:
CPT-4 Codes: AMA developed codes that describe
medical, surgical, and diagnostic services
performed by clinicians.
HCPCS Codes: Codes developed by HCFA to
describe the provision of supplies, injections,
materials, services, durable medical equipment,
and non-physician procedures.
Revenue Center Codes: These codes are used to
associate certain costs with specific revenue
centers in a facility. Revenue codes will be
present in the proc_cde field only when a HCPCS
or CPT code was not present on the claim.
Prescriber
Provider ID
prscbr_id
When populated NPI or DEA where available, else
Plan Specific Provider ID on the claim.
New
Prescriber
Provider Specialty
prscbr_spec
When available, specialty of the Prescriber
Provider.
New
Provider Type
ptypeflg
Quantity
quan
Provider Type:
0 Clinician
1 Facility
2 Other
Quantity of drug dispensed expressed in metric
decimal units as submitted by the pharmacy.
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PharMetrics Plus CLAIMS File Inventory
Data Variable
Description
Data
Variable
Field
Name
Data Variable Definition
Record Type
rectype
Record Type: Each record is classified as one of
the following six record
types:(M)management(S)surgical
(F)facility
(A)ancillary
(P)pharmacy
(J) J record type is assigned to cost adjustments
made for facility claims, if applicable.
Referring
Provider ID
ref_id
When populated, NPI where available, else Plan
Specific Provider ID on the claim.
New
Referring
Provider Specialty
Code
ref_spec
When available specialty of the Referring Provider.
New
Rendering
Provider ID
rend_id
When populated on medical and facility claims,
NPI where available, else Plan Specific Provider ID
on the claim. When populated on RX Claims,
Pharmacy NPI/NCPDP.
New
Rendering
Provider Specialty
Code
rend_spec
When available, specialty of the Rendering
Provider.
New
Revenue Center
Code
rev_code
These codes are used to associate certain costs
with specific revenue centers in a facility.
New
srv_unit
The quantity of units, times, days, visits, services,
or treatments for the service described by the
HCPCS code, revenue code or procedure code,
submitted by the provider.
New
Service Unit
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PharMetrics Plus CLAIMS File Inventory
Data Variable
Description
Data
Variable
Field
Name
Data Variable Definition
Submission Type
Code
sub_tp_cd
This field identifies how the claim was submitted
to the health plan by the provider/facility:
EL - Electronic
IN - Invalid
PA - Paper
SC - Scan
UN - Unknown
WB - Online
To Date
to_dt
The final date of service delivery. The To Date is
the same as From Date for same day services.
tos_flag
Type Of Service is assigned to facility claims.
0 Facility
1 Management/Surgery
2 Room and Board
This field is not available for professional and
pharmacy claims.
Type of Service
Flag
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PharMetrics Plus ENROLLMENT File Inventory
Data Variable
Description
Data Variable
Field Name
Data Variable Definition
Derived Sex
der_sex
If there is a sex listed on the enrollment
record, it is used. Otherwise, the sex is
derived from the claims file.
Derived Year of
Birth
der_yob
If there is a YOB listed on the enrollment
record, it is used. Otherwise, the YOB is
derived from the claims file.
enr_rel
This code is found in the common working file
(CWF) and is used by CMS to verify a
resident’s entitlement to and correct use of
Medicare benefits. Please refer to Appendices
Section.
Enrollment String
estring
Months Covered Template in string format: A
252 character string of “X”s and “-”s. Each
position in the ESTRING represents a single
month. It begins as of January 1995. If a
member is enrolled in a particular month, an
“X” is placed in the appropriate position. If
the member was not enrolled in that month, a
“-” is in the position.
First Claim Date
clm_frst
Date of patient's first claim.
Group/NonGroup Coverage
Indicator
grp_indv_cd
Specifies whether the contract is a group or
individual:
G - Group Coverage
I - Individual Coverage
U - Unknown
New
IMS Patient ID
anon_ims_pat_id
When populated, Patient identifier/key to
other IMS Real World Evidence products –
“allows ” patient linking”.
New
Enrollee
Relationship
Code
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PharMetrics Plus ENROLLMENT File Inventory
Data Variable
Description
Name
Data Variable
Field Name
Data Variable Definition
Last Claim Date
clm_last
Date of patient's last claim.
Last Date of
Enrollment
enr_last
Last date of Enrollment. Modified to
correspond with the date of complete claims
data for the plan.
Mental
Health/Chemical
Dependency
Benefit Indicator
MH_CD
Specifies whether the enrollee/patient has
mental health/chemical dependency benefits:
Y - Yes MH/CD Benefit
N - No MH/CD Benefit
U - Unknown/Missing
Mixed First Date
of Enrollment
mxce_fst
First enrollment date where it exists, else, the
first claim date.
Mixed Last Date
of Enrollment
mxce_lst
Last enrollment date where it exists, else, the
last claim date.
Patient ID
pat_id
Same patient ID as the claims file.
Patient Region
pat_region
Patients are assigned to 1 of 4 U.S. Census
regions based on residence.
E - Northeast
S - South
MW - MidwestW - West
Patient State
pat_state
State of residence for the enrollee/patient
from the most recent enrollment record.
New
Patient Zip Code
pat_Zip3
Zip code of the enrollee/patient is provided at
the 3 digit level (###XX) from the most
recent enrollment record.
New
Total Number of
Claim Lines
nbr_clm_lines
Total Number of Claim Lines.
Total Number of
Months Enrolled
mon_totl
Total Number of Months Enrolled.
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PharMetrics Plus ENROLLMENT2 File Inventory
Data Variable
Description
Patient ID
Data Variable
Field Name
pat_id
Data Variable Definition
Encrypted unique patient identifier. Same as
pat_id in claims and enrollment files.
There are 8 strings in the same construct as
the enrollment estring. Each position in a
string represents a single month. It begins as
of January 1995. Refer to each variable
definition for specifics. In each month to
month position values are reflective of:
RX Benefit Indicator
Pay Type
Product Type
Enrollment Eligibility Status*
Hospital Benefit Indicator*
Medical Benefit Indicator
Medical Coordination of Benefits Indicator
Pharmacy Coordination of Benefit Indicator
*Not externally provided at this time.
String Type
Enrollment II Strings
RX Benefit
Indicator
Pay Type
ben_rx
pay_type
Y RX benefit
N No RX Benefit
C - Commercial
K - State Children's Health
Insurance Program (SCHIP)
M - Medicaid
R - Medicare Risk (presently known
as Medicare Advantage)
S - Self-Insured
T - Medicare Cost (Medicare
Supplemental)
U - Unknown/Missing
X - RX Only
"-" - No Enrollment
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PharMetrics Plus ENROLLMENT2 File Inventory
Data Variable
Description
Data Variable Field
Name
Data Variable Definition
prd_type
H - Health Maintenance
Organization I Indemnity/Traditional
P - Preferred Provider Organization
S - Point of Service
D - Consumer Directed Health Care
U - Unknown/Missing
"-" - No Enrollment
enr_type
C - Cobra
R - Retiree
U - Unknown/Missing
A - Active
"-" No Enrollment
Code is determined by the most
span of data.
Restrictions apply.
*
Hospital Benefit
Indicator
ben_hosp
Y- Hospital benefit
N - No Hospital Benefit
U- Unknown/Missing
Restrictions apply.
*
Medical Benefit
Indicator
ben_med
Y - Medical benefit
N - No Medical Benefit
All patients have medical benefit
New
ben_mcob
P - Primary
M - Secondary to Medicare
S - Secondary to other commercial
payer
N - No medical coverage
"-" - No Enrollment
New
ben_pcob
P - Primary
M - Secondary to Medicare
S - Secondary to other commercial
payer
N - No medical coverage
"-" - No Enrollment
New
Product Type
Enrollment
Eligibility Status
Medical
Coordination of
Benefits Indicator
Pharmacy
Coordination of
Benefit Indicator
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Section 3: Appendices to PharMetrics Plus Files
Table I: Admit Source Codes
Admit
Source
Code
Value
Admit Source
Code Description
Admit Source Code Definition
1
Physician Referral
The patient was admitted to this facility upon the
recommendation of his or her personal physician.
2
Clinic Referral
The patient was admitted to this facility upon
recommendation of this facility’s clinic physician.
3
HMO Referral
The patient was admitted to this facility upon the
recommendation of a health maintenance organization
physician.
4
Transfer from a
Hospital
The patient was admitted to this facility as a hospital transfer
from an acute care facility where he or she was an inpatient.
5
Transfer from a
Skilled Nursing
Facility
The patient was admitted to this facility as a transfer from a
skilled nursing facility where he or she was an inpatient.
6
The patient was admitted to this facility as a transfer from a
health care facility other than an acute care facility or a
Transfer from
Another Health Care skilled nursing facility. This includes transfers from nursing
homes, long term care facilities and skilled nursing facility
Facility
patients that are at a non-skilled level of care.
7
Emergency Room
The patient was admitted to this facility upon the
recommendation of this facility's emergency room physician.
8
Court/Law
Enforcement
The patient was admitted to this facility upon the direction of
a court of law, or upon the request of a law enforcement
agency representative.
9
Information Not
Available
The means by which the patient was admitted to this hospital
is not known
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Admit
Source
Code
Value
Admit Source
Code Description
Admit Source Code Definition
A
Transfer from a
Critical Access
Hospital
The patient was admitted to this facility as a transfer from a
Critical Access Hospital where he or she was an inpatient.
B
Transfer from
Another Home
Health Agency
The patient was admitted to this home health agency as a
transfer from another home health agency.
C
Readmission to
Same Home Health
Agency
The patient was readmitted to this home health agency
within the existing 60-day payment.
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Table II: Admit Type Codes
Admit
Type
Code
Admit Type Code
Description
Admit Type Code Definition
Value
Emergency
The patient requires immediate medical intervention as a
result of severe, life threatening or potentially disabling
conditions. Generally, the patient is admitted through the
emergency room.
Urgency
The patient requires immediate attention for the care and
treatment of a physical or mental disorder. Generally the
patient is admitted to the first available and suitable
accommodation.
Elective
The patient's condition permits adequate time to schedule the
availability of a suitable accommodation.
Newborn
Use of this code necessitates the use of special Source of
Admission codes - see Form Locator 20.
Trauma Center
Visit to a trauma center/hospital as licensed or designated by
the state or local government authority authorized to do so,
or as verified by the American College of Surgeons
<u>and</u> involving a trauma activation.
Info NA
Information Not Available.
1
2
3
4
5
9
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Table III: Dispensed As Written Codes
Dispensed As
Written Code
Value
01
Dispensed as Written Code Description
Brand product is 'medically necessary' and therefore no
substitution is allowed by the prescriber. This would be used when
a brand name drug has consistently received better results than a
generic version and so a specific brand name version is deemed
required. This must be dispensed exactly as written.
02
Substitution allowed- patient requested product dispensed. This
means the patient chose the specific brand being dispensed. This
is used when generic substitution is allowed, but the patient wants
the brand name version.
03
Substitution allowed- pharmacist selected product dispensed. This
means the pharmacist chose which brand of a drug to provide,
even though a generic product option is available.
04
Substitution allowed- generic drug not in stock. This means a
brand name was dispensed instead of a generic version, because
the generics were all out of stock.
05
Substitution allowed- Brand dispensed as pharmacy's generic. This
means that the pharmacy used a "Branded Generic." This happens
when the generic isn't stocked by the pharmacy and they use a
brand name instead.
06
Override DAW Code. This is the all-purpose override code and is
used whenever an override is needed.
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Table IV: Enrollee Relationship Codes
Enrollee Relationship Code Value
01
04
05
07
10
15
17
18
19
20
21
22
23
24
29
32
33
36
39
40
41
43
53
G8
Enrollee Relationship Code Description
Spouse
Grandfather Or Grandmother
Grandson Or Granddaughter
Nephew Or Niece
Foster Child
Ward
Stepson Or Stepdaughter
Self
Child
Employee
Unknown
Handicapped Dependent
Sponsored Dependent
Dependent Of A Minor Dependent
Significant Other
Mother
Father
Emancipated Minor
Organ Donor
Cadaver Donor
Injured Plaintiff
Child Where Insured Has No Financial
Responsibility
Life Partner
Other Relationship
NOTE: It is not possible to detect whether patients are related within the database.
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Table V: Place of Service of Codes:
Place of Service
Code Value
01
02
11
12
21
22
23
24
25
26
31
32
33
34
41
42
50
51
52
53
54
55
56
62
61
65
71
72
81
99
00
XX
ZZ
Place of Service Description
Unspecified Inpatient code
Unspecified Outpatient Code
Office
Patient's Home
Inpatient Hospital
Outpatient Hospital
Emergency Room-Hospital
Ambulatory Surgical Center
Birthing Center
Military Treatment Facility
Skilled Nursing Facility
Nursing Facility
Custodial Care Facility
Hospice
Ambulance-Land
Ambulance-Air or Water
Federally Qualified Health Center
Inpatient Psychiatric Hospital
Psych. Facility Partial Hospital
Community Mental Health Center
Intermediate Care Facility/Mentally Retarded
Residential Substance Abuse Treatment Facility
Psych Residential Treatment Center
Comprehensive OP Rehab Facility
Comprehensive IP Rehab Facility
End Stage Renal Disease Treatment Facility
State or Local Pub Health Clinic
Rural Health Clinic
Independent Lab
Other Unlisted Facility
Pharmacy
Other
Unknown
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Table VI: Payer Type Codes
Plan
Payer
Type
Value
C
Plan Payer Type
Description
Plan Payer Type Table Definition
Commercial Plan
Commercial Plan: Commercial plans are primarily employer
based.
The health plan assumes the risk of insuring the
enrolled members.
K
State Children's
Health Insurance
Program (SCHIP)
A Medicaid variant, primarily earmarked for children. It has
been segmented as often this population exhibits less
enrollment variation, but generally can be considered
identical to the Medicaid category.
M
Medicaid
Medicaid, a state and federal health insurance program for
qualifying low income individuals, contracts in some cases
with private health insurers to manage the health care for
Medicaid enrollees. The health plan assumes the financial
risk of insuring the enrollees and typically manages the plan
like an HMO.
R
Medicare Risk
Medicare, a federal health plan for senior individuals and
individuals with selected disabilities, contracts in some
cases with private health insurers to manage the health
care for Medicare enrollees. The health plan assumes the
financial risk of insuring the enrollees and typically manages
the plan like an HMO. Medicare Risk plans typically cover
more services, including drugs, than traditional Medicare
insurance, although the choice of providers and access to
providers is more limited than traditional Medicare
insurance.
T
Medicare Cost
Medicare Cost (also known as Medicare Gap or Medicare
Supplemental) insurance is insurance purchased by
individuals to cover services not covered by traditional
Medicare insurance.
Patients submit claims to either
Medicare or the Medicare Cost insurer depending on the
services consumed.
Only the data submitted to the
Medicare Cost insurer is in the health plan database.
Medicare Cost plans are structured similarly to indemnity
plans.
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Table VII: Product Type Codes
Plan
Product
Type
Values
D
Plan Product Type
Description
Consumer Directed
Health Care
H
Health Maintenance
Organization
I
Indemnity Plan
S
Point Of Service
P
Preferred Provider
Organization
U
Other or Unknown
Plan Product Type Definition
A self-identified plan option, thought to be similar to a
commercial plan, but with underlying benefit plan
design changes.
These options can show a high
degree of variation, but are thought to be highdeductible/high co-insurance plans.
Historically, HMO coverage is associated with lower
premiums, lower patient contributions (through
relatively modest co-payments and deductibles),
tightest provider network management controls, most
restrictions on choice of providers and the most
restrictions on the ability to self-refer. Over time,
however, many HMO plans have changed to offer more
choice and greater access to providers.
Indemnity insurance is traditional health insurance.
Typically, indemnity insurance has the highest
premiums and greatest patient choice of providers and
very few restrictions on self-referral. Patients typically
pay 20% of fees paid to providers while the plan
typically pays the remaining 80%. Patients also pay
deductibles, typically higher than HMO plans, on
selected services such as Emergency Room visits and
Inpatient Admissions.
POS plans are a hybrid of HMO and Indemnity plans.
If a patient stays within the provider network and does
not self-refer, patient contributions are structured like
an HMO (i.e. relatively modest co-payments and
deductibles) but the patient may elect to self refer and
pay standard 20% coinsurance rates and typically
higher deductibles.
PPO plans are a hybrid of managed-care-like plans and
indemnity plans. Patient contributions are structured
like an indemnity plan (i.e. patient typically pay 20%
coinsurance rates and deductibles on selected
services), but if the patient stays within the network,
the fees paid to providers are discounted.
Like
traditional indemnity plans, there are very few
restrictions on self-referral.
Product type is unknown.
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Table VIII: Provider Specialty Table
Provider Specialty Type
Value
ALLERGY
ANESTH
ASC
CARDIOL
CHIRO
COLON_SR
CT_SRG
DENTIST
DERMATOL
DME_HH
ENDOCRIN
ENT
ER_PHYS
GASTRO
GENETICS
GERIATRC
GP_FP
HAND_SRG
HEMATOL
HEM_ONC
HOSPITAL
INF_DIS
INTERN
MHSA_FAC
MIDWIFE
NEONAT
NEPHROL
NEUR_SRG
NEUROL
--no cpi-N/A
NRS_ANES
NRS_PRCT
OB_GYN
OCC_THER
OPHTHAL
OPTOMTRY
ORTH_SRG
ORTHO
Provider Specialty Type Description
Allergy and Immunology
Anesthesiology
Ambulatory Surgery Center
Cardiology
Chiropractic
Colon-Rectal Surgery
Cardio-Thoracic Surgery
Dentist
Dermatology
Durable Medical Equipment/Home Health
Endocrinology
ENT
Emergency Medicine Physician
Gastroenterology
Medical Genetics
Geriatrics
General Practice/Family Practice
Hand Surgery
Hematology
Hematology/Oncology
Hospital
Infectious Disease
Internal Medicine
Mental Health/Substance Abuse Facility
Midwife
Neonatology
Nephrology
Neurosurgery
Neurology
The record doesn’t group to a cluster, therefore no specialty
is assigned.
Not Available
Nurse Anesthetist
Nurse Practitioner
Obstetrics and Gynecology
Occupational Therapy
Ophthalmology
Optometry
Orthopedic Surgery
Orthopedics
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Provider Specialty Type
Value
Provider Specialty Type Description
OSTOPATH
Osteopath
OTHER
OTHR_FAC
OTHR_SPC
OTHR_SRG
PATHOL
PED
PHYS_AST
PHYS_MED
PLST_SRG
PODIATRY
PSYCHIAT
PSYCHOL
PT
PULMONAR
RADIOL
RAD_ONC
RHEUM
RN
SOC_WORK
SNF
SURGERY
URG_FAC
URGENT
UROLOGY
VAS_SRG
Other
Other Facility
Other Specialty
Other Surgeon
Pathology
Pediatrics
Physician Assistant
Physical Medicine and Rehabilitation
Plastic Surgery
Podiatry
Psychiatry
Psychology
Physical Therapy
Pulmonology
Radiology
Radiation Oncology
Rheumatology
Registered Nurse
Social Work
Skilled Nursing Facility/Long Term Care
General Surgery
Urgent Care Facility
Urgent Care Medicine
Urology
Vascular Surgery
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Section 3: Clinical Code Reference Files
NDC Reference File
Variable
Description
Ahfscc
The American Hospital Formulary Service (AHFS) publishes the
AHFSCC Pharmacologic-Therapeutic Classification Compilation
codes which are used throughout the health care industry as a
means for drug classification. It is less specific than both the
GPI therapeutic classification and the USC therapeutic
classification system.
Brand_indicator
The brand indicator identifies whether a product is trademark,
generic or branded generic (gen_brand). Branded generics are:
• generally a generic drug product
• more than one company manufactures this drug
product
• the manufacturer can be a research and
development company or a generic company
• sold under a branded generic or a generic name
Brand_name
The Brand or Trademark name
Dosage_form
The Dosage Form indicates the form (solid, liquid, or gas) in which
the drug product is dispensed. The “C6” refers to the sixth subset
of the GPI which generally represents the Dosage Form (for
example, the GPI for Furosemide Tab 20 mg, 37 20 00 30 00 03 05,
has an “03” in the C6 position designating the Dosage Form “TAB”).
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NDC Reference File
Variable
Description
Drug_class
The first four digits (second subset) of the GPI code represent
the Drug Class which identifies specific therapeutic drug classes
designed to accommodate more detailed market research. The
Drug Class also serves as the structural base for most
therapeutic drug monitoring applications (such as dosage
screening and disease contraindication monitoring). For
example, Drug Group 37, DIURETICS, includes the following
Drug Classes:
37-00-00-00-00 *DIURETICS*
37-10-00-00-00 *Carbonic Anhydrase Inhibitors**
37-20-00-00-00 *Loop Diuretics**
37-30-00-00-00 *Mercurial Diuretics**
37-40-00-00-00 *Osmotic Diuretics**
37-50-00-00-00 *Potassium Sparing Diuretics**
37-60-00-00-00 *Thiazides**
37-90-00-00-00 *Miscellaneous Diuretics**
37-99-00-00-00 *Combination Diuretics**
The number “99” found in the second or third subset in some
GPIs is used in Facts and Comparisons' TCS to identify
combination drug products.
Fd_drug_name
GPI Generic Name. Identifies the product represented by the
GPI which includes generic name, strength and dosage form.
Gen_nm
Generic Name/Active Ingredient
Gpi
The 14-character GPI (generic product indicator) consists of a
hierarchy of seven subsets, each providing increasingly more
specific information about drug products. These subsets are
structured and identified below:
GPI Record
12-xx-xx-xx-xx-xx-xx Drug Group *MISC. ENDOCRINE*
12-34-xx-xx-xx-xx-xx Drug Class *Posterior Pituitary**
12-34-56-xx-xx-xx-xx Drug Subclass *Vasopressin***
12-34-56-78-xx-xx-xx Drug Name Desmopressin
12-34-56-78-90-xx-xx Drug Name Acetate
12-34-56-78-90-12-xx Dosage Form Tablet
12-34-56-78-90-12-34 Strength 0.1MG
Last_chg_dt
The Last Change Date identifies the most recent date any field
in the drug file was changed.
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NDC Reference File
Variable
Description
Manufacturer_name
The Manufacturer’s (Labeler) Name indicates the manufacturer,
distributor, and/or division whose name is included on the label.
Drug products are identified and reported using an 11-digit, 3segment number called the National Drug Code (NDC), which is
a universal product identifier for human drugs. The NDC code
identifies the labeler, product, and trade package size. The first
segment (5-digits), the labeler code, is assigned by the FDA. A
labeler is any firm that manufactures (including repackers or
relabelers), or distributes (under its own name) the drug. The
second segment (4-digits), the product code, identifies a
specific strength, dosage form, and formulation for a particular
firm. The third segment (2-digits), the package code, identifies
package sizes and types. Both the product and package codes
are assigned by the firm. The NDC code is reported in the
following configuration: 5-4-2.
Ndc
Route_admin
Rx_group
Rx_otc
The Route of Administration indicates how the medication's dosage
form is administered to the patient. Examples are:
ORAL (OR) Taken by mouth
RECTAL (RE) Administered into the rectum
SUBCUTANEOUS (SC) Injection through the skin into the loose
subcutaneous tissue under the skin
INHALATION (IN) Drug administration into the lungs (either during
a drawn or forced breath)
INJECTION (IJ) A set of one or more injectable routes or the route
of injection is not specified
INTRAMUSCULAR (IM) Injection into a muscle group
Drug Group
The two-character Drug Group (first two digits and first subset
of the GPI code) classifies general drug products. Examples are:
01-00-00-00-00 *PENICILLINS*
25-00-00-00-00 *CONTRACEPTIVES*
27-00-00-00-00 *ANTIDIABETIC*
36-00-00-00-00 *ANTIHYPERTENSIVE*
86-00-00-00-00 *OPHTHALMIC*
Indicates whether the product is available only by prescription (Rx)
or over-the-counter (OTC).
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NDC Reference File
Variable
Strength
Tee_code
Unit
Usc_code
Usc_description
Variable
DX
Diag_description
Description
The Strength is present for products with a single active ingredient.
For combination products, the strength is designated as zero. The
“C7” refers to the seventh subset of the GPI which generally
represents the product Strength (for example, the GPI for
Furosemide Tab 20 mg, 37 20 00 30 00 03 05, has an “05” in the
C7 position designating the product Strength 20mg)
A two-character code indicating the FDA rating of the
therapeutic equivalence of a drug product with other
pharmaceutically equivalent drug products, as published in the
Orange Book. Use of the TEE Code with the GPI enables the
end-user to have a list of bioequivalent, substitutable drug
products sharing the same active ingredients including the
same route, strength, and dosage form.
The Strength Unit of Measure, when combined with the Strength
represents the dosage strength as provided by the manufacturer.
For example:
Drug Product: Indocin
Strength: 25
Strength Unit of Measure: MG
Interpreted Strength: Indocin 25 mg
The Uniform System of Classification (USC) is a therapeutic
classification system created by IMS America and the
Pharmaceutical Marketing Research Group. This system is marketoriented and is unique to the United States. The USC Classification
System is more specific than the American Hospital Formulary
Service (AHFS) Therapeutic Classification System and less specific
than Medi-Span’s Therapeutic Classification System. One USC Code
can be applied to multiple GPI’s while a GPI will have only one USC
code. Not all GPIs have a USC Code.
Text description of the USC code.
Diagnosis Reference File
Description
Alpha-numeric code for the ICD-9-CM Diagnosis Code
Short version of the text description for the code
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