Supplemental Data ExchangeOverview and Participation Requirements

What you need to know about submitting HEDIS supplemental data to the Blues

What is the Supplemental Data Exchange?

• The Supplemental Data Exchange is a standardized process that allows the enterprise to collect supplemental information for the Healthcare Effectiveness Data Information Set® (HEDIS) measures.

• Supplemental information refers to additional clinical data about a member, beyond administrative claims, received by a health plan.

• Data for all Blues plans, including Blue Care Network (BCN), Blue Cross Complete, the Blue Cross Blues Shield of Michigan (BCBSM) Commercial PPO, and the Medicare Advantage PPO can be delivered to the Blues using a single consolidated entry point.

Why did the Blues establish a data exchange?

• To build and report a comprehensive view of population health and performance of HEDIS measures.

• To reward groups who provide high quality care.• To drive appropriate, high quality patient care. • To be efficient in delivering care by reducing replication of

services.• To identify population-level quality and process improvement

opportunities. • To report data to accrediting agencies such as the National

Committee on Quality Assurance (NCQA) and the Centers for Medicare & Medicaid Services (CMS).

What is HEDIS supplemental data?

• Supplemental data is information outside of claims about delivery of health services to a plans members for calculating HEDIS measures.

• Supplemental data may help determine:– The numerator – Optional exclusions – Eligible-population required exclusions which are not related to

timing of the denominator event or diagnosis• Supplemental data may not be used to determine:

– Denominator events (cannot add data to the denominator)• Plans may not create and use records to identify denominator events,

other than for optional exclusions and appropriate required exclusions

What is HEDIS supplemental data? (cont.)

• There are two types of supplemental data. Standard and non-standard.

• Standard supplemental data are electronic files that come from providers who rendered services to members. Production of these files follows clear policies and procedures, and standard file layouts remain stable from year to year.

• Non-standard supplemental data is data used to capture missing service data not received through administrative sources, or in the standard files. Plans must have clear policies and procedures that describe how the data is collected, validated and used for HEDIS reporting.

• All supplemental data sources are subject to regular audits.• To become familiar with supplemental data definitions and audit

requirements, please visit the NCQA website at www.ncqa.org for the most current requirements.

How does the Blues handle supplemental data?

• The Blues currently accepts only standard supplemental data through this data exchange.

• The Blues uses a standardized file layout to receive data from authorized POs and other groups through a secure server.

• We require all participating entities to complete on-boarding processes, sign a legal agreement, complete process milestones and engage in ongoing data quality management activities.

• Our expectation is that the providers will collaborate with us to continually improve our data intake processes and to ensure that all data sent to us is accurate, valid, and can be substantiated in the member’s legal medical record.

Supplemental Data Exchange on-boarding process overview• The Blues require all prospective POs and other groups to

complete a readiness assessment prior to consideration for participation the Supplemental Data Exchange.

• It is critical that our participating partners share our collaborative philosophy and have the capacity to work together to generate data feeds to the plan on a regular basis.

• Once a PO receives the green light to participate in data exchange, they are required to complete & return a data contract to the Blues.

• Once the contract is complete, the Blues will assign your group an Origin ID that identifies your organization and the data source from which the feed originates. A data contract must be in place to proceed.

• Once an Origin ID is assigned you, Blues team members will schedule time for a discussion about next steps.

Supplemental Data Exchange on-boarding process overview (cont.)

• We expect that you and your team will review the Supplemental Data Exchange file layout, related FAQ documents and checklists.

• The Blues will also work with you ensure that you have a secure way to send your data files to us. This may include setting up new EDDI boxes for your feed.

• Once these activities are complete we expect you to create a test file in a timely manner. In general, it can take between two and four weeks to generate the first test file, if IT resources are already in place.

• Providing a test file to the Blues is the first milestone in the on-boarding process.

• It may take some time to pass the testing and pre-audit processes in their entirety.

Creating your Test File• Once you have completed and returned your data contract and

receive an Origin ID, you will be expected to generate a test file.• The Blues is currently accepting data in Version 23 of the file layout.• Version 23 can be found on the PGIP Collaboration site on the

Supplemental Data Exchange initiative page. – If you do not have access to the site, contact Jessica Kauffmann a

jkauffmann@bcbsm.com • In order to position yourself to pass the IT testing and pre-audit

processes you will need to review the layout tabs and other job aides provided on the Supplemental Data Exchange page.

• Your test file should include all of the data elements, service type codes and member populations you plan to send to the Blues in a production environment.

Reviewing the File Layout• Version 23 of the file layout contains the following elements:

– Change History – Catalogues updated and what was changed on the file layout. – Data Dictionary – Provides information about fields, field types, field length, descriptions, comments,

valid values and required fields.– File Layout Group to BCN – Explains all Field Names, whether field is required or optional, special

conditions that apply and field descriptions.– Header Row – Contains an example of what the header row should look like.– Data Caveats – Explains all mapping caveats which may not be understood in HEDIS Specs– HEDIS CODE REF – Describes what measures are what mapped to each code, HEDIS Measure Code,

Record Type and additional coding instructions.– Ethnicity Code and Description – Provides values and descriptions for ethnicity. – Race code and Description - Provides values and descriptions for race. – Language code and Description - Provides values and descriptions for language. – Country Code and Description - Provides values and descriptions for country.– CMS NPI List – Lists CMS NPIs (list is not complete, visit this http://nppes.viva-it.com/NPI_Files.html

for a complete list).– OrigDataSourceType code & desc – Describes source of record (EMR, DMR, Lab, HIE etc.)– OrigDataSourceName code & desc – Describes data source name (Wellcentive, Quest etc.)– OrigSource_Type&Name_Job Aid – Helps give real time examples of source type/source name

combinations– OrigSource_Type&Name_Examples – Dummy data examples.– File Level Validation Rules – Contains file level IT testing rules.– Record Level Validation Rules – Contains record level IT testing rules.

Reviewing the File Layout (cont.)• If you have questions about the layout or the information in it,

please contact us! • In addition to reviewing the layout, review available job aids

including the Service Type Code Job Aid.• This job aid was designed to ensure appropriate use of record

types received. For example, a pharmacy record type submitted should not include a result.

• Using correct service type codes are essential to ensuring records received can be loaded.

• If you are planning to submit BMI data, you must include the height, weight, and BMI records on separate rows.

• Once you have a full understanding of the layout you should proceed with developing your test file and delivering it to the Blues.

• You do not have to submit data for all of the service types included in the file layout.

Understanding the IT Testing Process • The IT testing process is the first milestone you will need to pass

before moving your files into production. • It may take some time to pass the IT testing process in its

entirety.• There are two phases of the IT testing process:

– File level validation • File level validation rules included are in the file layout

– Record level validation • Record level validation rules included in the file layout

• Files must have an error rate of less than 10% before your Origin ID passes IT testing. – Exception: Member not match. Error rates of greater than

10% in the member not match category are permissible as membership tables may not by up-to-date in the testing environment

IT testing and pre-audit checklist• Any group or PO planning to submit HEDIS supplemental data to

the Blues is required to review the IT test and pre-audit checklists. • The checklist is located on the Supplemental Data Exchange page

of the PGIP Collaboration website. The file name is: – HEDIS Supplemental Data Exchange Testing and Pre-Audit

Checklist• If you do not have access to the PGIP Collaboration site, please

contact Jessica Kauffmann at jkauffmann@bcbsm.com for an email copy of the checklists.

• The checklists contain pertinent information about file naming conventions, date formatting, header row information, and the type of data that should be include in your file.

• Do not submit a test file to the Blues without first reviewing the checklists.

• If you need clarification, or have questions please contact us.

IT Test Error Reports• You will receive an error report summary via email that gives you a

high level look at where testing errors occurred.• A full error report will be dropping into the EDDI box where your

file was delivered.

Common IT Testing Errors• Incorrect naming file convention (file level validation error)

– Auto sweep skips files with incorrect names, no alert sent to it, file sits– Naming convention is on checklist:

• TEST_OriginId_EMR_SUPPLEMENTAL_INFO_yyyymmddhhmm• Incorrect header rows (file level validation error)

– The header record format is provided on the “Header Row” worksheet– The header record consists of - ORIGIN_ID, FILE_CREATION_DT , and

RECORD_CT field– The RECORD_CT field is used to perform this file level validation

• Incorrect date formatting: – Naming convention formatting is: yyyymmddhhmm– File creation date and all dates within records are: DD-MM-YYYY (all

records will have same creation date)• Text in numerical fields

You’ve Passed IT Testing! Now What?• After your Origin ID passes the IT testing process your file will be

assessed to ensure it has the appropriate data needed for a pre-audit. • All of the elements we are looking for are included in the pre-audit

checklist. • We will also be looking to be sure that source code combinations are

correct and that you have included the appropriate amount of records for the populations and service type codes you want to submit in production.

• Next step? We will be auditing for data that you would like to send in production.

Supplemental Data Pre-audit Process• After your test file is processed, and passes IT testing milestones, the

Blues will contact you about completing a pre-audit. • We pre-audit all new data submission sources to ensure that our health

plan (BCBSM) can continue to accept standard supplemental data, and use it for HEDIS reporting and incentive programs.

• The data sent to us on your file layout must be reasonably supported by documentation in your patient medical records.

• The pre-audit process entails pulling a sample of the records in your test file.

• The sample will include 10 records for each service type submitted (5 BCBSM, 3 BCN, 2 MAPPO) .

• A pass rate of 98% is required for the HEDIS service types that you would like to submit to the Blues in production.

• Remember, you do not have to submit data for all of the service types included in the file layout.

Supplemental Data Pre-audit Process (cont.)• Your sample will be provided to you in a PDF and MS Access file via

your PGIP EDDI box (or other EDDI for non-PGIP groups)• You will find a cover letter along with a list of the patient(s) and

their services along with a fax cover sheet.• What do I do next? Review your patient list and services and

provide secure copies of the pages in the patient’s medical record where this information was obtained.

• You may follow the instructions on the cover sheet to return documentation to our review nurses.

• In many cases, POs may only pass a portion of the service types in the first round of pre-audit. Opportunities to correct data and submit test files for service types that did not pass, are available.

• If you have questions or concerns about your sample, contact Jessica Kauffmann at jkauffmann@bcbsm.com early on.

Moving into Production • Once pre-audit milestones have been completed your feed may move

into the production phase.• Before sending production files, all submitters are required to complete a

pre-production meeting with BCBSM. • Together, your PO and the BCBSM, Medical Informatics and Value

Partnerships teams will agree on a date that you may send your first production file, and the measures your PO will be sending.

• Information about EDDI boxes and feeds contacts will also be verified at this time.

• In addition to regular submission of incremental files, BCBSM will ask for historical data for your population.

• Please keep in mind that we cannot accept a production file for before the agreed upon date as IT environment set up may not be complete.

• Also, be mindful of naming requirements for all production files

Having a Successful Journey

Tips & techniques for successful submission of supplemental data:

• Review your data management processes and ensure that data following in your system is accurate and valid

• Remember that lab service type codes require results, and service do not

• Notify your practices that they should be ready to provide medical record documentation for the pre-audit process, review requirements with them

• Review your pre-audit sample closely, remember to provide documentation of what was requested, such as documentation for lab test dates requested in the sample, not those the patient’s most recent test

Having a Successful Journey (cont.)• Ensure medical record documentation for lab test include a

note indicating the date when the test was performed, along with the results of the test for lab services. Documentation can be lab reports or progress/physician notes.

• Learn and review HEDIS® measure specifications. Measure specifications can be purchased through NCQA. Specs can help you understand what will create a numerator hit for specific measures.

• Use measure specifications or mapping table to define look-back periods for historical files. • Use the YRS_HISTORY column in the HEDIS CODE REF tab

of the file layout for years of history by code • Alternate – Minimum of 3.5 years recommended

• Review error reports for test and production files

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