This file includes beneficiary-level information for participants in the Part D Medication Therapy Management (MTM) program, required of CMS Part D plans. Eligible beneficiaries include those enrolled in Part D plans with multiple chronic disease, those taking multiple Part D drugs and those likely to have expenditures exceeding a specified level as described by federal regulations.
This Medicare Part D file identifies beneficiaries covered by the Low Income Subsidy (LIS) program for Part D Plan enrollment.
When a Medicare beneficiary with Part D coverage fills a prescription, the prescription drug plan submits a record to CMS. The PDE file includes all transactions covered by the Medicare prescription drug plan for both Prescription Drug Plans (PDPs) and Medicare Advantage Prescription Drug Plans (MA-PDs).
The Medicare Part D Formulary file is a suite of three sub-files: formulary, excluded drug and Over the Counter Drug that contain information on how the plan covers the prescription drugs filled (as described in the Part D Drug Event (PDE) 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.
The Plan Characteristics file contains Medicare Advantage plan and Prescription Drug Plan information separated into six subfiles.The subfiles are:Plan “Base” or Benefit package filePremiumCost Sharing TierService AreaSpecial Needs Plansmulti-year crosswalk file.
The Medicare Part D Prescriber Characteristics file contains descriptive information for the prescriber identified on a Part D Event file record.
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.
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...
The Durable Medical Equipment (DME) file contains fee-for-service claims submitted by Durable Medical Equipment suppliers to the DME Medicare Administrative Contractor (MAC).
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).
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).
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).
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...
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).
The MedPAR file contains information about inpatient (IP) hospital and skilled nursing facility (SNF) stays that were covered by Medicare. MedPAR records are created by rolling up information for a single stay from individual IP and SNF claims. The data on these claims was originally submitted on the CMS 1450 or UB04.