Data related to an individual’s insurance coverage for healthcare.

Data Element
Payer Name
Description

The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.
Submitted By: Shelly Spiro / Pharmacy HIT Collaborative
Data Element Information
Data Element Description The program or plan underwriter or payor including both insurance and non-insurance agreements, such as patient-pay agreements.
Use Case Description(s)
Use Case Description With the Pharmacist eCare Plan it is required to capture the coverage.payor when sharing and exchanging eCare Plans to capture clinical data for payor value-based programs.
Estimate the breadth of applicability of the use case(s) for this data element There are over 70 payor programs currently with CPESN (https://www.cpesn.com) which is a network of over 2600 pharmacies.
Link to use case project page https://www.ecareplaninitiative.com/
Healthcare Aims
  • Improving patient experience of care (quality and/or satisfaction)
  • Improving the health of populations
  • Reducing the cost of care
  • Improving provider experience of care
Maturity of Use and Technical Specifications for Data Element
Applicable Standard(s) Coverage type and self paid codes; Many of the defined elements in a resource are references to other resources. Using these references, the resources combine to build a web of information about healthcare; ID assigned to the subscriber
http://hl7.org/fhir/valueset-coverage-type.html
Additional Specifications http://hl7.org/fhir/coverage.html
Current Use This data element has been used at scale between multiple different production environments to support the majority of anticipated stakeholders
Supporting Artifacts The CPESN network of over 2600 pharmacies are capturing coverage.payor data within the Pharmacist eCare Plan (hitps://www.ecareplaninitiative.com).
https://www.cpesn.com
Extent of exchange 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders.
Supporting Artifacts The CPESN network of over 2600 pharmacies are capturing coverage.payor data within the Pharmacist eCare Plan (hitps://www.ecareplaninitiative.com).
https://www.cpesn.com
Potential Challenges
Restrictions on Standardization (e.g. proprietary code) Based on the HL7 FHIR eCare Plan implementation guide.
Restrictions on Use (e.g. licensing, user fees) For SNOMED CT UMLS license
Privacy and Security Concerns None known.
Estimate of Overall Burden Burden is linked to the implementation of the FHIR standards.

Comment

Submitted by CDC_DSMH_WG on

CDC's comment for inclusion in USCDI v7

National Hospital Care Survey includes expected source of payment information as a data element in restricted use data files. We’ve demonstrated the utility of including health insurance in analyses of restricted use data files in the following publications: National Health Statistics Reports Number 201” National Hospital Care Survey Demonstration Projects: Examination of Maternal Health Outcomes by Housing Assistance Status” at https://www.cdc.gov/nchs/data/nhsr/nhsr201.pdf, NCHS Data Brief No. 438 “Characteristics of Visits to Health Centers: United States, 2020” at https://www.cdc.gov/nchs/products/databriefs/db438.htm, “Comparison of Estimates From the 2020 National Hospital Care Survey to the 2020 Nationwide Emergency Department Sample and 2020 National Hospital Ambulatory Medical Care Survey” at https://www.cdc.gov/nchs/data/nhcs/NHCS2020_ED_WhitePaper.pdf, and “Comparison of Estimates From the 2020 National Hospital Care Survey and 2020 National Inpatient Sample” at https://www.cdc.gov/nchs/data/nhcs/NHCS2020_IP_WhitePaper.pdf. Inclusion of Payer Name as a data element will allow improved mapping of health insurance, thereby allowing more accurate estimates of maternal outcomes by health insurance and housing assistance status.

b. Location of data element in the current HCS CDA IG V1.2: x-path /ClinicalDocument/componentOf/structuredBody/component/section[templateId/@root="2.16.840.1.113883.10.20.34.2.4"]/entry/act[templateId/@root="2.16.840.1.113883.10.20.22.4.129"]/entryRelationship/act/code

c. This data element is in C-CDA 4.0. Link in the C-CDA IG - - Payers Section - Consolidated CDA (C-CDA) v4.0.0

 (https://build.fhir.org/ig/HL7/CDA-ccda/StructureDefinition-PayersSection.html)

d. Description of what DHCS currently receives in production: All EHR encounters included payer name information in the NHCS.

Submitted by CDC_DSMH_WG on

CDC's comment for proposed inclusion in USCDI v7

National Hospital Care Survey (NHCS) includes expected source of payment information as a data element in restricted use data files. Inclusion of this data element would improve accuracy of reporting expected source of payment in official federal statistics produced by NHCS data.

Location of data element in the current HCS CDA IG V1.2: x-path /ClinicalDocument/componentOf/structuredBody/component/section[templateId/@root="2.16.840.1.113883.10.20.34.2.4"]/entry/act[templateId/@root="2.16.840.1.113883.10.20.22.4.129"]/entryRelationship/act/code

This data element is in C-CDA 4.0. Link in the C-CDA IG - - Payers Section - Consolidated CDA (C-CDA) v4.0.0

Description of what DHCS currently receives in production: All EHR encounters included payer name information in the NHCS.

Submitted by CDC_DSMH_WG on

CDC's Comment for draft USCDI v6

CDC is requesting that the following Level 2 data element be added for consideration to USCDI V6 to inform hospital and ambulatory medical care survey data collection efforts.

Justification:  National Healthcare Surveys includes expected source of payment information as a data element in restricted use data files. Inclusion of this data element would improve accuracy of reporting expected source of payment in official federal statistics produced by National Healthcare Surveys data.

Submitted by rdillaire on

CMS-CCSQ Supports Payer Name for USCDI v6

Recommendation: CMS CCSQ recommends advancing the Medicare Patient Identifier element to Level 2 and inclusion of the Coverage Period, Group Name, Payer Name, Plan Name, and Medicare Patient Identifier data elements in final USCDI v6.

Rationale: Inclusion of these common health insurance data elements for nationwide interoperability is essential for such use cases as value-based care, including affordability for lower-income individuals, and enabling patients to determine costs and affordability up front. This Health Insurance Information data class is associated with the overall primary and secondary coverage for the individual. In some cases, it may be different from the benefit used for a particular encounter or claim (e.g., worker's comp benefits). While these data elements are already included in the latest Fast Healthcare Interoperability Resources (FHIR) US Core and Consolidated Clinical Document Architecture (CDA) implementation guides (IGs) referenced in the Health, Data, Technology, and Interoperability-1 Final Rules (HTI-1), the implementation community can benefit from more clarity on how to consistently populate these fields—in particular Payer Name and Group Name—as there is variation between what a typical insurance card shows versus what is best used on real-time eligibility (RTE) queries with health plans.

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