BCDA Partially Adjudicated Enhancement Upcoming Production Launch

[Beneficiary Claims Data API (BCDA) Community]

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce the upcoming production release of Beneficiary Claims Data Application Programming Interface (BCDA) Partially Adjudicated Enhancement on May 16th, 2023. This initial release expands the data available to Medicare providers from BCDA and is available to Accountable Care Organizations (ACOs) participating in the ACO Realizing Equity, Access, and Community Health (ACO REACH) Model.

Access to partially adjudicated claims data reduces the time to access Parts A and B fee-for-service claims to 2-4 days after claim submission, while it is typically up to 14 days for adjudicated claims data. As ‘partially adjudicated’ claims, these claims have entered the Medicare processing system, but are not paid or fully processed by CMS and may be subject to changes. This enhancement helps to increase care coordination, improve healthcare outcomes, and reduce overall healthcare cost for Medicare beneficiaries.

The BCDA Partially Adjudicated Claims Enhancement production launch follows the successful completion of a limited launch period. During limited launch, a small group of REACH ACOs evaluated the partially adjudicated claims data and provided feedback on the value and possible uses of the data in their specific claims processing. For example:

• "We have ingested Partially adjudicated claims into our systems. We have a few use cases for it but will probably start by using it to enhance our readmission prevention programs. We alert providers of admissions from ADT and Claims. Having the partially adjudicated claims means we can alert faster."

How does the BCDA Partially Adjudicated Enhancement fit into the current BCDA production environment?

REACH ACOs with BCDA credentials can currently access adjudicated claims data through three (3) bulk Fast Healthcare Interoperability Resource (FHIR®) resource types: Explanation of Benefit, Patient, and Coverage.

The BCDA Partially Adjudicated Enhancement provides the following two (2) new resource types under the bulk FHIR® specification:

Claim
The Claim resource type provides information about professional and institutional claims providers submit for payment (including the services that beneficiaries receive).

ClaimResponse
The ClaimResponse resource type provides information about a claim’s adjudication status and processing results.

The BCDA Partially Adjudicated Enhancement does not modify or impact the BCDA adjudicated claims data current accessed through the three (3) bulk FHIR® resource types.

Partially adjudicated claims are dynamic; users can view the claim processing changes as near-daily updates. By comparison, adjudicated claims reflect final-action processing and updates are less common.

Characteristics of the BCDA Partially Adjudicated Enhancement.

1. Adds additional data to a subset of fields that exist in BCDA today. These fields have the potential to be beneficial in support care coordination. 
2. Provides Fee-for-Service (FFS) claims from the Medicare Fiscal Intermediary Shared System (FISS, for institutional claims) and Medicare Multi-Carrier System (MCS, for professional claims).
3. Does not include Part D (drug coverage) or Durable Medical Equipment (DME) claims.
4. Filters claims data so that REACH ACOs only receive data about their aligned beneficiaries (who have not opted out of data sharing). BCDA also excludes all claims with substance abuse codes (as required by the Confidentiality of Alcohol and Drug Abuse Patient Records Regulations, 42 CFR Part 2).

What to do if you want access to partially adjudicated claims data.

1. REACH ACO with current BCDA credentials:
   1. To gain access to partially adjudicated claims data, you need to be using BCDA V2.

   2. Making a call to BCDA V2 will by default retrieve all five (5) bulk FHIR® resource types. No more action is necessary to retrieve the new Claim and ClaimResponse resource types for partially adjudicated claims data. On the BCDA website, there is type query parameter information. This parameter allows users to select the bulk FHIR® resources they want to receive by selecting specific resource types. To retrieve all five (5) resource types, exclude the type parameter. For a subset of resource types, the desired resources are set in the type query parameter. For example, to request only partially adjudicated claims data, make sure you include Claim and ClaimResponse in the type query parameter:

      For partially adjudicated claims access

      GET /api/v2/Group/$export?_type=Claim,ClaimResponse

      
      

2. REACH ACO without current BCDA credentials:
   1. To obtain your organization’s credentials to access the BCDA production environment, you must have obtained BCDA credentials from your 4Innovation (4i) account. To view instructions on how to manage BCDA credentials, log into your 4i account and navigate to the 4i Knowledge Library: https://4innovation.cms.gov/secure/knowledge-management/view/537.
      1. For questions related to the 4i system access, please contact the Tier 1 Help Desk Support at 1 (888) 734-6433 and select “Option 1”.
   2. Once you have obtained your BCDA credentials, please follow the steps previously mentioned in step #1 titled "REACH ACO with current BCDA credentials".

What to do if you do not want access to partially adjudicated claims data.

1. BCDA V2 will by default deliver partially adjudicated claims data to REACH ACOs in the form of the two (2) new bulk FHIR® resource types (Claim and ClaimResponse).
   1. On the BCDA website, there is type query parameter information. This parameter allows REACH ACOs to select the bulk FHIR® resources they want to receive. If you are not using the type query parameter, you will automatically see partially adjudicated claims data available in your results.

   2. To request only adjudicated claims data, make sure you specify the desired resources types, Explanation of Benefit, Coverage, and Patient, in the type query parameter:

      For adjudicated claims access
      GET /api/v2/Group/$export?_type=ExplanationOfBenefit,Coverage,Patient

2. There are no other impacts or changes to your access to BCDA adjudicated claims data.

CMS's goal is to assist the REACH ACOs with access to and use of partially adjudicated claims data. To that end, we are pleased to inform you about the following:

• Access the BCDA website at: https://bcda.cms.gov for more information on BCDA and partially adjudicated data.

• All REACH ACOs can try out the synthetic partially adjudicated FFS claims data in the BCDA Sandbox environment, without any BCDA Production environment credentials or approval by BCDA. To get started using synthetic partially adjudicated claims data in the BCDA Sandbox environment, REACH ACOs should follow the guidance outlined at https://bcda.cms.gov/guide.html#try-the-api, with minor adaptations:

  1. Use the cURL command along with one of the synthetic data sets below, to submit credentials for an access token
  2. Use the cURL command to start a job
  3. Check the job status
  4. Download partially adjudicated claims data
• CMS is hosting a webinar on May 2, 2023, from 1:00 pm - 2:00 pm (EDT) to provide more information on how to prepare for the production release. The webinar is open for all REACH ACOs who would like to learn more about BCDA partially adjudicated claims data. No advance registration is needed; Click here on May 2 to join the webinar; full invitation details will be emailed to REACH ACOs the week before the webinar.
• Supporting documentation (BCDA Partially Adjudicated Enhancement User Guide and Data Dictionary) will be available to REACH ACOs by May 16, 2023. Access instructions will be provided at the May 2, 2023 webinar and by email on May 16, 2023.

We look forward to seeing you at our production pre-launch webinar on May 2, 2023.

In the meantime, do not hesitate to reach out to us if you have any other questions.

With regards,

BCDA Partially Adjudicated Enhancement Team

Email: bc...@cms.hhs.gov