Accessing real-time patient & claims data

[Michael Franzidis]

Good morning,

My colleagues and I are looking investigating the possibility of providing a service to various Home Health Agencies wherein we would help these agencies by pulling down MediCare data on their patients and claims in real time (and historical) into an Excel spreadsheet.

Having looked around the CMS API site, it looks like this is probably the tool most likely to help with that, but I'm still a little unclear on exactly what data this API would be returning.

Would I be correct to say that our application could register multiple organisations, receiving a different token for each one? We could then query the API and return claims and patient data in real time as it is updated in the MediCare database? Or would there still be quite a lag between claim status changes and these changes being available through the API?

Appreciate any help on the above.

Many thanks,

Mike

[Data at the Point of Care (DPC) Community]

Hi Mike,

Thanks for your question. 

The DPC API pilot provides Medicare Fee-For-Service claims, specifically Parts A, B, and D. Because the data is adjudicated, there is a delay of up to a few weeks from the time the claim is processed to when it becomes available through our API.

For more information on the data itself, we will refer you to the “Understanding the Data” section of the BCDA website. As the BCDA and DPC APIs share the same data source, this page will provide you with the same information about the data that is also accessible through the DPC pilot.

As the DPC implementer, your organization will be able to onboard multiple home health agencies with unique credentials for each. First, you will need to test the DPC solution in the sandbox portal. Once you have tested and built your solution, you may apply to our production pilot with a home health agency. During this onboarding process, we will ask you to share documents that fulfill a list of requirements and will also provide you with production credentials. Upon this initial successful onboarding, you would then be able to onboard subsequent home health agencies. 

At this time, the DPC pilot requires that HIPAA covered entities and their business associates must have a treatment related purpose for requesting the claims data. You can read about the Attestation and Attribution requirements here and our Terms of Service here.

Please note that participation in the DPC pilot is limited and will allow CMS to test solutions in a production environment with actual users does not guarantee an end product for your organization. As CMS continues to gather feedback and conduct research, it is possible that we may make significant changes to the DPC API.

Please let us know if you have any other questions,
The DPC Team

[Michael Franzidis]

Good morning,

Thank you for the information.

I would just like to confirm one point: you note that there is a delay of several weeks between claims being processed and being available through the API. Does this mean that if a claim is submitted and subsequently approved or rejected, a home health agency would be able to see this result through the online portal several weeks prior to us being able to pull it through the API? Or is this delay generic across both the portal and the API?

Many thanks,

Mike

[Data at the Point of Care (DPC) Community]

Hi Mike,

The portal is the entry point for the sandbox environment, where you can test the DPC API pilot using synthetic data that we provide. You would not be able to directly access the adjudicated Medicare FFS claims in the sandbox portal. 

After successfully onboarding to the pilot production environment, then you would be able to access adjudicated Medicare FFS claims through the pilot API. Again, this data would be made available with some delay after the claims have gone through the adjudication process.

Let us know if you have further questions,
The DPC Team