Tip: TPA and PBM Replacement Data for EBD

0124

99EBD1, 95442

06 Mar 2023 14 Apr 2023 14 Jul 2023

Included in the July 2023 data tips email with update.

See Description.

Update:

A new field has been added to the APCD - ME001_CAT. See data tip https://achiapcd.atlassian.net/wiki/spaces/ADRS/pages/3167027315/Redefined+field+-+ME001+CAT for definitions.

EBD members can be selected where ME001_CAT in ('EBD','EBD_TPA','EBD_PBM','EBD_RET','EBD_NOHLTH'). Submitting Entity ID (ME001) and Member ID (ME107) for records with these values in ME001_CAT can be matched to medical and pharmacy claims for claim selection.

Description below pertains to data from Spring 2023/22D update.

TPA replacement data for EBD

EBD medical claims and pharmacy claims data submission has changed. Older EBD claims data is still sourced from EBD while new data is now sourced by third party administrators (TPA) and pharmacy benefit managers (PBM).

This is applicable only to data requested after March 2023. Data users with data pulled before March 2023 should NOT use this tip.

The selection criteria is described here:

Member Data:

All EBD member/enrollment data sourced from EBD for 2014-12-31 back is usable for both EBD medical and pharmacy claims in that time period. To select these data:

select records from member data
  where ME001 = '99EBD1' and ME162A <= '2014-12-31' and 
  ME163A >= '2013-01-01'.

Only EBD member/enrollment data source from EBD and associated with EBD Pharmacy claims is usable for 2015-01-01 to 2022-05-31:

select records from Member data
  where ME001 = '99EBD1' 
  and ME162A <= '2022-05-31' and ME163 >= '2015-01-01'

To find EBD member/enrollment data for the EBD TPA Health Advantage from 2015-01-01 forward:

Select records from member data
  where ME001 = '95442' and ME003 = 'EBD'

Future Member Data: Member data associated with EBD pharmacy data managed by its pharmacy benefit manager, MedImpact (99MDI2 and 99MDI3), are still being finalized.

Medical Claims:

select records from medical claims
  where MC001 = '99EBD1' and MC059 <= '2014-12-31'
  Note:  There are no records where MC001 = '99EBD1' 
  and MC017 > '2015-01-01'

To find associated EBD member/enrollment data sourced from EBD for medical claims 2014-12-31 back:

select records from Member data
  where ME001 = '99EBD1' 
  and MC012 = ME013 (member gender)
  and MC013 = ME014 (member date of birth, else MC013_year = ME014_year)
  and MC137 = ME107 (carrier specific unique member ID)
  and MC017 (Paid Date) is between (ME162A (member enrollment date) 
     and ME163A (member disenrollment date))
  or MC059 (Date of Service) is between (ME162A (member enrollment date)
     and ME163A (member disenrollment date))
  
  Note: MC017 is recommended because the DSG submission 
  requirement specify MC017.  MC059 will yield different
  counts.
 

Medical claims data from 2015-01-01 forward are no longer sourced from EBD and are now sourced from Health Advantage (Arkansas Blue Cross and Blue Shield). There is no field to flag a claim as EBD so the medical claims must be matched to the member data to identify it as an EBD claim.

select records from Member data
where MC001 = '95442' and ME001 = ‘95442’
  and ME003 = ‘EBD’  
  and ME107 = MC137 (Member Number)
  and ME006 = MC006 (Group number)
  and ME009 = MC008 (Contract number)
  and ME013 = MC012 (Member Gender)
  and MC059 >= ‘2015-01-01’ or MC017 >= ‘2015-01-01’ 
  (MC017 is recommended because the DSG submission 
  requirement specify MC017.  MC059 will yield different
  counts.)

Pharmacy Claims:

Pharmacy claims data 2022-05-31 back are still sourced from EBD:

select records from pharmacy claims
  where PC001 = '99EBD1' and PC017 <= '2022-05-31'
  Note:  There are no records where PC001= '99EBD1' 
  and PC017 > '2022-06-01'

To find associated EBD member/enrollment data for pharmacy claims:

select records from Member data
  where ME001 = '99EBD1' 
  and PC012 = ME013 (member gender)
  and PC013 = ME014 (member date of birth, else MC013_year = ME014_year)
  and PC107 = ME107 (carrier specific unique member ID)
  and PC017 (paid date) is between (ME162A (member enrollment date) 
  and ME163A (member disenrollment date))

Pharmacy claims data from 2022-06-01 forward are no longer sourced from EBD and will be submitted by its TPA MedImpact. These data are not available yet. Once available, selection criteria will be provided.

Therefore, medical claims and associated member data (whether from EBD or Arkansas Blue Cross Blue Shield) is available from 2013-01-01 through current. Pharmacy claims and associated member data is available from 2013-01-01 through 2022-05-31.

Linking between EBD and TPAs:

EBD, Arkansas Blue Cross and Blue Shield, and MedImpact member IDs do not match across source systems. Users must use the Study ID methodology to join members across submitters. See Data Tip: Tip: APCD Unique ID, aka Hash ID

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