Tip: Identifying Claims Duplicated across Carriers

0093

Sep 14, 2021

Mar 14, 2023 May 24, 2023

Included in June 2023 data tips email

Identifying Duplicate Claims across Carriers

Active

Duplicate medical, pharmacy, and dental claims do not always represent a data quality issue.

Periodically, submitting entities switch or add claims processors, TPAs or PBMs.  For example, Arkansas Medicaid PASSE entities and Arkansas Medicaid submit pharmacy claims for their individual systems for the same prescriptions.

To identify duplicate submissions, group the claims within your analytic dataset on any one or combination of the listed fields to group claims for same enrollees from different pharmacy submitters.

1. Build groups by first appending the member’s associated Study ID (concatenated APCD Unique ID (ME998) and Gender (ME013) to the medical, pharmacy, or dental claims based on a Member ID match (ME001 = MC001, PC001, DC001 and ME107 = MC137, PC107, DC056).

2. Next step by file type:

   1. Medical claims - Group by Study ID, Service Date (MC059), Procedure Code (MC055), and Service Provider NPI (MC026). NOTE, other fields may be required depending on the diagnosis and service.

   2. Pharmacy claims - Group by Study ID, Fill Date (PC032), Drug Code (PC026), and Service Provider NPI (PC021).

   3. Dental Claims - Group by Study ID, Service Date (DC035), Procedure Code (DC032), and Service Provider NPI (DC020). NOTE, other fields may be required depending on the diagnosis and service.

3. If groups came from more than one submitting entity, pull the claims associated with these members and examine to determine if and how the claims are related.  Evaluate the grouped records for data inconsistencies that might indicate the group does not represent the same prescription or member.

When possible duplicate claims are identified, note the values in Submitting Entity ID (MC001, PC001, DC001) then review the Arkansas APCD Data Tips for information about merged submitters to determine which claims to omit.

Special note:  When utilizing pharmacy data, it is recommended that the data user always look for possible duplicate submissions. When working with Arkansas Medicaid pharmacy claim data and the overlapping Arkansas PASSE data* (Tip: Identifying Arkansas PASSE claims ), do not utilize the Arkansas Medicaid claims but use the matching PASSE pharmacy claims for analysis.  

*Arkansas Medicaid PASSEs - Summit (60217), Empower (16244), Arkansas Total Care (16256)

Merged SE & Overlap

Data Quality

Tip