All Payer Claims Databases
Background and overview
Over the past five years, at least 12 states have enacted laws that let them collect health care claims data from
commercial and public payers for all-payer claims databases. All-payer claims databases are used for various
research and policy purposes, including public health, health services and public policy research; consumer
tools, employer coalition reporting, and payer and provider negotiation. All-payer claims databases typically
include data from member eligibility files, provider files, medical and pharmacy claims files, and, in a few states,
dental claims files.
As states where we do business enact these laws, our company must send claims data to them regularly. The
data rules and data submission rate varies from state to state, and strict security measures are in place to
protect all the data we send.
Operational readiness
We now report claims data in Maine, Massachusetts, New Hampshire and Vermont. Several other states are
implementing their all-payer claims databases, including Colorado, which is expected to start collecting claims
data in spring 2012, and New York, where several stakeholders are developing the required data elements for
their all-payer claims database. As states show interest in creating all payer claims databases, we are joining in
discussions to let lawmakers and stakeholders know about best practices as well as the challenges and
limitations of the data supplied to all-payer claims databases. Reporting rules differ among the states. Some
collect only fully insured data while others also collect data on ASO plans. We have strict security measures to
protect all the data we send.
Our position on all-payer claims databases
Policy
paper_si_09122011.docx
Frequently asked questions
1. What are all payer claims databases?
All-payer claims databases are large-scale databases that systematically collect health care claims data
from various payer sources. Payer sources may include insurance carriers, third-party administrators,
pharmacy benefit managers, dental benefit administrators, state Medicaid agencies, CMS (Medicare),
Federal Employees Health Benefit Plan administrators and TRICARE administrators. All-payer claims
databases are typically created by state law. In some states, reporting is mandated, while in others, taking
part is voluntary.
2. What type of data is in these databases?
Databases by and large include data from medical claims, pharmacy claims, eligibility files, provider
(physician and facility) files, and dental claims from private and public payers.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In
Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the
Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO
benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not
underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the City of Fairfax, the Town of
Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the
PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi
collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem
Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
3. Where does the data come from?
All-payer claims databases collect data from claims transaction systems used by health care providers
(facility and practitioners) and payers. The information typically collected in an all-payer claims database
includes patient demographics, provider demographics, and clinical, financial and utilization data. We feed
data from various source systems to our regional and enterprise data warehouses, which produce the allpayer claims files for reporting.
4. What is the data used for?
All-payer claims databases are used for various research and policy purposes, including public health,
health services and public policy research; consumer tools and employer coalition reporting.
5. Is there a fee for sending this data for self-funded clients?
No. We do not charge our self-funded clients a fee for sending data for them.
6. Do self-funded clients need to permit our company to send data for them?
No. Contracts with our self-funded accounts say that if we are mandated to send data to a regulatory
authority, we will do so for our clients. We do not need specific authorization from the self-funded client as:
a) we only send plan data that is mandated by regulation; and b) claims data does not constitute a “plan
asset.” As a result, unless we were to hear otherwise from a self-funded client, we don’t believe there is an
ERISA pre-emption issue.
7. Do all states have the same data collection rules?
No. Data collection rules vary from state to state. We urge states to adopt the standard data set developed
by the All-Payer Claims Database Council.
8. What security measures are in place to protect data submissions?
Except for Massachusetts, states where we are mandated to send data use a third-party vendor as the gobetween for encrypted file submission. Massachusetts requires that payers send data through a software
package called SENDS+. Per the rules of the states’ mandate and our internal privacy policies, all data is
encrypted before it is sent to the designated entity. Any data reported out of the all-payer claims database
must also be stripped of identification as stated by HIPAA’s standards.
9. Are all-payer claims databases part of health care reform?
All-payer claims databases go hand-in-hand with health care reform, which calls for states to show access
to health care and which services and coverages their residents use. Our company is working with many
state and federal groups to encourage standardization and simplification of these data rules, which will let
us comply more efficiently and cost-effectively.
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In
Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the
Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO
benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not
underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the City of Fairfax, the Town of
Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the
PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi
collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem
Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
10. Where can I learn more about specific state rules?
www.apcdcouncil.org
Anthem Blue Cross and Blue Shield is the trade name of: In Colorado and Nevada: Rocky Mountain Hospital and Medical Service, Inc. In Connecticut: Anthem Health Plans, Inc. In
Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the
Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO
benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not
underwrite benefits. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Company. In Virginia (excluding the City of Fairfax, the Town of
Vienna and the area east of State Route 123.): Anthem Health Plans of Virginia, Inc. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the
PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi
collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem
Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.