Health Care Payments Data Program Submitters
AB 80 (Chapter 12, Statutes of 2020) provides HCAI (formerly OSHPD) the authority to establish the Health Care Payments Data (HPD) Program, often referred to as an All Payer Claims Database or APCD, a large-scale database that systematically collects health care claim and encounter data from multiple payer sources within a state. The enabling legislation identifies the following entities as mandatory submitters to the HPD:
- Health care service plans, including a specialized health care service plan.
- Insurers licensed to provide health insurance, as defined in Section 106 of the Insurance Code.
- Self-insured plans subject to Section 1349.2, or a state entity, city, county, or other political subdivision of the state, or a public joint labor management trust that offers self-insured or multiemployer-insured plans that pay for or reimburse any part of the cost of health care services.
- The State Department of Health Care Services, for those enrolled in Medi-Cal and other insurance affordability programs, whether enrolled in Medi-Cal managed care, fee-for-service Medi-Cal, or any other payment arrangement.
- The legislation also specifies additional voluntary submitters, who can opt-in to submit their data to the HPD System.
Pursuant to Section 127672 of the Health and Safety Code, HCAI is authorized to convene stakeholder committees or workgroups as necessary to support effective operation of the system. In addition to the statutorily mandated HPD Advisory Committee, HCAI is convening a submitter group to provide a forum for HPD Data Submitters to receive up to date information on submission requirements, troubleshoot data submissions, and address any other technical issues as related to data submission.
These meetings are intended for entities that will be required to submit or are supporting the submission of data to the HPD System. If you are interested in learning more about joining the submitter group meetings, please email firstname.lastname@example.org describing your interest in attending.
April 14, 2022
January 13, 2022
October 14, 2021
July 15, 2021
The following are resources for the Healthcare Payments Data Program:
HPD Submitter Training Presentation Materials:
- Introduction to HPD and APCD-CDL™ (February 24, 2022)
- SFTP and PGP Encryption (March 1, 2022)
- HPD Plan Registration (March 3, 2022)
- HPD Submitter Registration (March 30, 2022)
- Introduction to Claims Data Manager (CDM), Validations, and Variances (April 7, 2022)
1. Who will be required to submit data to HPD?
Commercial plans licensed with the Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI), who have greater than the threshold of covered lives defined in the HPD Regulations.
Public self-insured entities who have greater than the threshold of covered lives defined in the HPD Regulations.
Qualified Health Plans offered by the California Health Benefit Exchange (Covered CA) is a mandatory submitter regardless of the threshold.
For more information on what entities are required to submit to the HPD, please refer to California Code of Regulation Sections 97310 and 97314.
2. Can anyone else submit data to HPD?
Yes, private self-insured entities, and any other submitter with less than the threshold of covered lives, may apply to voluntarily submit data to HPD. Please refer to California Code of Regulations Section 97305 for more information.
3. Is it required that we report all claims for services provided in CA or all claims for Californians, even if they were provided out of state?
HPD requires data for CA residents, regardless of where the services were provided. For more information, please refer to California Code of Regulations Section 97342.
4. What type of data does HPD require?
Initially, submitters are required to send medical claims and encounters, pharmacy claims, eligibility, and provider data. Dental claims data will be required in 2024.
The HPD Program anticipates collecting healthcare data for 30 to 34 million Californians, sourced from: the Department of Health Care Services (DHCS) for Medi-Cal members; the Centers for Medicare & Medicaid Services (CMS) for Medicare fee-for-service members; and health plans and insurers for those with employer-based, individual, or Medicare Advantage coverage.
5. Is Medicare Advantage data being collected?
Medicare Advantage data is within the scope of the HPD data collection. This data will be coming directly from commercial health plans. Medicare FFS data will come directly from CMS.
6. How often will submitters need to provide data?
Ongoing data submission will be on a monthly basis. Submitters will also provide historical data (June 29, 2017 through December 2021), and production 2022 monthly files (catch-up files) as part of initial HPD data collection.
7. What data formats will be used?
For the four initial files, HCAI will use the All Payer Claims Database -Common Data Layout (APCD-CDL™) version 2.1, developed by the National Association of Health Data Organizations (NAHDO) and the APCD Council. Copies of the APCD-CDL™ can be obtained at the following location: https://www.apcdcouncil.org/common-data-layout.
8. How can data submitters provide input on future updates to the APCD-CDLTM?
The APCD-CDLTM has been developed by NAHDO and the APCD Council. This national effort has prioritized, and continues to incorporate, input from various stakeholders, including health plans. You can find out more information about the data maintenance request process on the APCD Council website: https://www.apcdcouncil.org/common-data-layout. HCAI will solicit feedback from California health plans about the APCD CDLTM and can facilitate sharing consolidated feedback to the APCD Council to represent the state’s unique and diverse healthcare landscape. Email email@example.com for more information.
9. When are test and production submissions scheduled to occur?
For medical claims and encounters, pharmacy, eligibility, and provider files:
- Testing for historical data submission is planned to start in Q2 2022 with testing to be completed by July 29, 2022.
- Testing for monthly data submission is planned to start in Q3 2022.
- Monthly production submissions are expected to begin no later than January 2023.
10. Other than the statute, what other documentation is available for potential submitters to review?
- The HPD Regulations were approved in December 2021. The HPD Regulations describe how HCAI is implementing the statute and are available on our website.
- The Data Submission Guide describes the requirements of the datasets. The Data Submission Guide is incorporated in the HPD Regulations.
- The Reporting Manual consists of discussion and comments related to the implementation of HPD regulations.
11. Will a submitter be able to apply for a temporary data variance, if they are unable to comply with the Data Submission Guide?
Yes. The process for requesting a temporary data variance is included in California Code of Regulations Section 97370. A data variance is intended to allow a submitter relief from specific requirements for a limited time while they enhance their data collection processes. Information on how to request a data variance is also included in the HPD Reporting Manual.
12. What type of edits will HPD apply to submitted files, and what happens if there are errors in the submission?
The HPD System will initially compare submitted data files to the data element definitions in the APCD-CDL™ with regard to data element position, field length, and defined data format. The system will then validate that any required or situational data elements have been populated as defined in the Data Submission Guide. Further edits that will be applied include: coding standards, file format and naming conventions, timeliness of submission, duplicated data, and others.
A submitted file will either be accepted or rejected. Rejection is at the file level not the record level. If a file is rejected, the submitter must correct the file and resubmit.
13. Where can submitters find out more about how to register for data submission to HPD?
This information is included in the California Code of Regulations Section 97330-97334 and in the HPD Reporting Manual.
For questions regarding the registration process, please contact Onpoint Health Data at firstname.lastname@example.org.
14. Where can submitters find out more about data specifications and mapping of required HPD datasets?
required HPD datasets?
15. Where can I go if I have a question?
For program related questions, please contact email@example.com and a HCAI staff member will assist .
For technical questions on data submission, please contact firstname.lastname@example.org and an Onpoint staff member will assist.
16. Do we need to include Dental ONLY membership in the Member Eligibility file?
Submission of dental claims data is not required until the 2024 timeframe. However, dental services submitted on an 837 P/I that are covered under a member’s medical benefits are expected and should be reported within the medical claim file. These types of claims include services that are deemed “medically necessary” and would not include data elements such as tooth number or tooth surface, with CDT codes reported in the procedure code field (CDLMC088). Please refer to the HPD Reporting Manual regarding submitting dental data.
17. What is the HCAI Size limitation on the monthly and historical file?
The preference is that files would not exceed 10 million records per file. If you intend to submit a monthly file larger than 10 million records please reach out to the Onpoint HPD Support team.
18. For the historical data submissions, is HCAI expecting one file per year or all this data in one historical file.
Historical data can be provided in monthly, quarterly, or annual increments.
19. What is the File naming convention that needs to be followed for each of the files?
Per the HPD Reporting Manual, the file naming convention is at the discretion of the submitter, but submitters are encouraged to include a submission date/version number in the file name reported so as to better identify multiple iterations of the same file type and reporting period.
20. Can a submitter choose any date of the month to send the files or is there a date each month HCAI would need the extracts?
Please refer to California Code and Regulations Section 97340. Submitters are encouraged to report data prior to the submission due date. This allows for our team to work through timely data validation. Submission prior to the due date as outlined in the HPD Regulations is at the discretion of the submitter.
21. When are the historical and production HPD data files due?
For these initial file types (eligibility, medical, pharmacy, and provider files), submitters will send historical data (June 29, 2017 through December 2021) by October 28, 2022. By February 1, 2023, submitters will send production 2022 monthly files (catch-up files). Submitters will be required to send dental claims data starting with historical data (June 29, 2017 through December 2021) by October 31, 2024. By February 1, 2024, submitters will send production 2024 monthly dental files begin with the month of November and all remaining data between January 2022 through October 2024 (catch up files). For more information, please refer to California Code of Regulations Sections 97350, 97351, and 97352).
1. What is my payer code (data element codes CDLHD003 and CDLTR003)?
Your Payer Code will be supplied upon registering to submit data to the HPD program. A list of approved Payer Codes will be provided to submitters prior to reporting data to the HPD initiative, and submitters must include the Payer Code as part of each reported submission. However, if a submitter reports data on behalf of more than one plan, they should leave the Payer Code in the Header and Trailer records of each file null.
2. What is my submitter code (data elements CDLHD002 and CDLTR002)?
The submitter code will be assigned to each submitting organization as part of the Submitter Registration process. The same submitting entity may report data under more than one Submitter Code if a submitting entity needs to report claims adjudicated under different methods/systems in separate or if a submitting entity finds that mapping separate source systems per file type is easier to do so under separate mappings (e.g., one Submitter Code provided for mapping HMO data, another Submitter Code provided for mapping PPO data, etc.).
3. What reporting period (data elements CDLME005 and CDLME006) should I be using to submit my files?
Historical files may be submitted to the HPD program using the timespan preferred by the submitter (e.g., monthly, quarterly, annually). An organization expects to submit files larger than 15-20 million records per month, please reach out to Onpoint at email@example.com so that we can help facilitate the most efficient submission process for your organization.
Once submitters have reported all historical data to the HPD program, submitters will be sending files monthly as part of their regular reporting.
Submitters should be using the following dates to report each file type:
- Eligibility: enrollment start and end dates (earliest CDLME005/CDLME006 reported for the Period Beginning Date and latest CDLME005/CDLME006 reported for the Period End Date).
- Medical: paid date (earliest CDLMC024 reported for the Period Beginning Date and latest CDLMC024 reported for the Period End Date).
- Pharmacy: paid date (earliest CDLPC024 reported for the Period Beginning Date and latest CDLPC reported for the Period End Date).
- Provider: Period Beginning Date and Period End date here should align with data reported for enrollment and claims (i.e., provider-level information submitted in this file for providers present in eligibility and claims files).
4. How do I find my organization’s CMS National Plan ID (data elements CDLME003, CDLMC003, CDLPC003)?
The CMS National Plan ID is an identifier whose assignment/use has been rescinded by CMS. Please report this field null.
5. How do I select the most appropriate insurance/product categories (data elements CDLME004, CDLMC004, CDLPC004) to map my organization’s data to based on the list provided in the Appendix G-1 of the APCD-CDL TM ?
While there are many options for types of Insurance/Product Category codes provided in Appendix G-1, HCAI prefers submitters map their data to a subset of these values to promote a standard across California APCD reporting. This list is included in the HPD Reporting Manual.
6. How do I report a member’s enrollment properly in my organization’s eligibility file (data elements CDLME005 and CDLME006)?
Enrollment coverage should be reported using the “Start Year of Submission” (CDLME005) and the ‘Start Month of Submission’ (CDLME006) fields in the eligibility file.
The “Start Year of Submission” corresponds to the year for the month of enrollment that is being reported per member. Each row in the eligibility file should report a per-member-per-month record of enrollment.
The “Start Month of Submission” corresponds to the month of enrollment that is being reported per member. Each row in the eligibility file should report a per-member-per-month record of enrollment. For example, if a submitter is reporting John Doe’s continuous enrollment throughout the entire year of 2019, we would expect to see 12 records reporting a different value/different month in the CDLME006 for each month of John Doe’s eligibility, and CDLME005 would be reported as “2019” for each of those 12 records.
7. What field in Appendix G-2 should I be using to map Race codes (data element CDLME029)?
Submitters should use the first two characters of the “Hierarchical Code” column in the CDC’s Race Code Set located here: https://www.cdc.gov/nchs/data/dvs/Race_Ethnicity_CodeSet.pdf.
8. What field in Appendix G-2 should I be using to map Ethnicity codes (data element CDLME033)?
Submitters should use the six characters (including the hyphen) of the “Unique Identifier” column in the CDC’s Ethnicity Code Set located here: https://www.cdc.gov/nchs/data/dvs/Race_Ethnicity_CodeSet.pdf.
9. The Actuarial Value (data element code CDLME066) indicates I should be submitting a decimal included within the field’s reported value. Is this correct?
Yes, there are certain fields that the APCD-CDL TM Version 2.1 requires submitters to report a decimal in, such as the Units of Service/Quantity fields and the Actuarial Value. Most other fields require submitters to refrain from reporting decimals or other punctuation.
10. The APCD-CDL TM Version 2.1 requires the Member’s Medicare Beneficiary Identifier (data element code CDLME075) reported for only Medicare Supplemental/Companion Plans, but the HPD Data Submission Guide requests this field populated for all Medicare members– who is required to populate this field?
Members receiving a Medicare Advantage, Medicare Part D, and Medicare Supplemental/Companion Plans should report this field; please populate as available with either the Medicare enrollee’s MBI or HICN.
11. It seems the formatting between the Quantity fields in the Medical and Pharmacy files vary between file types (data element codes CDLMC121 and CDLPC032); is that correct?
Yes. Submitters should report three digits past the decimal in the Medical file and two digits past the decimal in the Pharmacy file.
12. In the Provider file, should we report the Payer Assigned Provider ID for only Member PCPs or for all providers (data element code CDLPV004)?
Please report the Payer Assigned Provider ID for all providers, not just for Member PCPs.
13. Do I just need to submit the data specified in the Data Submission Guide?
No. The Data Submission Guide (DSG) is based upon the APCD-CDLTM specifications. The DSG only includes those data elements that HPD have designated as Required or Situational, and submitters are reminded to include all fields per the APCD-CDLTM specifications. APCD-CDLTM data elements not identified in the DSG as either Required or Situational must still be populated as data is available. Please refer to California Code of Regulations Section 97344.
Contact HPD at firstname.lastname@example.org for additional HPD questions or inquiries.
To receive regular informational updates about the program, subscribe to the HPD mailing list.