Prior to 2022, Home Health Agencies (HHA) billed Medicare for partial payment before an episode of care was complete by submitting a Request for Anticipated Payment or RAP that would later be replaced by a traditional Medicare claim once the episode of care ended(1).

Emergency department (ED) utilization serves as a foundational metric across health services research. Because ED visits are high-cost and high-intensity, the identification of these events is critical for measurement and evaluation of healthcare quality(1). Health researchers rely…

Medicare beneficiaries may enroll in a private managed care plan (Medicare Advantage (MA)) or in Fee-for-Service (FFS) Medicare (Original Medicare). The Master Beneficiary Summary File (MBSF) includes all beneficiaries enrolled in Medicare for at least one day of the year and contains…

Provider IDs are state-reported variables, meaning that states can include their own provider numbers when submitting records to T-MSIS. In the TAF data, these numbers are delineated by variables with a specific Provider ID suffix.

The TAF Pharmacy files (TAF RX) are a CMS Research Identifiable File (RIF) that contains pharmacy prescription fill and over the counter (OTC) drug information covered by Medicaid. They are sourced from the T-MSIS, which is a repository of service utilization and reimbursement records…

Professional and technical components are HCPCS modifiers that splits Medicare payment into supervision/interpretative and equipment/facility costs. This allows separate entities to bill for their portion of a service.

Part C encounter RIF data includes two types of records: service records and chart reviews. Medicare Advantage Organizations (MAOs) perform retrospective reviews of their beneficiaries’ medical records to identify diagnoses that were not originally submitted by providers or were…

The Claims Processing Manual (CPM) is the rulebook for submitting claims to CMS. It covers a wide range of medical coding instructions by clinical setting and form.

Medicare fee-for-service (FFS) research identifiable files (RIFs) include both approved and denied claims as well as claims that are denied in part. Claim denials are common, surprisingly complicated, and important for researchers to consider. The choice to include or exclude them…

The Master Beneficiary Summary File: Base file (MBSF: Base), a research identifiable file offered by CMS, contains two annual race variables: the Beneficiary Race Code and the Research Triangle Institute (RTI) Race Code.