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HEALTHCARE RESEARCH

RESEARCH CAPABILITIES

Learn about the research sample set available for your custom research.

DATA DETAILS

Learn about the specifics that can be researched.

DATA VALIDATION

Explore the details of data validation performed before research begins.

RESEARCH CAPABILITIES

PearlDiver has partnered with Comprehensive Health Insights to integrate Humana’s full claims database in to the PearlDiver research program.

As of June, 2017 Humana represents 22 million patients throughout the duration of the set including claims from 2007 through Q2 2016. No sampling is performed on this data. Research is conducted over the full set including commercial and Medicare advantage populations. While de-identified and HIPAA compliant, this research set is fully capable of longitudinal research based upon unique patient identifier codes.

Research can be performed utilizing any one or combination of identifiable fields on the claim record processed by Humana. Fields include but are not limited to; ICD-9 & ICD-10 diagnosis coding, DRG procedural coding, ICD-9 & ICD-10 procedural coding, CPT procedural coding, prescription NDC coding, lab record LOINC coding, discharge status, demographic, physician specialty, and geographic region or state.

DETAILS

Scope: National Time Period: 2007 – Q2 2016

Total Patient Volume: 22 million

Longitudinal: Yes, time specific capable

Providers: Facility, physician, ancillary services, pharmacy

Geographic Inclusion: All U.S. states and territories

Researchable procedure/drug/lab coding: DRG, ICD-9 Diagnosis, ICD-10 Diagnosis, ICD-9 procedural, ICD-10 procedural, CPT, NDC, LOINC

Additional filters: Age, date, discharge status, drug group, field number (primary, secondary, tertiary, etc.), gender, length of stay, physician specialty, plan type, race, region, service location, and state

Payer Types: Individual commercial, state-based Medicaid, Medicare stand alone PDP, group Medicare Advantage, and Individual Medicare Advantage

Modifiers included: Yes

Cost of Care Availability: Insurer reimbursed amount per claim

Updates: Data is updated on a quarterly basis

DATA VALIDATION

  • Humana regularly conducts patient record audits, Provider Payment Integrity (PPI) audits, on-site audits, and desk audits to ensure integrity within Humana claims. Audit policy details are available at www.humana.com/provider/medical-providers/education/claims/financial-recovery/hospital-audits.
  • In addition to internal review, as a Medicare Advantage Organization (MAO) and insurer of government employees, Humana is required on an annual basis to contract with qualified independent third parties to conduct defined audits on the validity and reliability of data.
  • Medicare Part A claims are subject to DRG validation review under CMS Publication 100-08, Chapter 6, Section 6.5.3. The purpose of DRG validation is to ensure that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician's description and the information contained in the beneficiary's medical record.
  • Medicare Part B validates claims under the Hospital Outpatient Quality Reporting Program (Hospital OQR). Under the Hospital OQR Program, hospitals must meet administrative, data collection and submission, validation, and publication requirements or receive a 2-percentage point reduction in their annual payment update (APU) under the Outpatient Prospective Payment System (OPPS).
  • Medicare Part C: Organizations contracted to offer Medicare Part C and Part D benefits are required to report data to CMS on a variety of measures. CMS has developed reporting standards and data validation specifications with respect to the Part C and Part D reporting requirements. These standards and specifications provide a review process for Medicare Advantage Organizations (MAOs), Cost Plans, and Part D sponsors to use to conduct data validation checks on their reported Part C and Part D data. The data validation is “retrospective,” referring to the fact that it normally occurs in the year subsequent to the measurement year. For example, the data validation for CY 2012 data was conducted in CY 2013. In order to ensure the independence of the data validation, organizations will not use their own staff to conduct the data validation. Instead, MAOs, Cost Plans, and Part D sponsors will be responsible for acquiring external data validation resources.

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