DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
 
 
 
MMCO - CMCS Informational Bulletin  
 
 
DATE:  May 11, 2011 
 
FROM: Melanie Bella  
Director  
   Medicare-Medicaid Coordination Office  
 
Cindy Mann  
Director  
Center for Medicaid, CHIP and Survey & Certification  
  
SUBJECT: Access to Medicare Data to Coordinate Care for Dual Eligible Beneficiaries 
 
The Federal Coordinated Health Care Office (Medicare-Medicaid Coordination Office) and the 
Center for Medicaid, CHIP and Survey & Certification (CMCS) are issuing this Informational 
Bulletin to inform State Medicaid Agencies of the availability of and process for requesting timely 
Medicare Parts A, B and D claims/event data for their dual eligible beneficiaries to support care 
coordination.  Having access to Medicare data is an essential tool for States seeking to coordinate 
care, improve quality, and control costs for dual eligible beneficiaries.  States whose requests are 
approved will be able to combine Medicare Parts A and B claims and Medicare Part D Prescription 
Drug Event (PDE) data and link to the States Medicaid data for whole-person analysis of the dual 
eligible experience.  States may also request Medicare eligibility and enrollment data on their dual 
eligible beneficiaries.   
 
The Centers for Medicare & Medicaid Services (CMS) has permitted states to request access to 
Medicare Part D PDE data since 2008, but until now, had limited availability to final action 
data (i.e., not subject to subsequent adjustment).  However, States have expressed concerns that 
final action data are not timely enough to support care coordination.  For example, currently final 
action data are only available for dates of service through 2009.  We are pleased to announce that 
CMS is now making available to States more timely non-final action (i.e., subject to subsequent 
adjustment) Medicare Part D PDE data for the specific purpose of supporting care coordination 
activities that have the potential to improve care for dual eligible beneficiaries at the individual 
level.  These data will be made available at no cost to States.  Please see Attachments 1-3 for 
details.  For all other uses permitted by 42 CFR 423.505, States will continue to be limited to final 
action data. 
 
 
1  CMS has provided States the ability to request timely Medicare Parts A and B claims data since 
2008, and Medicare Parts A, B, C, and D eligibility/enrollment data since 2009.  We have 
learned some States are unaware of these options, so are including a reminder in this Informational 
Bulletin.  For details on the availability of and process for requesting Medicare Parts A and B 
claims data, please see Attachment 4.  For details on requesting access to Medicare eligibility and 
enrollment data, please see Attachment 5.  Both are available at no cost to States.  Please note that 
at this time, Medicare Part C health plan encounter data are not collected.   
 
For Additional Information  
We hope these data will help States as they seek to coordinate and improve care for people eligible 
for Medicare and Medicaid. 
States that have additional questions may contact the Medicare-Medicaid Coordination Office at 
MedicareMedicaidCoordination@cms.hhs.gov.  
 
 
 
Attachments (5): 
 
1  Process for Requesting Medicare Part D PDE Data 
2  Limitations of Medicare Part D PDE Data 
3  Medicare Part D PDE Data Element Availability  
4  Process for Requesting Medicare Parts A and B Claims Data 
5  Process for Requesting Medicare Eligibility/Enrollment Data 
 
 
   
 
2  Attachment 1  Process for Requesting Medicare Part D PDE Data 
 
 
As described in the October 3, 2008 State Medicaid Letter, States have been able to request final 
action (i.e., not subject to subsequent adjustment) Medicare Part D Prescription Drug Event 
(PDE) data since 2008.  CMS is now permitting States to request more timely non-final action 
Medicare Part D PDE data, specifically for care coordination activities that have the potential to 
improve care for dual eligible beneficiaries at the individual level.  Please note that there are 
limitations to the data, e.g., the data are subject to lags that may impact their efficacy for care 
coordination (please see Attachment 2 for additional details).  
 
The release of Medicare Part D PDE data by CMS is governed by 42 CFR 423.505(m), which 
includes various privacy protections for these data, and requires CMS to allow only the release of 
minimum data necessary to a requestor.  Accordingly, States will only receive PDE data on 
individuals who are full-benefit dual eligible beneficiaries in that particular State, and must justify 
the necessity for each data element requested for their care coordination efforts.  CMS has 
determined that financial data elements will not be made available, nor will internal plan and 
pharmacy prescription identification numbers.   Please see Attachment 3 for the list of specific data 
elements available for release. 
 
Given the sensitivity of these data, States requesting these data will need to provide strong 
protections for them.  CMS will only permit these data to be shared with downstream entities if 
necessary to support specific care coordination efforts, and the State must demonstrate how it will 
ensure that the downstream entities safeguard these data.  Please note that CMS will generally not 
approve further re-release or sharing from the first level downstream entity to other downstream 
entities.  Finally, please note that these data will not be permitted to be used by the State Medicaid 
Agency, nor matched with files from other State agencies, for any purpose other than care 
coordination for dual eligible beneficiaries, e.g., investigating fraud or conducting research.   
 
States may request one historical baseline file and monthly files thereafter of non-final action 
Medicare Part D PDE data to support care coordination for dual eligible beneficiaries.  There is 
no cost to States for Medicare Part D PDE data shared under this process.  For more information 
on requesting non-final action Medicare Part D PDE for care coordination purposes, please visit 
our website at http://www.cms.gov/Medicare-Medicaid-Coordination.  
   
 
3  Attachment 2 -- Limitations of Medicare Part D PDE Data 
 
 
States interested in receiving non-final action (i.e., data that may be subsequently adjusted) 
Medicare Part D Prescription Drug Event (PDE) data for care coordination of their dual eligible 
beneficiaries should be aware there are some limitations to these data.   As described below, the 
primary limitation is that Medicare Part D PDE data do not necessarily represent a complete 
picture of prescription drugs used by dual eligible beneficiaries.  In addition, the data are subject to 
lags that may impact their efficacy for care coordination.  A more detailed discussion of limitations 
follows.   
 
  PDE data have lags that may reduce their efficacy for care coordination.  State Medicaid 
Agencies may be used to obtaining prescription drug claims in close to real time when they 
are the primary payer.  However, as noted below, PDE data are not claims.  Medicare 
prescription drug plans must submit PDE data to CMS every 30 days; however, at this time 
there is no timely filing limit, except that related to the annual financial reconciliation 
process.  In addition, while PDE data are loaded into CMS system daily, CMS will only 
send files of these data once a month to States whose requests for non-final action data are 
approved. 
 
  PDE data received may be non-final action; subsequent non-financial adjustments may 
occur.  For example, a pharmacy may submit a corrected National Drug Claim (NDC) 
number or days supply.  However, these types of adjustments are very rare. 
 
  PDE data may not provide a complete picture of drugs dispensed to dual eligible 
beneficiaries.  Reasons include: 
o  PDE data are only available for dual eligible beneficiaries enrolled in a Medicare 
Part D prescription drug plan.  Individuals not enrolled in those plans will have no 
PDE data.  This includes individuals receiving their prescription drug coverage 
from other sources such as an employer/union plans (which may or may not claim 
the Part D Retiree Drug Subsidy), Veterans Administration, Tricare, or the Federal 
Employees Health Benefit Plan.   
o  Dual eligible beneficiaries enrolled in a Medicare prescription drug plan may obtain 
drug coverage through other sources, e.g., drugs  may be covered under Medicare 
Part B; Medicaid; a pharmaceutical patient assistance program outside of the Part D 
benefit; other coverage; or paid for out-of-pocket by a beneficiary.   Prescription 
drugs explicitly excluded by Part D, as well as over the counter drugs, will not have 
PDE data associated with them.   
 
  PDE data are not the same as individual drug claim transactions.  Instead, they are similar 
to encounter data in that they represent summary extracts using CMS-defined standard 
fields.  Requestors using the PDE data should keep in mind that a PDE is not the actual 
claim paid at the pharmacy, but a record of that claim that has been created by the Part D 
sponsor prior to its submission to CMS for payment reconciliation.   
 
   
 
4  Attachment 3 -- Medicare Part D PDE Data Element Availability  
 
This chart shows the non-final action data elements that are available for release to State Medicaid 
Agencies for care coordination for dual eligible beneficiaries.  Please note that under CMS 
minimum necessary data policy a requestor would not automatically receive all of the available 
elements, but would only receive those necessary for its care coordination efforts. 
 
Identifiers 
Data Elements  Availability 
Beneficiary ID   Available 
(HIC Number, Cardholder ID, Patient date of birth) 
Plan ID    Available 
(PBP identifier, Contract identifier) 
Prescriber ID  Available 
(Prescriber Identifier) 
Pharmacy ID  Available 
(Service provider identifier) 
Qualifying Identifiers  Available 
(Service & Prescriber Identifier Qualifiers  codes that denote whether 
NPI, NCPDP, UPIN, state license number,  DEA, or non-standard code 
is used)  
Internal plan/pharmacy prescription identification numbers  Not available 
(Claim Control Number - a code  intended for the plan to identify   
unique events & Prescription Service Reference Number  a code   
assigned by the pharmacy at the time the prescription is filled) 
 
Drug Utilization Information 
Data Elements  Availability 
Date of Service  Available 
Drug information  Available 
(Product/Service Identifier, Quantity Dispensed, Days Supply, 
Compound Code, Fill Number, Dispensing Status.) 
Other utilization information  Available 
(Dispense as Written/Product Selection Code, Drug Coverage Status 
Code) 
   
 
5  Drug Cost Information 
Data Elements  Availability 
Total Drug Costs  Not available 
(Ingredient Cost, Dispensing Fee, Total Amount Attributable to Sales 
Tax)   
 
Coverage Information 
Data Elements  Availability 
Date Paid  Available 
Plan Paid Amounts  Not available 
(Covered D Plan Paid Amount, Non-covered Plan Paid Amounts)  
Beneficiary cost sharing  Not available 
(Patient Pay Amount) 
Other Payer Amounts   Not available 
(Other True Out of Pocket Amount, Patient Liability due to Other Payer 
Amount 
Low-Income Subsidy Amount  Not available 
Other Financial Information  Not available 
(Gross Drug Cost below Out-of-pocket Threshold, Gross Drug Cost 
Above Out-of-pocket Threshold)  
 
Other Descriptive Data 
Data Elements  Availability 
Patient gender  Available 
Catastrophic Coverage Indicator  Not available 
(Catastrophic Coverage Code) 
In-network versus OON or MSP claim  Available 
(Pricing Exception code) 
Electronic versus Paper Claim  Available 
(Non-Standard format Code) 
Original versus Adjusted PDE (Adjustment/Deletion code)  Available 
   
 
6  Attachment 4  Process for Requesting Medicare Parts A and B Claims Data 
 
 
As described in the October 3, 2008 State Medicaid Director Letter, State Medicaid Agencies that 
have executed a modified Coordination of Benefits Agreement (COBA) may seek CMS 
permission to re-use Medicare Parts A and B claims sent to States to pay dual eligible 
beneficiaries Medicare cost-sharing for additional specified care coordination and quality 
improvement purposes.   
   
States may request to re-use COBA data for activities that fall within paragraphs (1) and (2) of the 
Health Insurance Portability and Accountability Act (HIPAA) definition of health care operations 
(see 45 CFR 164.501).  The COBA data are non-final action, i.e., subject to subsequent 
adjustment, which may result in more than one record for a given service.  However, these data are 
timely, as there is only a two week lag between the time the claims are adjudicated by Medicare 
and the time that a State would receive them, so they are still effective in supporting care 
coordination. 
 
States whose requests are approved may re-use older crossover claims they have stored in their 
systems for the new purposes.  On a go-forward basis, they may also re-use data received in their 
existing crossover file, or may obtain a second file of crossover and non-crossover claims.  These 
data are available at no cost to States.  Please refer to the October 3, 2008 State Medicaid Director 
Letter for detailed procedures, on our website at:  
http://www.cms.gov/SMDL/SMD/itemdetail.asp?filterType=none&filterByDID=-
99&sortByDID=1&sortOrder=descending&itemID=CMS1215727&intNumPerPage=10.     
However, please send requests for information to 
MedicareMedicaidCoordinaton@cms.hhs.gov rather than the e-mail address listed in that 
State Medicaid Director letter. 
 
 
   
 
7  Attachment 5  Process for Requesting Medicare Eligibility/Enrollment Data 
 
 
This section describes two mechanisms that CMS makes available to State Medicaid Agencies to 
confirm enrollment in Medicare Parts A, B, C and D.  The first is the online query tool called the 
Medicare Advantage & Part D Integrated User Interface (MAPD IUI), which allows States to 
query at the individual beneficiary level.  The second is the Territory Batch Query (TBQ), which 
allows States to query on a batch basis by submitting a TBQ file to CMS.   
 
Individual Look-Up 
The MAPD IUI is an online query tool that allows role-based access to States for Medicare 
eligibility, low income subsidy (LIS) status, and detailed health plan enrollment information at an 
individual beneficiary level. States have a defined role that permits access to certain screens within 
the MAPD IUI.  Access to this query is granted through a web based registration process referred 
to as the Individuals Authorized Access to the CMS Computer Services (IACS). Users will need to 
register for an IACS User ID in order to access the MAPD IUI.  For more information on the IACS 
registration process or the MAPD IUI, contact Carolyn Lawson at 410-786-0704 or 
Carolyn.Lawson@cms.hhs.gov or Clarice Burrell at 410-786-3344 or 
Clarice.Burrell@cms.hhs.gov. 
 
 
Batch Query Process 
The TBQ is a voluntary batch query finder file process.  For each TBQ file the State submits, CMS 
will return a response file.  If the States submitted record for a given beneficiary is successfully 
matched to the CMS database, the record returned will contain the eligibility and enrollment 
information pertaining to that beneficiary; if not, the response record will contain an appropriate 
return code indicating  the record was not matched.  The response record will be almost identical 
to the current MMA RESPONSE FILE record, except for a few fields which would remain blank 
(i.e., pertaining to Phasedown billing activity).  The submission of the file should occur using the 
same mechanism used for the MMA files. The file will be differentiated from the MMA file by the 
use of a unique file name. 
 
For additional information on the TBQ process or file layout, please contact Carolyn Lawson at 
410-786-0704 or Carolyn.Lawson@cms.hhs.gov or Goldy Austen at 410-786-6450 or 
Goldy.Austen@cms.hhs.gov.  
 
8