All-Payer Claims Database

Under Virginia Senate Bill 1216, which went into effect on July 1, 2019, all of the following entities are required to submit paid claims data to the Virginia APCD:

• Issuers of individual or group accident and sickness insurance policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis; corporations providing individual or group accident and sickness subscription contracts; and health maintenance organizations providing a healthcare plan for healthcare services, for at least 1,000 covered lives in the most recent calendar year;

• Third-party administrators and any other entities that receive or collect charges, contributions, or premiums for, or adjust or settle healthcare claims for, at least 1,000 Virginia covered lives on behalf of group health plans other than ERISA plans;

• Third-party administrators, and any other entities, that receive or collect charges, contributions, or premiums for, or adjust or settle healthcare claims for, an employer that maintains an ERISA plan that has opted in to data submission to the All-Payer Claims Database pursuant to subsection P;

• The Department of Medical Assistance Services with respect to services provided under programs administered pursuant to Titles XIX and XXI of the Social Security Act;

• State government health insurance plans;

• Local government health insurance plans, subject to their ability to provide such data and to the extent permitted by state and federal law; and

• Federal health insurance plans, to the extent permitted by federal law, include Medicare, TRICARE, and the Federal Employees Health Benefits Plan.

APCD data is used to inform research, guide policy decisions and improve healthcare across the Commonwealth. By providing a comprehensive view of utilization, cost and outcomes, the APCD supports a wide range of initiatives, including:

• Evaluating patterns in healthcare access, spending and quality
• Identifying opportunities to reduce low-value or avoidable care
• Supporting health equity and population health studies
• Measuring the impact of new programs, policies and interventions
• Informing public health planning and policy

While claims are a robust and flexible source of healthcare data, they are subject to certain limitations that should be considered before requesting data from the Virginia APCD for analysis.

Timeliness: Claims can often take several months to be completely adjudicated and are subject to revisions as well as reversals long after a patient’s date of service.

Structure: Claims data are submitted in what is referred to as a “line” format, meaning that an individual claim may contain several records of data. An individual patient encounter or procedure may also result in claims being submitted for payment by multiple entities (e.g., one from a facility, such as a surgery center, and one from an independent practitioner, such as an anesthesiologist). These structural characteristics add nuance to analyzing the “complete picture” of a particular service.

The Virginia APCD does not retain any personally identifiable information (PII), such as Social Security numbers, names or addresses. All data is fully de-identified before being loaded into VHI’s analytic environment. Additionally, any effort to re-identify individuals from APCD data is strictly prohibited.