Epic Claims Data

Overview

The Epic Claims process involves ingesting claims from individual payors and allowing external claims-based data elements required for use with the Cost and Utilization Dashboard, Episodic Variation - Claims Dashboard, HEDIS, Medical Claims Datalink, and Pharmacy Claims (Medication Dispense) Datalink functionality.

Details

Claims data is provided in a specific format by the vendor HDI. These “Raw Claims” are data from payors converted to the proper specification for ingestion into the Caboodle Datawarehouse. Files are loaded from a “Full” file containing up to date records from date of delivery with new “Incremental” files delivered on a monthly basis. The below demonstrates a high-level overview of the process.

Accomplishments

The following twelve populations are loaded into Epic as of December 2021:

BCBSLA Blue Connect, BCBSLA QBVP, BCBSLA STPH Sherriff’s Office, BCBSSC EHP, Humana MA, Humana TCA, Humana TCC, Humana VB LGHN, Humana VB OPP, Humana VP STQN, PHN, United

Feedback

From Philip Krause Schmidt with Ochsner Health Network:

“The processing of claims is vital to both patient care outcomes and performance on value based contracts: for patients receiving the majority of care with OHN partners who are not on Ochsner's Epic, these claims represent the only way OHN receives clinical data for patients on OHN's valuebased care contracts which is critical for recording which preventative health and quality screenings have been completed which results on both improved patient outcomes through OHN's clinical care coordination approach as well as improved performance on our value-based care contracts.”

ISDM “partnered with OHN PMO to identify root cause of payor care gaps reported for well child visit measures which extended to processing and integration of OEP and United claims into Epic, representing most claims Ochsner processes. The issues were resolved in under one month.”