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Gym Benefits and Hearing Aid Discounts: New Codes for APCDs

Senior Consultant ,

Janice Bourgault is a nationally recognized leader and subject matter expert with over thirty years of experience in the healthcare industry, including over fourteen years working with and supporting the implementation and operation of All Payer Claims Databases (APCDs). She specializes in data submission guidelines and technical specifications and chairs two National Association of Health Data Organizations (NAHDO) committees, leading efforts to develop national standards for APCD claims data collection, maintain the APCD Common Data Layout (APCD-CDLTM), and develop standards for non-claim payments data collection.

Are you interested in collecting supplemental benefit information provided by payer health and wellness programs such as gym memberships and over-the-counter drugs, and discounts on eyeglasses and hearing aids in your All-Payer Claims Database (APCD)? Take advantage of CMS’s new guidance and technical documentation for reporting supplemental benefits.

Medicare Advantage Organizations (MAO) have been reporting their encounters to CMS using the X12 837I and 837P (institutional and professional) transaction sets starting with 2014 dates of service. Many MAOs offer supplemental benefits as part of their Medicare Advantage plans, and although it has been required that they report this data to CMS, they have inconsistently reported the supplemental services.

Reasons for these inconsistencies include:

  • The X12 837 formats do not accommodate reporting for these services.
  • These services are often provided by atypical providers who are not eligible for a National Provider Identifier (NPI).
  • There are no standard codes to report these services.

The availability of supplemental benefits offered to Medicare Advantage members has increased, and so has interest in them. Earlier this year, CMS released guidance on how to report these supplemental benefits in encounter data records submitted to CMS. MAOs are to begin reporting this data as part of their 2024 calendar year submissions.

CMS developed this guidance to provide standard instructions and code sets to break down the barriers preventing MAOs to consistently report these supplemental benefits when paid or used by the member. These standards can be used for APCD data collection.

For example, CMS provided standard codes to report these specific services: https://www.csscoperations.com/internet/csscw3_files.nsf/F2/Appendix%20B_SBSC%20Codes_508.pdf/$FILE/Appendix%20B_SBSC%20Codes_508.pdf

They also provided guidance on the reporting of atypical providers by creating default NPIs and Employer Identification Numbers (EIN).

Additional reporting guidance is provided for other data (e.g., place of service codes, charge and payment information, dates of service, etc.). For questions or further information, please contact Senior Consultant Janice Bourgault at [email protected].

FHC continues to support data collection efforts and is an active participant in the National Association of Health Data Organizations (NAHDO) and the APCD Council’s committees for the development and maintenance of APCD national standards: the All-Payer Claims Database Common Data Layout (APCD-CDL™) and the Non-Claims Payment committees.


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