See Filters tab for sample filters.Data Element Name Years Requested Filters Applied Justification

clmid Claim ID 2015 Necessary to properly interpret duplicate claim linesline Claim line 2015 Necessary to properly interpret duplicate claim linesclmstatus Claim status 2015 Necessary to properly interpret duplicate claim linespersonkey Unique person identifier 2015 Necessary to properly interpret duplicate claim linesfromdate From date 2015 Necessary to properly interpret duplicate claim linestodate To date 2015 Necessary to properly interpret duplicate claim linespaydate Payment date 2015 Necessary to properly interpret duplicate claim linespaid Total payment 2015 Necessary to properly interpret duplicate claim linesrevcode Revenue code 2015 Necessary to properly interpret duplicate claim linesfilldate Fill date 2015 Necessary to properly interpret duplicate claim linesproccode CPT or HCPCS procedure code 2015 Necessary to properly interpret duplicate claim linesmod1 Procedure code modifier 1 2015 Necessary to properly interpret duplicate claim linesndc NDC 2015 Necessary to properly interpret duplicate claim linesqtydisp Quantity dispensed 2015 Necessary to properly interpret duplicate claim linesmsdrg MS-DRG 2015 Necessary to properly interpret duplicate claim linesbillid Billing provider ID 2015 Necessary to properly interpret duplicate claim lines

paytype Payer type 2015Identification for appropriate analyses PCPCH, PEBB, Commercial

prod Product code 2015Identification for appropriate analyses PCPCH, PEBB, Commercial

payer APAC Payer 2015Identification for appropriate analyses PCPCH, PEBB, Commercial

medflag Medical coverage flag 2015 case selection/stratificationrxflag Pharmacy coverage flag 2015 stratification and control variablepebb PEBB flag 2015 For PEBB/OEBB analysis stratificationoebb OEBB flag 2015 For PEBB/OEBB analysis stratificationgender Gender 2015 stratification and control variable

yob Birth year 2015

stratification and control variable, creation of quality measures (child and adolescent well care, preventive screenings, diabetes care, prenatal&postpartum care)

You may request any of the data elements APAC collects, including any data elements in the limited data sets, and any listed in the Data Elements Collected by APAC section of the APAC Data User Guide. Complete columns A-E for all data elements requested. Provide any optional notes in column F. Direct identifiers such as patient name, address, or exact dates of service are only released under special circumstances that comply with HIPAA requirements, and may require specific approvals such as Institutional Review Board (IRB) approval and patient consent, and review by the Department of Justice.

Custom Data Set

Please Note: Only complete this tab if you are requesting a custom data set instead of a limited data set.

OHA recommends certain data elements for all requests depending on claim type, as they are necessary to properly interpret duplicate claim lines. These elements are pre-populated in the table below. Requesters should still fill out columns C and D for these elements. If you do not wish to receive a pre-populated element, delete the entire row.

If requesting a custom data set, you must also complete the Payers tab.

See Instructions tab for further instructions and information about pre-populated elements.

Indicate year(s) for each element

requested.

Specify filters for each element requested, if applicable.

Justify why each element requested is necessary.

Indicate data elements requested. Use extract column name for elements from limited data sets. Use data element format AA### for elements from the Data Elements Collected by APAC section of

the APAC Data User Guide.Indicate the name of each

element requested.

Data Element Name Years Requested Filters Applied Justification

mob Birth month 2011-2015

Requested for individuals born in the following years:1935-1939, 1946-1950, 1960-1964, 1987-1993, 1993-1997, 1999-2003, 2009-2014

creation of quality measures - need to know months in which members meet age criteria for quality measures. Age-specific measures include: well child visits (0-15 months), adolescent well care (12-21), depression screening (12 and up), SBRIT screening (18 and up) cervical cancer screening (24-64), colorectal cancer screening (51-75), diabetes care (18-64)

RE1 Race 2015 stratification and control variableRE2 Ethnicity 2015 stratification and control variableRE3 Primary spoken language 2015 stratification and control variableMSA Member MSA code 2011-2015 stratification and control variableurban Urban indicator 2011-2015 stratification and control variablestate Member state 2015 stratification and control variabletob Type of bill 2015 analytic variable construction (identify type of claim)pos Place of service code 2015 analytic variable construction (identify type of claim)hcg HCG code 2015 analytic variable construction (identify type of claim)

dx1 Principal diagnosis 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx2 Diagnosis 2 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx3 Diagnosis 3 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx4 Diagnosis 4 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx5 Diagnosis 5 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx6 Diagnosis 6 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx7 Diagnosis 7 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx8 Diagnosis 8 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx9 Diagnosis 9 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx10 Diagnosis 10 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx11 Diagnosis 11 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx12 Diagnosis 12 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

dx13 Diagnosis 13 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

px1 Principal inpt procedure 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px2 Procedure 2 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px3 Procedure 3 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Data Element Name Years Requested Filters Applied Justification

px4 Procedure 4 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px5 Procedure 5 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px6 Procedure 6 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px7 Procedure 7 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px8 Procedure 8 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px9 Procedure 9 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px10 Procedure 10 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px11 Procedure 11 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px12 Procedure 12 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

px13 Procedure 13 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

mod2 Procedure code modifier 2 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

mod3 Procedure code modifier 3 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

mod4 Procedure code modifier 4 2015

analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

ptstatus Discharge status 2015 analytic variable construction (inpatient readmissions)

attid Attending provider ID 2015identification of primary care, attribution to primary care practice and linkage to PCPCH data

spec Attending provider specialty 2015identification of primary care, attribution to primary care practice and linkage to PCPCH data

entity Billing provider entity name 2015attribution to primary care practice and linkage to PCPCH data

icdver ICD version 2015analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

NPID national provider ID 2015 linkage to PCPCH data

ME001 Payer type 2015Identification for appropriate analyses PCPCH, PEBB, Commercial

Data Element Name Years Requested Filters Applied Justification

ME003 Product code 2015Identification for appropriate analyses PCPCH, PEBB, Commercial

ME004A Eligibility date 2015Identification for appropriate analyses PCPCH, PEBB, Commercial

ME005A Termination date 2015Identification for appropriate analyses PCPCH, PEBB, Commercial

ME009A PEBB flag 2015 For PEBB/OEBB analysis stratificationME009B OEBB flag 2015 For PEBB/OEBB analysis stratificationME013 Member gender 2015 stratification and control variableME016 Member state 2015 stratification and control variable

ME018 Medical coverage flag 2015Identification for appropriate analyses PCPCH, PEBB, Commercial

ME019 Prescription drug coverage flag 2015Identification for appropriate analyses PCPCH, PEBB, Commercial

ME206 Primary Insurance Indicator 2015Identification for appropriate analyses PCPCH, PEBB, Commercial

Mark each payer you are requesting with "X".

Justify why each payer requested is necessary. See Filters tab for sample filters. Payer Type

Payer Requested Justification Filters Applied Payer

X

required for PCPCH analysis, CCM spread analysis, and cross-state analysis

NOT requesting Medicare Advantage All Payers

N/A N/A MedicaidMedicare AdvantagePrivate Commercial Insurance (includes OEBB/PEBB)OEBB/PEBBMedicare FFS

The following payers are available for request. You may request all payers, or one or more specific payer. Requesters must provide a justification for

Specify filters for each element requested, if applicable.

Name Years Requested Justification

Claim ID2015 Necessary to properly interpret duplicate claim lines

Claim line2015 Necessary to properly interpret duplicate claim lines

Claim status2015 Necessary to properly interpret duplicate claim lines

Unique person identifier2015 Necessary to properly interpret duplicate claim lines

From date2015 Necessary to properly interpret duplicate claim lines

To date2015 Necessary to properly interpret duplicate claim lines

Payment date2015 Necessary to properly interpret duplicate claim lines

Total payment2015 Necessary to properly interpret duplicate claim lines

Revenue code2015 Necessary to properly interpret duplicate claim lines

Fill date2015 Necessary to properly interpret duplicate claim lines

CPT or HCPCS procedure code2015 Necessary to properly interpret duplicate claim lines

Procedure code modifier 12015 Necessary to properly interpret duplicate claim lines

NDC2015 Necessary to properly interpret duplicate claim lines

Quantity dispensed2015 Necessary to properly interpret duplicate claim lines

MS-DRG2015 Necessary to properly interpret duplicate claim lines

Billing provider ID2015 Necessary to properly interpret duplicate claim lines

Name Years Requested Justification

Payer type 2015 Identification for appropriate analyses PCPCH, PEBB, Commercial

Product code 2015 Identification for appropriate analyses PCPCH, PEBB, Commercial

APAC Payer 2015 Identification for appropriate analyses PCPCH, PEBB, Commercial

Medical coverage flag 2015 case selection/stratification

Pharmacy coverage flag 2015 stratification and control variable

PEBB flag 2015 For PEBB/OEBB analysis stratification

OEBB flag 2015 For PEBB/OEBB analysis stratification

Gender 2015 stratification and control variable

Birth year 2015stratification and control variable, creation of quality measures (child and adolescent well care, preventive screenings, diabetes care, prenatal&postpartum care)

Birth month 2011-2015

creation of quality measures - need to know months in which members meet age criteria for quality measures. Age-specific measures include: well child visits (0-15 months), adolescent well care (12-21), depression screening (12 and up), SBRIT screening (18 and up) cervical cancer screening (24-64), colorectal cancer screening (51-75), diabetes care (18-64)

Race 2015 stratification and control variable

Ethnicity 2015 stratification and control variable

Primary spoken language 2015 stratification and control variable

Member MSA code 2011-2015 stratification and control variable

Urban indicator 2011-2015 stratification and control variable

Member state 2015 stratification and control variable

Name Years Requested Justification

Type of bill 2015 analytic variable construction (identify type of claim)

Place of service code 2015 analytic variable construction (identify type of claim)

HCG code 2015 analytic variable construction (identify type of claim)

Principal diagnosis 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 2 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 3 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 4 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 5 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 6 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 7 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 8 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 9 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 10 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 11 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 12 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Diagnosis 13 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

Name Years Requested Justification

Principal inpt procedure 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 2 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 3 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 4 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 5 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 6 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 7 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 8 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 9 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 10 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 11 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 12 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure 13 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure code modifier 2 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure code modifier 3 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Procedure code modifier 4 2015analytic variable construction (many quality and utilization measures, such as preventative screenings, well-care visits, diabetes management, prenatal care)

Name Years Requested Justification

Discharge status 2015 analytic variable construction (inpatient readmissions)

Attending provider ID 2015 identification of primary care, attribution to primary care practice and linkage to PCPCH data

Attending provider specialty 2015 identification of primary care, attribution to primary care practice and linkage to PCPCH data

Billing provider entity name 2015 attribution to primary care practice and linkage to PCPCH data

ICD version 2015 analytic variable construction (identify diabetes, deliveries, mental health visits, well-care visits)

national provider ID 2015 linkage to PCPCH data

Payer type 2015 Identification for appropriate analyses PCPCH, PEBB, Commercial

Product code 2015 Identification for appropriate analyses PCPCH, PEBB, Commercial

Eligibility date 2015 Identification for appropriate analyses PCPCH, PEBB, Commercial

Termination date 2015 Identification for appropriate analyses PCPCH, PEBB, Commercial

PEBB flag 2015 For PEBB/OEBB analysis stratification

OEBB flag 2015 For PEBB/OEBB analysis stratification

Member gender 2015 stratification and control variable

Member state 2015 stratification and control variable

Medical coverage flag 2015 Identification for appropriate analyses PCPCH, PEBB, Commercial

Prescription drug coverage flag 2015 Identification for appropriate analyses PCPCH, PEBB, Commercial

Name Years Requested Justification

Primary Insurance Indicator 2015 Identification for appropriate analyses PCPCH, PEBB, Commercial