APAC Data Use Agreement Amendment - Limited or Custom Data Set Instructions Use this form for amendments or renewals of Limited or Custom All Payer All Claims (APAC) data request applications that have been submitted, approved and have an executed Data Use Agreement. If you have not received an Application Number and wish to make changes to your submitted application, please contact [email protected]. The Application Number and Applicant Name must match the information from the original application and Data Use Agreement. Please list changes in the appropriate section and provide sufficient details to allow staff to evaluate the request. All changes supersede the original application and Data Use Agreement. Completed form should be sent to: [email protected]Or Office of Health Analytics - APAC 421 SW Oak Street, Suite 850 Portland, OR 97204 If you have questions while completing this application, please follow these steps: 1. Visit the APAC website for more information about the APAC Reporting Program at http://www.oregon.gov/oha/analytics/Pages/All-Payer-All-Claims.aspx 2. Visit the APAC Data Request page for more information about the data request process at http://www.oregon.gov/oha/analytics/Pages/APAC-Data-Requests.aspx 3. Review the APAC Frequently Asked Questions to determine if your question has been answered there. 4. If you still have questions, a. Direct questions about APAC or this application to: [email protected]b. Direct data privacy questions to: [email protected]c. Direct data security questions to: [email protected]OFFICE OF HEALTH ANALYTICS All Payer All Claims Data Reporting Program Kate Brown, Governor 421 SW Oak Street, Suite 850 Portland, OR 97204 Website: www.oregon.gov/oha/analytics
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APAC Data Use Agreement Amendment - Limited or Custom Data Set
Instructions Use this form for amendments or renewals of Limited or Custom All Payer All Claims (APAC) data requestapplications that have been submitted, approved and have an executed Data Use Agreement. If you have not received an Application Number and wish to make changes to your submitted application, please contact [email protected].
The Application Number and Applicant Name must match the information from the original application and Data Use Agreement. Please list changes in the appropriate section and provide sufficient details to allow staff to evaluate the request. All changes supersede the original application and Data Use Agreement.
Completed form should be sent to:
[email protected] Or Office of Health Analytics - APAC 421 SW Oak Street, Suite 850 Portland, OR 97204
If you have questions while completing this application, please follow these steps:
1. Visit the APAC website for more information about the APAC Reporting Program athttp://www.oregon.gov/oha/analytics/Pages/All-Payer-All-Claims.aspx
2. Visit the APAC Data Request page for more information about the data request process athttp://www.oregon.gov/oha/analytics/Pages/APAC-Data-Requests.aspx
3. Review the APAC Frequently Asked Questions to determine if your question has been answeredthere.
4. If you still have questions,a. Direct questions about APAC or this application to: [email protected]. Direct data privacy questions to: [email protected]. Direct data security questions to: [email protected]
OFFICE OF HEALTH ANALYTICS All Payer All Claims Data Reporting Program
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SECTION 1: PROJECT INFORMATION
1.1 Contact Information: Please provide the project contact information below.
Applicant name (must be the same applicant of original project):
Application Number (example: APACYYYYXXXX or XXXX_description_of_project):
Organization:
Address:
City: State: Zip:
Phone:
Email:
Original Application Date:
Is this an amendment (changes to the application—including revising project staff, request of additional data not specified in original application, etc.) or a renewal of an expiring Data Use Agreement or Institutional Review Board approval without any changes to the original application? Please choose only one. An amendment will also renew the Data Use Agreement.
Amendment ☐ Please continue to Section 2
Renewal ☐ Please continue to Section 3
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2.2 List any staff that will no longer be working on the project:
Name: Role:
Name: Role:
Name: Role:
Name: Role:
Name: Role:
2.3 What is the reason for the amendment?
2.4 Did the original application include an Institutional Review Board review and approval?
Yes ☐ No ☐
(If no, proceed to question 2.7)
2.5 Is the amendment within the scope of the original IRB approval?
Yes ☐ No ☐
If yes, please explain:
If no, requestor must submit new application, not an amendment.
2.6 Is an amended IRB approval attached? (An amended IRB approval is required for any
amendments to the scope of the project.)
Yes ☐ No ☐
Date amended IRB approval expires:
2.7 Are you requesting additional data files, data elements, or years of data?
Yes ☐ No ☐
(If yes, proceed to question 2.8-11. If no, skip question 2.8-11.)
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2.8 Limited Data Sets: In the table below, indicate which additional data file(s) you are requesting. Refer to the Data Element Workbook for more information about the data elements included in each Limited data set. Please note: OHA will only provide the minimum necessary required data for the project at hand. In other words, you will only receive those data elements that you request and adequately justify.
a. Are you requesting a Limited data set?
☐ Yes ☐ NoIf yes, please complete parts b and c below.
b. In the table below, indicate which Limited data file(s) you are requesting (refer toQuestion 2.11 for the cost of each file).
Payer
All Payers1
Medicaid Medicare
Advantage Commercial Insurance
OEBB/ PEBB
Medicare FFS2
Data File
Episodes of Care3 ☐ ☐ ☐ ☐ ☐ ☐
All Medical Claims4 ☐ ☐ ☐ ☐ ☐ ☐
Hospital Inpatient Claims ☐ ☐ ☐ ☐ ☐ ☐
Emergency Department Claims ☐ ☐ ☐ ☐ ☐ ☐
Ambulatory Surgery Claims ☐ ☐ ☐ ☐ ☐ ☐
Ambulatory Outpatient Claims ☐ ☐ ☐ ☐ ☐ ☐
All Pharmacy Claims5 ☐ ☐ ☐ ☐ ☐ ☐
c. Please indicate the year(s) requested for the data files selected above.
☐ 2011 ☐ 2012 ☐ 2013 ☐ 2014 ☐ 2015
1 All Payers includes Medicaid, Medicare Advantage, and Commercial Insurance (including OEBB/PEBB). 2 Medicare FFS data will only be given to projects in which OHA is funding and directing. Projects requesting Medicare FFS data will also need to be approved by requester’s Institutional Review Board. 3 Episodes of Care file contains all medical claims, all pharmacy claims, and fields from the Medical Episode Grouper (MEG). MEG is a proprietary grouping algorithm that creates episodes that describe a patient’s complete course of care for a single illness or condition. If requesting Episodes of Care file, no other data file is needed. 4 All Medical Claims file includes hospital inpatient, emergency department, ambulatory surgery and ambulatory outpatient claims, and other hospital treatment settings. If requesting all medical claims, you do not need to request these other data sets. 5 All Pharmacy Claims file contains only pharmacy claims.
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2.9 Custom Data Sets: Refer to the Data Elements Collected by APAC section of the Data User Guide for a list of data elements available. Please note: OHA will only provide the minimum necessary data for the project. In other words, you will only receive those data elements that you request and adequately justify. a. Are you requesting a Custom data set?
☐ Yes ☐ No
2.10 Data Element Workbook: For both Limited and Custom data set amendment requests, please complete the Data Element Workbook according to the instructions on the “Instructions” tab and attach it to this amendment.
☐ Data Element Workbook completed and attached, including justifications for each element requested and payers tab completed.
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2.11 Cost of Data: If requesting additional data from the Limited data set, please calculate the cost below. (This table should match the files/years selected in Questions 2.8b and 2.8c.) Please include payment with the application. Checks should be made to Oregon Health Authority and will not be cashed until application is approved. If requesting a Custom data set, an invoice will be sent if/when OHA approves request.
Payers
All Payers
Medicaid Medicare
Advantage
Commercial Insurance
OEBB/ PEBB
Medicare FFS
Dat
a Fi
le
Episodes of Care ☐ $3,000 ☐ $1,000 ☐ $1,000 ☐ $1,000 ☐ $1,000 ☐ $1,000
All Medical Claims ☐ $1,500 ☐ $500 ☐ $500 ☐ $500 ☐ $500 ☐ $500
c. Enter number of years ofdata requested (Q2.8.c)
d. Multiply rows b and c
e. OHA Production Cost $560
f. Add rows d and e for TotalPayment
☐ Check box if payment is not included because Custom data set is requested.
☐ Check box if payment is not included for another reason. Please explain.
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SECTION 3: RENEWAL
Please check the appropriate boxes. This section is for those renewing an existing Data Use Agreement or Institutional Review Board approval that is about to expire without requesting further changes to the content of the original application.
OHA Data Use Agreement Renewal (for applicants in which the OHA Data Use Agreement is about to expire)
By checking the above box, applicant hereby attests that the project shall continue to be conducted as specified in the Data Use Agreement referenced in Section 1 and the project has been renewed by Principal Investigator’s Institutional Review Board, if applicable. (If original application required Institutional Review Board approval, an amended Institutional Review Board approval is required for renewal outside the original Institutional Review Board approval timeframe.)
Amended Institutional Review Board approval documentation is attached. ☐
Original Institutional Review Board approval is still valid for more than 3 months. ☐
Original application did not include Institutional Review Board approval. ☐
Institutional Review Board Approval Renewal (for applicants in which the OHA Data Use Agreement is still valid, but the original Institutional Review Board approval is about to expire)
By checking the above box, applicant hereby attests that the project shall continue to be conducted as specified in the Data Use Agreement referenced in Section 1 and the project has been renewed by applicant’s Institutional Review Board. (Amended Institutional Review Board approval is required for renewal outside the original Institutional Review Board approval timeframe.)
Amended Institutional Review Board documentation is attached. ☐
See Filters tab for sample filters.
Data Element Name Years Requested Filters Applied Justification Notes
Member Months
personkey Unique person identifier 2012-2015 Needed as a linkage variable
patid Encrypted patient ID 2012-2015 Needed as a linkage variable
effdate Effective date 2012-2015 Needed to create enrollment periods for patients/beneficiaries
termdate Termination date 2012-2015 Needed to create enrollment periods for patients/beneficiaries
payer APAC Payer 2012-2015 Needed to partition member months into payer categories
prod Product code 2012-2015 Needed to separate members enrolled in HMO plans
medflag Medical coverage flag 2012-2015 Needed to identify whether medical services are covered (as opposed to just not used)
rxflag Pharmacy coverage flag 2012-2015 Needed to identify whether pharmacy services are covered (as opposed to just not used)
pebb PEBB flag 2012-2015 Plan type vairable needed to construct comparison groups
oebb OEBB flag 2012-2015 Plan type vairable needed to construct comparison groups
Age Member age (years) 2012-2015 Needed as an independent variable in statistical models to account for person-level demographic effects
gender Member gender 2012-2015 Needed as an independent variable in statistical models to account for person-level demographic effects
Race Member race 2012-2015 Needed as an independent variable in statistical models to account for person-level demographic effects
Ethn Member ethnicity 2012-2015 Needed as an independent variable in statistical models to account for person-level demographic effects
Lang Primary spoken language 2012-2015 Needed as an independent variable in statistical models to account for person-level demographic effects
Zip Member ZIP code of residence 2012-2015 Needed as an independent variable in statistical models to account for person-level demographic effects
county Member county of residence 2012-2015 Needed as an independent variable in statistical models to account for person-level demographic effects
Msa MSA 2012-2015 Needed as an independent variable in statistical models to account for person-level demographic effects
year Calendar year 2012-2015 Needed as an independent variable in statistical models to account for person-level demographic effects
tpa_or_pbm_duplicate_mm Third party administrator or pharma 2012-2015 Needed to deduplicate member months
yob Member year of birth 2012-2015 Needed to precisely calculate age as required for specific quality measures
medicaid Type of Medicaid coverage (FFS, M 2012-2015 Custom field created by OHA using CCO ID variable; in combination with Payer and Prod variables, allows partition of member months into payer categories
medicare Type of Medicare coverage (MED, A 2012-2015 Custom field created by OHA using A.PAYER_LOB; in combination with Payer and Prod variables, allows partition of member months into payer categories
Dual Indicator for dual coverage (enrolled 2012-2015 Custom field created by OHA; in combination with Medicaid and Medicare variables, allows identification of dual eligible members for subgroup analysis
NonElg Eligible for Medicaid 2012-2015 Custom field created by OHA; in combination with Payer and Prod, allows identification of Medicaid members
SNP Indicator for enrollment in Duals Sp 2012-2015 Custom field created by OHA; in combination with Payer and Prod, allows identification of members in dual eligible special needs plans for subgroup analysis
Payer ID Unique identifier for each payer that 2012-2015 Needed to filter out certain payers identified by OHA as having problematic data
Carrier name Name of health insurance carrier as 2012-2015 Needed to filter out certain payers identified by OHA as having problematic data
2012-2015
All Medical 2012-2015
clmid Claim ID 2012-2015 Needed to de-duplicate claim lines
line Claim line 2012-2015 Needed to de-duplicate claim lines
clmstatus Claim status 2012-2015 Needed to de-duplicate claim lines
cob COB status
2012-2015
Y/N flag Needed to adjust for individuals with coverage from
multiple plans
paytype Payer type
2012-2015
Needed to provide additional granularity on differences in
patient populations and utilization across payers
prod Product code
2012-2015
Needed for analysis separating individuals covered under
HMO plans vs. individuals covered in PPO plans
payer APAC Payer 2012-2015 Needed to account for different payment rates
medflag Medical coverage flag
2012-2015
Y/N flag Needed to identify individuals with medical coverage
only, rx coverage only, or both (e.g., to exclude
individuals with medical coverage only in analyses of total
cost)
rxflag Pharmacy coverage flag
2012-2015
Y/N flag See line 13; allows for inclusion/exclusion criteria (e.g.,
individuals without rx coverage could be included in
analyses of hospitalizations in order to improve power but
excluded from analyses of total cost due to missing data)
pebb PEBB flag
2012-2015
0/1 flag Plan type vairable needed to construct comparison
groups
oebb OEBB flag
2012-2015
0/1 flag Plan type vairable needed to construct comparison
groups
patid Encrypted patient ID 2012-2015 Needed to de-duplicate claim lines
personkey Unique person identifier 2012-2015 Needed to de-duplicate claim lines
gender Gender
2012-2015
F, M, or U Needed as an independent variable in statistical models
to account for person-level demographic effects
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.
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.
Provide any notes about the data elements requested, if applicable.
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.
Data Element Name Years Requested Filters Applied Justification Notes
yob Birth year
2012-2015
Needed as an independent variable in statistical models
to account for person-level demographic effects
race Race
2012-2015
Needed as an independent variable in statistical models
to account for person-level demographic effects
ethn Ethnicity
2012-2015
Needed as an independent variable in statistical models
to account for person-level demographic effects
lang Primary spoken language
2012-2015
Code set available from the NISO w Needed as an independent variable in statistical models
to account for person-level demographic effects
msa Member MSA code
2012-2015
See United States Census Bureau Needed as an independent variable in statistical models
to account for person-level demographic effects
state Member state
2012-2015
Standard two character abbreviatio Needed as an independent variable in statistical models
to account for person-level demographic effects
zip Member zip code
2012-2015
Freely available in the public doma Needed to develop metrics for distance to provider
(access proxy)
fromdate From date
2012-2015
YYYY-MM-DD Needed to understand utilization patterns (e.g. whether
office visit was before or after hospitalization)
todate To date 2012-2015 YYYY-MM-DD See line 27
paid Total payment
2012-2015
Needed to track expenditures (primary dependent
variable)
copay Co-payment
2012-2015
Needed to provide granularity on patient out-of-hospital
expenses
coins Co-insurance
2012-2015
Needed to provide granularity on patient out-of-hospital
expenses
deduct Deductible
2012-2015
Needed to provide granularity on patient out-of-hospital
expenses
oop Patient pay amount
2012-2015
Required if deductible, co-pay, or c Needed to assess changes over time when comparing
Medicaid with Commercial or other other coverage
tob Type of bill
2012-2015
Needed to categorize claims by service setting and type
pos Place of service code
2012-2015
Needed to categorize claims by service setting and type
revcode Revenue code
2012-2015
See NUBC web site Needed to categorize claims by service setting and type
qty Quantity 2012-2015 Needed to analyze utilization
hcg HCG code
2012-2015
Needed to categorize claims by service setting and type
dx1 Principal diagnosis
2012-2015
See current ICD documentation fro Needed for episode grouper, as well as identification of
specific patient populations and co-morbidities. For
example, patients with mental health conditions are a
focus of our study and ICD-9 codes allow us to create
that cohort as well as to stratify by all mental illness and
serious mental illness. ICD-9 Codes are also necessary
for quality measures (including AHRQ Prevention Quality
Indicators) that are part of the study
dx2 Diagnosis 2
2012-2015
See current ICD documentation fro See line 39; while not all diagnosis codes are populated
for every claim, codes from dx2 through dx13 improve
accuracy of episode grouper output where populated
dx3 Diagnosis 3
2012-2015
See current ICD documentation fro See line 39; while not all diagnosis codes are populated
for every claim, codes from dx2 through dx13 improve
accuracy of episode grouper output where populated
dx4 Diagnosis 4
2012-2015
See current ICD documentation fro See line 39; while not all diagnosis codes are populated
for every claim, codes from dx2 through dx13 improve
accuracy of episode grouper output where populated
dx5 Diagnosis 5
2012-2015
See current ICD documentation fro See line 39; while not all diagnosis codes are populated
for every claim, codes from dx2 through dx13 improve
accuracy of episode grouper output where populated
dx6 Diagnosis 6
2012-2015
See current ICD documentation fro See line 39; while not all diagnosis codes are populated
for every claim, codes from dx2 through dx13 improve
accuracy of episode grouper output where populated
dx7 Diagnosis 7
2012-2015
See current ICD documentation fro See line 39; while not all diagnosis codes are populated
for every claim, codes from dx2 through dx13 improve
accuracy of episode grouper output where populated
dx8 Diagnosis 8
2012-2015
See current ICD documentation fro See line 39; while not all diagnosis codes are populated
for every claim, codes from dx2 through dx13 improve
accuracy of episode grouper output where populated
X Comparison between payers on access, costs All Payers All Payers includes Medicaid, Medicare Advantage, and Private Commercial Insurance (includes OEBB/PEBB).
Medicaid
REQUESTERS MAY NOT REQUEST MEDICAID DATA ONLY. For those that only want Medicaid data, APAC is not the
appropriate data source. Please contact [email protected] for further instruction.
Medicare Advantage
Private Commercial Insurance (includes OEBB/PEBB)
OEBB/PEBB Select if requesting OEBB/PEBB data only
Medicare FFS Medicare FFS data will only be given to projects in which OHA is funding and directing.
Payers
The following payers are available for request. You may request all payers, or one or more specific payer. Requesters must provide a justification for each payer requested.
Specify filters for each
element requested, if
APPROVAL OF SUBMISSION
December 28, 2016 Dear Investigator:
On 12/28/2016, the IRB reviewed the following submission:
IRB ID: STUDY00015633 MOD or CR ID: CR00001566 Type of Review: Continuing Review
Title of Study: Examining the impact of health care reform on publicly funded family planning in Oregon
Principal Investigator: Maria Rodriguez Funding: Name: DHHS NIH Natl Inst of Child Hlth & Human
The IRB granted final approval on 12/28/2016. The study is approved until 12/27/2017.
Review Category: Expedited Category # 5
Copies of all approved documents are available in the study's Final Documents (far right column under the documents tab) list in the eIRB. Any additional documents that require an IRB signature (e.g. IIAs and IAAs) will be posted when signed. If this applies to your study, you will receive a notification when these additional signed documents are available.
Ongoing IRB submission requirements:
• Six to ten weeks before the expiration date, you are to submit a continuing review to request continuing approval.
• Any changes to the project must be submitted for IRB approval prior to implementation.
• Reportable New Information must be submitted per OHSU policy.
• You must submit a continuing review to close the study when your research is completed.
Guidelines for Study Conduct
In conducting this study, you are required to follow the guidelines in the document entitled, "Roles and Responsibilities in the Conduct of Research and Administration of Sponsored Projects," as well as all other applicable OHSU IRB Policies and Procedures.
Requirements under HIPAA
If your study involves the collection, use, or disclosure of Protected Health Information (PHI), you must comply with all applicable requirements under HIPAA. See the HIPAA and Research website and the Information Privacy and Security website for more information.
IRB Compliance
The OHSU IRB (FWA00000161; IRB00000471) complies with 45 CFR Part 46, 21 CFR Parts 50 and 56, and other federal and Oregon laws and regulations, as applicable, as well as ICH-GCP codes 3.1-3.4, which outline Responsibilities, Composition, Functions, and Operations, Procedures, and Records of the IRB.