About UDS Insurance Groupings

Introduction

Both the UDS Zip Codes Table and Table 4 classify patients by insurance. In each case, the UDS manual specifies that patients should be classified based on their primary medical insurance at the time of the patient’s last visit during the UDS year.

In Relevant, patient insurance for UDS purposes is controlled by the “Insurance Enrollments” data element. If you’re looking to see how this works, we recommend examining the mapping for this data element. Its logic can be configured by your health center, with or without assistance from Relevant.

Note: in some cases, limitations in the EHR data mean that an approximation of the UDS definition is required. For example, although the UDS manual states that a patient’s primary medical insurance as of the patient’s last visit during the UDS year should be used even if a different insurance happened to be applied at that visit, this data may not be reliably available. In that case, we recommend using the insurance that is actually applied to the latest visit during the UDS year as the best available approximation.

In addition to consulting the Insurance Enrollments data element mapping, you may also find the  ”UDS Validation: Payer Assignments” report helpful. It lists patients by UDS insurance, the Table 4 insurance grouping, and a SQL translation of the Table 4 categorization logic (described below). If this report is not available on your instance, it can be added by an administrator with the “Manage Reports” ability via the Report Library.

Technical details

Note: we do not use the Payer Groups data element for UDS payer categorization. Although Payer Groups are used throughout the rest of Relevant, they are highly customizable. Since UDS provides specific rules about how to group payers, we handle the UDS logic separately.

For UDS payer groupings, we first pull a payer for the UDS year in question from the Insurance Enrollments data element, which corresponds to the insurance_enrollments table. The payer_id column references a payer’s id in the payers table. In the payers table, boolean fields specify whether a given payer is medicaid, medicare, chip, private_insurance, or uninsured.

From there, we use these booleans to group payers into the Table 4 payer categories. The boolean values described above do most of the work. For example, for Line 8b, “CHIP Medicaid,” we look for payers where medicaid is true and chip is true. For Line 10b, “Other Public Insurance CHIP,” we look for payers where chip is true and all the other boolean columns are false. (Note: when private_insurance, medicaid, and medicare are false, this means “other” private insurance, i.e. other than Medicare or Medicaid.) The one exception is for Line 9a, “Dually Eligible Medicare and Medicaid.” Since this is not a property of a single payer, we record this data in the insurance_enrollments table, in the medicare_dually_eligible column, and pull it from there.

For the ZIP Codes Table, we follow the same logic as described above for Table 4, but combine certain categories as required by UDS.

References: 2023 UDS Manual, instructions for Zip Codes, p. 26: “Report the patient’s primary medical insurance covering medical care, if any, as of their last visit during the calendar year”; and instructions for Table 4A, p. 41: “Report the primary medical insurance patients had at the time of their last visit regardless of whether that insurance was billed or paid for any or all of the visit services.”