Enrollment basis for prescription coverage

[rusincovitch]

During the PCORnet pilot Medicare linkage project, the DRNOC team worked with transforming CMS data into the PCORnet CDM. In the ENROLLMENT table, they’ve pointed out that “Enrollment basis (ENR_BASIS) doesn’t differentiate medical insurance coverage and prescription medication insurance coverage”. This is relevant to Medicare because the enrollment windows for medical coverage (Parts A & B) do not always overlap with the enrollment windows for prescription medication coverage (Part D).

Because both types of enrollment would have been coded as insurance-based (ENR_BASIS = ‘I’), they chose not to load any prescription medication coverage enrollment information into the ENROLLMENT table in order to avoid the problem of having overlapping enrollment windows with the same basis. They chose to only include information about medical coverage, because the need for understanding enrollment related to clinical encounters and events was considered to be more important than understanding enrollment related to prescription drug dispensing.

The Sentinel CDM v5 has variables that would cover this specific situation: MedCov and DrugCov on the ENROLLMENT table. However, they are not currently part of the PCORnet CDM.

References (some are internal access):

• Sentinel CDM v5.0.1.: http://www.mini-sentinel.org/data_activities/distributed_db_and_data/details.aspx?ID=105
• Overview of pilot linkage project (slides from February 1): https://pcornet.imeetcentral.com/p/aQAAAAACnQCz
• Pilot linkage project ETL ADD (annotated data dictionary): https://pcornet.imeetcentral.com/p/aQAAAAACnIJT
• Pilot linkage project Data Transformations document https://pcornet.imeetcentral.com/p/ZgAAAAAAPfRt

With many thanks to Brad Hammill (@bghammill) and Laura Qualls (@lqualls) for developing and describing this use case!

[rusincovitch]

Because this is not an errata, merged into https://github.com/CDMFORUM/CDM-GUIDANCE/issues/3