Type of Service is a category that encompasses information on the provider type and the category of service provided to a recipient on a given date. It is a complex classification developed from federal reporting standards and several important caveats and limitations.
Data on prescription drugs is captured in three ways: implicitly, in Chronic Illness and Disability Payment System (CDPS) diagnostic information released in Data Set I; in aggregate as a Type of Service; and explicitly, in the claims-level data released in Data Set II.
In the first case, national drug codes (NDCs) for prescription drugs are used to augment ICD-9 diagnostic codes. In other words, a cancer diagnosis flag can exist in the data set due to the recipients’ healthcare record containing the relevant ICD-9 diagnostic code. Alternately, a cancer diagnosis flag can exist for that recipient because they were prescribed a drug classified as a cancer treatment, even if this recipient’s data lacked other information on the malignancy. The cancer prescription will be incorporated into the CDPS data for this recipient, increasing the overall accuracy of the data. CDPS has some rather complex rules for combining the diagnosis and drug flags so that they don’t contain redundant information. We have applied the rules. See the CDPS documentation.
Claims-level data will include pharmaceutical use, recorded as events and units.
A unit is the number of itemized services (generally defined by procedure codes) associated with a given healthcare service event. It is a term used in the data set together with “event” to quantify the services rendered to recipients. For the healthcare use that occurs by one recipient, on one day, with one provider, a unit is each single procedure completed. For emergency care, all procedures are recorded as one unit. For a single event that spans multiple days, such as inpatient hospitalization or long-term care, the units recorded are equal to the number of days the event lasts. For a pharmaceutical prescription, the number of units is the number of days the prescription lasts. Please see the table below:
Table 1: Descriptions of Events and Units by Type of Service
Type of Service
What is an Event?
What is a Unit?
One hospital stay is one event.
Each day of the hospital stay is one unit.
Other Institutionalization Care
One month is one event. The first and last months may be counted as partial events.
Each day of the stay is one unit.
One prescription is one event.
Each day of prescription drug use is one unit.
Emergency Room (ER)
One recipient, one ER facility, on one day is one event.
Each ER visit is one unit (therefore events=units unless there is more than one visit in one day).
All Other Services
One recipient, one provider, on one day is one event.
Each paid procedure is counted as one distinct unit.
Managed Care Organizations (MCOs) receive capitation payments, paid ‘per member per month (PMPM),’ irrespective of what services have been provided that month. (This differs from Fee for Service claims, which are paid based on each service rendered.) Recipients who were enrolled with MCO will have the services they received from the MCO represented as ‘encounter claims.’ These provide proof of the provision of services rather than requests for payment, and do not further detail the Type of Service provided.
Some Types of Service are excluded from MCO services, however. These include services from dentists, pharmacists, optometrists, mental health clinics (via community behavioral health providers), substance use disorder rehabilitation service providers, vision testing providers, Nursing Facilities, Intermediate Care Facilities for the Mentally Retarded/Developmentally Disabled, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service providers, and school-based clinics. Specific restrictions apply to the provision of abortion, sterilization, and hysterectomy.
Services excluded from MCO coverage are represented elsewhere in the data sets. For example, a recipient enrolled in MCO who gets dental care from another Medicaid-affiliated provider will have this service recorded as a distinct Type of Service, irrespective of their MCO encounter claims data.
Additional Types of Service excluded from MCO payments are also excluded from other Medicaid programs found in the data sets. These Types of Service are those services funded by the Juvenile Rehabilitation Services Medicaid Matching Fund; experimental or investigational services; non-authorized services from an unaffiliated provider; services delivered without an appropriate referral or prior authorization; and medical and surgical services for cosmetic purposes. As these are not represented in our data sets, they are therefore not associated with costs or any other values in the data sets.
Recipients who enrolled in an MCO at some point in the experience period will have the services they received prior to their MCO enrollment recorded in the data sets as various Types of Service. The premiums paid to MCOs will be listed under The Type of Service ‘Health Insurance Payments: MCOs.’
Per 42 U.S.C. §1396d(i), an Institute for Mental Diseases is “a hospital, nursing facility, or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related services.” These facilities offer a Type of Service for which federal financial participation in Medicaid coverage is prohibited, a unique distinction. For this reason, Institutes for Mental Diseases are not included in federal reporting. They are, however, included in the data sets, under ‘Nursing Facilities,’ and are subject to care coordination.
Many other Types of Service to persons with mental illness (including substance use disorders) are found in the data sets. They include Rehabilitative Services - Mental Illness, Rehabilitative Services - Substance Abuse, FQHC /RHC Mental Health Services, Inpatient Hospital: Psychiatric, Inpatient Hospital: Substance Abuse, and Mental Health Facility Services - Regular Payments. Additional Types of Service provided to specific groups of patients, such as waiver recipients, can group care for mental health together with other services.
Illinois Health Connect (IHC) is a program that enrolls the Medicaid recipients into medical homes with a specific primary care physician (PCP). This program is mandatory for many full benefits recipients of Medicaid and All Kids. Exclusions include some children, waiver recipients, and others, as described on the IHC Web site.
The data sets refer to this program as “Primary Care Case Management (PCCM).” Items in the provider file gives you the number of patients a given provider saw who were PCCM (IHC) patients, plus figures for events, units, and costs for this Type of Service. Matching fields can be found in the recipient file. All such fields use the acronym “PCCM” as an element of the name. (None use “IHC.”) There are no fields in the data set the specific health plans that administer PCCM enrollment.