The Basics of Claims Data 

What is Claims Data?

Healthcare claims are submitted by providers to insurers for reimbursement. Nearly every encounter a patient has with the health care system generates a claim which, along with payment information, contains data on a patient’s diagnoses, procedures, and medications using standardized billing codes. This real-world data can be used for commercial targeting, health economics and outcomes research (HEOR), market landscape analysis, network analysis, utilization studies, patient out-of-pocket (OOP) cost analysis, and payer landscape assessments.

Medical and Pharmacy Claims

Medical claims include data on diagnoses, procedures, provider details, facility information, and payer types. They are submitted by healthcare providers and processed through clearinghouses (or “switches”) to insurance companies. These claims may have a long processing time as payers adjudicate coverage. Data may flow back and forth through the “switches” before the final remittance decision is made by the insurer.

Pharmacy claims provide data on drug prescriptions, including NDC-level drug coding, prescription dates, quantity dispensed, days supply, cost information, and payer details. These claims are submitted by pharmacies and processed similarly to medical claims through clearinghouses. Unlike medical claims, pharmacy claims typically involve a faster adjudication process, with claims being processed almost instantly.

Open Claims

Open claims data is generated through various systems, such as clearinghouses (data suppliers), physician billing systems, and pharmacies. These claims provide a snapshot of patient interactions across different settings and payers, offering near real-time insights on patient and market trends.  One of the main advantages of open claims data is its national coverage, resulting in higher patient counts.  However, open claims can be affected by issues like duplication and missing information and will not have complete longitudinal patient data over a defined time period.

Closed Claims

Closed claims data is generated from insurance providers.  These claims provide a more comprehensive picture of a patient’s healthcare journey across different care settings over a defined time period. This allows for longitudinal analyses offering insights into the path to diagnosis, line of therapy decisions, provider referral patterns, and health outcomes. While closed claims data tends to be more accurate and detailed, it takes several months to process and finalize claims. Additionally, closed claims are limited to a specific time frame and payer, providing a less complete picture of the landscape compared to open claims.

Selecting the Right Data

Claims data is essential for healthcare insights. The near-real-time data from open claims can be used for a broad range of analyses, from tracking market trends to prescription patterns to rare disease studies.  The completeness of closed claims over a defined time period allows for patient-level longitudinal analyses for health economics and outcomes research (HEOR). Together, they enable a deeper understanding of patient behavior, treatment patterns, and healthcare utilization.

Claims Data and Magnolia Market Access

Magnolia’s Data Repository for Innovative Value and Evidence (DRIVE) contains medical and pharmacy claims from both open and closed sources allowing us to select the most appropriate data for your needs.