All Payer All Claims Data Submissions

Overview

The All Payer All Claims Reporting Program (APAC) has been integral to Oregon’s health system transformation since it was established in 2009. It contains administrative health care data such as insurance coverage, health service cost and utilization for Oregon’s insured populations. APAC provides access to timely and reliable data essential to assess the cost of health care, improve quality, reduce costs and promote transparency.

The purposes of APAC are described in statute (ORS 442.373) and include:

Allowing health care policymakers to make informed choices
Improving the quality and affordability of health care and health care coverage
Comparing the costs and effectiveness of treatment settings and approaches
Providing information to consumers and purchasers of health care

Data submissions are due on or before the dates listed within the 2024 Data Submission Schedule. If a submitted file requires correction, OHA rule allows a 14-day correction period to work with APAC's data vendor (HSRI) to correct the errors. If errors cannot be corrected within the 2-week grace period, the mandatory reporter must submit a request for an exemption from the validation rule or an extension to avoid a civil penalty.

2025 APAC Data Submission Schedule

Current File Layouts

Below are the current file layouts, organized by Appendix.

APAC 2024 claims file layout Appendices A-G

Appendix A: Enrollment
Appendix B: Medical Claims
Appendix C: Pharmacy Claims
Appendix D: Dental Claims
Appendix E: Provider File
Appendix F: Subscriber Billed Premium
Appendix G: Control Totals

We encourage data submitters to utilize these layouts when submitting files to APAC.

The Oregon Health Authority identifies mandatory reporters based on the type of organization, the number of lives it covers in Oregon, and the lines of business it operates.

Mandatory reporters are identified in ORS 442.372 and OAR 409-025-0110 as:

Insurance carriers and fraternal benefit societies with more than 5,000 covered lives as residents of Oregon
Third-party administrators with more than 5,000 covered lives as residents of Oregon
All pharmacy benefits managers
All coordinated care organizations
All insurers providing benefits under Medicare Part A, B, or D
All insurers providing benefits for dual eligible (Medicare and Medicaid)
All insurers offering a plan in Oregon's health insurance exchange and
All insurers providing group health insurance to PEBB or OEBB

List of 2024 Mandatory reporters

What Lines of Business Are Required to be Reported to APAC?

Reportable lines of business are identified in OAR 409-025-0110 as:

Medicare Advantage Part C and Medicare Part D
Medicaid
Individual health insurance
Small employer health insurance
Large group health insurance
Health insurance provided through associations and trusts
PEBB and OEBB group health insurance plans
Self-insured plans not subject to ERISA and
Dental insurance

Below is a table that lists the files required by type of submitter.

File Name	Carrier*	TPA	PBM	Dental Plan†	CCOs
Quarterly Submission of Claims Data
Appendix A: Enrollment
Appendix B: Medical Claims
Appendix C: Pharmacy Claims
Appendix D: Dental Claims
Appendix E: Provider
Appendix F: Subscriber Billed Premium
Appendix G: Control Totals
Annual Submission of Payment Arrangement File
Appendix 1: Payment Arrangement
Appendix 2: Payment Arrangement Control

* In the above, “carrier" includes insurers offering plans for Medicare, dual eligible, PEBB/OEBB, and on the health insurance exchange.

† Dental plan includes standalone dental plans or plans that are part of other carrier benefits

Beginning with service dates in 2025, CCOs will be required to submit data as detailed under 'Required Files for Submission'. The APAC team will collaborate with each CCO to understand and address any assistance needed for this reporting. Files should be submitted starting May 1, 2025, for enrollments and services occurring from January through March 2025.

Additionally, the APAC team will host workgroup meetings to prepare CCO staff for APAC claims data submission. Below is the schedule of the meetings:

September 17, 2024, 9:05 am (PST)| Overview of file layouts and submission schedule| link to recording here
October 24, 2024, 9:05 am (PST)| Frequently asked questions and discussion| link to meeting here
November 19, 2024, 9:05 am (PST)| General check-in and any topics raised by CCOs| link to meeting here
February 4, 2025 9:05 am (PST)| General check-in and any topics rasied by CCOs| link to meeting here
April 15, 2025 9:05 am (PST)| Check in on file building and submission questions| link to meeting here

For any questions, please contact the APAC inbox at apac.admin@odhsoha.gov.

Waivers

To request a waiver, fill out the APAC-1a form and return it to the APAC inbox by December 2 to receive a waiver from reporting for the following reporting year. Waivers are required if an organization is identified as a mandatory reporter and expects no data to report. This may happen if:

The number of covered lives in Oregon drops below 5,000 for carriers and third-party administrators (excluding ERISA-reported lives). A mandatory attestation form might be needed to document both ERISA and non-ERISA counts.
All business lines are excluded from APAC reporting (see OAR 409-025-0110 for details).
All business lines are for federal entities or sovereign tribal groups that don't report voluntarily.
For pharmacy benefit managers and others not restricted by the 5,000 covered lives threshold, the organization believes the reporting burden outweighs the benefits. Approval is at the program's discretion.

Waivers may also be requested for specific files, particularly for third-party administrators who don't bill for subscriber-level premiums. Waivers are approved for one calendar year only, as the conditions for approval may change annually.

APAC -1a Waiver Application Form

APAC Mandatory Reporter Attestation Form

Extensions

If a mandatory reporter or their data submitter can't meet the submission deadline, they must request an extension. Per Oregon Administrative Rule, requests must be made at least 14 days before the due date. Extensions can be requested by submitting the APAC-1b form via email or through the HSRI portal as outlined in the user manual.

APAC-1b Extension Application Form

Exemptions

If a file fails validation, exemptions for specific data elements can be requested in the HSRI portal. Each exemption request must be filed for each rule failure and should include the reason for the request and plans to correct the issue in future submissions. Instructions for submitting exemptions are available here.

The requirements for the annual submission of Appendices 1 and 2 of the PAF are detailed below. Submission occurs through the Human Services Research Institute (HSRI) portal, which can be found here. The file layouts, rules (including definitions), memorandum, and training information may also be useful when submitting Exhibit L as required by contract for CCOs.

File layouts for Appendices 1 and 2, version 2023.1

Appendix 1, payment arrangement file created July 31, 2024
Appendix 2, payment arrangement control file created August 16, 2024

Submission schedule: Files are required by September 30 of each year for the prior calendar year.

Available PAF Training

Additional PAF Resources

Every spring, data submitters will be given access to an annual report comparing metrics in the APAC data warehouse with their system. This report serves as a data quality validation point aimed at improving the quality and usefulness of APAC. Data submitters must review and confirm the accuracy of their report or report any discrepancies within the specified deadlines. For further details about data submission requirements, please refer to the links provided below.

APAC Program email: APAC.Admin@odhsoha.oregon.gov

Claims data training

Technical Assistance at HSRI:

Help desk email at HSRI: APAChelp@hsri.org
HSRI APAC Data Submission and Quality Portal: User Manual
HSRI APAC Data Submission and Quality Portal: FAQs

Detailed information on Validation Rule application to files is available within the submission portal under Guides > Validation Rules.

Oregon Administrative Rules (OARs)

409-025-0100 Definitions
409-025-0110 General Reporting Requirements
409-025-0120 Claims Data File Layout, Format, and Coding Requirements
409-025-0125 Payment Arrangement Reporting: File Layout, Format, and Coding Requirements
409-025-0130 Data Submission Requirements
409-025-0140 Waivers and Exceptions
409-025-0150 Compliance and Enforcement
409-025-0160 Data Access and Release
409-025-0170 Public Disclosure
409-025-0180 APAC Technical Advisory Group
409-025-0190 Data Review Committee

Oregon Revised Statutes

Chapter 413

413.032(2) Creation of all payer claims database

Chapter 442

442.372 Definitions for PRS 442.372 and 442.373
442.363 Health care data reporting by health insurers
442.993 Civil penalties for failure to report health care data of health insurers