[Insured-Specific Outpatient Claims Data in Private Health Insurance - Part 2: Data Origin and Data Flow]

Scientific research with claims data provided by private health insurance companies (PHI companies) requires a basic understanding of the regulatory processes of the utilisation of health-related services by persons with private health insurance, the submission of invoices for healthcare services rendered/prescriptions redeemed to a PHI company, their billing and storage of data. Previous research projects have shown that, with knowledge of the special features of data from PHI companies, these can be used in projects involving claims data in a similar way to data from statutory health insurers. This second part of the series of articles on the scientific utilisation of private health insurance claims data focuses on the creation and flow of insured person and associated billing data in the private health insurance system for the sector of outpatient medical care, including medication. Using an exemplary data flow model for the sectors mentioned, processes and special features in the private health insurance system are systematically illustrated. Taking into account the process-related particularities of data generation and the associated content-related consequences, this article is intended to provide a basic understanding of these data. The information gathered can help decision-makers when planning a study with PHI data. The description of the data flow should support data analysts to consider the administrative and data content challenges in data preparation and evaluation. It is also essential for data analysts to be familiar with the data flow as well as with certain administrative and data content-related challenges. The evaluation of data availability and quality is necessary on an individual basis for each PHI company due to the divergent IT infrastructures and insurance rates. Future research projects with health-related claims data from individual or several PHI companies will expand expertise and empirical knowledge. The use of linkage methods is of particular importance here. The additional use of primary or survey data from privately insured persons will allow the realisation of validation studies that are designed, for instance, to examine the plausibility of recorded diagnoses. The increasing digitalisation of the healthcare system, for example through electronic invoicing and electronic prescriptions, can contribute to improving data content and availability in the future.