Annual Validity Study. The Department will conduct an annual validity study to determine the completeness, accuracy and timeliness of the Encounter data provided by the Contractor. Completeness will be determined by assessing whether the Encounter data transmitted includes each service that was provided. Accuracy will be determined by evaluating whether or not the values in each field of the Encounter accurately represent the service that was provided. Timeliness will be determined by assuring that the Encounter was transmitted to the Department the month after adjudication. The Department will randomly select an adequate sample which will include hospital claims, provider claims, drug claims and other claims (any claims except in-patient hospital, provider and drug), to be designated as the Encounter Processing Assessment Sample (EPAS). The Contractor will be responsible to provide to the Department the following information as it relates to each Claim in order to substantiate that the Contractor and the Department processed the claim correctly: A copy of the claim, either paper or a generated hard copy for electronic claims; Data from the paid claim’s file; Member eligibility/enrollment data; Provider eligibility data; Reference data (i.e., diagnosis code, procedure rates, etc.) pertaining to the Claim; Edit and audit procedures for the Claim; A copy of the remittance advice statement/explanation of benefits; A copy of the Encounter Record transmitted to the Department; and A listing of Covered Services. The Department will review each Claim from the EPAS to determine if complete, accurate and timely Encounter data was provided to the Department. Results of the review will be provided to the Contractor. The Contractor will be required to provide a corrective action plan to the Department within sixty (60) Days if deficiencies are found.
Appears in 4 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract, Medicaid Managed Care Contract
Annual Validity Study. The Department will conduct an annual validity study to determine the completeness, accuracy and timeliness of the Encounter data Record provided by the Contractor. Completeness will be determined by assessing whether the Encounter data record transmitted includes each service that was provided. Accuracy will be determined by evaluating whether or not the values in each field of the Encounter record accurately represent the service that was provided. Timeliness will be determined by assuring that the Encounter record was transmitted to the Department the month after adjudication. The Department will randomly select an adequate sample which will include hospital claims, provider claims, drug claims and other claims (any claims except in-patient hospital, provider and drug), to be designated as the Encounter Processing Assessment Sample (EPAS). The Contractor will be responsible to provide to the Department the following information as it relates to each Claim in order to substantiate that the Contractor and the Department processed the claim correctly: • A copy of the claim, either paper or a generated hard copy for electronic claims; • Data from the paid claim’s file; • Member eligibility/enrollment data; • Provider eligibility data; • Reference data (i.e., diagnosis code, procedure rates, etc.) pertaining to the Claim; • Edit and audit procedures for the Claim; • A copy of the remittance advice statement/explanation of benefits; • A copy of the Encounter Record transmitted to the Department; and • A listing of Covered Services. The Department will review each Claim from the EPAS to determine if complete, accurate and timely Encounter data Record was provided to the Department. Results of the review will be provided to the Contractor. The Contractor will be required to provide a corrective action plan to the Department within sixty (60) Days if deficiencies are found.
Appears in 1 contract
Samples: Managed Care Contract (Wellcare Health Plans, Inc.)
