Definition and Uses of Encounter Data. The Contractor shall submit an encounter claim to the State fiscal agent for every service rendered to a member for which the Contractor either paid or denied reimbursement. Encounter data provides reports of individual patient encounters with the Contractor’s health care network. These claims contain fee-for-service equivalent detail as to procedures, diagnoses, place of service, units of service, billed amounts and rendering providers’ identification numbers and other detailed claims data required for quality improvement monitoring and utilization analysis. The State shall use the encounter data to make tactical and strategic decisions related to the Hoosier Healthwise program and to the Contract. The State shall primarily use encounter data to calculate the Contractor’s future capitation rates, with alternative data sources utilized as appropriate to meet actuarial and federal standards. Encounter data will also be used to calculate incentive payments to the Contractor, monitor quality and to assess the Contractor’s Contract compliance. See Exhibit 3 for a schedule of liquidated damages that OMPP will assess for non-compliance with encounter data submission requirements.
Definition and Uses of Encounter Data. The Contractor shall submit an encounter claim to the State fiscal agent for every service rendered to a member for which the Contractor either paid or denied reimbursement. Encounter data provides reports of individual patient encounters with the Contractor’s health care network. These claims contain fee-for-service equivalent detail as to procedures, diagnoses, place of service, units of service, billed amounts and rendering providers’ identification numbers and other detailed claims data required for quality improvement monitoring and utilization analysis. The State shall use the encounter data to make tactical and strategic decisions related to the HIP program and to the Contract. The State shall primarily use encounter data to calculate the Contractor’s future capitation rates, with alternative data sources utilized as appropriate to meet actuarial and federal standards. Encounter data will also be used to calculate incentive payments to the Contractor, monitor quality and to assess the Contractor’s Contract compliance. See Exhibit 4 for a schedule of liquidated damages that OMPP will assess for non-compliance with encounter data submission requirements.
