Encounter Data. Party shall provide encounter data to the Agency of Human Services and/or its departments and ensure further that the data and services provided can be linked to and supported by enrollee eligibility files maintained by the State.
Encounter Data. (a) LIDDA shall submit timely monthly encounter data files for all IDD services, which has a rejection rate of less than 1% of the total number of records, in accordance to Attachment A-8 (IDD Submission Calendar).
(b) LIDDA shall submit accurate and comprehensive monthly encounter data for all IDD services, including all required data fields and values, in accordance with the IDD Service Grid Instructions, IDD Service Data Integrity, HHSC Service Grid and Field Definitions as well as procedures and instructions established by HHSC.
(c) LIDDA shall notify contract manager and submit in writing a System Migration Plan for any related client management software system transitions prior to implementation. Plan must clearly outline the timeline for completion and include assurances to ensure all obligations under this section will be maintained. Required status updates may be established by HHSC.
Encounter Data. The HMO must provide complete Encounter Data for all Covered Services, including Value-added Services. Encounter Data must follow the format, and data elements as described in the HIPAA-compliant 837 format. HHSC will specify the method of transmission, the submission schedule, and any other requirements in the Uniform Managed Care Manual. The HMO must submit Encounter Data transmissions monthly, and include all Encounter Data and Encounter Data adjustments processed by the HMO. Encounter Data quality validation must incorporate assessment standards developed jointly by the HMO and HHSC. The HMO must submit complete and accurate encounter data not later than the 30th calendar day after the last day of the month in which the claim was adjudicated. The HMO must make original records available for inspection by HHSC for validation purposes. Encounter Data that do not meet quality standards must be corrected and returned within a time period specified by HHSC. In addition to providing Encounter Data in the 837 format described above, HMOs may be requested to submit an Encounter Data file to HHSC's EQRO, in the format provided in the Uniform Managed Care Manual. This additional submission requirement is time-limited and may not be required for the entire term of the Contract. For reporting Encounters and fee-for-service claims to HHSC, the HMO must use the procedure codes, diagnosis codes, and other codes as directed by HHSC. Any exceptions will be considered on a code-by-code basis after HHSC receives written notice from the HMO requesting an exception. The HMO must also use the provider numbers as directed by HHSC for both Encounter and fee-for-service claims submissions, as applicable.
Encounter Data. Provider agrees to cooperate with United to comply with United’s obligation to prepare timely encounter data submissions, reports, and clinical information including, without limitation, child and adolescent health check-up reporting, EPSDT encounters, and cancer screening encounters, as applicable, and such other reporting regarding Covered Services as may be required under the State Contract. Encounter data must be accurate and include all services furnished to a Covered Person, including capitated provider’s data and rendering provider information. Encounter data must be provided within the timeframes specified and in a form that meets United and State requirements. By submitting encounter data to United, Provider represents to United that the data is accurate, complete and truthful, and upon United’s request Provider shall certify in writing, that the data is accurate, complete, and truthful, based on Provider’s best knowledge, information and belief.
Encounter Data. The Contractor shall submit encounter data to the Department at a frequency and level specified by the Department and CMS. (42 C.F.R. § 438.242(c)(2).) The Contractor shall ensure collection and maintenance of sufficient beneficiary encounter data to identify the provider who delivers service(s) to the beneficiary. (42 C.F.R. § 438.242(c)(1).) The Contractor shall submit all beneficiary encounter data that the Department is required to report to CMS under § 438.818. (42 C.F.R. § 438.242(c)(3).) The Contractor shall submit encounter data to the state in standardized Accredited Standards Committee (ASC) X12N 837 and National Council for Prescription Drug Programs (NCPDP) formats, and the ASC X12N 835 format as appropriate. (42 C.F.R. § 438.242(c)(4).)
Encounter Data. The MCO must maintain patient encounter data to identify the physician who delivers services or supervises services delivered to Enrollees, as required by §1903(m)(2)(A)(xi) of the Social Security Act, 42 USC §1396b(m)(2)(A)(xi). The MCO agrees to furnish information from its records to the STATE, or the STATE’s agents that are required in State or federal law or which the STATE may reasonably require to administer this Contract. The MCO shall provide the STATE upon the STATE’s request in the format determined by the STATE and for the time frame indicated by the STATE, the following information: Individual Enrollee-specific, claim-level encounter data for services provided by the MCO to Enrollees detailing all Medicare and Medicaid medical and dental diagnostic and treatment encounters, all pharmaceuticals (including Medicare Part D items), supplies and medical equipment dispensed to Enrollees, Home and Community-Based Services, Nursing Facility services, and Home Care Services for which the MCO is financially responsible. The MCO shall submit encounter data that includes all paid lines and all MCO- denied lines associated with the claim. Claims and lines for which Medicare or another Third Party has paid in part or in full are considered paid and shall be submitted as such.
(a) All denied claims, except those claims that are denied because the enrollee was not enrolled in the MCO must be submitted to the STATE. Claim-level data must be reported to the STATE using the following claim transaction formats: 1) the X12 837 standard format for physician, professional services, physician-dispensed pharmaceuticals (837P), specified Elderly Waiver Services (837P), inpatient and outpatient hospital services, Nursing Facility services (837I), and dental services (837D) that are the responsibility of the MCO; and 2) the NCPDP Batch 1.2/D.0 pharmacy. The MCO may submit the NCPDP Batch 1.2/D.0 for non-durable medical supplies which have an NDC code. All encounter claims must be submitted electronically.
(a) The MCO must comply with state and federal requirements, including the federal Implementation Guides, and the STATE’s 837 Encounter Companion Guide for Professional, Institutional and Dental Claims, and the Pharmacy Encounter Claims Guide posted on the STATE’s managed care website.
(b) The MCO must submit charge data using HIPAA standard transaction formats. Charge data shall be the lesser of the usual and customary charge (or appropriate amount from a Relative Valu...
Encounter Data. Provider agrees to cooperate with Subcontractor and/or Health Plan to comply with Subcontractor and/or Health Plan’s obligation to prepare timely encounter data submissions, reports, and clinical information including, without limitation, child and adolescent health check-up reporting, EPSDT encounters, and cancer screening encounters, as applicable, and such other reporting regarding Covered Services as may be required under the State Contract. Encounter data must be accurate and include all services furnished to a Covered Person, including capitated provider’s data and rendering provider information. Encounter data must be provided within the timeframes specified and in a form that meets Subcontractor, Health Plan and State requirements. By submitting encounter data to Subcontractor and/or Health Plan, Provider represents to Subcontractor and/or Health Plan that the data is accurate, complete and truthful, and upon Subcontractor’s and/or Health Plan’s request Provider shall certify in writing, that the data is accurate, complete, and truthful, based on Provider’s best knowledge, information and belief.
Encounter Data. The MCO must provide complete Encounter Data for all Covered Services, including Value-added Services. Encounter Data must follow the format and data elements as described in the HIPAA-compliant 837 Companion Guides and Encounter Submission Guidelines. HHSC will specify the method of transmission, the submission schedule, and any other requirements in Uniform Managed Care Manual Chapter 5.0, "Consolidated Deliverables Matrix." The MCO must submit Encounter Data transmissions at least monthly, and include all Encounter Data and Encounter Data adjustments processed by the MCO. In addition, Pharmacy Encounter Data must be submitted no later than 25 calendar days after the date of adjudication and include all Encounter Data and Encounter Data adjustments processed by the MCO. Encounter Data quality validation must incorporate assessment standards developed jointly by the MCO and HHSC. The MCO must submit complete and accurate Encounter Data not later than the 30th calendar day after the last day of the month in which the claim was adjudicated. The MCO must make original records available for inspection by HHSC for validation purposes. Encounter Data that does not meet quality standards must be corrected and returned within a time period specified by HHSC. For reporting claims processed by the MCO and submitted on Encounter 837 and NCPDP format, the MCO must use the procedure codes, diagnosis codes, provider identifiers, and other codes as directed by HHSC. Any exceptions will be considered on a code-by-code basis after HHSC receives written notice from the MCO requesting an exception. The MCO's Provider Agreements must require Network Providers to comply with the requirements of Texas Government Code § 531.024161, regarding reimbursement of claims based on orders or referrals by supervising providers.
Encounter Data. The Contractor shall prepare and submit encounter data on a monthly basis to SDOH through its designated Fiscal Agent. Each provider is required to have a unique identifier. Submissions shall be comprised of encounter records, or adjustments to previously submitted records, which the Contractor has received and processed from provider encounter or claim records of any contracted services rendered to the Enrollee in the current or any preceding months. Monthly submissions must be received by the Fiscal Agent by the Tuesday before the last Monday of the month to assure the submission is included in the Fiscal Agent's monthly production processing.
Encounter Data. Provider agrees to cooperate with Subcontractor and Health Plan to comply with Subcontractor and Health Plan’s obligation to prepare encounter data submissions, reports, and clinical information including, without limitation, child and adolescent health check- up reporting, EPSDT encounters, and cancer screening encounters, as applicable, and such other reporting regarding Covered Services as may be required under the State Contract.
