Encounter Data Reporting.
3.14.1.1 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 SSA, 42 USC §1396b(m)(2)(A)(xi).
3.14.1.2 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 [42 CFR §§438.2; 438.242; 438.604; 438.818]:
(1) 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 covered 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.
(2) The MCO shall submit electronic 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.
(3) All denied claims, except claims that are denied because the enrollee was not enrolled in the MCO must be submitted to the STATE.
(4) Claim-level data must be reported to the STATE using the following claim formats, as described in the STATE’s technical specifications for encounter claims: 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 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. The MCO shall comply with the applicable provisions of Subtitle F (Administrative Simplification) of the Health Insurance Portability and Accountability Act of 1996 and any regulations promulgated pursuant to its authority, including the 5010 transaction standards. The MCO shall cooperate with the STATE as necessary to ensure compliance. The MCO must comply with state and federal requiremen...
Encounter Data Reporting. In order to assess quality of care, determine utilization patterns and access to care for various health care services, the CMHSP shall submit encounter data containing detail for each recipient encounter reflecting all services provided by the CMHSP. Encounter records shall be submitted monthly via electronic media in the format specified by the MDHHS. Encounter level records must have a common identifier that will allow linkage between the MDHHS’s and the CMHSPs management information systems. Encounter data requirements are detailed in the Reporting Requirements attached to this contract. The CMHSP agrees to participate in the reporting of encounter data quality improvement data, Medicaid performance indicator data and sub element cost data consistent with PIHP Medicaid requirements.
Encounter Data Reporting. A. The Contractor shall collect, process, format, and submit electronic encounter records for all services delivered to an enrollee. This requirement excludes services reimbursed directly to service providers by the Division on a fee-for-service basis. The Contractor shall capture all required encounter record elements using coding structures recognized by the Department. The Contractor shall process the encounter records, integrating any manual or automated systems to validate the adjudicated encounter records. The Contractor shall interface with any systems or modules within its organization to obtain the required encounter record elements. The Contractor shall submit the encounter records to the Department’s fiscal agent electronically according to specifications in the HMO Systems Guide, which may be periodically updated, and which is available at xxx.xxxxxx.xxx. The encounter data processing system shall have a data quality assurance plan to include timely data capture, accurate and complete encounter records, and internal data quality audit procedures. If DMAHS determines that changes to the encounter data processing system are required, the Contractor shall be given advance notice and time to make the change according to the extent and nature of the required change.
B. The Contractor shall ensure that data received from providers is accurate and complete by:
1. Verifying the accuracy and timeliness of reported data;
2. Screening the data for completeness, logic, and consistency; and
3. Collecting service information in standardized formats The Contractor shall make all collected data available to DMAHS and upon request, to CMS.
C. Regardless of whether the Contractor is considered a covered entity under HIPAA, the Contractor shall use the HIPAA Transaction and Code Sets as the exclusive format for the electronic communication of health care claims and encounter record submitted, regardless of date of service. When submitting encounter records, the Contractor shall adhere to all HIPAA transaction set requirements as specified in the HMO Systems Guide.
Encounter Data Reporting. A. Contractor shall maintain a MIS that collects and reports Encounter Data to DHCS in compliance with 42 CFR 438.242, and pursuant to applicable DHCS All Plan Letters (APL).
B. Contractor shall implement policies and procedures for ensuring the complete, accurate, reasonable, and timely submission of Encounter Data to DHCS for all items and services furnished to a Member under this Contract, whether directly or through Subcontracts or other arrangements, including capitated Providers. Encounter Data shall be submitted on at least a monthly basis in a form and manner specified by DHCS.
C. Contractor shall require Subcontractors and non-contracting Providers to submit claims and Encounter Data to Contractor to meet its administrative functions and the requirements set forth in this Section. Contractor shall have in place mechanisms, including edit and reporting systems sufficient to assure Encounter Data is complete, accurate, reasonable, and timely prior to submission to DHCS. Contractor shall ensure the completeness, accuracy, reasonability, and timeliness of all Subcontractor Encounter Data regardless of whether Subcontractor is reimbursed on a Fee-For- Service (FFS) or capitated basis.
D. Contractor shall submit complete, accurate, reasonable, and timely Encounter Data within six (6) business days of the end of each month following the month of payment, under this Contract or as otherwise agreed upon by DHCS, and in the format specified by DHCS.
E. DHCS shall review and validate the Encounter Data for completeness, accuracy, reasonability, and timeliness.
F. If DHCS finds deficiencies regarding the completeness, accuracy, reasonability, and timeliness of the Encounter Data, DHCS may notify Contractor in writing of the deficiency and request correction and resubmission of the relevant Encounter Data. Contractor shall ensure that corrected Encounter Data is resubmitted within 15 calendar days of the date of DHCS' notice. Upon Contractor's written request, DHCS may grant an extension for submission of corrected Encounter Data.
G. Contractor shall ensure all Encounter Data is submitted to DHCS within two (2) months of adjudication of a FFS claim or receipt of a capitated Encounter. Subcontractors and Providers must comply with this Provision for submission of Encounter Data to Contractor. All Encounter Data shall be submitted to Contractor no later than 12 months from the date of service.
H. DHCS or its agent will periodically, but not less frequently than ...
Encounter Data Reporting. In order to assess quality of care, determine utilization patterns and access to care for various health care services, affirm capitation rate calculations and estimates, the PIHP shall submit encounter data containing detail for each recipient encounter reflecting all services provided by the PIHP. Encounter records shall be submitted monthly via electronic media in the HIPAA-compliant format specified by MDCH. Encounter level records must have a common identifier that will allow linkage between MDCH’s and the PIHP’s management information systems. Encounter data requirements are detailed in the PIHP Reporting Requirements Attachment P.6.5.
1.1 to this contract. The following ASC X12N 837 Coordination of Benefits loops and segments are required by MDCH for reporting services provided by and/or paid for by the PIHP and/or CMHSP. Loop 2320 – Other Subscriber Information SBR – Other Subscriber Information DMG – Subscriber Demographic Information OI – Other Insurance Coverage Information Loop 2330B – Other Payer Name NM1 – Other Payer Name REF – Other Payer Secondary Identifier Submission of data for any other payer other than the PIHP and/or CMHSP is optional. Reporting monetary amounts in the ASC X12N 837 version 4010 is optional.
Encounter Data Reporting. General Requirements, is amended by INSERTING the following paragraph after the first paragraph of this section: “The Contractor will comply with the requirements of Section 6507 of the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), regarding “Mandatory State Use of National Correct Coding Initiatives,” including all applicable rules, regulations, and methodologies, as amended or modified, in accordance with EOHHS policy.”
Encounter Data Reporting. The contractor shall collect, process, format, and submit electronic encounter data for all services delivered for which the contractor is responsible. The contractor shall capture all required encounter data elements using coding structures recognized by the Department. The contractor shall process the encounter data, integrating any manual or automated systems to validate the adjudicated encounter data. The contractor shall interface with any systems or modules within its organization to obtain the required encounter data elements. The contractor shall submit the encounter data to the Department's fiscal agent electronically, via diskette, tape, or electronic transmission, according to specifications in the Electronic Media Claims (EMC) Manual found in Section B.3.3 of the Appendices. The encounter data processing system shall have a data quality assurance plan to include timely data capture, accurate and complete encounter records, and internal data quality audit procedures. If DMAHS determines that changes are required, the contractor shall be given advance notice and time to make the change according to the extent and nature of the required change.
Encounter Data Reporting electronic submission of encounter data from an MCO to the Department. See Article XIV.B, Encounter Reporting, for requirements pertaining to the reporting of encounter data.
Encounter Data Reporting. A. The contractor shall collect, process, format, and submit electronic encounter data for all services delivered for which the contractor is responsible. The contractor shall capture all required encounter data elements using coding structures recognized by; the Department. The contractor shall process the encounter data, integrating any manual or automated systems to validate the adjudicated encounter date. The contractor shall interface with any systems or modules within its organization to obtain the required encounter data elements. The contractor shall submit the encounter data to the Department’s fiscal agent electronically via diskette, tape or electronic transmission, according to specifications in the HIPPA Implementation and Companion Guides (HICG) Division’s Electronic Media Claims (EMC) Manual which will be distributed with regular updates may be periodically updated, and which are available at wxx.xxx-xxx.xxx/xxxxx and wxx.xxxxxx.xxx respectively. The encounter data processing system shall have a data quality assurance plan to include timely data capture, accurate and complete encounter records, and internal data quality audit procedures. If DMAHS determines that changes are required, the contractor shall e given advance notice and time to make the change according to the extent and nature of the required change.
B. The contractor shall ensure that data received from providers is accurate and complete by:
1. Verifying the accuracy and timeliness of reported data;
2. Screening the data for completeness, logic, and consistency; and
3. Collecting service information in standardized formats to the extent feasible and appropriate.
C. Regardless of whether the contractor is considered a covered entity under HIPAA, the contractor shall use the HIPAA Transaction and Code Sets as the exclusive format for the electronic communication of health care claims and encounter data for data with dates of service on or after October 16, 2003.submitted on or after January 1, 2005, regardless of date of service. The contractor shall adhere to all HIPAA transaction set requirements as specified in the national HIPAA Implementation Guide and the New Jersey Medicaid HIPAA Companion Guide when submitting encounters.
Encounter Data Reporting. Complete accurate and timely reporting of encounter data is crucial to the success of the AHCCCS program. AHCCCS uses encounter data to pay reinsurance benefits, set fee-for-service and capitation rates, determine disproportionate share payments to hospitals, and to determine compliance with performance standards. The Contractor shall submit encounter data to AHCCCS for all services for which the Contractor incurred a financial liability and claims for services eligible for processing by the Contractor where no financial liability was incurred including services provided during prior period coverage. This requirement is a condition of the CMS grant award [42 CFR 438.242(b)(1)] [42 CFR 455.1 (a)(2)]. The Contractor must successfully exchange encounter data for all applicable form types with AHCCCS no later than 120 days after the start of the contract or be subject to possible corrective actions up to and including sanctions and enrollment caps.
