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Common use of Encounter Data Reporting Clause in Contracts

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 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 web site. (5) 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 Value Scale for missing or unavailable charges) or submitted charge. (6) The MCO shall submit on the encounter claim for 837P, 837I, 837D and NCPDP Batch 1.2/D.0 the Provider allowed and paid amounts. (a) For MSHO, this requirement applies to both Medicaid and Medicare services, excluding Part D. For MSC+ this includes MCO payment for Medicare crossover claims. (b) For the purposes of this section “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing. For the purposes of this section “allowed amount” is defined as the Provider contracted rate prior to any exclusions or add-ons. In accordance with Minnesota Statutes, §256B.69, subd. 9c, (a), the data reported herein is defined as non-public in Minnesota Statutes, §13.02. (c) If the MCO uses a Subcontractor to administer a benefit, for example a dental administrator or Pharmacy Benefit Manager, the “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing by the Subcontractor. (d) Paid amounts for services rendered under subcapitated risk-based arrangements must be estimated using usual and customary payment or an appropriate amount from a Relative Value Scale or the DHS FFS fee schedule, and must not include administrative costs or other incentives. (7) The MCO will submit Medicaid drug information on pharmacy (NCPDP Batch 1.2/D.0), professional (837P) and institutional (837I) encounter claims in accordance with STATE data element specifications related to the collection of drug rebates. These specifications will be outlined in the Encounter Companion Guides for the NCPDP Batch 1.2/D.0 Pharmacy, 837 Professional and 837 Institutional encounter claims. The MCO and its Subcontractor, if applicable, must comply with these specifications and submit encounter data every two weeks and no later than thirty (30) days for original claims and forty-five (45) days for adjusted claims, after the MCO (or its Subcontractor) adjudicates both outpatient pharmacy and physician-administered drug claims. This process enables the STATE to comply with‌ 1927(b), 1903m(2)(A) and 1927(j)(1) of the SSA as amended by Section 2501 (c) of the Patient Protection and Affordable Care Act.‌‌‌‌ (8) The MCO shall submit individual-enrollee specific, claim-level data on all post-payment recoveries for pharmacy claims from liable third parties on a quarterly basis, in a format determined by the STATE. This report shall contain only the post-payment recoveries for pharmacy claims that cannot be reported as encounters in section (7) above.‌‌ (9) The MCO shall be responsible for submitting claim-level encounter data that distinguishes between the Skilled Nursing Facility (SNF) and the Nursing Facility (NF) days used by the Enrollee. (10) The MCO shall submit Home and Community-Based Services encounter data pursuant to the X12 837 national standard. This includes type of service, units of service, and dates of service, sufficient to provide CMS with the required audit trail.‌ (11) The MCO agrees to participate in a workgroup with the STATE to ensure that all units of service, HCPCS codes and modifiers are being submitted correctly for encounter data for home care and Home and Community-Based Services. (12) The MCO shall submit encounter data on all Personal Care Assistance (PCA) services using the X12 837P standard transaction format, and report PCAs as treating Providers. The MCO shall submit complete encounter data on PCA services, including the date of service, the paid units of service by date, and the treating PCA provider. The STATE will monitor PCAs as treating Providers. (13) The MCO shall not submit encounters for administrative care coordination. Case management services provided for an Enrollee on EW shall be submitted as encounters per section 3.14.1.2(10).‌‌ 3.14.1.3 The MCO shall notify the STATE ninety (90) days prior to any change in the submitter process, including but not limited to the use of a new submitter. 3.14.1.4 The MCO shall submit original submission encounter claims no later than thirty (30) days after the date the MCO adjudicates the claim. The MCO shall make submissions for each transaction format at least bi-weekly. If the MCO is unable to make a submission during a certain month, the MCO shall contact the STATE to notify it of the reason for the delay and the estimated date when the STATE can expect the submission. The MCO’s submission of claim adjustments must be done by voiding the original claim and submitting a corrected claim, within forty-five (45) days of the date adjusted at the MCO. See also section 9.4.

Appears in 2 contracts

Samples: Contract for Minnesota Senior Health Options and Minnesota Senior Care Plus Services, Contract for Minnesota Senior Health Options and Minnesota Senior Care Plus Services

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 those 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 transaction 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 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 web site. (5) 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 Value Scale for missing or unavailable charges) or submitted charge. (6) The MCO shall submit on the encounter claim for 837P, 837I, 837D and NCPDP Batch 1.2/D.0 the Provider allowed and paid amounts. (a) For MSHO, this requirement applies to both Medicaid and Medicare services, excluding Part D. For MSC+ this includes MCO payment for Medicare crossover claims. (b) For the purposes of this section “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing. For the purposes of this section “allowed amount” is defined as the Provider contracted rate prior to any exclusions or add-ons. In accordance with Minnesota Statutes, §256B.69, subd. 9c, (a), the data reported herein is defined as non-public in Minnesota Statutes, §13.02. (c) If the MCO uses a Subcontractor to administer a benefit, for example a dental administrator or Pharmacy Benefit Manager, the “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing by the Subcontractor. (d) Paid amounts for services rendered under subcapitated risk-based arrangements must be estimated using usual and customary payment or an appropriate amount from a Relative Value Scale or the DHS FFS fee schedule, and must not include administrative costs or other incentives. (7) The MCO will submit Medicaid drug information on pharmacy (NCPDP Batch 1.2/D.0), professional (837P) and institutional (837I) encounter claims in accordance with STATE data element specifications related to the collection of drug rebates. These specifications will be outlined in the Encounter Companion Guides for the NCPDP Batch 1.2/D.0 Pharmacy, 837 Professional and 837 Institutional encounter claims. The MCO and its Subcontractor, if applicable, must comply with these specifications and submit encounter data every two weeks and no later than thirty (30) days for original claims and forty-five (45) days for adjusted claims, after the MCO (or its Subcontractor) adjudicates both outpatient pharmacy and physician-administered drug claims. This process enables the STATE to comply with‌ with 1927(b), 1903m(2)(A) and 1927(j)(1) of the SSA as amended by Section 2501 (c) of the Patient Protection and Affordable Care Act.‌‌‌‌Act. (8) The MCO shall submit individual-enrollee specific, claim-level data on all post-payment recoveries for pharmacy claims from liable third parties on a quarterly basis, in a format determined by the STATE. This report shall contain only the post-payment recoveries for pharmacy claims that cannot be reported as encounters in section (7) above.‌‌. (9) The MCO shall be responsible for submitting claim-level encounter data that distinguishes between the Skilled Nursing Facility (SNF) and the Nursing Facility (NF) days used by the Enrollee. (10) The MCO shall submit Home and Community-Based Services encounter data pursuant to the X12 837 national standard. This includes type of service, units of service, and dates of service, sufficient to provide CMS with the required audit trail.‌ (11) The MCO agrees to participate in a workgroup with the STATE to ensure that all units of service, HCPCS codes and modifiers are being submitted correctly for encounter data for home care and Home and Community-Based Services.Services.‌‌‌ (12) The MCO shall submit encounter data on all Personal Care Assistance (PCA) services using the X12 837P standard transaction format, and report PCAs as treating Providers. The MCO shall submit complete encounter data on PCA services, including the date of service, the paid units of service by date, and the treating PCA provider. The STATE will monitor PCAs as treating Providers. (13) The MCO shall not submit encounters for administrative care coordination. Case management services provided for an Enrollee on EW shall be submitted as encounters per section 3.14.1.2(10).‌‌ 3.14.1.3 The MCO shall notify the STATE ninety (90) days prior to any change in the submitter process, including but not limited to the use of a new submitter. 3.14.1.4 The MCO shall submit original submission encounter claims no later than thirty (30) days after the date the MCO adjudicates the claim. The MCO shall make submissions for each transaction format at least bi-weekly. If the MCO is unable to make a submission during a certain month, the MCO shall contact the STATE to notify it of the reason for the delay and the estimated date when the STATE can expect the submission. The MCO’s submission of claim adjustments must be done by voiding the original claim and submitting a corrected claim, within forty-five (45) days of the date adjusted at the MCO. See also section 9.49.9.

Appears in 2 contracts

Samples: Contract for Minnesota Senior Health Options and Minnesota Senior Care Plus Services, Contract for Minnesota Senior Health Options and Minnesota Senior Care Plus Services

Encounter Data Reporting. 3.14.1.1 3.16.1.1 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 3.16.1.2 The MCO agrees to furnish information from its records to the STATE, 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 to the STATE STATE, upon the STATE’s request 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 of the following: 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 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. Third Party paid claims include immunizations which are paid for by the Minnesota Vaccines for Children Program (MNVFC). (3) All denied claims, except those 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, and for physician- dispensed pharmaceuticals (837P), specified Elderly Waiver Services (837P), inpatient and outpatient hospital services, Nursing Facility services (837I), Nursing Facility services, and dental services (837D) that are the responsibility of the MCO; and  The NCPDP Batch 1.2/1.2/ D.0 pharmacy. The MCO may submit the NCPDP Batch 1.2/1.2/ 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 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 web site. (5) 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 Value Scale for missing or unavailable charges) or submitted charge. (6) The MCO shall submit on the encounter claim for 837P, 837I, 837D 837D, and NCPDP Batch 1.2/D.0 the Provider allowed and paid amounts. (a) For MSHO, this requirement applies to both Medicaid and Medicare services, excluding Part D. For MSC+ this includes MCO payment for Medicare crossover claims. (b) . For the purposes of this section “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing. For the purposes of this section “allowed amount” is defined as the Provider contracted rate prior to any exclusions or add-ons. In accordance with Minnesota Statutes, §256B.69, subd. 9c, (a), the data reported herein is defined as non-public in Minnesota Statutes, §13.02., (ca) If the MCO uses a Subcontractor to administer a benefit, for example a dental administrator or Pharmacy Benefit Manager, the “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing by the Subcontractor. (db) Paid amounts for services rendered under subcapitated risk-based arrangements must be estimated using usual and customary payment or an appropriate amount from a Relative Value Scale or the DHS FFS fee schedule, and must not include administrative costs or other incentives. (7) The MCO will submit Medicaid drug information on pharmacy (NCPDP Batch 1.2/D.0), professional (837P) and institutional (837I) encounter claims in accordance with STATE data element specifications related to the collection of drug rebates. These specifications will be outlined in the Encounter Companion Guides for the NCPDP Batch 1.2/D.0 Pharmacy, 837 Professional and 837 Institutional encounter claims. The MCO and its Subcontractor, if applicable, must comply with these specifications and submit encounter data every two weeks and no later than thirty (30) days for original claims and forty-five (45) days for adjusted claims, after the MCO (or its Subcontractor) adjudicates both outpatient pharmacy and physician-administered drug claims. This process enables the STATE to comply with‌ with 1927(b), ) 1903m(2)(A) and 1927(j)(1) of the SSA as amended by Section 2501 (c) of the Patient Protection and Affordable Care Act.‌‌‌‌Act.‌‌‌ (8) The MCO shall submit individual-enrollee specific, claim-level data on all post-payment recoveries for pharmacy claims from liable third parties on a quarterly basis, in a format determined by the STATE. This report shall contain only the post-payment recoveries for pharmacy claims that cannot be reported as encounters in section (7) above.‌‌. (9) All encounter data for Nursing Facility and Skilled Nursing Facility services must be submitted according to procedures as prescribed by the STATE in the current EDI specifications on the STATE web site at xxxx://xxx.xxx.xxxxx.xx.xx/provider/mco.‌‌ (10) The MCO shall be responsible for submitting claim-level encounter data that distinguishes between the Skilled Nursing Facility (SNF) and the Nursing Facility (NF) days used by the Enrollee. (10) The MCO shall submit Home and Community-Based Services encounter data pursuant to the X12 837 national standard. This includes type of service, units of service, and dates of service, sufficient to provide CMS with the required audit trail.‌ (11) The MCO agrees to participate in a workgroup with the STATE to ensure that all units of service, HCPCS codes and modifiers are being submitted correctly for encounter data for home care and Home and Community-Based Services. (12) The MCO shall submit encounter data on all Personal Care Assistance (PCA) services using the X12 837P standard transaction format, and report PCAs as treating Providers. The MCO shall submit complete encounter data on PCA services, including the date of service, the paid units of service by date, and the treating PCA provider. The STATE will monitor PCAs as treating Providers. (13) The MCO shall not submit encounters for administrative care coordination. Case management services provided for an Enrollee on EW shall be submitted as encounters per section 3.14.1.2(10).‌‌ 3.14.1.3 3.16.1.3 The MCO shall notify the STATE ninety (90) days prior to any change in the submitter process, including but not limited to the use of a new submitter. 3.14.1.4 3.16.1.4 The MCO shall submit original submission encounter claims no later than thirty (30) days after the date the MCO adjudicates the claim. The MCO shall make submissions for each transaction format at least bi-weekly. If the MCO is unable to make a submission during a certain month, the MCO shall contact the STATE to notify it of the reason for the delay and the estimated date when the STATE can expect the submission. The MCO’s submission of claim adjustments must be done by voiding the original claim and submitting a corrected claim, within forty-five (45) days of the date adjusted at the MCO. See also section 9.49.9.6 below regarding claims voided or reversed because of program integrity concerns.‌‌ 3.16.1.5 When the STATE returns or rejects a file of encounter claims the MCO shall have twenty (20) calendar days from the date the MCO receives the rejected file to resubmit the file with all of the required data elements in the correct file format. 3.16.1.6 The STATE will provide a remittance advice, on a schedule specified by the STATE, for all submitted encounter claims, including void claims. The remittance advice will be provided in the X12 835 standard transaction format.

Appears in 1 contract

Samples: Contract for Special Needs Basiccare Program Services

Encounter Data Reporting. 3.14.1.1 3.16.1.1 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 3.16.1.2 The MCO agrees to furnish information from its records to the STATE, 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 to the STATE STATE, upon the STATE’s request 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 of the following: 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 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. Third Party paid claims include immunizations which are paid for by the Minnesota Vaccines for Children Program (MNVFC). (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, and for physician- dispensed pharmaceuticals (837P), specified Elderly Waiver Services (837P), inpatient and outpatient hospital services, Nursing Facility services (837I), Nursing Facility services, and dental services (837D) that are the responsibility of the MCO; and The NCPDP Batch 1.2/1.2/ D.0 pharmacy. The MCO may submit the NCPDP Batch 1.2/1.2/ 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 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 web site. • Service location must be populated on all encounter submissions, except NCPDP, effective August 1, 2021. This is required even if the service location is the same as the billing location. It is also required on claims having either consolidated NPIs or non-consolidated NPIs. (5) 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 Value Scale for missing or unavailable charges) or submitted charge. (6) The MCO shall submit on the encounter claim for 837P, 837I, 837D 837D, and NCPDP Batch 1.2/D.0 the Provider allowed and paid amounts. (a) For MSHO, this requirement applies to both Medicaid and Medicare services, excluding Part D. For MSC+ this includes MCO payment for Medicare crossover claims. (b) . For the purposes of this section “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing. For the purposes of this section “allowed amount” is defined as the Provider contracted rate prior to any exclusions or add-ons. In accordance with Minnesota Statutes, §256B.69, subd. 9c, (a), the data reported herein is defined as non-public in Minnesota Statutes, §13.02., (ca) If the MCO uses a Subcontractor to administer a benefit, for example a dental administrator or Pharmacy Benefit Manager, the “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing by the Subcontractor. (db) Paid amounts for services rendered under subcapitated risk-based arrangements must be estimated using usual and customary payment or an appropriate amount from a Relative Value Scale or the DHS FFS fee schedule, and must not include administrative costs or other incentives. (7) The MCO will submit Medicaid drug information on pharmacy (NCPDP Batch 1.2/D.0), professional (837P) and institutional (837I) encounter claims in accordance with STATE data element specifications related to the collection of drug rebates. These specifications will be outlined in the Encounter Companion Guides for the NCPDP Batch 1.2/D.0 Pharmacy, 837 Professional and 837 Institutional encounter claims. The MCO and its Subcontractor, if applicable, must comply with these specifications and submit encounter data every two weeks and no later than thirty (30) days for original claims and forty-five (45) days for adjusted claims, after the MCO (or its Subcontractor) adjudicates both outpatient pharmacy and physician-administered drug claims. This process enables the STATE to comply with‌ with 1927(b), ) 1903m(2)(A) and 1927(j)(1) of the SSA as amended by Section 2501 (c) of the Patient Protection and Affordable Care Act.‌‌‌‌ (8) Act. The MCO shall submit individual-enrollee specific, claim-level data on all post-payment recoveries for pharmacy claims from liable third parties on a quarterly basis, in a format determined by the STATE. This report shall contain only the post-payment recoveries for pharmacy claims that cannot be reported as encounters in section (7) above.‌‌above.‌ (8) All encounter data for Nursing Facility and Skilled Nursing Facility services must be submitted according to procedures as prescribed by the STATE in the current EDI specifications on the STATE web site at xxxx://xxx.xxx.xxxxx.xx.xx/provider/mco. (9) The MCO shall be responsible for submitting claim-level encounter data that distinguishes between the Skilled Nursing Facility (SNF) and the Nursing Facility (NF) days used by the Enrollee. (10) The MCO shall submit Home and Community-Based Services encounter data pursuant to the X12 837 national standard. This includes type of service, units of service, and dates of service, sufficient to provide CMS with the required audit trail.‌ (11) The MCO agrees to participate in a workgroup with the STATE to ensure that all units of service, HCPCS codes and modifiers are being submitted correctly for encounter data for home care and Home and Community-Based Services. (12) The MCO shall submit encounter data on all Personal Care Assistance (PCA) services using the X12 837P standard transaction format, and report PCAs as treating Providers. The MCO shall submit complete encounter data on PCA services, including the date of service, the paid units of service by date, and the treating PCA provider. The STATE will monitor PCAs as treating Providers. (13) The MCO shall not submit encounters for administrative care coordination. Case management services provided for an Enrollee on EW shall be submitted as encounters per section 3.14.1.2(10).‌‌ 3.14.1.3 3.16.1.3 The MCO shall notify the STATE ninety (90) days prior to any change in the submitter process, including but not limited to the use of a new submitter. 3.14.1.4 3.16.1.4 The MCO shall submit original submission encounter claims no later than thirty (30) days after the date the MCO adjudicates the claim. The MCO shall make submissions for each transaction format at least bi-weekly. If the MCO is unable to make a submission during a certain month, the MCO shall contact the STATE to notify it of the reason for the delay and the estimated date when the STATE can expect the submission. The MCO’s submission of claim adjustments must be done by voiding the original claim and submitting a corrected claim, within forty-five (45) days of the date adjusted at the MCO. See also section 9.49.4.6 below regarding claims voided or reversed because of program integrity concerns. 3.16.1.5 When the STATE returns or rejects a file of encounter claims the MCO shall have twenty (20) calendar days from the date the MCO receives the rejected file to resubmit the file with all of the required data elements in the correct file format. 3.16.1.6 The STATE will provide a remittance advice, on a schedule specified by the STATE, for all submitted encounter claims, including void claims. The remittance advice will be provided in the X12 835 standard transaction format.

Appears in 1 contract

Samples: Special Needs Basiccare Program Services Contract

Encounter Data Reporting. 3.14.1.1 3.16.1.1 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 3.16.1.2 The MCO agrees to furnish information from its records to the STATE, 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 to the STATE STATE, upon the STATE’s request 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 of the following: 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 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. Third Party paid claims include immunizations which are paid for by the Minnesota Vaccines for Children Program (MNVFC). (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, and for physician- dispensed pharmaceuticals (837P), specified Elderly Waiver Services (837P), inpatient and outpatient hospital services, Nursing Facility services (837I), Nursing Facility services, and dental services (837D) that are the responsibility of the MCO; and  The NCPDP Batch 1.2/1.2/ D.0 pharmacy. The MCO may submit the NCPDP Batch 1.2/1.2/ 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 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 web site. (5) 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 Value Scale for missing or unavailable charges) or submitted charge. (6) The MCO shall submit on the encounter claim for 837P, 837I, 837D 837D, and NCPDP Batch 1.2/D.0 the Provider allowed and paid amounts. (a) For MSHO, this requirement applies to both Medicaid and Medicare services, excluding Part D. For MSC+ this includes MCO payment for Medicare crossover claims. (b) . For the purposes of this section “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing. For the purposes of this section “allowed amount” is defined as the Provider contracted rate prior to any exclusions or add-ons. In accordance with Minnesota Statutes, §256B.69, subd. 9c, (a), the data reported herein is defined as non-public in Minnesota Statutes, §13.02., (ca) If the MCO uses a Subcontractor to administer a benefit, for example a dental administrator or Pharmacy Benefit Manager, the “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing by the Subcontractor. (db) Paid amounts for services rendered under subcapitated risk-based arrangements must be estimated using usual and customary payment or an appropriate amount from a Relative Value Scale or the DHS FFS fee schedule, and must not include administrative costs or other incentives. (7) The MCO will submit Medicaid drug information on pharmacy (NCPDP Batch 1.2/D.0), professional (837P) and institutional (837I) encounter claims in accordance with STATE data element specifications related to the collection of drug rebates. These specifications will be outlined in the Encounter Companion Guides for the NCPDP Batch 1.2/D.0 Pharmacy, 837 Professional and 837 Institutional encounter claims. The MCO and its Subcontractor, if applicable, must comply with these specifications and submit encounter data every two weeks and no later than thirty (30) days for original claims and forty-five (45) days for adjusted claims, after the MCO (or its Subcontractor) adjudicates both outpatient pharmacy and physician-administered drug claims. This process enables the STATE to comply with‌ with 1927(b), ) 1903m(2)(A) and 1927(j)(1) of the SSA as amended by Section 2501 (c) of the Patient Protection and Affordable Care Act.‌‌‌‌ (8) Act. The MCO shall submit individual-enrollee specific, claim-level data on all post-payment recoveries for pharmacy claims from liable third parties on a quarterly basis, in a format determined by the STATE. This report shall contain only the post-payment recoveries for pharmacy claims that cannot be reported as encounters in section (7) above.‌‌above.‌‌‌‌‌‌‌ (8) All encounter data for Nursing Facility and Skilled Nursing Facility services must be submitted according to procedures as prescribed by the STATE in the current EDI specifications on the STATE web site at xxxx://xxx.xxx.xxxxx.xx.xx/provider/mco.‌‌ (9) The MCO shall be responsible for submitting claim-level encounter data that distinguishes between the Skilled Nursing Facility (SNF) and the Nursing Facility (NF) days used by the Enrollee. (10) The MCO shall submit Home and Community-Based Services encounter data pursuant to the X12 837 national standard. This includes type of service, units of service, and dates of service, sufficient to provide CMS with the required audit trail.‌ (11) The MCO agrees to participate in a workgroup with the STATE to ensure that all units of service, HCPCS codes and modifiers are being submitted correctly for encounter data for home care and Home and Community-Based Services. (12) The MCO shall submit encounter data on all Personal Care Assistance (PCA) services using the X12 837P standard transaction format, and report PCAs as treating Providers. The MCO shall submit complete encounter data on PCA services, including the date of service, the paid units of service by date, and the treating PCA provider. The STATE will monitor PCAs as treating Providers. (13) The MCO shall not submit encounters for administrative care coordination. Case management services provided for an Enrollee on EW shall be submitted as encounters per section 3.14.1.2(10).‌‌ 3.14.1.3 3.16.1.3 The MCO shall notify the STATE ninety (90) days prior to any change in the submitter process, including but not limited to the use of a new submitter. 3.14.1.4 3.16.1.4 The MCO shall submit original submission encounter claims no later than thirty (30) days after the date the MCO adjudicates the claim. The MCO shall make submissions for each transaction format at least bi-weekly. If the MCO is unable to make a submission during a certain month, the MCO shall contact the STATE to notify it of the reason for the delay and the estimated date when the STATE can expect the submission. The MCO’s submission of claim adjustments must be done by voiding the original claim and submitting a corrected claim, within forty-five (45) days of the date adjusted at the MCO. See also section 9.49.9.6 below regarding claims voided or reversed because of program integrity concerns.‌‌ 3.16.1.5 When the STATE returns or rejects a file of encounter claims the MCO shall have twenty (20) calendar days from the date the MCO receives the rejected file to resubmit the file with all of the required data elements in the correct file format. 3.16.1.6 The STATE will provide a remittance advice, on a schedule specified by the STATE, for all submitted encounter claims, including void claims. The remittance advice will be provided in the X12 835 standard transaction format.

Appears in 1 contract

Samples: Contract for Special Needs Basiccare Program Services

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- 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:  claims:‌ • The X12 837 standard 837-like format for physician, professional services, physician- 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. [42 CFR 438.818(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 web site. (5) 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 Value Scale for missing or unavailable charges) or submitted charge. (6) The MCO shall submit on the encounter claim for 837P, 837I, 837D and NCPDP Batch 1.2/D.0 the Provider allowed and paid amounts. (a) For MSHO, this requirement applies to both Medicaid and Medicare services, excluding Part D. For MSC+ this includes MCO payment for Medicare crossover claims. (b) For the purposes of this section “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing. For the purposes of this section “allowed amount” is defined as the Provider contracted rate prior to any exclusions or add-ons. In accordance with Minnesota Statutes, §256B.69, subd. 9c, (a), the data reported herein is defined as non-public in Minnesota Statutes, §13.02. (c) If the MCO uses a Subcontractor to administer a benefit, for example a dental administrator or Pharmacy Benefit Manager, the “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing by the Subcontractor. (d) Paid amounts for services rendered under subcapitated risk-based arrangements must be estimated using usual and customary payment or an appropriate amount from a Relative Value Scale or the DHS FFS fee schedule, and must not include administrative costs or other incentives. (7) The MCO will submit Medicaid drug information on pharmacy (NCPDP Batch 1.2/D.0), professional (837P) and institutional (837I) encounter claims in accordance with STATE data element specifications related to the collection of drug rebates. These specifications will be outlined in the Encounter Companion Guides for the NCPDP Batch 1.2/D.0 Pharmacy, 837 Professional and 837 Institutional encounter claims. The MCO and its Subcontractor, if applicable, must comply with these specifications and submit encounter data every two weeks and no later than thirty (30) days for original claims and forty-five (45) days for adjusted claims, after the MCO (or its Subcontractor) adjudicates both outpatient pharmacy and physician-administered drug claims. This process enables the STATE to comply with‌ 1927(b), 1903m(2)(A) and 1927(j)(1) of the SSA as amended by Section 2501 (c) of the Patient Protection and Affordable Care Act.‌‌‌‌ (8) The MCO shall submit individual-enrollee specific, claim-level data on all post-payment recoveries for pharmacy claims from liable third parties on a quarterly basis, in a format determined by the STATE. This report shall contain only the post-payment recoveries for pharmacy claims that cannot be reported as encounters in section (7) above.‌‌ (9) The MCO shall be responsible for submitting claim-level encounter data that distinguishes between the Skilled Nursing Facility (SNF) and the Nursing Facility (NF) days used by the Enrollee. (10) The MCO shall submit Home and Community-Based Services encounter data pursuant to the X12 837 national standard. This includes type of service, units of service, and dates of service, sufficient to provide CMS with the required audit trail.‌ (11) The MCO agrees to participate in a workgroup with the STATE to ensure that all units of service, HCPCS codes and modifiers are being submitted correctly for encounter data for home care and Home and Community-Based Services. (12) The MCO shall submit encounter data on all Personal Care Assistance (PCA) services using the X12 837P standard transaction format, and report PCAs as treating Providers. The MCO shall submit complete encounter data on PCA services, including the date of service, the paid units of service by date, and the treating PCA provider. The STATE will monitor PCAs as treating Providers. (13) The MCO shall not submit encounters for administrative care coordination. Case management services provided for an Enrollee on EW shall be submitted as encounters per section 3.14.1.2(10).‌‌ 3.14.1.3 The MCO shall notify the STATE ninety (90) days prior to any change in the submitter process, including but not limited to the use of a new submitter. 3.14.1.4 The MCO shall submit original submission encounter claims no later than thirty (30) days after the date the MCO adjudicates the claim. The MCO shall make submissions for each transaction format at least bi-weekly. If the MCO is unable to make a submission during a certain month, the MCO shall contact the STATE to notify it of the reason for the delay and the estimated date when the STATE can expect the submission. The MCO’s submission of claim adjustments must be done by voiding the original claim and submitting a corrected claim, within forty-five (45) days of the date adjusted at the MCO. See also section 9.4.for

Appears in 1 contract

Samples: Contract for Minnesota Senior Health Options and Minnesota Senior Care Plus Services

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 SSASocial Security Act, 42 USC §§ 1396b(m)(2)(A)(xi). 3.14.1.2 . The MCO agrees to furnish information from its records to the STATE, 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 to the STATE STATE, upon the STATE’s request 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) information: Individual Enrollee-specific, claim-level encounter data for services provided by the MCO to Enrollees detailing all of the following: 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 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- 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. . Third Party paid claims include immunizations which are paid for by the Minnesota Vaccines for Children Program (3) MNVFC). All denied claims, except those 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 : 1) the STATE’s technical specifications for encounter claims:  The X12 837 standard format for physician, professional services, physician- and for physician-dispensed pharmaceuticals (837P), specified Elderly Waiver Services (837P), inpatient and outpatient hospital services, Nursing Facility services (837I), Nursing Facility services, and dental services (837D) that are the responsibility of the MCO; and  The 2) the NCPDP Batch 1.2/1.2/ D.0 pharmacy. The MCO may submit the NCPDP Batch 1.2/1.2/ 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 standardsAll encounter claims must be submitted electronically. The MCO shall cooperate with the STATE as necessary to ensure compliance.  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 web site. (5) . 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 Value Scale for missing or unavailable charges) or submitted charge. (6) The MCO shall submit on the encounter claim for 837P, 837I, 837D and NCPDP Batch 1.2/D.0 the Provider allowed and paid amounts. (a) For MSHO, this requirement applies to both Medicaid and Medicare services, excluding Part D. For MSC+ this includes MCO payment for Medicare crossover claims. (b) For the purposes of this section “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing. For the purposes of this section “allowed amount” is defined as the Provider contracted rate prior to any exclusions or add-ons. In accordance with Minnesota Statutes, §256B.69, subd. 9c, (a), the data reported herein is defined as non-public in Minnesota Statutes, §13.02. (c) If the MCO uses a Subcontractor to administer a benefit, for example a dental administrator or Pharmacy Benefit Manager, the “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing by the Subcontractor. (d) Paid amounts for services rendered under subcapitated risk-based arrangements must be estimated using usual and customary payment or an appropriate amount from a Relative Value Scale or the DHS FFS fee schedule, and must not include administrative costs or other incentives. (7) The MCO will submit Medicaid drug information on pharmacy (NCPDP Batch 1.2/D.0), professional (837P) and institutional (837I) encounter claims in accordance with STATE data element specifications related to the collection of drug rebates. These specifications will be outlined in the Encounter Companion Guides for the NCPDP Batch 1.2/D.0 Pharmacy, 837 Professional and 837 Institutional encounter claims. The MCO and its Subcontractor, if applicable, must comply with these specifications and submit encounter data every two weeks and no later than thirty (30) days for original claims and forty-five (45) days for adjusted claims, after the MCO (or its Subcontractor) adjudicates both outpatient pharmacy and physician-administered drug claims. This process enables the STATE to comply with‌ 1927(b), 1903m(2)(A) and 1927(j)(1) of the SSA as amended by Section 2501 (c) of the Patient Protection and Affordable Care Act.‌‌‌‌ (8) The MCO shall submit individual-enrollee specific, claim-level data on all post-payment recoveries for pharmacy claims from liable third parties on a quarterly basis, in a format determined by the STATE. This report shall contain only the post-payment recoveries for pharmacy claims that cannot be reported as encounters in section (7) above.‌‌ (9) The MCO shall be responsible for submitting claim-level encounter data that distinguishes between the Skilled Nursing Facility (SNF) and the Nursing Facility (NF) days used by the Enrollee. (10) The MCO shall submit Home and Community-Based Services encounter data pursuant to the X12 837 national standard. This includes type of service, units of service, and dates of service, sufficient to provide CMS with the required audit trail.‌ (11) The MCO agrees to participate in a workgroup with the STATE to ensure that all units of service, HCPCS codes and modifiers are being submitted correctly for encounter data for home care and Home and Community-Based Services. (12) The MCO shall submit encounter data on all Personal Care Assistance (PCA) services using the X12 837P standard transaction format, and report PCAs as treating Providers. The MCO shall submit complete encounter data on PCA services, including the date of service, the paid units of service by date, and the treating PCA provider. The STATE will monitor PCAs as treating Providers. (13) The MCO shall not submit encounters for administrative care coordination. Case management services provided for an Enrollee on EW shall be submitted as encounters per section 3.14.1.2(10).‌‌ 3.14.1.3 The MCO shall notify the STATE ninety (90) days prior to any change in the submitter process, including but not limited to the use of a new submitter. 3.14.1.4 The MCO shall submit original submission encounter claims no later than thirty (30) days after the date the MCO adjudicates the claim. The MCO shall make submissions for each transaction format at least bi-weekly. If the MCO is unable to make a submission during a certain month, the MCO shall contact the STATE to notify it of the reason for the delay and the estimated date when the STATE can expect the submission. The MCO’s submission of claim adjustments must be done by voiding the original claim and submitting a corrected claim, within forty-five (45) days of the date adjusted at the MCO. See also section 9.4.

Appears in 1 contract

Samples: Contract for Special Needs Basiccare Program Services

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 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 web site. • Service location must be populated on all encounter submissions, except NCPDP, effective August 1, 2021. This is required even if the service location is the same as the billing location. It is also required on claims having either consolidated NPIs or non-consolidated NPIs. (5) 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 Value Scale for missing or unavailable charges) or submitted charge. (6) The MCO shall submit on the encounter claim for 837P, 837I, 837D and NCPDP Batch 1.2/D.0 the Provider allowed and paid amounts. (a) For MSHO, this requirement applies to both Medicaid and Medicare services, excluding Part D. For MSC+ this includes MCO payment for Medicare crossover claims. (b) For the purposes of this section “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing. For the purposes of this section “allowed amount” is defined as the Provider contracted rate prior to any exclusions or add-ons. In accordance with Minnesota Statutes, §256B.69, subd. 9c, (a), the data reported herein is defined as non-public in Minnesota Statutes, §13.02. (c) If the MCO uses a Subcontractor to administer a benefit, for example a dental administrator or Pharmacy Benefit Manager, the “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing by the Subcontractor. (d) Paid amounts for services rendered under subcapitated risk-based arrangements must be estimated using usual and customary payment or an appropriate amount from a Relative Value Scale or the DHS FFS fee schedule, and must not include administrative costs or other incentives. (7) The MCO will submit Medicaid drug information on pharmacy (NCPDP Batch 1.2/D.0), professional (837P) and institutional (837I) encounter claims in accordance with STATE data element specifications related to the collection of drug rebates. These specifications will be outlined in the Encounter Companion Guides for the NCPDP Batch 1.2/D.0 Pharmacy, 837 Professional and 837 Institutional encounter claims. The MCO and its Subcontractor, if applicable, must comply with these specifications and submit encounter data every two weeks and no later than thirty (30) days for original claims and forty-five (45) days for adjusted claims, after the MCO (or its Subcontractor) adjudicates both outpatient pharmacy and physician-administered drug claims. This process enables the STATE to comply with‌ with 1927(b), 1903m(2)(A) and 1927(j)(1) of the SSA as amended by Section 2501 (c) of the Patient Protection and Affordable Care Act.‌‌‌‌Act.‌ (8) The MCO shall submit individual-enrollee specific, claim-level data on all post-payment recoveries for pharmacy claims from liable third parties on a quarterly basis, in a format determined by the STATE. This report shall contain only the post-payment recoveries for pharmacy claims that cannot be reported as encounters in section (7) above.‌‌above. (9) The MCO shall be responsible for submitting claim-level encounter data that distinguishes between the Skilled Nursing Facility (SNF) and the Nursing Facility (NF) days used by the Enrollee. (10) The MCO shall submit Home and Community-Based Services encounter data pursuant to the X12 837 national standard. This includes type of service, units of service, and dates of service, sufficient to provide CMS with the required audit trail.‌ (11) The MCO agrees to participate in a workgroup with the STATE to ensure that all units of service, HCPCS codes and modifiers are being submitted correctly for encounter data for home care and Home and Community-Based Services. (12) The MCO shall submit encounter data on all Personal Care Assistance (PCA) services using the X12 837P standard transaction format, and report PCAs as treating Providers. The MCO shall submit complete encounter data on PCA services, including the date of service, the paid units of service by date, and the treating PCA provider. The STATE will monitor PCAs as treating Providers. (13) The MCO shall not submit encounters for administrative care coordination. Case management services provided for an Enrollee on EW shall be submitted as encounters per section 3.14.1.2(10).‌‌3.14.1.2(10). 3.14.1.3 The MCO shall notify the STATE ninety (90) days prior to any change in the submitter process, including but not limited to the use of a new submitter. 3.14.1.4 The MCO shall submit original submission encounter claims no later than thirty (30) days after the date the MCO adjudicates the claim. The MCO shall make submissions for each transaction format at least bi-weekly. If the MCO is unable to make a submission during a certain month, the MCO shall contact the STATE to notify it of the reason for the delay and the estimated date when the STATE can expect the submission. The MCO’s submission of claim adjustments must be done by voiding the original claim and submitting a corrected claim, within forty-five (45) days of the date adjusted at the MCO. See also section 9.49.4.6.5 below regarding claims voided or reversed because of program integrity concerns. 3.14.1.5 When the STATE returns or rejects a file of encounter claims, the MCO shall have twenty (20) calendar days from the date the MCO receives the rejected file to resubmit the file with all of the required data elements in the correct file format. 3.14.1.6 The STATE will provide a remittance advice on a schedule specified by the STATE, for all submitted encounter claims, including void claims. The Remittance Advice will be provided in the X12 835 standard transaction format.

Appears in 1 contract

Samples: Contract for Minnesota Senior Health Options and Minnesota Senior Care Plus Services

Encounter Data Reporting. 3.14.1.1 3.16.1.1 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 3.16.1.2 The MCO agrees to furnish information from its records to the STATE, 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 to the STATE STATE, upon the STATE’s request 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 of the following: 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 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. Third Party paid claims include immunizations which are paid for by the Minnesota Vaccines for Children Program (MNVFC). (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, and for physician- dispensed pharmaceuticals (837P), specified Elderly Waiver Services (837P), inpatient and outpatient hospital services, Nursing Facility services (837I), Nursing Facility services, and dental services (837D) that are the responsibility of the MCO; and The NCPDP Batch 1.2/1.2/ D.0 pharmacy. The MCO may submit the NCPDP Batch 1.2/1.2/ 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 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 web site. • Service location must be populated on all encounter submissions, except NCPDP, effective August 1, 2021. This is required even if the service location is the same as the billing location. It is also required on claims having either consolidated NPIs or non-consolidated NPIs. (5) 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 Value Scale for missing or unavailable charges) or submitted charge. (6) The MCO shall submit on the encounter claim for 837P, 837I, 837D 837D, and NCPDP Batch 1.2/D.0 the Provider allowed and paid amounts. (a) For MSHO, this requirement applies to both Medicaid and Medicare services, excluding Part D. For MSC+ this includes MCO payment for Medicare crossover claims. (b) . For the purposes of this section “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing. For the purposes of this section “allowed amount” is defined as the Provider contracted rate prior to any exclusions or add-ons. In accordance with Minnesota Statutes, §256B.69, subd. 9c, (a), the data reported herein is defined as non-public in Minnesota Statutes, §13.02. (c) If the MCO uses a Subcontractor to administer a benefit, for example a dental administrator or Pharmacy Benefit Manager, the “paid amount” is defined as the amount paid to the Provider excluding Third Party Liability, Provider withhold and Provider incentives, and Medical Assistance cost-sharing by the Subcontractor. (d) Paid amounts for services rendered under subcapitated risk-based arrangements must be estimated using usual and customary payment or an appropriate amount from a Relative Value Scale or the DHS FFS fee schedule, and must not include administrative costs or other incentives. (7) The MCO will submit Medicaid drug information on pharmacy (NCPDP Batch 1.2/D.0), professional (837P) and institutional (837I) encounter claims in accordance with STATE data element specifications related to the collection of drug rebates. These specifications will be outlined in the Encounter Companion Guides for the NCPDP Batch 1.2/D.0 Pharmacy, 837 Professional and 837 Institutional encounter claims. The MCO and its Subcontractor, if applicable, must comply with these specifications and submit encounter data every two weeks and no later than thirty (30) days for original claims and forty-five (45) days for adjusted claims, after the MCO (or its Subcontractor) adjudicates both outpatient pharmacy and physician-administered drug claims. This process enables the STATE to comply with‌ 1927(b), 1903m(2)(A) and 1927(j)(1) of the SSA as amended by Section 2501 (c) of the Patient Protection and Affordable Care Act.‌‌‌‌ (8) The MCO shall submit individual-enrollee specific, claim-level data on all post-payment recoveries for pharmacy claims from liable third parties on a quarterly basis, in a format determined by the STATE. This report shall contain only the post-payment recoveries for pharmacy claims that cannot be reported as encounters in section (7) above.‌‌ (9) The MCO shall be responsible for submitting claim-level encounter data that distinguishes between the Skilled Nursing Facility (SNF) and the Nursing Facility (NF) days used by the Enrollee. (10) The MCO shall submit Home and Community-Based Services encounter data pursuant to the X12 837 national standard. This includes type of service, units of service, and dates of service, sufficient to provide CMS with the required audit trail.‌ (11) The MCO agrees to participate in a workgroup with the STATE to ensure that all units of service, HCPCS codes and modifiers are being submitted correctly for encounter data for home care and Home and Community-Based Services. (12) The MCO shall submit encounter data on all Personal Care Assistance (PCA) services using the X12 837P standard transaction format, and report PCAs as treating Providers. The MCO shall submit complete encounter data on PCA services, including the date of service, the paid units of service by date, and the treating PCA provider. The STATE will monitor PCAs as treating Providers. (13) The MCO shall not submit encounters for administrative care coordination. Case management services provided for an Enrollee on EW shall be submitted as encounters per section 3.14.1.2(10).‌‌ 3.14.1.3 The MCO shall notify the STATE ninety (90) days prior to any change in the submitter process, including but not limited to the use of a new submitter. 3.14.1.4 The MCO shall submit original submission encounter claims no later than thirty (30) days after the date the MCO adjudicates the claim. The MCO shall make submissions for each transaction format at least bi-weekly. If the MCO is unable to make a submission during a certain month, the MCO shall contact the STATE to notify it of the reason for the delay and the estimated date when the STATE can expect the submission. The MCO’s submission of claim adjustments must be done by voiding the original claim and submitting a corrected claim, within forty-five (45) days of the date adjusted at the MCO. See also section 9.4.,

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Samples: Special Needs Basiccare Program Services Contract