Common use of Encounter Data Reporting Clause in Contracts

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. 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.formats 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.