Encounter Data Submission and Processing Sample Clauses

Encounter Data Submission and Processing. (1) Contractor shall submit valid Encounter Data at least once per calendar month, on forms or formats specified by OHA and in accordance with OAR 410-141-3430 and OAR 943- 120-0100 through 943-120-0200. The Encounter Data submitted must represent 50 percent of all Encounter claim types received and adjudicated by Contractor during that calendar month, including the paid amounts regardless of whether the Provider is paid on a fee-for-service or capitated basis, or whether the Provider is in network (participating) or out of network (non-participating). (2) Contractor shall correct errors in Encounter Data if the Encounter Data cannot be processed because of missing or erroneous information. Corrective Action may be initiated if more than 10% of any Encounter Data submission cannot be processed because of missing or erroneous information. (3) To prevent Corrective Action, Contractor may submit documentation to OHA citing specific circumstances that delay Contractor’s timely submittal of Valid Encounter Data. OHA will review the documentation and make a determination within 30 days on whether the circumstances cited are Acceptable. These “Acceptable” circumstances may include, but are not limited to:

Encounter Data Submission and Processing a. (1) Contractor shall submit Valid Encounter Data at least once per calendar month, including Encounter Pharmacy Data, in accordance with the AP Standard not later than the last day of the Final Submission Month. (2) Contractor shall submit valid Encounter Data on forms or formats specified by OHA and in accordance with OAR 410-141-3430 and OAR 943-120-0100 through 943-120-0200. (3) The Encounter Data submitted must represent no less than 50 percent of all Encounter claim types received and adjudicated by Contractor during that calendar month, including the paid amounts regardless of whether the Provider is paid on a fee-for-service or capitated basis, or whether the Provider is in network (participating) or out of network (non-participating). (4) Contractor shall correct errors in Encounter Data if the Encounter Data cannot be processed because of missing or erroneous information. Corrective Action will be initiated if more than 5% of any Encounter Data submission cannot be processed because of missing or erroneous information. (5) For purposes of this section, the AP Standard allows for Contractor delay of no more than 5% of non-pharmacy encounter claims for the Subject Month with prior notification to OHA. Contractor may submit documentation to OHA citing specific circumstances that will result in a delay to Contractor’s timely submittal of Valid Encounter Data. (6) If Contractor submits documentation of a delay in encounter claims submission, OHA will review the documentation and make a determination within 30 days on whether the circumstances cited are Acceptable and that a Corrective Action Plan is not necessary to remedy the deficiency. g. (7) These “Acceptable” circumstances may include, but are not limited to: (a) Member's failure to give the Provider necessary claim information;