Encounter Data Submission Requirements i. The MCOP shall collect data on services furnished to members through a claims system and shall report encounter data electronically to ODM as specified in Appendix L.
ii. The MCOP shall have the capability to report all elements in the Minimum Data Set as set forth in the ODM Encounter Data Specifications and shall submit a test file in the ODM-specified medium in the required formats prior to contracting or prior to an information systems replacement or update. Acceptance testing of encounter data is required as specified in Section 43 of this appendix.
iii. A certification letter shall accompany the submission of an encounter data file in the ODM-specified medium. The certification letter shall be signed by the MCOP’s Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an individual who has delegated authority to sign for, and who reports directly to, the MCOP’s CEO or CFO.
Encounter Data Submission Requirements. 4.16.3.1 The Georgia Families program utilizes encounter data to determine the adequacy of medical services and to evaluate the quality of care rendered to members. DCH will use the following requirements to establish the standards for the submission of data and to measure the compliance of the Contractor to provide timely and accurate information. Encounter data from the Contractor also allows DCH to budget available resources, set contractor capitation rates, monitor utilization, follow public health trends and detect potential fraud. Most importantly, it allows the Division of Managed Care and Quality to make recommendations that can lead to the improvement of healthcare outcomes.
4.16.3.2 The Contractor shall work with all contracted Providers to implement standardized billing requirements to enhance the quality and accuracy of the billing data submitted to the health plan.
4.16.3.3 The Contractor shall instruct contracted Providers that the Georgia State Medicaid ID number is mandatory, and must be documented in record. The Contractor will emphasize to Providers the need for a unique GA Medicaid number for each practice location.
4.16.3.4 The Contractor shall submit to Fiscal Agent weekly cycles of data files. All identified errors shall be submitted to the Contractor from the Fiscal Agent each week. The Contractor shall clean up and resubmit the corrected file to the Fiscal Agent within seven (7) Business Days of receipt.
4.16.3.5 The Contractor is required to submit 100% of Critical Data Elements such as state Medicaid ID numbers, NPI numbers, SSN numbers, Member Name, and DOB. These items must match the states eligibility and provider file.
4.16.3.6 The Contractor submitted claims must consistently include: • Patient name • Date of birth • Place of service • Date of service • Type of service • Units of service • Diagnosis-primary & secondary • Treating provider • NPI number • Tax Identification Number • Facility code • A unique TCN • All additionally required CMS 1500 or UB 04 codes • CMO Paid Amount
4.16.3.7 For each submission of claims per 4.16.3.5 and 4.16.3.6, Contractor must provide the following Cash Disbursements data elements: • Provider/Payee Number • Name • Address • City • State • Zip • Check date • Check number • Check amount • Check code ( i.e. EFT, paper check, etc) Contractor will assist DCH in reconciliation of Cash Disbursement check amounts totals to CMO Paid Amount totals for submitted claims.
4.16.3.8 The Contractor shall maint...
Encounter Data Submission Requirements. 4.16.3.1 The Georgia Families program utilizes encounter data to determine the adequacy of medical services and to evaluate the quality of care rendered to members. DCH will use the following requirements to establish the standards for the submission of data and to measure the compliance of the Contractor to provide timely and accurate information. Encounter data from the Contractor also allows DCH to budget available resources, set contractor capitation rates, monitor utilization, follow public health trends and detect potential fraud. Most importantly, it allows the Division of Managed Care and Quality to make recommendations that can lead to the improvement of healthcare outcomes.
4.16.3.1 The Contractor shall work with all contracted providers to implement standardized billing requirements to enhance the quality and accuracy of the billing data submitted to the health plan.
4.16.3.2 The Contractor shall instruct contracted providers that the Georgia State Medicaid ID number is mandatory, and must be documented in record. The Contractor will emphasize to providers the need for a unique GA Medicaid number for each practice location.
4.16.3.3 The Contractor shall submit to Fiscal Agent weekly cycles of data files. All identified errors shall be submitted to the Contractor from the Fiscal Agent each week. The Contractor shall clean up and resubmit the corrected file to the Fiscal Agent within seven (7) Business Days of receipt.
4.16.3.4 The Contractor is required to submit 100% of Critical Data Elements such as state Medicaid ID numbers, NPI numbers, SSN numbers, Member Name, and DOB. These items must match the states eligibility and provider file.
4.16.3.5 The Contractor submitted claims must consistently include:
4.16.3.5.1 1 patient name 4.16.3.5.2 2- date of birth 4.16.3.5.3 3- place of service 4.16.3.5.4 4- date of service 4.16.3.5.5 5- type of service 4.16.3.5.6 6- units of service 4.16.3.5.7 7- diagnosis-primary & secondary 4.16.3.5.8 8- treating provider 4.16.3.5.9 9- NPI number 4.16.3.5.10 10- Medicaid Number 4.16.3.5.11 11- facility code 4.16.3.5.12 12- a unique TCN 4.16.3.5.13 13- all additionally required CMS 1500 or UB 04 codes. 4.16.3.5.14 14 – CMO Paid Amount
4.16.3.6 For each submission of claims per 4.16.3.5, Contractor must provide the following Cash Disbursements data elements:
1. Provider/Payee Number
2. Name 3. address 4. city 5. state 6. zip 7. check date 8. check number
Encounter Data Submission Requirements. General Requirements Each MCP must collect data on services furnished to members through an encounter data system and must report encounter data to the ODJFS. MCPs are required to submit this data electronically to ODJFS on a monthly basis in the following standard formats: - Institutional Claims - UB92 flat file - Noninstitutional Claims - National standard format - Prescription Drug Claims - NCPDP ODJFS relies heavily on encounter data for monitoring MCP performance. The ODJFS uses encounter data to measure clinical performance, conduct access and utilization reviews, reimburse MCPs for newborn deliveries and aid in setting MCP capitation rates. For these reasons, it is important that encounter data is timely, accurate, and complete. Data quality, performance measures and standards are described in the Agreement. An encounter represents all of the services, including medical supplies and medications, provided to a member of the MCP by a particular provider, regardless of the payment arrangement between the MCP and the provider. For example, if a member had an emergency department visit and was examined by a physician, this would constitute two encounters, one related to the hospital provider and one related to the physician provider. However, for the purposes of calculating a utilization measure, this would be counted as a single emergency department visit. If a member visits their PCP and the PCP examines the member and has laboratory procedures done within the office, then this is one encounter between the member and their PCP. Appendix C Covered Families and Children (CFC) population Page 19 If the PCP sends the member to a lab to have procedures performed, then this is two encounters; one with the PCP and another with the lab. For pharmacy encounters, each prescription filled is a separate encounter. Encounters include services paid for retrospectively through fee-for-service payment arrangements, and prospectively through capitated arrangements. Only encounters with services (line items) that are paid by the MCP, fully or in part, and for which no further payment is anticipated, are acceptable encounter data submissions, except for immunization services. Immunization services submitted to the MCP must be submitted to ODJFS if these services were paid for by another entity (e.g., free vaccine program). All other services that are unpaid or paid in part and for which the MCP anticipates further payment (e.g., unpaid services rendered during a delivery...
Encounter Data Submission Requirements
