Common use of Encounter Data Submission Requirements Clause in Contracts

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 maintain an Encounter Error Rate of <5% weekly as monitored by the Fiscal Agent and DCH. The Encounter Error Rate is the occurrence of a single error in any Transaction Control Number (TCN) or encounter claim counts as an error for that encounter (this is regardless of how many other errors are detected in the TCN.) 4.16.3.9 The Contractors failure to comply with defined standard(s) will be subject to a CAPA/PC and may be liable for liquidated damages (LD’s).

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 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 Providers that the Georgia State Medicaid ID number is mandatory, and must be documented in record. The Contractor will emphasize to providers 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 maintain an Encounter Error Rate of <5% weekly as monitored by the Fiscal Agent and DCH. The Encounter Error Rate is the occurrence of a single error in any Transaction Control Number (TCN) or encounter claim counts as an error for that encounter (this is regardless of how many other errors are detected in the TCN.) 4.16.3.9 The Contractors failure to comply with defined standard(s) will be subject to a CAPA/PC and may be liable for liquidated damages (LD’s's).

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 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 Providers that the Georgia State Medicaid ID number is mandatory, and must be documented in record. The Contractor will emphasize to providers 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 maintain an Encounter Error Rate of <5% weekly as monitored by the Fiscal Agent and DCH. The Encounter Error Rate is the occurrence of a single error in any Transaction Control Number (TCN) or encounter claim counts as an error for that encounter (this is regardless of how many other errors are detected in the TCN.) 4.16.3.9 The Contractors failure to comply with defined standard(s) will be subject to a CAPA/PC and may be liable for liquidated damages (LD’s's).

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 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 Providers that the Georgia State Medicaid ID number is mandatory, and must be documented in record. The Contractor will emphasize to providers 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 maintain an Encounter Error Rate of <5% weekly as monitored by the Fiscal Agent and DCH. The Encounter Error Rate is the occurrence of a single error in any Transaction Control Number (TCN) or encounter claim counts as an error for that encounter (this is regardless of how many other errors are detected in the TCN.) 4.16.3.9 The Contractors failure to comply with defined standard(s) will be subject to a CAPA/PC and may be liable for liquidated damages (LD’s).