Common use of Encounter Data Submission Clause in Contracts

Encounter Data Submission. In accordance with the terms of this Contract and all applicable state and federal laws, the Contractor shall submit complete, accurate, and timely Encounter Data to the Department within thirty (30) Days of Claim adjudication. This includes all paid and denied Claims, corrected Claims, adjusted Claims, voided Claims, and zero dollars ($0) paid Claims processed by the Contractor or by its Subcontractors. The Contractor shall have a computer and data processing system sufficient to accurately produce the data, reports, and Encounter Files set in formats and timelines prescribed by the Department as defined in the Contract. The system shall be capable of following or tracing an Encounter within its system using a unique Encounter identification number for each Encounter. At a minimum, the Contractor shall electronically provide Encounter Files to the Department, on a weekly schedule. Encounter Files must follow the format, data elements and method of transmission specified by the Department. All changes to edits and processing requirements due to Federal or State law changes shall be provided to the Contractor in writing no less than sixty (60) Business Days prior to implementation, whenever possible. Other edits and processing requirements shall be provided to the Contractor in writing no less than thirty (30) Business Days prior to implementation. The Contractor shall submit electronic test data files as required by the Department in the format referenced in this Contract and as specified by the Department. The electronic test files are subject to Department review and approval before production of data. The Department will process the Encounter data through defined edit and audit requirements and reject Encounter data that does not meet its requirements. Threshold edits, those which will enable the Encounter File to be accepted, and informational editing, those which enable the Encounter to be processed, shall apply. The Department reserves the right to change the number of, and the types of edits used for threshold processing based on its review of the Contractor’s monthly transmissions. The Contractor shall be given thirty (30) Business Days’ prior notice of the addition/deletion of any of the edits used for threshold editing. The Contractor’s weekly electronic Encounter data submission is to include all adjudicated (paid and denied) Claims, corrected Claims and adjusted Claims processed by the Contractor. Contractor shall submit all Claims within thirty (30) Days of adjudication. Encounter File transmissions that exceed a five percent (5%) threshold error rate (total Claims/documents in error equal to or exceed five percent (5%) of Claims/documents records submitted) will be subject to penalties as provided in the Contract. Encounter File transmissions with a threshold error rate not exceeding five percent (5%) will be accepted and processed by the Department. Only those Erred Encounters will be returned to the Contractor for correction and resubmission. Denied Claims submitted for Encounter processing will not be held to normal edit requirements and rejections of denied Claims will not count towards the minimum five percent (5%) rejection. Encounter data must be submitted in the format defined by the Department as follows: Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 transaction 837 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version 2.2. Example transactions include the following:

Encounter Data Submission. In accordance The Contractor shall ensure that Encounter data is consistent with the terms of this Contract and all applicable state and federal laws, the Contractor shall submit complete, accurate, and timely . (See Appendix F. “Encounter Data to the Department within thirty (30Submissions Requirements and Quality Standards.”) Days of Claim adjudication. This includes all paid and denied Claims, corrected Claims, adjusted Claims, voided Claims, and zero dollars ($0) paid Claims processed by the Contractor or by its Subcontractors. The Contractor shall have a computer and data processing system sufficient to accurately produce the data, reports, reports and Encounter Files set in formats and timelines prescribed by the Department as defined in the Contract. The system shall be capable of following or tracing an Encounter within its system using a unique Encounter identification number for each Encounter. At a minimum, the Contractor shall be required to electronically provide Encounter Files to the Department, on a weekly schedule. Encounter Files must follow the format, data elements and method of transmission specified by the Department. All changes to edits and processing requirements due to Federal or State law changes shall be provided to the Contractor in writing no less than sixty (60) Business Days business days prior to implementation, whenever possible. Other edits and processing requirements shall be provided to the Contractor in writing no less than thirty (30) Business Days business days prior to implementation. The Contractor shall submit electronic test data files as required by the Department in the format referenced in this Contract and as specified by the Department. The electronic test files are subject to Department review and approval before production of data. The Department will process the Encounter data through defined edit and audit requirements and reject Encounter data that does not meet its requirements. Threshold edits, those which will enable the Encounter File to be accepted, and informational editing, those which enable the Encounter to be processed, shall apply. The Department reserves the right to change the number of, and the types of edits used for threshold processing based on its review of the Contractor’s monthly transmissions. The Contractor shall be given thirty (30) Business Days’ working days prior notice of the addition/deletion of any of the edits used for threshold editing. The Contractor’s weekly electronic Encounter data submission is to include all adjudicated (paid and denied) Claims, corrected Claims and adjusted Claims processed will be utilized by the ContractorDepartment for the following:  To evaluate access to health care, availability of services, quality of care and cost effectiveness of services;  To evaluate contractual performance;  To validate required reporting of utilization of services;  To develop and evaluate proposed or existing Capitation Rates;  To meet CMS Medicaid reporting requirements; and  For any purpose the Department deems necessary.  For Risk Adjustments  For Clinical Performance Measures  For Report Card Status  For Fraud and Waste observation Data quality efforts of the Department shall incorporate the following standards for monitoring and validation:  Edit each data element on the Encounter for required presence, format, consistency, reasonableness and/or allowable values;  Edit for Member eligibility;  Perform automated audit processing (e.g. duplicate, conflict, etc.) using history Encounter and same-cycle Encounter data;  Identify exact duplicate Encounters;  Maintain an audit trail of all error code occurrences linked to a specific Encounter; and  Update Encounter history files with both processed and incomplete Encounter data. The Contractor shall submit have the capacity to track and report on all Claims within thirty (30) Days of adjudicationErred Encounter Records. The Contractor shall be required to use procedure codes, diagnosis codes and other codes used for reporting Encounters in accordance with guidelines defined by the Department in writing. The Contractor must also use appropriate NPI/Provider numbers for Encounters as directed by the Department. The Encounter File transmissions that exceed a five percent (5%) threshold error rate (total Claims/documents in error equal to or exceed five percent (5%) of Claims/documents records submitted) will shall be subject to penalties as provided in the Contract. Encounter File transmissions with a threshold error rate not exceeding five percent (5%) will be accepted received and processed by the Department’s Fiscal Agent and shall be stored in the existing MMIS. Only those Erred Encounters will be returned All Subcontracts with Providers or other vendors of service must have provisions requiring that an Encounter is reported/submitted in an accurate and timely fashion. The Contractor shall specify to the Contractor Department the name of the primary contact person assigned responsibility for correction submitting and resubmission. Denied Claims submitted for Encounter processing will not be held to normal edit requirements correcting Encounters, and rejections of denied Claims will not count towards the minimum five percent (5%) rejection. Encounter data must be submitted a secondary contact person in the format defined event the primary contact person is not available. The Contractor shall be required to submit encounter data after the contract ends for services rendered during the contract period for a sufficient time as determined by the Department as follows: Health Insurance Portability to ensure timely filing and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 transaction 837 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version 2.2. Example transactions include the following:complete data.

Encounter Data Submission. In accordance The Contractor shall ensure that Encounter data is consistent with the terms of this Contract and all applicable state and federal laws, the Contractor shall submit complete, accurate, and timely . (See Appendix F. “Encounter Data to the Department within thirty (30Submissions Requirements and Quality Standards.”) Days of Claim adjudication. This includes all paid and denied Claims, corrected Claims, adjusted Claims, voided Claims, and zero dollars ($0) paid Claims processed by the Contractor or by its Subcontractors. The Contractor shall have a computer and data processing system sufficient to accurately produce the data, reports, reports and Encounter Files set in formats and timelines prescribed by the Department as defined in the Contract. The system shall be capable of following or tracing an Encounter within its system using a unique Encounter identification number for each Encounter. At a minimum, the Contractor shall be required to electronically provide Encounter Files to the Department, on a weekly schedule. Encounter Files must follow the format, data elements and method of transmission specified by the Department. All changes to edits and processing requirements due to Federal or State law changes shall be provided to the Contractor in writing no less than sixty (60) Business Days business days prior to implementation, whenever possible. Other edits and processing requirements shall be provided to the Contractor in writing no less than thirty (30) Business Days business days prior to implementation. The Contractor shall submit electronic test data files as required by the Department in the format referenced in this Contract and as specified by the Department. The electronic test files are subject to Department review and approval before production of data. The Department will process the Encounter data through defined edit and audit requirements and reject Encounter data that does not meet its requirements. Threshold edits, those which will enable the Encounter File to be accepted, and informational editing, those which enable the Encounter to be processed, shall apply. The Department reserves the right to change the number of, and the types of edits used for threshold processing based on its review of the Contractor’s monthly transmissions. The Contractor shall be given thirty (30) Business Daysworking days’ prior notice of the addition/deletion of any of the edits used for threshold editing. The Contractor’s weekly electronic Encounter data submission is to include all adjudicated (paid and denied) Claims, corrected Claims and adjusted Claims processed will be utilized by the ContractorDepartment for the following:  To evaluate access to health care, availability of services, quality of care and cost effectiveness of services;  To evaluate contractual performance;  To validate required reporting of utilization of services;  To develop and evaluate proposed or existing Capitation Rates;  To meet CMS Medicaid reporting requirements; and  For any purpose the Department deems necessary.  For Risk Adjustments  For Clinical Performance Measures  For Report Card Status  For Fraud and Waste observation Data quality efforts of the Department shall incorporate the following standards for monitoring and validation:  Edit each data element on the Encounter for required presence, format, consistency, reasonableness and/or allowable values;  Edit for Member eligibility;  Perform automated audit processing (e.g. duplicate, conflict, etc.) using history Encounter and same-cycle Encounter data;  Identify exact duplicate Encounters;  Maintain an audit trail of all error code occurrences linked to a specific Encounter; and  Update Encounter history files with both processed and incomplete Encounter data. The Contractor shall submit have the capacity to track and report on all Claims within thirty (30) Days of adjudicationErred Encounter Records. The Contractor shall be required to use procedure codes, diagnosis codes and other codes used for reporting Encounters in accordance with guidelines defined by the Department in writing. The Contractor must also use appropriate NPI/Provider numbers for Encounters as directed by the Department. The Encounter File transmissions that exceed a five percent (5%) threshold error rate (total Claims/documents in error equal to or exceed five percent (5%) of Claims/documents records submitted) will shall be subject to penalties as provided in the Contract. Encounter File transmissions with a threshold error rate not exceeding five percent (5%) will be accepted received and processed by the Department’s Fiscal Agent and shall be stored in the existing MMIS. Only those Erred Encounters will be returned All Subcontracts with Providers or other vendors of service must have provisions requiring that an Encounter is reported/submitted in an accurate and timely fashion. The Contractor shall specify to the Contractor Department the name of the primary contact person assigned responsibility for correction submitting and resubmission. Denied Claims submitted for Encounter processing will not be held to normal edit requirements correcting Encounters, and rejections of denied Claims will not count towards the minimum five percent (5%) rejection. Encounter data must be submitted a secondary contact person in the format defined event the primary contact person is not available. The Contractor shall be required to submit encounter data after the Contract ends for services rendered during the Contract period for a sufficient time as determined by the Department as follows: Health Insurance Portability to ensure timely filing and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 transaction 837 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version 2.2. Example transactions include the following:complete data.

Encounter Data Submission. In accordance The Contractor shall ensure that Encounter Records are consistent with the terms of this Contract and all applicable state and federal laws, the Contractor shall submit complete, accurate, . (See Appendix D and timely Encounter Data to the Department within thirty (30Appendix E.) Days of Claim adjudication. This includes all paid and denied Claims, corrected Claims, adjusted Claims, voided Claims, and zero dollars ($0) paid Claims processed by the Contractor or by its Subcontractors. The Contractor shall have a computer and data processing system sufficient to accurately produce the data, reports, reports and Encounter Files Record set in formats and timelines prescribed by the Department as defined in the Contract. The system shall be capable of following or tracing an Encounter within its system using a unique Encounter Record identification number for each Encounter. At a minimum, the Contractor shall be required to electronically provide Encounter Files Record to the Department, on a weekly schedule. Encounter Files Record must follow the format, data elements and method of transmission specified by the Department. All changes to edits and processing requirements due to Federal or State law changes shall be provided to the Contractor in writing no less than sixty (60) Business Days working days prior to implementation, whenever possible. Other edits and processing requirements shall be provided to the Contractor in writing no less than thirty (30) Business Days prior to implementation. The Contractor shall submit electronic test data files as required by the Department in the format referenced in this Contract and as specified by the Department. The electronic test files are subject to Department review and approval before production of data. The Department will process the Encounter data Record through defined edit and audit requirements and reject Encounter data Record that does not meet its requirements. Threshold edits, those which will enable the Encounter File to be accepted, and informational editing, those which enable the Encounter to be processed, editing shall apply. The Department reserves the right to change the number of, and the types of edits used for threshold processing based on its review of the Contractor’s monthly transmissions. The Contractor shall be given thirty (30) Business Days’ working days prior notice of the addition/deletion of any of the edits used for threshold editing. The Contractor’s weekly electronic Encounter data submission is to include all adjudicated (paid and denied) Claims, corrected Claims and adjusted Claims processed by the Contractor. Contractor shall submit all Claims within thirty (30) Days of adjudication. Encounter File transmissions that exceed a five percent (5%) threshold error rate (total Claims/documents in error equal to or exceed five percent (5%) of Claims/documents records submitted) Record will be subject to penalties as provided in the Contract. Encounter File transmissions with a threshold error rate not exceeding five percent (5%) will be accepted and processed by the Department. Only those Erred Encounters will be returned to the Contractor for correction and resubmission. Denied Claims submitted for Encounter processing will not be held to normal edit requirements and rejections of denied Claims will not count towards the minimum five percent (5%) rejection. Encounter data must be submitted in the format defined utilized by the Department as follows: Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 transaction 837 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version 2.2. Example transactions include the following:

Encounter Data Submission. In accordance with the terms of this Contract and all applicable state and a nd federal laws, the Contractor shall submit complete, accurate, and timely Encounter Data to the Department within thirty (30) Days of Claim adjudication. This includes all paid and denied Claims, corrected Claims, adjusted Claims, voided Claims, and zero dollars ($0) paid Claims processed by the Contractor or by its Subcontractors. The Contractor shall have a computer and data processing system sufficient to accurately produce the data, reports, and Encounter Files set in formats and timelines prescribed by the Department as defined in the Contract. The system shall be capable of following or tracing an Encounter within its system using a unique Encounter identification number for each EncounterEncounter . At a minimum, the Contractor shall electronically provide Encounter Files to the Department, on a weekly schedule. Encounter Files must follow the format, data elements and method of transmission specified by the Department. All changes to edits and processing requirements due to Federal or State law changes shall be provided to the Contractor in writing no less than sixty (60) Business Days prior to implementation, whenever possible. Other edits and processing requirements shall be provided to the Contractor in writing no less than thirty (30) Business Days prior to implementation. The Contractor shall submit electronic test data files as required by the Department in the format referenced in this Contract and as specified by the Department. The electronic test files are subject to Department review and approval before production of data. The Department will process the Encounter data through defined edit and audit requirements and reject Encounter data that does not meet its requirements. Threshold edits, those which will enable the Encounter File to be accepted, and informational editing, those which enable the Encounter to be processed, shall apply. The Department reserves the right to change the number of, and the types of edits used for threshold processing based on its review of the Contractor’s monthly transmissions. The Contractor shall be given thirty (30) Business Days’ prior notice of the addition/deletion of any of the edits used for threshold editing. The Contractor’s weekly electronic Encounter data submission is to include all adjudicated (paid and denied) Claims, corrected Claims and adjusted Claims processed by the Contractor. Contractor shall submit all Claims within thirty (30) Days of adjudication. Encounter File transmissions that exceed a five percent (5%) threshold error rate (total Claims/documents in error equal to or exceed five percent (5%) of Claims/documents records submitted) will be subject to penalties as provided in the Contract. Encounter File transmissions with a threshold thresho ld error rate not exceeding five percent (5%) will be accepted and processed by the Department. Only those Erred Encounters will be returned to the Contractor for correction and resubmission. Denied Claims submitted for Encounter processing will not be held to normal edit requirements and rejections of denied Claims will not count towards the minimum five percent (5%) rejection. Encounter data must be submitted in the format defined by the Department as follows: Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 transaction 837 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version 2.2. Example transactions include the following:

Encounter Data Submission. In accordance The Contractor shall ensure that Encounter Records are consistent with the terms of this Contract and all applicable state and federal laws, the Contractor shall submit complete, accurate, . (See Appendix D. and timely Encounter Data to the Department within thirty (30Appendix E.) Days of Claim adjudication. This includes all paid and denied Claims, corrected Claims, adjusted Claims, voided Claims, and zero dollars ($0) paid Claims processed by the Contractor or by its Subcontractors. The Contractor shall have a computer and data processing system sufficient to accurately produce the data, reports, reports and Encounter Files Record set in formats and timelines prescribed by the Department as defined in the Contract. The system shall be capable of following or tracing an Encounter within its system using a unique Encounter Record identification number for each Encounter. At a minimum, the Contractor shall be required to electronically provide Encounter Files Record to the Department, on a weekly schedule. Encounter Files Record must follow the format, data elements and method of transmission specified by the Department. All changes to edits and processing requirements due to Federal or State law changes shall be provided to the Contractor in writing no less than sixty (60) Business Days working days prior to implementation, whenever possible. Other edits and processing requirements shall be provided to the Contractor in writing no less than thirty (30) Business Days prior to implementation. The Contractor shall submit electronic test data files as required by the Department in the format referenced in this Contract and as specified by the Department. The electronic test files are subject to Department review and approval before production of data. The Department will process the Encounter data Record through defined edit and audit requirements and reject Encounter data Record that does not meet its requirements. Threshold edits, those which will enable the Encounter File to be accepted, and informational editing, those which enable the Encounter to be processed, editing shall apply. The Department reserves the right to change the number of, and the types of edits used for threshold processing based on its review of the Contractor’s monthly transmissions. The Contractor shall be given thirty (30) Business Days’ working days prior notice of the addition/deletion of any of the edits used for threshold editing. The Contractor’s weekly electronic Encounter data submission is to include all adjudicated (paid and denied) Claims, corrected Claims and adjusted Claims processed Record will be utilized by the ContractorDepartment for the following: • To evaluate access to health care, availability of services, quality of care and cost effectiveness of services; • To evaluate contractual performance; • To validate required reporting of utilization of services; • To develop and evaluate proposed or existing Capitation Rates; • To meet CMS Medicaid reporting requirements; and • For any purpose the Department deems necessary. Data quality efforts of the Department shall incorporate the following standards for monitoring and validation: • Edit each data element on the Encounter Record for required presence, format, consistency, reasonableness and/or allowable values; • Edit for Member eligibility; • Perform automated audit processing (e.g. duplicate, conflict, etc.) using history Encounter Record and same-cycle Encounter Record; • Identify exact duplicate Encounter Record; • Maintain an audit trail of all error code occurrences linked to a specific Encounter; and • Update Encounter history files with both processed and incomplete Encounter Record. The Contractor shall submit have the capacity to track and report on all Claims within thirty (30) Days of adjudicationErred Encounter Records. The Contractor shall be required to use procedure codes, diagnosis codes and other codes used for reporting Encounter File transmissions that exceed a five percent (5%) threshold error rate (total ClaimsRecord in accordance with guidelines defined by the Department in writing. The Contractor must also use appropriate NPI/documents in error equal to or exceed five percent (5%) of Claims/documents records submitted) will Provider numbers for Encounter Records as directed by the Department. The Encounter Record shall be subject to penalties as provided in the Contract. Encounter File transmissions with a threshold error rate not exceeding five percent (5%) will be accepted received and processed by the Department’s Fiscal Agent and shall be stored in the existing MMIS. Only those Erred Encounters will be returned All Subcontracts with Providers or other vendors of service must have provisions requiring that Encounter Record is reported/submitted in an accurate and timely fashion. The Contractor shall specify to the Contractor Department the name of the primary contact person assigned responsibility for correction submitting and resubmission. Denied Claims submitted for correcting Encounter processing will not be held to normal edit requirements Record, and rejections of denied Claims will not count towards the minimum five percent (5%) rejection. Encounter data must be submitted a secondary contact person in the format defined by event the Department as follows: Health Insurance Portability and Accountability Act (HIPAA) Accredited Standards Committee (ASC) X12 version 4010A1 to ASC X12 version 5010 transaction 837 and National Council for Prescription Drug Programs (NCPDP) version 5.1 to NCPDP version 2.2. Example transactions include the following:primary contact person is not available.