Encounter Claims definition

Encounter Claims means claims, with all details and in a format consistent with HFS requirements, which are submitted to CountyCare for each ride provided to Riders who are CountyCare Enrollees and to CCH for each ride provided to CCH Patients who do not have coverage for Non-Emergency Medical Transportation.
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Encounter Claims means data representing each item and service provided to an MA enrollee and submitted in the X12 837 5010 format. (ED is described at Section 422.310(d) as data that conform to CMS’ requirements for data equivalent to Medicare fee-for-service data.)
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Examples of Encounter Claims in a sentence

  • Contractor’s MIS shall have processes that support the interactions between Financial, Member/Eligibility; Provider; Encounter Claims; Quality Management/Quality Improvement/Utilization; and Report Generation subsystems.

  • The MCO must comply with state and federal requirements, including the federal Implementation Guides, and the STATE’s 837 Encounter Companion Guide for Professional, Institutional and Dental Claims, and the Pharmacy Encounter Claims Guide posted on the STATE’s managed care website.

  • Contractor shall submit all Encounter Claims Data to OHA electronically using HIPAA Transactions and Codes Sets or the National Council for Prescription Drug Programs (NCPDP) Standards and in accordance with OHA rules.

  • Contractor’s Management and Information System (MIS) shall have processes that support the interactions between Financial, Member/Eligibility; Provider; Encounter Claims; Quality Management/Quality Improvement/Utilization; and Report Generation subsystems.

  • Corrective action may be initiated if more than 10% of the Encounter Claims submitted are over 180 days after the date of service or if the submission of duplicate claims exceed 10% per month.

  • Contractor shall submit all Encounter Claims Data to OHA electronically using HIPAA Transactions and Codes Sets or the National Council for Prescription Drug Programs (NCPDP) Standards and Accredited Standardized Committee (ASC) X12N 834 and ASC X12N 835, formats as appropriate in accordance with OHA rules.

  • Valid Encounter Claims Data‌ In order to ensure the integrity of the Medicaid program, OHA and CMS require compliance with a wide range of obligations relating to the verification of services provided to Members.

  • The MCO must comply with STATE and federal requirements, including the federal Implementation Guide, and the STATE’s 837 Encounter Companion Guide for Professional, Institutional and Dental Claims, and the Pharmacy Encounter Claims Guide posted on the STATE’s managed care website.

  • The Contractor shall submit all Encounter Claims Data and complete pay recovery costs for dates of service during which time this Contract was in effect, regardless of whether this Contract is terminated for any reason.

  • Claims Administrator: The entity engaged by DCH to provide Administrative Service(s) to the CMOs in connection with processing and adjudicating risk-based payment, and recording Encounter Claims data for Members.