Requirements for Encounter Data Submission

The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicaid and all other health insurance payers in the United States comply with the EDI standards for health care as established by the Secretary of Health Services. The ASC X12N implementation guides have been established as the standards of compliance for claim transactions.

Reimbursement for Medicaid and Medicare claims depends heavily upon timely submission of encounter data that meet minimum timeliness and data quality requirements established by each state. Encounter Data (ED) submissions following EDI standards can present challenges to many health plans, as specialized understanding of both health care claim data and EDI standards is required. ED submissions are categorized into the following four distinct claim types and file formats:

Each claim type and file format has specific requirements that must be followed in a precise manner. Failure to adhere to these requirements can result in file rejections, claim rejections, or claim denials, all of which can have a negative effect on reimbursements.

Understanding the response files that are generated by each ED file submitted, and taking swift and appropriate actions based on the data in those files, is a critical component of successful ED submissions. Timely corrections to data, followed by resubmissions, can result in higher reimbursement rates.

BlueStem Encounter Data Services

Current Encounter Data System Assessment

Because of the complexity of encounter data (ED) requirements, many health plans struggle with numerous challenges in creating ED. Failing to meet ED requirements can come with costly consequences including compliance issues, lower risk scores, and lower reimbursements.

We can lend our expertise to your current ED process to uncover issues that are hindering complete success. We will identify any weakness and make suggestions for remedying issues that are negatively affecting your reimbursement rates. We will also identify any existing potential compliance issues. Our evaluation includes identification of issues stemming from inadequate provider billing, inefficient or ineffective data processing or ETL (extracting, transformation, and loading), missed or poorly understood requirements, and lack of mechanisms for responding to information in the response and remittance advice files.

For Medicaid Claims

We work closely with each state to understand their specific requirements for Medicaid ED. Our evaluation applies these state-specific requirements to ensure your submissions meet all data quality and timeliness requirements for 100% reimbursement rates.

For Medicare Claims

Getting on top of your ED submissions now will help you Medicare Advantage Organization (MAO) avoid negative impacts to reimbursements as CMS transitions from RAPS to EDS for calculating risk scores. This transition has been shown to have a negative effect on risk scores according to a 2017 study by Milliman CMS has been delaying this transition due to the challenges this change presents to MAOs. However, CMS is not likely to extend this “understanding” indefinitely. We can help you enter into this change with 100% confidence in your EDS-calculated risk scores.

We can also help you analyze your EDS return files and RAPS return files to compare risk scores and identify the source of EDS deficiencies.

Full Encounter Data Services

Our full encounter data services take the burden of creating and sending Medicaid and/or Medicare encounter data files off of your IT staff, freeing them up for other important projects. We can provide an affordable alternative to your current solution that will result in full compliance; and the high level of timeliness, completeness, and quality will ensure maximum reimbursements and premiums.

Our automated system includes full assessment of incoming data to identify data issues up-front, timely submission of encounter data meeting all requirements for optimal reimbursements, and comprehensive analysis of issues sent back in response files. Our reporting portal enables you to monitor important metrics showing encounters submitted and accepted, encounters with data issues needing attention, and issues resolved.

BlueStem Advantage

We are experts in ED submissions: