Medi-Cal Managed Care Encounter Data Reporting
Background
In accordance with federal regulations, DHCS contractually requires that Medi-Cal Managed Care Plans (MCPs) submit to DHCS complete, accurate, and timely encounter data for services provided to enrolled beneficiaries. Prior to November 2014, MCPs traditionally met their contractual requirement to submit encounter data to DHCS utilizing a variety of proprietary and standard formats. After November 1, 2014, DHCS implemented a new system to receive and process encounter data in the national standard transactions, ASC X12 837 5010 and NCPDP. This new system was implemented to meet state and federal Medicaid monitoring and reporting requirements and to accommodate receipt of ICD10 Diagnosis Codes in accordance with HIPAA requirements.
Effective January 1, 2015, DHCS, in support of its ongoing encounter data quality improvement initiatives, only accepts national standard file formats and coding schemes for managed care encounter data submissions. By May 2015, all MCPs had transitioned from the previous proprietary formats to production encounter data submissions in the national standard formats.
Encounter Data Reporting Requirements
MCPs are required to submit encounter data in the following Health Insurance Portability and Accountability Act compliant national standard transactions in accordance with the most recent DHCS Companion Guides issued for each transaction type:
a)
Institutional encounter data shall be submitted in compliance with the Accredited Standards Committee (ASC) X12 837 Institutional (837I), version 5010 x223;
b)
Professional encounter data shall be submitted in compliance with the ASC X12 837 Professional (837P), version 5010 x222; and
c)
Pharmacy encounter data shall be submitted in compliance with the NCPDP Encounter Data Transaction format, Post Adjudication Payer Sheet version 2.2 or 4.2.
For other reporting requirements, such as submission frequency and process, response files, correction of encounter data, and submission tracking, please refer to the most recent All Plan Letter for Encounter Data Submission Requirements.
Quality Measures for Encounter Data
DHCS measures the quality of the Medi-Cal managed care encounter data for completeness, accuracy, reasonability, and timeliness using the most recently published version of the Quality Measures for Encounter Data (QMED) document. The measure results are calculated, reported to the MCPs, and are used to drive data quality improvement efforts. Please refer to APL 14-020, Quality Measures for Encounter Data and the QMED Document , Quality Measures for Encounter Data, Version 1.1, for specific performance measures DHCS uses to assess the quality of submitted encounter data.
Contacts
Questions regarding encounter data technical issues or processing status may be directed to the
PACES team.
Helpful Links and Resources
Medi-Cal Managed Care Encounter Data Reporting Related Documents:
APL 14-009 (PDF), Transition of Encounter Data Submission to National Standard Transactions (ASC X12 837 5010, NCPDP 2.2 or 4.2)
