Using EDI for Capitated Encounter Submission (Health Net)
Capitated participating physician groups (PPGs), hospitals and ancillary providers are required to provide complete encounter data about professional services rendered to Health Net members.
To comply with the requirements of the U.S. Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS), the California Department of Health Care Services (DHCS), the California Disproportionate Share Hospital Program (DSH), the Managed Risk Medical Insurance Board (MRMIB), and the National Committee for Quality Assurance (NCQA), Health Net requires information about use of health services by its members.
These services include office visits, X-rays, laboratory tests, surgical procedures, anesthesia, physician visits to the hospital, inpatient, outpatient, emergency room, out-of-area, or skilled nursing facility (SNF) services, and all professional referral services. Capitated participating facilities (and PPGs with dual-risk contracts) are required to provide encounter data monthly about institutionally based services rendered to Health Net members.
Encounter data submissions must include all member-paid cost share amounts, such as copayments, coinsurance and deductibles applicable to the member’s benefit. In addition, any rejected encounter data must be corrected and resubmitted in order for complete information and correct member-paid cost share amounts to be captured and accumulated. Encounter data submission is also an integral part of the Health Net Quality of Care Improvement Program (QCIP) (applicable only for HMO and Point of Service (POS) products) and Healthcare Effectiveness Data and Information Set (HEDIS®)*. Refer to the Quality Improvement (QI) topic for more information on QCIP.
Reporting of encounter data is extremely important. Health Net and its affiliated health plans are required to provide encounter data to regulatory agencies. The following procedures are required for encounter reporting:
- Reporting of services must be on a per member, per visit basis, rather than a monthly summary. An accounting of all services rendered by date and member must be submitted to Health Net or Molina Healthcare, depending on the member’s health plan affiliation. The encounter data should be submitted via electronic transmission in the H ANSI 837 5010 X12 format through the encounter clearinghouse, TransUnion. Encounter records must include the same data elements as would be required on a fee-for-service (FFS) claim form.
- Health Net does not accept encounter and encounter summary reports on paper or directly from capitated PPGs. Providers should forward electronic encounters only. For additional information about how to submit encounters electronically, refer to 837 5010 Professional and Institutional Standards (pdf), 837 Institutional Companion Guide (pdf) and 837 Professional Companion Guide (pdf).
- All encounter reporting must identify members by their Health Net identification numbers. This number is on each member’s identification card. Submission of encounter data without the member identification number is not acceptable and is returned for correction.
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