Encounter Data Processing

Encounter Data Processing Procedures (IEHP and Providers)

Encounter Data processing and reporting is a shared obligation of IEHP and Providers. CMS/DHCS has
mandated encounter data report formats and reporting timelines with which IEHP is required to comply. IEHP, in turn, contractually requires capitated Providers to provide encounter data based on IEHP’s regulatory obligations. IEHP has streamlined reporting requirements, to the extent possible, and implemented electronic methodologies for Providers to transfer encounter data as securely, economically, and efficiently as possible.

In accordance with CMS/DHCS regulations, IEHP requires Providers to submit encounter data within ninety (90) days of each month end. Encounter data must be submitted for all covered services provided to assigned capitated Members. Covered services include PCP visits as well as sub capitated services, regardless of place of service, type of service, or method of reimbursement to the Provider of Services. Failure to provide adequate and valid encounter data in the required format results in penalties being imposed as described in the IEHP Capitated Agreement. The attached Companion Guides describe some specific data element and format requirements for submission of encounter data to IEHP.

IEHP requires Providers to utilize the HIPAA Compliant 837I & 837P Version 5010 transaction code set, as well as compliance with IEHP companion guides when submitting encounter data. Records are identified by a unique Claim Reference Number (CRN) and the IEHP assigned Provider code. Notes describing some of the required data elements are outlined in this manual.

Upon receipt of an encounter data file, IEHP provides the TA1 (upon request), 999 and EVR response report. The TA1 is an X12 Interchange Acknowledgement Report that verifies the accuracy of the interchange segments (ISA, GS, GE, ST, SE and IEA). The 999 is a Functional Acknowledgment report that notifies Providers of any structural syntax errors. After IEHP processes and edits the encounter data received, a third report known as the Encounter Data Validity Report (EVR) is generated and uploaded to the Trading Partners Secure File Transfer Protocol (SFTP) folder. The EVR report, formatted with either a RPH (Institutional) or RPM (Professional) extension, provides information describing the reasons the invalid data elements were denied\rejected.

All valid encounters are then uploaded to the IEHP encounter data processing system and prepared for submission to DHCS or CMS. After the outbound encounters have been submitted to DHCS and CMS, both regulatory bodies provide their own distinct set of response reports communicating the status for each encounter IEHP submitted. DHCS provides the 277CA and XML\EVR reports. While CMS provides the 277CA and MAO reports. IEHP will forward this information on to Providers in addition to the initial
response reports provided.

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