HIPAA training

Difference between Encounters VS Claims (Louisiana Healthcare Connections Explained)

An encounter is a claim which is paid at zero dollars as a result of the provider being pre-paid or capitated for the services he/she provided Louisiana Healthcare Connections members. For example, if you are the PCP for a Louisiana Healthcare Connections member and receive a monthly capitation amount for services, you must file an encounter (also referred to as a proxy claim) on a CMS 1500 for each service provided. Since you will have received a pre-payment in the form of capitation, the encounter, or proxy claim, is paid at zero dollar amounts. It is mandatory that your office submits encounter data.

Louisiana Healthcare Connections utilizes the encounter reporting to evaluate all aspects of quality and utilization management, and it is required by HFS and by CMS. Encounters do not generate an EOP. FQHC/RHC providers will bill using an encounter code for all services. Louisiana Healthcare Connections will reimburse contracted FQHC/RHC the Prospective Payment System (PPS) rate in effect on the date of service for each encounter. No prior authorization is required for this provider type.

A claim is a request for reimbursement either electronically or by paper for any medical service. A claim must be filed on the proper form such as CMS 1500 or UB 04. A claim will be paid or denied with an explanation for the denial. For each claim processed, an EOP will be mailed to the provider who submitted the original claim. Claims will generate an EOP.

You are required to submit either an encounter or a claim for each service that you render to a Louisiana Healthcare Connections member.

To learn more about EDI and become a certifiedĀ EDI Professional, please visit ourĀ course schedule page.

Leave a Reply

Your email address will not be published.

Post Navigation