Encounter Claims Data Sample Clauses

The Encounter Claims Data clause defines the requirements and procedures for the collection, submission, and management of data related to healthcare service encounters and claims. Typically, this clause outlines the types of data that must be reported, the format and frequency of submissions, and the responsibilities of each party involved, such as healthcare providers or insurers. For example, it may require providers to submit detailed records of patient visits and services rendered to a centralized database within a specified timeframe. The core practical function of this clause is to ensure accurate and timely reporting of healthcare utilization, which supports billing, regulatory compliance, and data analysis for quality improvement and oversight.
Encounter Claims Data a. Contractor shall submit all Encounter Claims Data to OHA electronically using HIPAA Transactions and Codes Sets or the National Council for Prescription Drug Programs (NCPDP) Standards and in accordance with OHA rules. b. Contractor shall become a trading partner and conduct data transactions in accordance with OHA Electronic Data Transmission Rules; OAR 943-120-0100 through 943-120-0200. c. Contractor shall demonstrate to OHA through proof of enrollment information, Encounter Data Certification and Validation that Contractor is able to attest to the accuracy, completeness and truthfulness of information required by OHA, in accordance with 42 CFR 438.604 and 438.606. Contractor shall submit the following reports to OHA as described in each report.
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Encounter Claims Data a. Contractor shall submit all Encounter Claims Data to OHA electronically using HIPAA Transactions and Codes Sets or the National Council for Prescription Drug Programs (NCPDP) Standards and Accredited Standardized Committee (ASC) X12N 834 and ASC X12N 835, formats as appropriate in accordance with OARs and OHA requirements. b. Contractor shall become a trading partner and conduct data transactions in accordance with OHA Electronic Data Transmission Rules; OAR 943-120-0100 through 943-120-0200. c. Contractor shall certify and attest that based on best information, knowledge, and belief, the data, documentation, and information submitted in its encounter claims is accurate, complete, and truthful in accordance with 42 CFR 438.604 and 438.606. Certification must be provided by the Contractor’s Chief Executive Officer, Chief Financial Officer, or an individual who reports directly to the Chief Executive Officer or Chief Financial Officer with delegated authority to sign for the Chief Executive Officer or Chief Financial Officer. If the signing authority is delegated to another individual, the Chief Executive Officer or Chief Financial Officer retains final responsibility for the certification. d. Contractor shall demonstrate to OHA through proof of enrollment information, Encounter Data Certification and Encounter Data Validation that Contractor attests to the accuracy, completeness and truthfulness of information required by OHA. Contractor shall submit the following reports to OHA: e. Contractor shall maintain sufficient encounter data to identify the actual provider who delivers services to the Member per SSA section 1903(m)(2)(A)(xi). f. Contractor shall obtain a Coordination of Benefits Agreement (COBA) number and coordinate with COBA to receive direct crossover claims for dually eligible members with traditional Medicare per 42 CFR 438.3(t). g. ▇▇▇ will conduct periodic encounter data validation studies of the Contractor’s encounter submissions. These studies will review statistically valid random samples of encounter claims to establish a baseline error rate across Contractor’s provider network. h. The purpose of encounter validation studies is to compare recorded utilization information from a medical record or other source with the Contractor’s submitted encounter data. Any and all covered services may be validated as part of these studies. The criteria used in encounter validation studies may include timeliness, correctness, sufficiency of document...
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Encounter Claims Data a. Contractor shall submit all Encounter Claims Data to OHA electronically using HIPAA Transactions and Codes Sets or the National Council for Prescription Drug Programs (NCPDP) Standards and Accredited Standardized Committee (ASC) X12N 834 and ASC X12N 835, formats as appropriate in accordance with OHA rules. b. Contractor shall become a trading partner and conduct data transactions in accordance with OHA Electronic Data Transmission Rules; OAR 943-120-0100 through 943-120-0200.
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Encounter Claims Data a. Contractor shall provide all Encounter Claims Data to OHA’s Contract Administrator electronically in accordance with OAR 409-025-130(3) using HIPAA Transactions and Codes Sets or the National Council for Prescription Drug Programs (“NCPDP”) Standards and Accredited Standardized Committee (“ASC”) X12N 834 and ASC X12N 835, formats as appropriate in accordance with OAR and OHA requirements. b. Contractor shall become a trading partner and conduct data transactions in accordance with OHA Electronic Data Transmission Rules as set forth in OAR 943-120-0100 through 943-120-0200. c. Contractor shall provide, together with the Encounter Claims Data, documentation certifying and attesting that based on best information, knowledge, and belief, the data, documentation, and information submitted in its Encounter Claims, is accurate, complete, and truthful in accordance with 42 CFR 438.604 and 438.606. Certification and attestation must be made by the Contractor’s Chief Executive Officer, Chief Financial Officer, or an individual who reports directly to the Chief Executive Officer or Chief Financial Officer with delegated authority to sign for the Chief Executive Officer or Chief Financial Officer. If the signing authority is delegated to another individual, the Chief Executive Officer or Chief Financial Officer retains final responsibility for the certification. d. In providing OHA with the reports and forms listed below in this P.d of this S. 10, Ex. B-Part 8, Contractor is deemed to have attested to the accuracy, completeness and truthfulness of information required by OHA. Accordingly, Contractor shall provide to OHA’s Contract Administrator via Administrative Notice, all of the following reports: (1) Data Certification and Validation Report (2) Claim Count Verification Acknowledgement and Action Form, (3) Pharmacy Expense Report - Proprietary Exemption Request, and (4) Pharmacy Expense Report e. The report forms are available on the Contract Reports WebsiteContractor shall maintain sufficient Encounter Data to identify the actual Provider who delivers services to the Member per SSA section 1903(m)(2)(A)(xi). f. Contractor shall obtain a Coordination of Benefits Agreement (“COBA”) number and coordinate with COBA to receive direct crossover claims for dually eligible Members with traditional Medicare per 42 CFR 438.3(t). g. OHA will conduct periodic Encounter Data validation studies of the Contractor’s encounter submissions. These studies will review statisticall...
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Related to Encounter Claims Data

  • Encounter Data Party shall provide encounter data to the Agency of Human Services and/or its departments and ensure further that the data and services provided can be linked to and supported by enrollee eligibility files maintained by the State.

  • CLAIMS FOR DAMAGES 7.4.1 Should either party to the Contract suffer injury or damage to person or property because of any act or omission of the other party or of any of his / her employees, agents or others for whose acts he / she is legally liable, claim shall be made in writing to such other party within a reasonable time after the first observance of such injury or damage.

  • Errors, Questions, and Complaints a. In case of errors or questions about your transactions, you should as soon as possible contact us as set forth in Section 6 of the General Terms above. b. If you think your periodic statement for your account is incorrect or you need more information about a transaction listed in the periodic statement for your account, we must hear from you no later than sixty (60) days after we send you the applicable periodic statement for your account that identifies the error. You must: 1. Tell us your name; 2. Describe the error or the transaction in question, and explain as clearly as possible why you believe it is an error or why you need more information; and, 3. Tell us the dollar amount of the suspected error. c. If you tell us orally, we may require that you send your complaint in writing within ten (10) Business Days after your oral notification. Except as described below, we will determine whether an error occurred within ten (10) Business Days after you notify us of the error. We will tell you the results of our investigation within three (3) Business Days after we complete our investigation of the error, and will correct any error promptly. However, if we require more time to confirm the nature of your complaint or question, we reserve the right to take up to forty-five (45) days to complete our investigation. If we decide to do this, we will provisionally credit your Eligible Transaction Account within ten (10) Business Days for the amount you think is in error. If we ask you to submit your complaint or question in writing and we do not receive it within ten (10) Business Days, we may not provisionally credit your Eligible Transaction Account. If it is determined there was no error we will mail you a written explanation within three (3) Business Days after completion of our investigation. You may ask for copies of documents used in our investigation. We may revoke any provisional credit provided to you if we find an error did not occur.

  • Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

  • Claims Review Population A description of the Population subject to the Claims Review.