ENCOUNTER SUBMISSION Clause Samples
The Encounter Submission clause outlines the requirements and procedures for submitting records of patient encounters to a designated party, such as a payer or regulatory body. Typically, this clause specifies the format, timing, and content of the data to be submitted, and may require the use of specific electronic systems or templates. By establishing clear expectations for encounter data reporting, the clause ensures accurate and timely information exchange, which is essential for billing, compliance, and quality assurance purposes.
ENCOUNTER SUBMISSION. The MAO shall submit Medicare encounter data to AHCCCS in accordance with the requirements of Attachment 1: Chart of Deliverables AHCCCS has a data use Agreement with CMS to receive Medicare data for care coordination. This data will provide AHCCCS with information on services paid for by Medicare.
ENCOUNTER SUBMISSION. The MA D SNP Health Plan is required to submit Medicare encounter data as requested by the State. The State has completed a data use agreement with CMS to receive Medicare data for care coordination. This data will provide the State with information on services paid for by Medicare.
ENCOUNTER SUBMISSION. All reinsurance associated encounters, except as provided below for “Disputed Matters” must reach a clean claim status within 15 months from the end date of service, or date of eligibility posting, whichever is later.
ENCOUNTER SUBMISSION. 4.13.1 The MA Health Plan shall submit and maintain accurate, timely, and complete encounter data. The MA Health Plan shall comply with allthe following:
4.13.1.1 Designate a person dedicated to work collaboratively with HCA on quality control and review of encounter data submitted to HCA.
4.13.1.2 Submit to HCA complete, accurate, and timely data for all services for which the MA Health Plan provided services under this SMAC as reported to CMS.
4.13.1.3 Encounter data must be submitted to HCA via SFT upload monthly, at a minimum, and no later than 30 calendar days from the end of the month in which the MA Health Plan submitted encounter data to CMS.
4.13.1.4 Submitted encounters and encounter records shall have all fields required and found on standard healthcare claim billing forms or in electronic healthcare claim formats to support proper adjudication of an encounter.
4.13.1.5 The MA Health Plan shall submit to HCA, without alteration, omission, or splitting, all available claim data in its entirety from the MA Health Plan’s submission to CMS with the exception of adding the Medicaid enrolled ProviderOne ID.
4.13.1.5.1 Submitted encounters or encounter records must not be a duplicate of a previously submitted and accepted encounter or encounter record unless submitted as an adjustment or void per HIPAA.
4.13.2 MA Health Plan will develop and provide a Washington specific summary of provider networks, drug coverages, plan benefits, care coordination, supplemental benefits, and VAIS to assist with helping potential Members make plan choices to the Statewide Health Insurance Benefits Advisors (SHIBA). This information will be developed in a format decided by HCA and SHIBA to best support outreach efforts. This will be provided to ▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇.▇▇.▇▇▇ via email annually in advance of open enrollment no later than October 5th of each calendar year. This report will be shared by DSHS and HCA with the Area Agencies on Aging and posted to the HCA website.
4.14.1 The data quality standards listed within this SMACare incorporated by reference into this SMAC. The MA Health Plan shall make changes or corrections to any systems, processes, or data transmission formats as needed to comply with HCA’s data quality standards as defined and subsequently amended.
4.14.2 Additional detailsdetails can be found in the Encounter Data Reporting Guide published by HCA. The Encounter Data Reporting Guide, as currently existing and hereafter amended, is hereby incorporated b...