Encounter Data System 1 User Group June 21, 2012 User Thursday, - PDF document

Encounter Data System 1 User Group June 21, 2012 User Thursday, June 21, 2012 Encounter Data Group 3:00 P.M. – 4:00 P.M. ET

Encounter Data Agenda • Introduction • Session Guidelines • CMS Updates Group User • EDFES Updates • EDPS Updates • Questions and Responses 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 • Closing Remarks 2

Encounter Data Introduction The purpose of this session is to provide Medicare Advantage Organizations (MAOs) and other entities with information on policy Group User and operational guidance on testing and submitting production data to the Encounter Data System (EDS) 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 3

Encounter Data MAOs and Other Entities • CMS requires the following types of organizations to submit encounter data: – Medicare Advantage (MA) Plans – Medicare Advantage-Prescription Drug (MA-PD) Plans – Health Maintenance Organizations (HMOs) Group User – Special Needs Plans (SNPs) – Local Preferred Provider Organizations (PPOs) – Regional PPOs – Employer Group Health Plans – Programs of All-Inclusive Care for the Elderly (PACE) Plans 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 – Cost Plans (1876 Cost HMOs/CMPs and 1833 HCPPs) – Medical Savings Account (MSA) – Private Fee-for-Service Plans (PFFS) – Religious Fraternal Benefit Plans (RFBs) – Provider Sponsored Organizations (PSO) 4

Encounter Data Session Guidelines • This is a one (1) hour Encounter Data User Group for MAOs and other entities Group User • If time allows, we will respond to questions 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 5

6 CMS Updates User Thursday, June 21, 2012 Encounter Data Group 3:00 P.M. – 4:00 P.M. ET

Encounter Data End-to-End Testing Status Certification Status as of 06/19/2012 * Group Professional Institutional User Total Submitters 218 218 Number of Submitters Certified 178 1 Certified MAOs and Other Entities Represented 515 1 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 * These figures do not include PACE Plans 7

End-to-End Testing / Certification Encounter Data Timeline Testing Begins Testing Ends/Deadline for Certification Professional Encounters 1/4/12 5/31/12 Group Institutional Encounters 4/30/12 6/30/12 User DME Encounters 6/15/12 7/30/12 • CMS will not begin compliance measures without advance notice; however, the End-to-End Testing/Certification timeline 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 has not changed • MAOs and other entities that have not completed end-to-end testing should do so immediately 8

Encounter Data Tier 2 Testing • Tier 2 testing has been extended to allow for submission of Professional and Institutional data • Currently, CMS has not identified a Tier 2 testing deadline. CMS will notify MAOs and other entities Group User two (2) weeks prior to ending the Tier 2 testing capabilities • As of June 19, 2012: 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 – 361 Professional Tier 2 test files were processed – 53 Institutional Tier 2 test files were processed 9

Encounter Data Tier 2 Testing • MAOs and other entities that are end-to-end certified must begin submitting production data based on the submission timelines Group previously established User • MAO-002 reports are returned within seven (7) business days for test file submissions and within five (5) business days for production 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 file submissions 10

11 EDFES Updates User Thursday, June 21, 2012 Encounter Data Group 3:00 P.M. – 4:00 P.M. ET

Encounter Data EDFES Special Notifications • The EDFES will send special notifications to submitters when the file does not pass EDS customized edits • These notifications are sent in addition to the Group User standard acknowledgement reports and are intended to assist MAOs and other entities with correcting encounters in order to avoid returned, unprocessed files 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 • Each line is spaced-filled up to 80 characters 12

Encounter Data EDFES Special Notifications • File Name Record -------FILE NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX • File Control Record ----FILE CONTROL: XXXXXXXXX • Group File Count Record User NUMBER OF CLAIMS: 99,999 • File Separator Record -------- (up to 80 characters) • File Message Record 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S) • File Message Records XXXXXXXXXXXXXXXXXXXXXXXXXXXX (up to 80 characters) 13

Encounter Data EDFES Special Notifications • An example of the report format is as follows: -------FILE NAME: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XX Group User ----FILE CONTROL: XXXXXXXXX NUMBER OF CLAIMS: 99,999 FILE WAS NOT SENT TO THE EDPS BACK-END PROCESS FOR THE FOLLOWING REASON(S) 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 14

Encounter Data EDFES Special Notifications Notification Message File Type Notification Message Description FILE ID (XXXXXXXXX) IS A DUPLICATE OF A FILE ID The file ID must be unique for a 12 All SENT WITHIN THE LAST 12 MONTHS month period SUBMITTER NOT AUTHORIZED TO SEND CLAIMS The submitter is not authorized to Group All User FOR PLAN (CONTRACT ID) send for this plan PLAN ID CANNOT BE THE SAME AS THE The Contract ID cannot be the All SUBMITTER ID same as the Submitter ID AT LEAST ONE ENCOUNTER IS MISSING A All The Contract ID is missing CONTRACT ID IN THE 2010BB-REF02 SEGMENT The submitter must be front-end 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 All SUBMITTER NOT FRONT-END CERTIFIED certified to send encounters for validation THE DATE ON ALL CLAIMS MUST START IN THE Encounters must contain dates in All YEAR 2012 the year 2012 15

Encounter Data EDFES Special Notifications Notification Message File Type Notification Message Description SUBMITTER NOT CERTIFIED FOR The submitter must be certified to Production PRODUCTION send encounters for production THE INTERCHANGE USAGE INDICATOR MUST The Tier 2 file is being sent with a ‘P’ Production EQUAL ‘T’ in the ISA15 field Group User The number of encounters for a PLAN (CONTRACT ID) HAS (X,XXX) CLAIMS IN Tier 2 Contract ID cannot be greater than THIS FILE. ONLY 2,000 ARE ALLOWED 2,000 End-to-End Testing – File 1 FILE CANNOT CONTAIN MORE THAN XX The number of encounters cannot ENCOUNTERS be greater than XX End-to-End Testing – Additional File(s) 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 End-to-End Testing – PATIENT CONTROL NUMBERIS MORE THAN The Claim Control Number, File 1 20 CHARACTERS LONG THE TC# WAS including the Test Case Number, End-to-End Testing – TRUNCATED must not exceed 20 characters Additional File(s) 16

Encounter Data EDFES Special Notifications Notification Message File Type Notification Message Description End-to-End Testing – FILE CANNOT CONTAIN BOTH File 1 The test cases from File X and File UNLINKED AND LINKED TEST CASES Y cannot be in the same file End-to-End Testing – Group User Additional File(s) End-to-End Testing – CANNOT SEND LINKED TEST CASES The test cases for File Y cannot be File 1 UNTIL ALL UNLINKED TEST CASES HAVE sent before all File X test cases are End-to-End Testing – BEEN ACCEPTED accepted Additional File(s) End-to-End Testing – FILE CONTAINS (X) TEST CASE (X) The file must contain two (2) of 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 File 1 ENCOUNTER(S) each test case ADDITIONAL FILES CANNOT BE The MAO-002 report must be End-to-End Testing – VALIDATED UNTIL AN MAO-002 REPORT received before additional files can Additional File(s) HAS BEEN RECEIVED be submitted 17

Encounter Data Acknowledgement Reports • MAOs and other entities requested that separate mailboxes be established for receipt of Test and Production files Group User • The EDFES is unable to separate these files and will continue to submit TA1, 999 and 277CA reports in the current format 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 18

19 EDPS Updates User Thursday, June 21, 2012 Encounter Data Group 3:00 P.M. – 4:00 P.M. ET

20 Incident Tracking EDS User Thursday, June 21, 2012 Encounter Data Group 3:00 P.M. – 4:00 P.M. ET

Encounter Data Incident Tracking Tool • As of June 19, 2012, 271 incident inquiries have been received – 84% of these incidents have been resolved • Many of the remaining incidents are related to Group User Professional and Institutional edits that are being resolved, or are under further investigation and analysis • MAOs and other entities are encouraged to submit 3:00 P.M. – 4:00 P.M. ET Thursday, June 21, 2012 incident reports when these edits are received on the returned MAO-002 reports 21