Encounter data is detailed data generated by health care providers, such as doctors and hospitals, that documents both the clinical conditions they diagnose as well as the services and items delivered to beneficiaries to treat these conditions. The Centers for Medicare & Medicaid Services (CMS) began collecting encounter data from Medicare Advantage plans in 2012.
What are Medicaid encounters?
Medicaid claims and encounter data have a number of uses that can support delivery and payment reforms including identifi-cation of high-need, high-cost patients for care coordination; and measuring, supporting, and rewarding provider performance.
What does medical encounter mean?
Detailed Descriptions for the elements in the Encounter resource. Encounter. Element Id. Encounter. Definition. An interaction between a patient and healthcare provider (s) for the purpose of providing healthcare service (s) or assessing the health status of a patient. Cardinality. 0..*. Type.
What is Medicaid encounter?
Encounter data are the records of services delivered to Medicaid beneficiaries enrolled in managed care plans that receive a capitated, per-member-per-month payment. These records allow the Medicaid agency to track the services received by members enrolled in managed care.
What is Medicare encounter data?
Encounter Data in Medicare Advantage. Medicare Advantage encounter data is intended to capture the details of a Medicare Advantage beneficiary’s health and treatment based on “encounters” with clinicians. This data is used to understand the health status of enrollees.
What are encounter files?
The Medicare Carrier (Encounter) file includes Medicare Advantage plan paid records for professional providers, including physicians, physician assistants, clinical social workers, nurse practitioners.
What is the difference between an encounter and a claim?
Encounter data are similar to FFS claims data, but encounter data (1) are not tied to per-service payment from the state to the managed care organization (MCO), because the state is not paying for individual services, and (2) do not include a Medicaid-paid amount, although many states collect the amounts MCOs pay ...
What is encounter processing?
Senior Director Health Plan Operations Medical Claims and Encounter Processing. • Medical claims and encounter processing is part of an integrated organization. and process that is downstream of and dependent upon many other functions and departments within the Managed Care Organization (MCO).
What is an insurance encounter?
A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care. The transmission of encounter information for the purpose of reporting health care, if there is no direct claim.
What is an encounter form used for?
Encounter forms are a key component in accurate billing and collections. They document services rendered by capturing the diagnosis and procedure codes, which serve as the basis for billing and receipt of payment for services.
What is encounter data for Medicare Advantage?
CMS defines encounter data as the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner.
What is raps and EDPS?
Since 2008, Cigna has been required to submit patient data using both the Risk Adjustment Payment System (RAPS) and Encounter Data Processing System (EDPS) platforms. By 2020, Cigna will be required to solely submit all patient data through the EDPS platform and retire the RAPS legacy data submission process.
What is EDPS Medicare?
A Comprehensive Encounter Data Processing System. X. X. Wipro's Encounter Data Processing System (EDPS) assists Health Plans in submitting Medicare Advantage, Managed Medicaid, and Dual Demonstration encounter data to the Centers for Medicare and Medicaid (CMS), and States.
What is Encounter ID?
Definition: Used to identify a specific visit or encounter. The ID is intended to be local to the organization.
What is a Medicaid encounter toolkit?
This toolkit provides a practical guide to collecting, validating, and reporting Medicaid managed care encounter data. It is designed as a step-by-step guide for state Medicaid staff responsible for managing the daily operations involved in encounter data, as well as for senior managers and policymakers who oversee this function. It contains case studies, checklists, and links to resources that provide helpful tips and tools.
What is a CMS toolkit?
The toolkit provides practical information about Medicaid managed care encounter data validation that states can use to improve the quality of information they receive from managed care plans and report to the Centers for Medicare & Medicaid Services (CMS). The guidance is designed to support state Medicaid staff responsible for managing the daily operations involved in validating encounter data. It is also intended for senior managers and policymakers who oversee this function..
What does Medicare Part B cover?
Part B also covers durable medical equipment, home health care, and some preventive services.
Does Medicare cover tests?
Medicare coverage for many tests, items, and services depends on where you live . This list includes tests, items, and services (covered and non-covered) if coverage is the same no matter where you live.
When do you have to enroll in Medicare?
Medicare Initial Enrollment Period. But if you delay taking Social Security until a later age, you have to enroll for Medicare Part A and/or Part B on your own when you turn 65 . This Medicare Initial Enrollment Period: 1 . Starts three months before the month you turn 65. Includes the month you turn 65. Ends three months after the month you turn ...
What is Medicare Part C?
Medicare Part C. Medicare Part C is also called a Medicare Advantage Plan. Private companies that contract with Medicare offer these plans to provide all your Part A and Part B benefits. Most Medicare Advantage Plans include Part D (prescription drug) coverage, as well as extra benefits for vision, hearing, and dental.
How much is Medicare Part B 2021?
Most people should probably get at least Part B so that they have coverage for doctor visits and outpatient care. The standard premium for Part B coverage is $148.50 for 2021, which is deducted from your monthly Social Security benefit. There's also an annual deductible of $203 for Part B coverage. 10 .
What happens if you don't enroll in Medicare?
Medicare Penalty. If you don't enroll in Part A and Part B during your Initial Enrollment Period, you must wait to sign up, which can cause a gap in your coverage. You may also owe a lifetime late enrollment penalty that increases the longer you wait to sign up. 4 .
What is the Cares Act 2020?
The Bottom Line. Medicare is the nation’s health care program for citizens age 65 years and up, and younger people who meet certain eligibility criteria. Medicare Part A, Part B, Part C, and Part D cover many major medical expenses for participants. Choosing the right Medicare plan can be confusing, ...
Is Medicare a complex program?
Medicare is a complex program that has many parts and options to choose from. Don’t hesitate to seek professional guidance from a qualified financial advisor who has been trained in this area .
When does the enrollment window start?
Key Takeaways. Your enrollment window begins three months before the month you turn 65 and lasts for three months after that. Don't assume your spouse is covered just because you are. Make sure you have enough coverage for all your medical expenses.
