SCAN Health Plan
Provider Partners Webinar
SCAN Health Plan
SCAN Health Plan
Provider Partners Webinar
Provider Partners Webinar
CMS Full Encounter
Data by January, 2012
Presentation: May 25, 2011CMS Full Encounter
CMS Full Encounter
Data by January, 2012
Data by January, 2012
Presentation: May 25, 2011 Presentation: May 25, 2011
Introduction
SCAN FED Project Status
Updates on CMS Requirements
Impacts on Providers
Resources
CMS Full Encounter Data Agenda
CMS Full Encounter Data Agenda
Introduction
Introduction
Oct 29th, 2010: CMS formally announced decision to
transition to a new Encounter Data Processing System (EDPS) from the current Risk Adjustment Processing System (RAPS).
– Measuring healthcare utilization in MA organizations – Calibrating MA specific Risk Adjustment models
– Calculating disproportionate share hospital payments
EDPS Target Production Date of January 2nd, 2012
RAPS data submission will continue side-by-side during
Scope of encounter data collection
– We still want all the data…but now CMS wants it all too.
Accuracy of data
– Provider identification
– Codes and reference data
This mandates increased:
Introduction
Introduction
Complete Data Submission
MA must submit all data from all types of service, including:
Inpatient Hospital Inpatient Rehab
Inpatient Psychiatric Long Term Care
Skilled Nursing
Inpatient/Swing Bed
Skilled Nursing Outpatient Outpatient Hospital
Community Mental Health Home Health (DME)
End-Stage Renal Disease
Critical Access Hospital
Inpatient/Swing Bed
Critical Access Hospital
Outpatient
Rural health Clinic
Federally Qualified Health Center Outpatient Rehab
Physician/Professional Clinical Laboratory
Durable Medical Equipment Ambulatory Surgical Centers
Ambulance
Introduction
Introduction
SCAN
FED Project Status
SCAN
FED Project Status
CMS Full Encounter Data
SCAN FED Project Status
SCAN FED Project Status
SCAN is:
Developing an assessment readiness tool (
aProvider Readiness Assessment )and consulting
program to help you independently determine
your current status and needs
Preparing a CMS Full Encounter Data-specific
SCAN website and email address to allow
dialogue with Provider Partners on specific
questions
SCAN FED Project Status
SCAN FED Project Status
Working with our clearinghouses to put
together planning and tracking for all
Provider Partner implementations of CMS Full
Encounter Data
Office Ally and DDD are alerted and planning
to be ready on their end
Q: What do you envision in terms of sharing the
rejects with IPA/Medical Groups? Are you going to modify the existing provider portal to share the rejects there? Or are you going to produce reports? A: Existing portal and sharing rejects for
providers – will be opened up to all providers for direct remediation of encounter rejection. We may produce other reports like the CMS rejection report so that they can send corrections back.
SCAN FED Project Status
Updates on CMS
Full Encounter Data
Requirements
Updates on CMS
Full Encounter Data
Requirements
CMS Full Encounter Data
CMS Requirements Status
CMS Requirements Status
Encounters will be required for all
Medicare-covered and non-Medicare-Medicare-covered services
DME encounters will not be included in the
January 2012 start date, but instead will be
implemented separately by June 2012
SCAN will require all encounters be sent in
the 837v5010 format as of January 1, 2012
and will be operating under Full Encounter
Data Processing Guidelines as of that date
Timely Filing
– Encounter must be to CMS (cleanly passing all EDI and Adjudication Edits) within 13 months of the date of service
– Chart Review Data (ex – HCC Programs or RADV) can be submitted within the same Sweep Date timeframes as today
Direct Submissions (Alternative Submission Format)
– Format will remain the same or very similar (TBD)
– Encounter must first be on file at SCAN or direct submission record will be rejected – Must be used to delete specific DX codes from an encounter
Replacing and Voiding Encounters
– Resub/replace entire encounter • Claim Frequency Code = ’7’
CMS Requirements Status
CMS Requirements Status
Encounters/Claims to Submit
– All Paid & Denied (for contractual/payment reasons) must be submitted
– Rejected (for bad/incomplete date) should not be submitted
– Pending (not yet paid) should not be submitted
Submission Frequency
– SCAN recommends submitting encounter data on a weekly or bi-weekly basis.
– This helps with maintain a workable submission and rejection process
Provider Identification
– NPI is required; CMS still too provide final guidance for those providers without an NPI (NPPES will allow almost all provider specialties to enroll for an NPI)
– All addresses (Billing Provider, Servicing Facility, Ambulance Pick Up, etc) must have 9 digit zip code
– Billing address must be the physical address and cannot be a PO Box or lockbox.
– CMS/SCAN may require identifiers such as:
• CLIA and Mammography Certification Number
Multi-Specialty Providers
CMS Requirements Status
Diagnosis Codes – 837P = 12 fields – 837I = 23 Fields
– If more than allotted then:
• Can send duplicate encounter with remaining DX codes • Can add DX codes in SCAN’s Encounter Data Portal
• Can submit additional DX codes on Direct Submission format (after SCAN confirms initial encounter processing)
• Other ideas? Amount Fields
– Fields such as billed amount, paid amount, and patient responsibility should be populated
– If capitated and no dollar amount is available, then may populate with $0 – The patient responsibility must be populated for Medicare Out of Pocket Max
calculations
– 837 EDI encounter must “balance” to pass validation
CMS Requirements Status
CMS Requirements Status
Outstanding
Questions For CMS
Outstanding
Questions For CMS
CMS Full Encounter Data
Outstanding Questions for
CMS
Outstanding Questions for
CMS
What is the definition of an encounter? One
claim form? One DOS? One service?
• Q: How will provider data differentiate between a capitated claim versus a FFS claim in the 5010 file somehow? A: How is not yet completely clear. CMS may allow us to put zero dollars in an encounter
indicating that it was for a capitated service. SCAN may make this differentiation on your data as part of the data scrubbing / preparation for transmission to CMS. More information will be provided when CMS provides the answers.
Outstanding Questions for
CMS
Outstanding Questions for
CMS
Q: Can you define the scope and types of
validation edits (FFS edits) that are going to
be used for this project?
A: We don’t know for
sure the scope and pricing of FFS edits.
Outstanding Questions for
CMS
Outstanding Questions for
CMS
Q: What is CMS’s logic for dups in the
5010? What will be SCAN’s dup logic when this is implemented? A: CMS has not published their dup logic yet but it will be similar to their FFS side dup logic, based on information regarding the visit /
service. True duplicates will reject. However, we will still need to send multiple versions of the encounter in order to get more than 6 diag codes. CMS will
accommodate these addendums.
Outstanding Questions for
CMS
Outstanding Questions for
CMS
Impacts on Providers
Impacts on Providers
CMS Full Encounter Data
Identify a specific individual to maintain contact and coordination with SCAN for the duration of this
transition – there will be more webinars and Q&As Alert and prepare all of your downstream providers
of the upcoming changes
Prepare to work with SCAN on assessment
– Assess your current technical (IT) status and transition capabilities
– Assess workflow and resources for Encounter Data rejections
Develop a plan to accomplish the transition
Impacts on SCAN Provider Partners
Impacts on SCAN Provider Partners
Impacts on SCAN Provider
Partners
Impacts on SCAN Provider
Partners
Provider partners must submit valid Procedures
and DX codes. Diagnosis Code V70.0 is
routinely rejected in Medicare FFS claim
adjudication.
Providers partners must submit claims on the
Impacts on SCAN Provider Partners
Impacts on SCAN Provider Partners
Providers will need to begin submitting 100% of all encounter data for all services by 1/1/2012
SCAN provider partners will need to ensure that ALL your providers begin submitting claims or encounter data to you by 1/1/2012
Providers will need to change many files, formats,
business operations and processes to comply with the CMS Full Encounter Data requirements
2011 Second and Third Quarter Provider
Tasks:
Providers will need to assess and adjust
systems, data controls, file formats,
workflows and down stream communications
Providers will need an encounter extraction
Impacts on SCAN Provider Partners
2011 Third and Fourth Quarter Provider
Tasks
Test in the third and fourth quarter of 2011
your new formats and processes with SCAN
and our clearinghouses
Impacts on SCAN Provider Partners
Q&A Session
Q&A Session
CMS Full Encounter Data
SCAN Full Encounter Data Resources
SCAN Full Encounter Data Resources
Publishing industry-wide CMS Full Encounter
data updates and information to
www.hccuniversity.com
