Ch 14: Encounter Data

What is an Encounter?

An encounter is equivalent to the submission of claims data information. It details the specific services provided to a member by a provider, often used when the provider is pre-paid or receives a capitated payment for the services provided to VHP members. For example, if you are the PCP for a VHP member and receive a monthly capitation amount for services, you must submit an encounter file (ANSI X12N 837) or an encounter (also referred to as a “proxy claim”) on standard claims forms for each service provided. Since you receive a pre-payment in the form of capitation, the encounter or “proxy claim” is paid at zero dollars.

Encounter data is a very important source of information for administering and improving programs and instituting changes and improvements at VHP. VHP utilizes encounter data to evaluate all aspects of quality and utilization management, Healthcare Effectiveness Data and Information Set (HEDIS) reporting, capitation rates, and required data submission to federal and state agencies. VHP has contracted with UHIN, a data clearinghouse company, to assist providers with the proper formatting and timely and accurate submission of encounter data. For further information about VHP’s clearinghouse, UHIN, see Chapter 13, “Claims and Billing Submission.”

Encounter Data Requirements

All capitated providers contracted with VHP are required to submit encounter data for services provided under the capitated arrangement. Encounter data must be submitted, at minimum, monthly. Services must be coded accurately and comply with national standards.

Procedures for Filing Encounter Data Electronically

VHP requires that all providers file encounters electronically. VHP has the capability to receive an ANSI X12N 837 professional, institution or ancillary encounter transaction. In addition, VHP has the capability to generate an ANSI X12N 835 electronic remittance advice known as an Explanation of Payment (EOP).

A single encounter is defined as all services performed by a provider on a given date of service for an individual member. The following guidelines are intended to assist providers with submission of complete encounter data: • Reporting of services must be completed on a per member, per visit basis. • Reporting of all services rendered by date must be submitted to VHP. • All encounter data reporting is subject to, and must be in full compliance with, HIPAA and any other regulatory reporting requirements. • All encounter data must be submitted in a HIPAA compliant 837 format (ANSI X12N 837).

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CH 15: Provider Disputes & Member Grievances

This Chapter Includes:

1. Section I: Provider Disputes 2. Provider Dispute Resolution Procedure and Process 3. Dispute Resolution Mechanism 4. Provider Dispute Form (Page 1) 5. Provider Dispute Form (Page 2) - Multiple “Like” Claims 6. Dispute Resolution 7. No Punitive Action Against a Provider 8. Resolution via Corrected Claim

9. Section II: Member Appeals and Grievances 10.Member Grievance Procedure and Process

11. How to File a Grievance or Appeal 12.Standard Review Process

13.Expedited Review Process 14.Department of Managed Health Care (DMHC)

Alert

Alert draws attention to critical information that has changed this year.

Contact

Contact information on who to contact for assistance.

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