Encounter Data Quality Sample Clauses
The Encounter Data Quality clause establishes standards and requirements for the accuracy, completeness, and reliability of data collected during patient encounters. In practice, this clause may require healthcare providers to submit encounter data that meets specific formatting and content criteria, and may outline procedures for correcting errors or addressing data discrepancies. Its core function is to ensure that all encounter data used for reporting, billing, or analysis is trustworthy and consistent, thereby supporting effective healthcare management and compliance with regulatory requirements.
Encounter Data Quality.
3.14.2.1 The STATE shall monitor and evaluate encounter data lines and shall require correction of encounter data found deficient according to specifications published on the STATE’s managed care web site. Encounter data not corrected shall be assessed a penalty as specified in section 5.9 below. [42 CFR §438.242(d)]
(1) Within twenty-one (21) days after the end of each calendar quarter, the STATE shall provide to the MCO an error reference report (ERR) of erroneous encounter lines and/or headers processed during the quarter, as described in the technical specifications posted on the STATE’s managed care web site.
(2) The MCO shall, within the calendar quarter in which the ERR is provided, respond by appropriately voiding the erroneous encounter lines and/or headers and submitting corrected encounter data claims.
(3) The MCO shall include on each corrected encounter data claim a “tracking ICN” as defined in the technical specifications posted on the STATE’s managed care web site.
(4) The STATE will post on its managed care web site technical specifications including but not limited to definitions for encounter lines and headers; definitions for edits and errors; management of duplicate encounter lines or headers, submissions of multiple errors on one encounter claim, and voids that are within the same quarter; and a list of designated edits which may change at the discretion of the STATE. The STATE shall provide a minimum of ninety (90) days’ notice before implementing a new edit that will require correction.
(5) Encounter headers/lines identified by the STATE as errors subject to this section may not be voided as a method to avoid penalties. Encounter claims that should not have been submitted to the STATE and should not reside in STATE data as MCO accepted claims must be explicitly identified as such. Voided claims are subject to a validation process by the STATE.
(6) The MCO may contest encounter lines or claims the STATE has identified as erroneous by sending the encounter ICN and a detailed description of the contested encounter lines or claims by e-mail to the STATE’s Encounter Data Quality contact. The STATE will remove the encounter line from the penalty assessment pending resolution of the issue. Contested errors will not be adjusted retroactively, but can be removed from the penalty going forward (as defined in the technical specifications posted on the STATE’s managed care web site).
(7) The notice and opportunity to cure requirements in secti...