Claims and encounter definition

Claims and encounter means either aof the following: A request to obtain payment, and necessary accompanying information, from a health care provider to a health plan, for health care; or anAn inpatient stay or outpatient visit in which a claim is not generated.
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Claims and encounter means either of the following:
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Examples of Claims and encounter in a sentence

  • The reference subsystem provides a consolidated source of reference information which is accessed by the MIS during the performance of other functions, including Claims and encounter processing, TPL processing and utilization/quality reporting functions.

  • The maintenance of enrollment/member data is required to support Claims and encounter processing, third party liability (TPL) processing and reporting functions.

  • The maintenance of provider data is required to support Claims and encounter processing, utilization/quality processing, financial processing and report functions.

  • Claims and encounter records will be provided to the DEPARTMENT in an electronic medium as specified by the DEPARTMENT, and its agent(s).

  • Claims and encounter submission timeliness requirements apply regardless of whether the Contractor directly provides services, acts as a third party administrator for a network of crisis providers, or is paid on a capitation or a fee-for-service basis.

  • The objectives of the data integrity and systems assessments are to verify that: • Claims and encounter data exist in local MCO systems; • Data from local MCO systems is presented to the State correctly; • Data submitted to the State accurately reflects encounters; and • Data that resides with the State is an accurate reflection of what exists in the local MCO system.

  • Covered Entity will agree to provide the following information to the Data Recipient in the format as indicated below:  Claims and encounter data will be provided as pipe delimited text files.

  • If the Medical Data are not provided to ESI within such sixty (60) day period (for a reason other than ESI's breach of this Article VI), the pricing for the Prescription Drug Program, as set forth on EXHIBIT C, shall be adjusted retroactive to the date the Medical Data should have been provided to ESI in accordance with this Section 6.2. Claims and encounter data shall be provided to ESI on electronic tape or such other format mutually acceptable to ESI, NYLCare and Sponsor.

  • Claims and encounter submission timeliness requirements apply regardless of whether the Contractor directly provides services, acts as a third-party administrator for a network of crisis providers, or is paid on a capitation or a FFS basis.

  • The Contractor shall have an automated Claims and encounter processing system for pharmacy Claims that will support the requirements of this Contract and ensure the accurate and timely processing of Claims and encounters.