Encounter Record definition
Encounter Record means the record of the primary care services provided to a patient by the Physician, including simplified encounter codes (which capture the Physician’s practice activities) provided by the Medical Services Plan/Health Insurance BC, as amended from time to time, and diagnostic codes (ICD9).
Encounter Record means the number of service lines or products submitted as line items in the standard 837 format or the National Council for Prescription Drug Programs (NCPDP) Batch format.
Encounter Record. An electronically formatted list of encounter data elements per encounter as specified in the current Encounter User Guide. An encounter record may be prepared from paper claims such as the CMS 1500, UB-04, or electronic transactions such as ASC XX12N 837. Enrollee(see also definition of “Member”) : A BadgerCare Plus and/or Medicaid SSI member who has been certified by the State as eligible to enroll under this Contract, and whose name appears on the HMO Enrollment Rosters that the Department transmits to the HMO according to an established notification schedule. These terms are used interchangeably. Enrollment Area: The geographic area within which members must reside in order to enroll in the HMO under this Contract. Enrollment Specialist: An entity contracted by the Department to perform HMO choice counseling and HMO enrollment activities. Choice counseling refers to activities such as answering questions and providing unbiased information on available managed care organization delivery system options, and advising on what factors to consider when choosing among HMOs and in selecting a primary care provider. Enrollment activities refers to distributing, collecting, and processing enrollment materials and taking enrollments by phone, by mail, or in person. Estimated Data Completeness: A measure used by the Department to evaluate HMO compliance with encounter submission requirements. Excluded Services: Services that Medicaid does not pay for. Expedited Grievance or Appeal: An emergency or urgent situation in which a member or their authorized representative requests a review of a situation where further delay could be a health risk to the member, as verified by a medical professional. Experimental Surgery and Procedures: Experimental services that meet the definition of Wis. Adm. Code §DHS 107.035(1) and (2) as determined by the Department. External Quality Review (EQR): Per 42 CFR §438.320, the analysis and evaluation by an External Quality Review Organization of aggregated information on quality, timeliness, and access to the health care services that an HMO or their contractors furnish to Medicaid beneficiaries. External Quality Review Organization (EQRO): Per 42 CFR §438.320, an organization that meets the competence and independence requirements set forth in 42 CFR §438.354, and performs external quality review, other EQR-related activities as set forth in 42 CFR §438.358, or both. Fee-for-Service: A method of payment in which a provider is paid a fe...
Examples of Encounter Record in a sentence
An Encounter Record captures and reports information about each specific service provided each time a Member visits a Provider, regardless of the contractual relationship between the Contractor and Provider or Subcontractor and Provider.
At a minimum, there will be a Provider, Enrollee, Encounter Record and Capitation interface.
The Contractor shall be required to electronically transmit Encounter Record to the Department on a weekly basis, or on a department approved schedule that is determined by the Contractor’s financial schedule.
The Contractor’s Claims processing/encounter subsystem shall contain such items as: apply edit and audit criteria to verify timely, accurate and complete Encounter Record; edit for prior-authorized Claims; identify error codes for Claims.
Requirements to participate in QAPI activities, including submission of complete Encounter Record, are incorporated into all Provider and Subcontractor contracts and employment agreements.
More Definitions of Encounter Record
Encounter Record. An electronically formatted list of encounter data elements per encounter as specified in the Wisconsin Medicaid MCO Encounter Data User Manual. An encounter record may be prepared from a single detail line from a claim such as the CMS 1500, UB-92, or ASCX12N 837.
Encounter Record. An electronically formatted list of utilization data elements per encounter in a computer readable format as specified in ADDENDUM II for the Quarterly Utilization Report. Enrollment Area: Refers to Dane County and is the geographic area within which a member’s parent, guardian or primary caregiver must reside in order to enroll in the County’s Managed Care Program under this Contract. A member may enroll regardless of where the member’s parent, guardian, or primary caregiver lives when the member is legally the responsibility of the County. Excluded Services: Services that Medicaid does not pay for. Fraud: An intentional deception or misrepresentation made by a person or entity with the knowledge that the deception could result in some unauthorized benefit to him/herself, or to some other person or entity. It includes any act that constitutes fraud under applicable federal or state law.
Encounter Record. An electronically formatted list of utilization data elements per encounter in a computer readable format as specified in ADDENDUM II for the Quarterly Utilization Report. Enrollment Area: Refers to Milwaukee County and is the geographic area within which a member’s parent, guardian or primary caregiver must reside in order to enroll in the County’s Managed Care Program under this Contract. A member may enroll regardless of where the member’s parent, guardian, or primary caregiver lives when the member is legally the responsibility of the County. Excluded Services: Services that Medicaid does not pay for. Fraud: An intentional deception or misrepresentation made by a person or entity with the knowledge that the deception could result in some unauthorized benefit to him/herself, itself or to some other person or entity. It includes any act that constitutes fraud under applicable federal or state law.
Encounter Record. An electronically formatted list of encounter data elements per encounter as specified in the current Encounter User Guide. An encounter record may be prepared from paper claims such as the CMS 1500, UB-04, or electronic transactions such as ASC XX12N 837. Enrollee, Member, Participant and Consumer: A BadgerCare Plus and/or Medicaid SSI member who has been certified by the State as eligible to enroll under this Contract,
Encounter Record. An electronically formatted list of encounter data elements per encounter as specified in the current Encounter User Guide. An encounter record may be prepared from paper claims such as the CMS 1500, UB-04, or electronic transactions such as ASC XX12N 837. Enrollee, Member, Participant and Consumer: A BadgerCare Plus and/or Medicaid SSI member who has been certified by the State as eligible to enroll under this Contract, and whose name appears on the HMO Enrollment Rosters that the Department transmits to the HMO according to an established notification schedule. These terms are used interchangeably. Enrollment Area: The geographic area within which members must reside in order to enroll in the HMO under this Contract.
Encounter Record. An electronically formatted list of utilization data elements per encounter in a computer readable format as specified in the contract in ADDENDUM II for the Quarterly Utilization Report.
Encounter Record means an electronically formatted list of encounter data elements per encounter as specified in the current Wisconsin Medicaid HMO Encounter Data User Manual. An encounter record may be prepared from paper claims such as the HCFA 1500, UB-92, or electronic transactions such as ASC XX12N 837. Enrollee and Participant means a Medicaid or BadgerCare recipient who has been certified by the State as eligible to enroll under this Contract, and whose name appears on the HMO Enrollment Reports that the Department transmits to the HMO every month according to an established notification schedule. Children who are reported to the certifying agency within 100 days of birth shall be enrolled in the HMO their mother is enrolled in from their date of birth if the mother was an enrollee on the date of birth. Children who are reported to the certifying agency after the 100th day but before their first birthday may be eligible for Medicaid or BadgerCare on a fee-for-service (FFS) basis.