We are an MCO (managed care organization). We have three lines of business, commercial (both fully insured and self insured), Medicare +Choice, and Medicaid. These are all Managed Cared programs.
We currently are obligated by both CMS and our local Medicaid agency to report "encounter" data ("paid" claims data).
CMS came out this month and announced that they would no longer require "encounter" data, rather they will require "data to support risk adjustment". Further more this "data to support risk adjustment" is very condensed, (six fields total) and would not be required to be sent in the 837 format (although they will accept the 837 if an MCO chooses to use it).
Our Medicaid agency currently requires their version of the NSF and have not made a decision yet as to whether they will require the 837 or not.
We are very concerned about how, if our Medicaid agency requires the 837 format, we will bridge the gap between paper claims and the 837. If our Medicaid agency wants the 837, we will not have a choice to submit the incoming paper claims to them any differently than the incoming 837s.
Here's our question (at last), through our regional SNIP (NMCHILI) we have just started a workgroup to develop a state wide approach to this issue, but we are wondering how other MCOs in other states are dealing with this issue - especially states like Kansas and Michigan where their Medicaid agency is requiring the use of the 837?
Kris Owens
Senior IS Project Manager - HIPAA Project
Presbyterian Healthcare Services
Albuquerque, NM
505.923.8108
[EMAIL PROTECTED]
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