First I should make it really clear that I am talking about managed care programs ONLY. This may be different in other lines of business - I don't know.
CMS has come out and for Medicare +Choice programs, it is no longer considered encounter reporting, but rather it is now called "data to support risk adjustment" and the 837 is NOT required. MCOs may use the 837, their current format (generally an NSF format), or a new very brief format
For the Medicaid managed care programs, they are stating that the reporting of encounters from the MCOs to Medicaid is a Payer to Payer transaction. In the regulations it specifically says that the 837 is:
162.1101(a) A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care. (b) If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care.
As you see in part (a) it specifically references "provider to health plan". Now part (b) where we get into encounters does not make any reference one way or another.
So the stance that some of the Medicaid FI's are taking is that since the regulations are "silent" on the payer to payer transaction, it is not covered by the regulations and they have the option to use the 837 or not. Hence the reason some states are and some states are not, requiring the 837 for encounter reporting from the MCOs.
Hope this clarifies the issue.
Kris Owens
Senior IS Project Manager - HIPAA Project
Presbyterian Healthcare Services
Albuquerque, NM
505.923.8108
[EMAIL PROTECTED]
"Complex systems evolve from simple rules"
-----Original Message-----
From: Christopher J. Feahr, OD [mailto:[EMAIL PROTECTED]]
Sent: Thursday, July 18, 2002 1:30 PM
To: [EMAIL PROTECTED]
Subject: RE: Encounter Data
Kris,
Your statement is surprising to me (of course, a lot of things are... and
that certainly doesn't make them incorrect!). But are you saying that the
837 is NOT the definitive, HIPAA-standard for reporting of "encounter
data"? If the encounter data is sent to support a "capitated" payment
plan, I believe that the 837 is absolutely required. But are you saying
that "data to support risk adjustment" can be sent in any mutually
agreeable format? This seems to suggest that the payor's intended use of
the "claim or encounter" data will determine whether or not to use the 837
to send it... is this what you are saying? I'm still not sure I see how
this would let the Medicaids off the hook or make the 837 optional in some
way. Doesn't all this "risk adjustment data" eventually impact payments to
providers?
Thanks,
Chris
At 11:41 AM 7/17/2002 -0600, Owens, Kris wrote:
>Encounters to whom? The regs do list it as the format for both claims and
>encounter data.
>
>- For encounter data from a provider to a payer we say yes.
>- If you are an MCO working with Medicare (an M+ Choice plan) the answer
>is no. CMS is now requiring "data to support risk adjustment" and are
>asking for about 6 fields of data. They will accept the 837 if you want
>to send it or your current NSF format or their new format.
>
>- If you are reporting encounter data to a Medicaid agency the answer is
>maybe, ask their fiscal intermediary. About 1/2 the state Medicaid
>programs are asking for the 837 and about 1/2 are not.
>
>Kris Owens
>Senior IS Project Manager - HIPAA Project
>Presbyterian Healthcare Services
>Albuquerque, NM
>505.923.8108
>[EMAIL PROTECTED]
>
>"Complex systems evolve from simple rules"
>
>-----Original Message-----
>From: Goldman, Shellie
>[<mailto:[EMAIL PROTECTED]>mailto:[EMAIL PROTECTED]]
>Sent: Wednesday, July 17, 2002 11:10 AM
>To: '[EMAIL PROTECTED]'
>Subject: Encounter Data
>
>Is the 837 transaction set required for encounter data? I cannot find
>anywhere in the regs that indicate it is not. If you have the site in the
>regs, please let me know.
>
>
>
>
>
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>--- PRESBYTERIAN HEALTHCARE SERVICES DISCLAIMER ---
>
>This message originates from Presbyterian Healthcare Services or one of
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