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Ments that are required to be populated in order to pass Encounter Data System translator and CEM level edits are provided below. MAOs and other entities must include at least these minimum data elements when they submit encounter data. MAOs and other entities can use this information for the submission of paper claims, member reimbursement claims, claims from foreign providers, etc. The situational fields associated with these minimum data elements must also be submitted if the situation is pre.
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HI01-2 FAQ
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Encounter data is information that documents a person's diagnoses, treatments and services provided by a clinician or care facility for administrative purposes.
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* All-inclusive rates are billed by encounter, which means the calculation of a rate accounts for all of the allowable costs of providing care. This is the opposite of fee-for-service rates, where specific services are billed at specific rates, even if more than one service is provided during an encounter.
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A Comprehensive Encounter Data Processing System. Wipro's Encounter Data Processing System (EDPS) assists Health Plans in submitting Medicare Advantage, Managed Medicaid, and Dual Demonstration encounter data to the Centers for Medicare and Medicaid (CMS), and States.
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In summary, encounter data are similar to fee-for-service (FFS) claims data, but encounter data are not tied to per-service payment from the payer to the managed care provider, because the payer is not reimbursing individual services.
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>> DEFINITION OF PATIENT ENCOUNTERS CMS defines patient encounters as any encounter where a medical treatment is provided and/or evaluation and management services are provided, except a hospital inpatient department (Place of Service 21) or a hospital emergency department (Place of Service 23).
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Under the FFS model, the state pays providers directly for each covered service received by a Medicaid beneficiary. Under managed care, the state pays a fee to a managed care plan for each person enrolled in the plan.
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The encounter data set also includes selected information about the service provided including the date or dates of service, the procedure code, which tells which service was provided, and the diagnosis or diagnoses, describing the condition that required the care.
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An encounter is the actual provision of services to the patient. Claims are requests for reimbursement from healthcare providers for providing a service to a patient.
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Learn more -
Encounter Histories File – Gary C. White
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Learn more -
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Billing and Information Technology:
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