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Encounter Data

Overview

Managed care encounters are an important source for analytical processes that are used in evaluating the health of the Medi-Cal population.  The Center for Medicare and Medicaid (CMS) requires submission of encounter data in HIPAA compliant formats. The Department of Healthcare Services (DHCS) has developed a system to receive encounter data in the HIPAA compliant 837I, 837P and 837D transaction formats, as well as the NCPDP 4.2 prescription drug format. The system is named the Post-Adjudicated Claims and Encounters System (PACES). This system will eventually be involved in processing all Medicaid encounter data received by DHCS. Starting October 1, 2014, all HIPAA covered entities are required to use ICD 10 codes in reporting. PACES accepts ICD 10 codes. In addition, the system supports the Cal MediConnect Program. For more information about Cal MediConnect Program, please see the link below in Resources.

Impact

The Medi-Cal Managed Care Quality Management Division has created the Encounter Data Quality Unit (EDQU), as part of the overall Encounter Data Improvement Project. This unit will monitor encounters submitted by Medi-Cal health plans, with the objective of improving not only the quality of the data submitted, but ultimately the health and care of the Medi-Cal beneficiary population. By monitoring the encounter data, DHCS can work with plans to ensure that beneficiaries are receiving the proper care in a timely fashion. This will result in a healthier population. Implementing the PACES system is a significant step in receiving detailed and accurate data about healthcare in California.

Resources

Medi-Cal Managed Care Claims and Encounter Data Reporting

Dual Eligibles Coordinated Care Demonstration - Cal MediConnect

Last modified on: 6/20/2017 4:17 PM