Background

In accordance with federal regulations, DHCS contractually requires that Medi-Cal Managed Care Plans (MCPs) submit to DHCS complete, accurate, and timely encounter data for services provided to enrolled beneficiaries. Prior to November 2014, MCPs traditionally met their contractual requirement to submit encounter data to DHCS utilizing a variety of proprietary and standard formats. After November 1, 2014, DHCS implemented a new system to receive and process encounter data in the national standard transactions, ASC X12 837 5010 and NCPDP. This new system was implemented to meet state and federal Medicaid monitoring and reporting requirements and to accommodate receipt of ICD10 Diagnosis Codes in accordance with HIPAA requirements.

Effective January 1, 2015, DHCS, in support of its ongoing encounter data quality improvement initiatives, only accepts national standard file formats and coding schemes for managed care encounter data submissions. By May 2015, all MCPs had transitioned from the previous proprietary formats to production encounter data submissions in the national standard formats. 

Quality Measures for Encounter Data

DHCS measures the quality of the Medi-Cal managed care encounter data for completeness, accuracy, reasonability, and timeliness using the most recently published version of the Quality Measures for Encounter Data (QMED) document. The measure results are calculated, reported to the MCPs, and are used to drive data quality improvement efforts. Please refer to APL 26-003, Quality Measures for Encounter Data and the QMED Document, Quality Measures for Encounter Data, Version 2.0, for specific performance measures DHCS uses to assess the quality of submitted encounter data.

Quality Measures for Encounter Data (QMED) 2.0 Dashboard

To learn how to navigate and understand the features of this dashboard, please see the User Guide.

Encounter Data File Submission Formatting Requirements

ASC X12 Transaction Guidance

Health Insurance Portability and Accountability Act (HIPAA) of 1996 (HIPAA Compliant) resources pertaining to the ASC X12 data exchange transaction requirements for submitting encounter data to DHCS Post-Adjudicated Claims and Encounters System (PACES).

• ASC X12 Encounter Data Implementation Guides – X12.org Implementation Guides. Access to documentation requires membership with X12
• ASC X12 EDI Examples (X12 Electronic Data Interchange) – Examples for submitting 837 electronic data transaction files