​​​​​​​​​​​​​​​​​​​​​​​​​​​​DHCS Managed Care Data Quality Monitoring Frequently Asked Questions

1. We have been reporting mental health on our medical 274, including the flags for mental health areas of expertise. Are these going to be on a separate file now? 
   MCPs will continue submitting 274 files according to instructions in the 274 MCP Companion Guide. The Mental Health data referenced in the (CG) is related to mental health services offered by the MCP not the counties.  This includes the following two data elements:
   

• B.9 Mental Health Provider Area of Expertise Codes (2100EA N202)
  
• B.10 Mental Health Provider Practice Focus Codes (2100EA N202)​
  

2. ​Will there be new or revised 274 companion guide updates in the near future with regard to new APLs specific to new provider types such as Doula's and changes surrounding Nurse Practitioners who meet criteria for no longer requiring physician supervision and any other anticipated changes? 
   ​Companion Guide updates are made whenever new APLs and other changes require an update. When changes to Medicaid policy or HIPAA related regulations require changes in the way data is reported on an existing transaction, (such as the 274), the associated Companion Guide(s) will be updated to reflect those changes.
   

3. Does this new organization include oversight of Medi-Cal FFS data?  If so, what are the plans / timelines to move away from California’s local codes.  These codes continue to cause challenges within the Managed Care space? 
   This includes oversight of FFS data, however, the Provider Manual and other guidance found at the Medi-Cal site are not intended to provide coding or billing guidance to providers that are contracted to MCPs, or who submit claims to MCPs. Providers that are submitting FFS style claims to MCPs for payment are still​ required to use HIPAA Compliant, National Codes. Local codes are not allowed.
   

4. Sorry for repetition, but just to confirm MCPs will NOT need to submit a new, separate 274 for MH and will submit only a single 274 including both medical and MH providers? 
   ​County behavioral health services data are submitted separately by the counties, not the MCPs.
   

5. What is the most current version of the 274 companion guide?
   The most current version of the Medical/Physical 274 Provider Information companion guide is v. 2.2.
   The most current version of the Mental Health Companion Guide (CG) is v.1.7 (Please note, a new Behavioral Health CG will be published that includes both the Mental Health CG and the DMC-ODS CG. Version number and draft will be shared soon, TBD).​
   

6. When will be new 274 companion guide published? Like the information regarding some NP can practice without supervising physicians in the future, need update guidance how to report those NP on 274 without supervising physicians. 

   Typically, Companion Guides (CGs) are first published in DRAFT form and distributed to plans for review and input. Once that cycle has completed, the Final form of the CG is published to the DHCS Documentation Center (DDC).

   ​The companion guide for the Behavioral Health provider information transaction is being updated to include both Mental Health and DMC-ODS guidance. A DRAFT is in current review and will be shared with trading partner stakeholders for review within the next week or two.
   

7. Please confirm if QMED v2 still in the works? / Not 274 related, but Encounter data related.  Can we get an update on the status of QMED v2? 
   ​Yes, QMED v2 is still in the works.
   

8. Can you elaborate on "rectifying all warning messages"? So far, we did not have to do that. 
   ​Plans are required to address the warning messages and resubmit the file in case of any data discrepancy in the JSON file. If the plans do not identify any data issues in the specific metric, plans are required to just notify DHCS through email about the reason for the warning message.
   

9. Do we have to respond to the email even when plans have passed all the MDC data metrics?​
   ​Yes, we expect a response to the email, even if it's just an acknowledgement of receipt.
   

10. Can you let us know if e-consult only providers (who only communicate with other providers and not members) need to be included in the 274? 
    It will be updated as soon as we have a corresponding answer. Thank you for your patience.
    

11. Last month's 274 MDC covered periods prior to the most recent reporting month. Please advise if DHCS has changed from monthly reporting to cover earlier reporting periods.
    274 MDC reports cover data from the previous month, prior to the month of submission.
    

12. Can you please define QIMR? What is the go-live date for QIMR?
    QMIR is Quarterly Implementation Monitoring Report and QIMR is planned to "go live" during second half of 2024.
    

13. Current QIMR report (EXCEL) will be discontinued from Jan 2024?
    No. QIMR Excel report continues until all elements of the Excel report are converted to JSON format. 
    

1. For the Primary Care Physician Assignment (PCPA) file, is reporting for FQHCs done at the site level and not to a PCP?​ 
   The PCPA file uses data elements to report Primary Care Physician Assignments. Reporting is done at the provider level. There is no site level data element. 
   

2. We had proposed a list of potential new grievance types and benefit types to add to the existing list of grievance types currently in MCPD schema v3.02. We believe that these are distinct from existing grievance types and will help us to more accurately characterize our grievances and to improve the quality of our grievance reporting. When can we expect that these will be approved and available to use? 
   ​​​Grievances are being discussed and an update on the suggested new types will be shared soon.
   

3. Warnings in the MCPD and PCPA response files usually relate to membership issues which usually get sorted by the next submission. Under what circumstances would a plan need to resubmit the MCPD and PCPA data files with regards to Warning messages?
   During business edit validation, there may be instances where a warning message will be identified. Warning messages will not cause a file rejection and are intended as informational to the submitter identifying potential future issues that may become fully fledged errors in the future. DHCS asks that MCPs correct warnings and resubmit the file.
   

1. Does 274 go into PACES?
   Yes. All 274 files submitted to DHCS are processed by PACES.
   

2. What are the Health Care code sets? 
   Health Care code sets refers to those code sets (HCPCS, etc. that are required on X12 EDI and other transactions. Most code sets used on the 837 transactions are listed in an appendix found in the X12 5010 837 Implementation Guides.
   

3. We frequently see encounter data denial reasons which state "Only codes specified in code list 130 are allowed."  Is code list 130 publicly available? 
   Each X12 Implementation Guide publishes a list of Code lists referenced in the Guide or required in the transaction. Code List 130 is listed in Appendix A of the 837 Implementation Guides, which are available from X12.
   

• Code list 130 - Healthcare Common Procedural ​Coding System (HCPCS)
• AVAILABLE FROM: 
​Centers for Medicare & Medicaid Services 
7500 Security Boulevard
Baltimore, MD 21244​ 

4. ​​What is encounter data?
   ​​Encounter data is submitted on the X12 837 EDI transaction. Encounter data represents claim data that has already been adjudicated and paid. Encounter data is used in the Medical, Dental, and Behavioral Managed Care model.
   

5. ​Can we get guidance on the filtering used for the FQHC volumes so we can attempt to replicate for comparisons?
   Guidance has been disseminated to the associations and FQHC APM applicants. If you would like a copy, please reach out to the FQHCAPM@dhcs.ca.gov mailbox. 
   

6. ​Where can we find the current Companion Guides for the EDI transactions?

   Managed Care Encounter Companion Guides are posted to the DHCS Documentation Center, which is accessible to all DHCS Trading Partners upon request. Please send access requests to dataexchange@dhcs.ca.gov. Guides are available under different channels within the DHCS Documentation Center. 
   

7. As we know the Encounter Data requires National codes for claims billing.  In the DHCS website we can see notifications about cross-walking the Local codes to HIPAA Compliant National code, but when do you think this project will begin? We​ see there is a notice to Start the LTC in 2023, but there is not definitive date? Any insight for timelines for this project would be greatly appreciated. 
   

   The Notifications and guidance are intended for the audience of Fee-For-Service Providers that submit claims for payment directly to DHCS. DHCS is planning to clarify the guidance found on the Medi-Cal site, but it should be emphasized that providers submitting claims to Managed Care Plans should be using the HIPAA Compliant National Codes in all cases. Providers submitting claims to MCPs should ALWAYS use the HIPAA Compliant National Codes. ​

   The old FFS LTC form (LTC-25) is being retired. The new changes will be implemented in mid-2023 but the “go live” date for using the 837 and national codes has yet to be determined due to educational and training concerns regarding the present provider community. Tentative live dates include October 2023.
   

8. Is there a metadata/data dictionary we can be provided to use in hand with the 274 Companion Guide? 
   No. All business rules are identified in the 274 Companion Guide and the associated X12 274x109 Implementation Guide, available from X12. 
   

9. The claims data is now due 10 days after the COM? 
   ​No, it is not. The PACES system processes encounter data and provider network adequacy data. Encounter data should be submitted as soon as possible after the encounter, but there is no due date. Provider Network Adequacy data submissions reflect the status of any plan’s provider network within a given month. For this reason, Provider Network Adequacy data is expected to be submitted via the X12 274 transaction by the 10^th of each month. 
   

10. What is the URL for "Documentation Center"?
    ​Here is the launch page for the documentation center.  https://teams.microsoft.com/l/team/19%3aMTndJi9glI7WQS1AhqVyLh3AeBMf8syywgxG8KQ1Loo1%40thread.tacv2/conversations?groupId=3862053f-5e17-47be-9fd8-5bbe497e593a&tenantId=265c2dcd-2a6e-43aa-b2e8-26421a8c8526 ​
    

11. Is there limit on Number of staff members who can get access to DHCS Documentation Center (DDC)?
    ​There is no current limit on the amount of trading partner staff who can be granted access to the DHCS Documentation Center (DDC). If the number of accounts with access goes over the maximum upper limit of teams, the Department will consider a limit.​
    

1. What's a JSON file? 
   JSON files are a specific format used in transmitting data. 
   

2. I'm still unclear what SRF JSON is.  It might be helpful to spell out the acronym. 
   SRF = Submission Reconciliation File  
   JSON = JavaScript Object Notation
   SRF JSON = Submission Reconciliation File submitted in JSON format
   

3. DHCS sent a revised ECM-CS reporting template that will be effect​​ive in Nov for Q3 2023 data. Will they be replaced at the end of the year?
   More information is coming. Please stay tuned!
   

4. We have started submitting the ECM encounters, so will we have to submit the JSON file for the ECM in near future?
   Yes, MCPs will have to submit both the JSON file and encounters for ECM. 
   

5. Can you provide more details in regard to the ECM and CCM files that will be moving to a new JSON format? Which files will be replaced?
   More information is coming. Please stay tuned!

6. Can you specify what ECM / CS Reports will be built for JSON file? 
   More information is coming. Please stay tuned!
   

7. Is ECM/CS data (JSON) submission going to be monthly?
   Yes.
   

8. ​For the newly required Homeless flag being required for ECM/CS services, how is this data element supposed to be submitted for providers billing electronically via the 837 or via paper on the CMS 1500 form?
   It will be updated as soon as we have a corresponding answer. Thank you for your patience.​
   

9. ​JSON file be separate from MCPD file?
   Yes, it will be separate. 
   

10. ​Are there any plans of changing the 274 file format to JSON?
    The 274 file format is the proprietary delimited text file designed and owned by the X12 organization. X12 is the Standards Development Organization named in the HIPAA laws as the developer of file formats for Electronic Data Interchange. The 274 file is designed using the same format as the X12 837 Claim/Encounter file, the 835 payment remittance advice file, the 834 member enrollment file, and other transactions mandated for use in healthcare data exchange. There are no current plans to change the 274 file format to JSON.  But it will expand.
    

11. When can the plans expect to have the ECM/CS/CCM separate Companion Guide? Will an early draft of the ECM/CS/CCM companion guide be available for comments?
    More information is coming. Please stay tuned!
    

12. ​What email do we use to ensure we are on the distribution list of receiving these ECM/CS JSON notifications?
    These notifications will be sent out to MCPs using our existing email list serve that we have internally. 
    

1. ​ Has DHCS asked for the contacts (up to four) already been sent to MHP/DMC-ODS Counties? 
   DHCS has been asking for MHP and DMC/ODS contacts through the monthly 274 County Workgroup meetings.  The goal is to have four county contact per plan type (e.g., MHP versus DMC-ODS).  DHCS has not sent out a request yet for only four contacts.  We are using the list of contacts currently submitted by the counties.
   

2. Will you be expecting a separate 274 for each category? One for behavioral health, one for drugs and one for dental? Or one to include them all? 
   DHCS requires separate 274 EDI submissions for Medical, Dental and Behavioral Health managed care delivery models.
   

3. MHP and DMC-ODS will have separate 274 submissions? Or is it going to be one submission? 
   Separate 274 EDI submissions will be required for MHP and DMC-ODS submissions.  The Behavioral Health 274 Companion Guide will provide instructions for submitting MHP and DMC-ODS submissions.  The EDI file name and Health Care Plan (HCP) code will distinguish the plan type.   
   

4. For 274 BH, is the expectation that MCPs will send a separate 274 that only includes their BH network in additional to their current 274 submission? 
   DHCS will continue to have separate 274 EDI submissions for County Behavioral Health Managed Care Plans (MHP and DMC-ODS).
   

5. Does that mean the current way of submitting MHP 274 (X12 EDI format) will be replaced by JSON going forward? 
   

   The 274 is not being replaced with a JSON format. The X12 4050 274x109 is formatted in the proprietary and HIPAA mandated Electronic Data Interchange (EDI) format, which is developed and maintained by the X12 organization. 

   The MS Excel based Provider Data Submission Reconciliation File (PDSRF) may be replaced by a similar file utilizing JSON format. This replacement file is referred to as the “Submission Reconciliation File (SRF)".  The transition of the PDSRF to JSON format has not occurred yet.​
   

6. We have separate 274 for SUD/(substance abuse) and Mental health then is what you are saying? 
   DHCS is planning to have separate 274 EDI file submissions for Mental Health Plans and Drug Medi-Cal Organized Delivery Systems.
   

7. Is there any update on when the DMC-ODS 274 companion guide will be available? Can you please advise where the draft guide can be found? 
   ​The Draft Guide is already available for the DMC-ODS 274. It can be found on the 274 Expansion Website; it is Version 2 of the Original Guide.​
   

8. Outside of the 274 mailboxes, how are counties to identify their respective liaison? 
   Liaison not assigned yet because not in production.  All county support will be in workgroup led by Sara Rivera, until the counties are in production status.
   

9. With turnover happening in counties, how do counties find out current contacts of DHCS, update current county contacts (find out who is currently on file with DHCS as a contact and liaison)? 
   Any questions related to the county 274 Expansion Project should be sent to 274Expansion@dhcs.ca.gov. We also have a mailbox for Network Adequacy related questions: NAOS@dhcs.ca.gov.
   

1. Will Short-Doyle data be pulled daily from the SDMC claim system, or are MHP's supposed to submit different data on a daily basis? 
   MHPs can submit specialty mental health claims to Short Doyle on a daily basis. Typically, though, MHPs may submit claim files 1-3 times per month.
   

2. Is the limit of four (4) contacts per county only related to data quality or is that across the board?  For example, we have four or five people contacting MedCCC for claim question, a couple of people asking about technical, others asking about reporting, etc.  Will we have to change how we triage/assign asking questions? 
   Is the reference to 4 contacts about the number of ‘owners’ for Short Doyle? (2 for SMHS, 2 for DMC) Owners approve and delete data users for a county. 
   ​For MEDCCC, there is no restrictions to the number of county staff that can submit questions. 
   

3. Are there new mental health codes that we will need to use? Are there old codes that will be expired? If so, will these old codes be expired for providers, or will these need to be cross walked like the local codes?
   ​Beginning 7/1/23, under CalAIM​, DHCS is transitioning to CPT codes for behavioral health claiming in Short Doyle. Counties can obtain a listing of CPT and HCPCS codes and claiming rules in the Specialty Mental Health Services and Drug Medi-Cal Billing Manuals posted on the MEDCCC Library. Additional claiming resources are also found on the MEDCCC page.
   

Others

1. Will you be sharing the methodology that you have used to calculate match rates? Will you also provide guidance on how those #s can be improved? 
   ​​​DHCS has provided the matching methodology to FQHCs and MCPs. If you need a copy, please email FQHCAPM@dhcs.ca.gov. DHCS is working to identify the causes behind low match rates within the applicants for the APM. We will be providing guidance on our findings and how we would recommend FQHCS and MCPs work together to improve the data.​