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.
When will the EDQ report cards be updated to exclude Rx data?
Rx data will be excluded with the next version of QMED, which is planned for update before year end.
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.
What do you define as duplicate encounters?
Encounters are evaluated for duplicates at the service line level. If a service line is found to be a duplicate of a previously submitted service line, the entire encounter is denied.
Could you please give an example of duplicates?
A duplicate encounter/service line represents the same event as a previously submitted encounter. The PACES encounter system has duplicate logic which looks at a number of data elements to determine whether an encounter has been previously submitted. If the data elements match a previous encounter, it is denied as a duplicate. Section 3.8 of the DHCS Encounter Data Companion Guides provide details of duplicate encounters. You can download the Companion Guides from the DHCS Documentation Center. For permission to access the Doc Center please send a request to
DataExchange@dhcs.ca.gov.
Does this information apply to all types of claims, specifically, Behavioral Health claims?
Since BH claims are processed by the Short Doyle system, the logic discussed here does not apply to BH claims at this time. The Companion Guides posted to the BHIS folders are the ones to reference regarding BH claims.
Non-BH claims and non-pharmacy claims and encounter data are submitted to PACES as encounter data files. The duplicate encounters information pertains directly to these claims and encounters.
If we have questions about specific scenarios and/or
examples,who is the best person to contact?
Please send an email to Data Quality Reporting Unit
MMCDEncounterData@dhcs.ca.gov
Can you provide a list of those procedure codes that can very well be duplicates, when, for example, a procedure is applied to each eye, ear, etc separately?
We cannot provide a list of codes as requested. However, when an encounter utilizes the same type of procedure in multiple services, duplicates can be avoided by the use of procedure modifiers, such as 59, 76, and 77. But adding modifiers to the encounter, this signals the PACES system to bypass the duplicate logic and treat the encounter/service line as a unique event and not a duplicate of a previous encounter. See Section 3.8 of the DHCS Companion Guides
Have there been any discussions about NOT counting void transactions towards timeliness measures?
No, we have not had that discussion. We need the voids to ensure encounters are being completed. Will bring up the discussion to weight on pros and cons. Will provide update once that discussion has been had.
If we have to send a void and replacement, can DHCS consider penalizing plans on timeliness for one of those encounters rather than both?
QMED DRMT.001 scores Plans on the turnaround time between when an original encounter is denied and when a replacement/void is accepted. If you have to send a replacement and a void, QMED will score you on the first one that is accepted. As long as your timeliness is good, then QMED will not drop your score. See QMED v1.1, Section 4.1 DRMT.001 for details on denied encounters turnaround time.
Plans are required to submit large volume of replacement encounters related to Target Rate Increase adjustments by the end of this year. Will DHCS consider to waive timeliness penalty on these replacement encounters?
We will discuss with management and PACES team to determine what to do about that. Don't believe that is the case but will verify with management.
Isn't the algorithm for excluding replacement encounters part of QMED v2?
We will let you all know when QMED 2.0 is finalized.
Can DHCS share the documentation/publication regarding data privacy and offshoring. The link provided doesn't take you directly to the law/guidance/publication.
Link will be shared from your contact manager.
Are there any biggest areas of opportunity to improve data quality for encounters? A certain data field or error type?
We are currently performing analysis on areas of opportunity to improve data quality. More coordination and communication with Plans to come on that.
Are transportation encounters required for PACE?
Yes, PACE plans are to submit encounter data anytime they provide any service to any of their participants.
One consideration for PACE programs, in terms of dual PACE members we are currently working to fully submit all encounters for all aspects of care, medical, dental, specialist, day center, IDT disciplines, transportation, etc to both CMS and DHCS. We are approaching full duplication of encounter data reporting to both entities CMS and DHCS. Is there any plans to minimize the duplication of encounter data reporting for those dual members?
This issue will be reviewed as part of the Encounter Data Improvement Project.
Are Plans required to send denied encounters in their submissions?
a) To clarify – the term “denied claims/encounters" refers to claims that have been submitted by the provider to the plan but have been denied
payment or
acceptance by the plan.
b) For encounters submitted by the Plan but denied by DHCS, please refer to the DHCS-PACES 837I, 837D, and 837P Companion Guides, particularly Section 3.4. These guides contain instructions for submitting encounter files, including distinctions between
denied,
rejected, and
accepted encounters.
Denied
encounters must be corrected and resubmitted to the DHCS PACES system.
What measure will be used for paid amounts? Some submitters are reluctant to share paid amounts, can MCPs require this?
Capitated Plans (Contract Type = 5) must submit the required information as outlined in the Encounter Companion Guides, specifically Sections 3.18 – 3.29. As the Medicaid payer, DHCS is authorized to require the submission of paid amounts for any Medicaid service provided, whether through Capitation or direct payment to contracted providers by a Managed Care Plan.
Can a single provider have multiple provider types? Does DHCS monitor each provider type individually?
Yes, a single provider may have multiple provider types. To clarify, DHCS distinguishes between Type 1 (individual rendering providers) and Type 2 (organizational providers).
Are there targeted resources or training materials available for encounter submission quality?
Yes, there are several resources available for Encounter Data Submission:
Can a user guide or FAQ be made for local codes and state/federal requirements?
The current Medi-Cal Billing Guide, developed for the older FFS claim payment system, includes instructions for local code submission. However, DHCS' Managed Care program discourages the use of local codes in claim submissions. DHCS has provided a crosswalk for MCPs to map local codes to national HIPAA-compliant codes for encounter data processing. DHCS is also working on providing more specific guidance to help providers transition to national codes.
Why can't denied claims be accepted through encounters, and do they create duplicates?
DHCS is working to address the challenges related to collecting denied claims. Trading partners will be asked to share both the originally submitted but subsequently denied claim/encounter files and any plan-issued response files.
Will DHCS require a new field on claims to identify denied or 0 paid claims?
DHCS recognizes the challenges involved in submitting denied claims to an adjudicating system. Although no final decisions have been made, DHCS is designing a methodology for submitting denied claims to PACES. This methodology will consider claims that have been adjudicated prior to submission to DHCS.
Can DHCS clarify the differences between instructions in the Medi-Cal billing Manual and Encounter Data Companion Guides?
For managed care capitated encounters, plans and providers should refer to the PACES 837 Companion Guides. The Medi-Cal Billing Manual is intended for the Fee- For- Service (FFS) claims payment system and is not applicable to encounter submissions. Plan-contracted providers must rely on the DHCS-PACES 837 Encounter Data Companion Guides, not the Medi-Cal Billing Manual, when preparing claims and encounters for submission.
Can the Companion Guide provide additional guidance on institutional claims, such as type of bill and discharge dates?
DHCS is working to update the Companion Guides to include more specific coding and other documentation, such as revenue codes, type of bill codes, and LTC/PACE-specific coding. These updates will be posted to the DHCS Documentation Center and subsequently on the DHCS website.
Regarding Local Codes and Revenue Codes,
MCPs have been advised to use national codes, but the Medi-Cal fee schedule still lists local codes. What progress has been made?
Plans should use revenue codes in place of local codes. If a revenue code is listed in the MCP Local Code Crosswalk, it indicates that no procedure code can be mapped to the local code. For further information on local to national code transitions, please refer to the following documents:
Are there specific types of services or encounters with volume concerns?
There
is a concern around the number of encounters submitted with Contract Type Code
= 09, or other (2 million encounters for May 2025). It is recommended that Capitated
Plans should not submit encounters to DHCS PACES with Contract Type Code = 09.
In April 2025 and May 2025, it was discovered over 2 million encounters were
submitted with this contract type.
What
is the proper use of Contract Type Code 09?
In ASC X12N 837 formats, Contract Type codes are used in the CN1 segment to
identify the type of contract under which services are being provided. Please refer to Section 3.18 in Companion
Guide - Payment Information for the common contract type codes.
Data Submitters are required to provide actual payment information using the
established structure in the 837P. The type of arrangement used to pay the
encounter must be described in the CN1 segment in the 2300 loop – CN101
Contract Type Code. When the encounter has been paid on a fee-for-service
basis, CN102 is populated with the amount paid. DHCS requires that 2300 CN1 be provided
and requests the 2400 CN1 segment to be included. Any payments made to other
health insurance carriers must be included in the relevant coordination of
benefits segments.
- Are local codes allowed when the contract code is 05?
Local codes are not permitted in encounter submissions from Managed Care Plans (MCP), regardless of contract type. All MCP encounters must comply with 837 transaction requirements and use national codes exclusively.
Local codes are applied to Providers who are purely Fee for Service and not in the network of a Managed Care Plan. Providers enrolled with MCPs must submit national codes to the plan.
Will
there be a draft All Plan Letter (APL) review period for the plans?
A
draft APL review period is planned for September 2025.
Who
should be contacted for PACE-related duplicate rejections?
For validation error codes produced in the Validation Response File, please contact DataQualityReportingUnit@dhcs.ca.gov
For PACE-specific questions, contact your DHCS contract manager or PACECompliance@dhcs.ca.gov
We are getting local codes the DHCS has stated are allowed. However, if we submit local codes to DHCS they will deny.
DHCS PACES is a post-adjudicated system which differs from CA-MMIS (fee-for-service) in which Providers submit encounter claims to CA-MMIS for re-imbursements from the State. Local codes only apply to FFS claims that go through the CA-MMIS system. We appreciate the feedback and will address in a separate webinar.
Please note: providers who are exclusively Fee for Service, may only submit local codes to CA-MMIS. Any Provider who is sending encounter claims to a Managed Care Plan with local codes should deny that encounter claim and have the Provider submit the encounter claims using national codes for the Managed Care Plan to review. DHCS rolled out capitated arrangements with plans to ensure the Managed Care Plans will collect encounter records in accordance with 837 X12 transaction requirements.
If you have any further questions regarding local codes, please contact DataQualityReportingUnit@dhcs.ca.gov
Additional Information and Resources
DHCS Documentation Center (DDC): Companion Guides and reference materials for Post Adjudicated Claims & Encounters System (PACES), Capitation Payment Management System (CAPMAN), Managed Care Program Data (MCPD), and Primary Care Provider Assignment (PCPA) are available.
Access requests for the DDC can be submitted to dataexchange@dhcs.ca.gov
PACES handles 837 and 274 files. CAPMAN covers 820 and 834 files. MCPD and PCPA JSON guides are stored in dedicated folders within the DDC.
For capitated plans, the valid Contract Type Codes in CN101 are 01, 02, 03, 04, or 06, representing the amount paid by the plan under the contract with Medi-Cal. This amount corresponds to the AMT*D value for payers designated with SBR09 = “MC." Contract Type Code 09 (Other) shall not be used for capitated arrangements.
Is
there an anticipated timeline for the phases?
Please
refer to previous webinar presentations regarding the Encounter Data Quality
Improvement Efforts. Incorporating PACE Organizations will likely be no sooner
than 2027.
For
timeliness, if an original record is accepted then later voided in the same
quarter, will the original record be included as part of the timeliness
calculation?
No,
the submission lagtime will only include original encounters where in Loop
2300, CLM05-3, Claim Frequency Code is 1 (original submission) and the
encounter is accepted. Situations such as the above, the encounter would
not be an original but would be denoted as a void. Please refer to Sections
2.4, 3.3, and Appendix B in the DHCS Companion Guides for 837 I/P/D transaction
types in the DHCS Documentation Center.
Any chance provider documentation for Medi-Cal can be updated to align with the new timeliness requirements? Current statement in manual: Timelines for Claims Six-Month Billing Limit: “Original (or initial) Medi-Cal claims must be received by Medi-Cal within six months following the month in which services were rendered."
This is referring to the FFS Provider Manual. This resource should not be a source for Medical Managed Care Plans with capitated arrangements.
When
will the QMED 2.0 Technical Guide be shared with plans?
Targeting
2026
Why
are some states tagged as 1 and others as 2?
This
screenshot is from the CMS OBA outcomes. Please visit https://www.medicaid.gov/medicaid/data-systems/macbis/transformed-medicaid-statistical-information-system-t-msis
for where the screenshot was sourced.
Per this site, 1 denotes Critical Outcome Based Assessment (OBA) priorities and
2 denotes High Priority.
Please also visit https://www.medicaid.gov/state-overviews/scorecard/measure/T-MSIS-Data-Quality-Outcomes-Based-Assessment?measure=FS.11&measureView=state&stratification=534&dataView=pointInTime&chart=map&timePeriods=%5B%222024%22%5D
for detailed information on the analysis.
Not
all providers are contracted so how do we force them to submit more
timely?
From
Data Quality Branch perspective, all Medical Managed Care Plans with a
capitated arrangement should have Providers enrolled that see only Medi-Cal
members. The 2024 Managed Care Plan Boilerplate contract (https://www.dhcs.ca.gov/provgovpart/Documents/2024-Managed-Care-Boilerplate-Contract.pdf
) lists specific requirements Managed Care Plans need to ensure in their
policies and procedures that Providers and other downstream contracted parties
have the DHCS specific requirements in these contracts (Exhibit A, Attachment
III; Section 2.1.2; Section 2.1.4; Exhibit J) .
Are
FFS Medi-Cal transactions sent to CMS? If so, won't these
requirements apply across the board?
Fee for Service Medi-Cal Providers enrolled in PAVE are reimbursed differently than Providers enrolled in Medical Managed Care Plans as part of its network of providers.
- FFS Providers who submit claims directly to CA-MMIS reflect encounters for members that are NOT members of Medical Managed Care Plans. These Providers receive reimbursement from CA State Controller's Office
- Providers who are enrolled in a Medical Managed Care Plan's network and listed as an active Provider in its 274 Network Provider file receive reimbursement from the Medical Managed Care Plan (depending on the Contract Type the Managed Care Plan has with the Provider) for services rendered to Medi-Cal member beneficiaries. These are also capitated managed care plans who receive a capitated payment from DHCS based on pre-defined rates.
- Please refer to these previous webinar presentations for details: February, June, August, and September 2025.
How
do we fix Local Codes issues?
Please refer to the below APLs that pertain to this question. As of 2015, Local Codes are not accepted by DHCS Post-Adjudicated Claims and Encounters System as DHCS adopted the National Standard Transaction format per guidance from CMS. Please visit https://www.dhcs.ca.gov/formsandpubs/Pages/MgdCareAPLPLSubjectListing.aspx for a list of all DHCS All Plan Letters (APL) by topic.
- https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2014/APL14-009.pdf
- https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2014/APL14-020.pdf
- https://www.dhcs.ca.gov/formsandpubs/Documents/MMCDAPLsandPolicyLetters/APL2014/APL14-019.pdf
- https://www.cms.gov/priorities/key-initiatives/burden-reduction/administrative-simplification/hipaa/adopted-standards-operating-rules
Could
you clarify the types of encounters that cannot be corrected?
Please
review the webinar presentation https://www.dhcs.ca.gov/dataandstats/Documents/August-2025-Webinar-Presentation.pdf.
DHCS Documentation Center has resources Plans are expected to use, such as the
837 Companion Guides which inform, in detail, the encounters that are not able
to be corrected. Specific documents to be referenced include
- “Addenda – PACES Custom Error Messages v1.9",
- “MMC-837P-Professional Encounter PACES Companion Guide v3.7 – Appendix B",
- “MMC-837I-Institutional Encounter PACES Companion Guide v3.9 – Appendix B", and
- “MMC-837D-Dental Encounter PACES Companion Guide v2.3 – Appendix B"
