Sistema de Reclamaciones y Encuentros Post-Adjudicados
Visión general
El Department of Health Care Services (DHCS)) tiene el mandato de recopilar e informar sobre California reclamaciones y encuentros de Medicaid (Medi-Cal), ya sea que se presenten como parte de una tarifa por servicio o un acuerdo de atención administrada contratado. Muchos sistemas dentro de DHCS soportan esta función requerida.
One such system is the Post Adjudicated Claims & Encounters System (PACES). PACES plays a vital role in the collection of encounter and provider network data from Medi-Cal’s numerous managed care plans. PACES accepts encounter transactions from both medical and dental managed care plans and also accepts encounter-related pharmacy transactions. The information PACES gathers is stored in the DHCS data warehouse (MIS/DSS), where it can be used by many downstream applications within the State.
PACES extrae, transforma y vuelve a formatear los datos de encuentro que se han enviado en formatos ASC X12 837 y NCPDP. Actualmente, el sistema admite las transacciones de reclamo/encuentro ASC X12 837I, 837P y 837D, así como las transacciones de farmacia NCPDP 2.2 y 4.2.
PACES replaces the long-standing DHCS Paid Claims and Encounters (PCES) system. The new system is designed to ensure that all available claim and encounter data is retained and available for downstream analysis. The PACES system stores and distributes a richer, more complete data set than was possible using PCES. The goal of PACES is to enforce DHCS’s data quality requirements while also abiding by federal HIPAA transaction standards.
Various DHCS program areas, such as the Encounter Data Quality Unit (EDQU), use PACES’s reporting capabilities in order to analyze encounter data on a regular basis. This heightened ability to monitor managed care and other encounters supports DHCS initiatives that strive to improve the overall health, and health coverage, of Californians.
PACE también apoya la demostración de Cal MediConnect , que es parte de la Iniciativa de Atención Coordinada más amplia.