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Post-Adjudicated Claims and Encounters System

Overview

The Department of Health Care Services (DHCS) is mandated to collect and report on California Medicaid (Medi-Cal) claims and encounters, whether they be submitted as part of a fee-for-service or a contracted managed care arrangement. Many systems within DHCS support this required function.

 

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 extracts, transforms, and reformats encounter data that has been submitted in ASC X12 837 and NCPDP formats. The system currently supports the ASC X12 837I, 837P, and 837D claim/encounter transactions as well as the NCPDP 2.2 & 4.2 pharmacy transactions.

 

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.

 

PACES also supports the Cal MediConnect demonstration, which is part of the larger Coordinated Care Initiative.

Resources/Links

Last modified on: 2/22/2019 10:35 AM