裁决后的索赔和交涉系统
概述
卫生保健服务部 (DHCS) 负责收集和报告加州医疗补助 (Medi-Cal) 索赔和遭遇，无论它们是作为按服务收费还是合同管理医疗安排的一部分提交的。 DHCS 中的许多系统都支持此必需功能。
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 提取、转换和重新格式化以 ASC X12 837 和 NCPDP 格式提交的数据。 该系统目前支持 ASC X12 837I、837P 和 837D 索赔/遭遇交易以及 NCPDP 2.2 和 4.2 药房交易。
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 还支持 Cal MediConnect 演示，它是更大规模的协调护理计划的一部分。