Encounter and Claims Data

What is Encounter/Claims Data?

Encounter/Claims Data is defined as medical information submitted by health care providers (physicians, hospitals, Ancillaries, etc.) which documents both the clinical conditions, services and items delivered to the member to treat their conditions.  Preferred IPA is responsible for the timely gathering and processing of various encounter/claims data and submitting the data to the Health Plans. In turn, the Health Plans are responsible for submitting the data to the regulatory agencies (e.g., Department of Health Care Services). The regulatory agencies utilize the data to determine member payments to the Health Plans.

Best Practice for Providers:

  • Engage members at least twice a year for office visits.  Comprehensive Annual Wellness Visits are encouraged for each member and ensure accurate coding submission via electronic CMS-1500 layout (e.g., Office Ally EMR).
  • Timely submit all encounter/claims data within 30 days of date-of-service.
  • Provide future appointment card with date and time and conduct reminder call to members 1-3 days prior to the future appointment.
  • Ensure all HEDIS/Preventive services/screenings are completed.
  • Ensure medications are documented in the Medical Record and encourage members to switch to mail-order fill.
  • Document “no-shows” and engagement calls/mailings to members for office visits.
  • Document counseling/conversation on immunizations and capture in the medical record when members refuse to be immunized.