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5010 Encounter Data

Encounter data sent to CMS continues to drive the risk scores for MAO members and therefore the capitation they pay. In order for Cognisight to submit encounter data, it will have to be in the 5010 format and pass all CMS edits. CMS is also requiring Health Plans to submit encounter data for all services provided to members, not just those previously required for RAPS, by January 3, 2012. Because of the CMS mandate, Cognisight will create and send 5010 Encounter Data so that CMS can appropriately capture the risk scores of your members.

From a broader perspective, if the overall Encounter Data submitted is incomplete, CMS will not have an accurate picture of the range and intensity of services provided to MA members, which could lead to a reduction in reimbursement across the industry. Lastly, failure to submit accurate, complete data in the required format prevents us from storing and utilizing the data, which can impact member quality of care and your quality scores.

In preparation of Encounter Data 2012, Cognisight has completed the following:

  1. Constructed a core user group for identifying the necessary steps to become compliant by January 3, 2012.
  2. Identified a 3rd party EDI solution provider for handling Encounter Data translation.
  3. Hosted multiple online WebEx presentations for educating our clients on Encounter Data process and expectations.

    Note: To download a presentation; click on either of the links above.

  4. Attended multiple trade shows and educational seminars in preparation of Encounter Data compliance
  5. Continued Participation in CMS industry updates and by-weekly user group sessions.
  6. Begun the implementation of our complete Encounter Data Processing System. Click here to learn more.


Implementation Timline

  Cognisight CMS
Front End Testing NA 9/6/2011 1/3/12
End to End Testing 1/4/12 1/4/12
  Sequence:
Professional encounters
Institutional encounters
DME encounters
EDS Rollout 1/3/12 1/3/12
Profesional Certification NA 1/4/12-3/1/12
Institutional Certification NA 2/1/12-4/2/12
DEM Certification NA 5/7/12-7/2/12
Enforcement Discretion for Compliance NA March 31, 2012 (read more)
*RAPS Sunset 2014 2014

* CMS has indicated that both Benchmarking and Risk Score calculations will be completely driven by EDPS by March 2014. Information subject to change based on EDPS Participant Guide.

For more information on Encounter Data please email us at: EDPS@cognisight.com