Process Encounter

• The State Medicaid Agency (SMA) adjudicates an encounter.
• If applicable, alert sent to submitter via ASC X12 TA1 Interchange Acknowledgment, 997 Functional Acknowledgment, 999 Implementation Acknowledgment, and/or the 824 Application Advice transaction(s) per Trading Partner Agreement (TPA).
• If applicable, alert sent to send to submitter via ASC X12 277 Health Care Information Status Notification for requesting additional information.
• If applicable, receive alert from receiver via ASC X12 TA1 Interchange Acknowledgment, 997 Functional Acknowledgment, 999 Implementation Acknowledgment, and/or the 824 Application Advice transaction(s) per Trading Partner Agreement (TPA).
• Alert sent to Prepare Provider Payment business process for capitation payment.
• If applicable, alert sent to Generate Financial Report business process with payment and/or error report information.
• If applicable, alert sent to send to Manage TPL Recovery business process for third-party insurance.
• Tracking information as needed for measuring performance and business activity monitoring.

• Receive Inbound Transaction
• Submit Electronic Attachment

• Send Outbound Transaction
• Calculate Spend-down Amount
• Generate Financial Report
• Submit Electronic Attachment
• Manage Data

• EDI Translator data store including ASC X12 Implementation Guide Validation Edits for Levels 1 through 7 encounter data store including payment, in-house encounter number, and Patient Account Number information
• Provider data store including performing prospective program Integrity (e.g., HIPDB) and Medicare/Medicaid sanctions information, provider network, and contract information
• Member data store including demographics, eligibility, enrollment, and member-specific pricing
• Plan data store including health benefit information (e.g., covered services, units, life-time limits, units and funding limits for authorized services, and benefit package-specific rates)
• Reference data store including filing deadlines, code set, drug formulary, and service code formulary. Additional information includes Diagnosis Related Group (DRG), Ambulatory Payment Classification (APC), and National Correct Coding Initiative (NCCI) information
• Authorization data store including authorization and treatment plan information
• Rate setting data store including applicable rates
• Encounter data store including adjudication and encounter payment history information
• Financial data store including accounts receivable and accounts payable information

All encounter claim types will go through most of the steps within the Process Encounter business process main flow with some variance of business rules and information. Types of counter variances include: Institutional, Professional, Dental, Pharmacy, and Waiver encounters; Medicare Crossover and Medicare Part D pharmacy encounters; and Coordination of Benefits (COB) encounters received from payers secondary to Medicaid (e.g., for IHS eligibles). The business rules will conform to federal and state-specific rules and pricing algorithms. Editing, auditing, and pricing variances could exist on services billed by encounter claim type, provider taxonomy code, service line codes, and the process may require additional information. An adjustment to an encounter follows the same business process path except that it requires a link to the previously submitted and processed encounter in order to reverse the original encounter and associate the original to the adjustment.

• Encounter submitted without all the required information.
• Encounter submitted after encounter filing deadline. Other Edit Failures: Encounter information has other errors. For example:
• The SMA does not cover the service because it is not in the health benefit, or is not in an approved facility or performed by an approved provider type.
• Service is not appropriate based on member demographics.