EPS

Encounter Processing System

Encounter Processing Systems ingest encounter data (submissions and re-submissions) from MCOs and sends quality transaction feedback back to the plans to ensure appropriate industry standard format. The systems support the tracking of MCO submission requirements and allow the state to enforce consequences for non-compliance. The systems also support payment comparisons and cost of care analysis.

CMS-Required Outcomes (5)

Ref	Outcome	Sources
EPS1	The system ingests encounter data (submissions and re-submissions) from MCOs and sends quality transaction feedback back to the plans to ensure appropriate industry standard format. (Quality transaction checks include, but are not limited to: completeness, missing information, formatting, and the TR3 implementation guide business rules validations).	42 CFR 438.242
EPS2	The system ingests encounter data (submissions and re-submissions) from managed care entities in compliance with HIPAA security and privacy standards and performing quality checks for completeness and accuracy before submitting to CMS using standardized formatting, such as ASC X12N 837, NCPDP and the ASC X12N 835, as appropriate. (Quality checks include, but are not limited to completeness, character types, missing information, formatting, duplicates, and business rules validations, such as payment to dis-enrolled providers, etc.).	42 CFR 438.604
EPS3	The state includes submission requirements (timeliness, re-submissions, etc.), definitions, data specifications and standards, and consequences for non-compliance in its managed care contracts. The state enforces consequences for non-compliance.	42 CFR Part 438.3
EPS4	The state uses encounter data to calculate capitation rates and performs payment comparisons with FFS claims data.	42 CFR Part 438
EPS5	The state complies with federal reporting requirements.	42 CFR 438.818