Comprehensive Medical and Dental Programv

Encounters

Statement/Purpose

DCS Comprehensive Health Plan (DCS CHP) utilizes encounter data to measure the quality of health utilization and to verify that members are receiving quality healthcare services.

Definitions

Encounter:record of medically related services rendered by a registered AHCCCS provider to an AHCCCS member enrolled with CHP on the date services were rendered.

Managed Care Organization (MCO): A health plan which is focused on quality care while maximizing fiscal efficiencies to reduce healthcare costs.

Policy

DCS CHP follows requirements established by the Centers for Medicare and Medicaid Services (CMS) for mandatory encounter submissions from its contracted Managed Care Organization (MCO) to AHCCCS.

Health Insurance Portability and Accountability Act (HIPAA) complaint transmissions of encounters occur at least one time each month from DCS CHP’s contracted MCO to AHCCCS.

DCS CHP’s contracted MCO follows commercial insurance companies, Medicare, and AHCCCS guidelines for submitted individual encounters and health insurance industry billing standards. Some requirements are specific to the AHCCCS program.

Procedure

Schedule and File Processing

DCS CHP oversees its contracted MCO who follows AHCCCS guidelines as stated in the AHCCCS Encounter Manual for timely encounter submissions.

Encounter Measurements

Each month after the Pended Aging Report is complete, the DCS CHP Claims and Encounter Oversight Manager reviews the report as an oversight activity of the contracted MCO. Any questions and concerns are submitted to the contracted MCO through the DCS CHP Compliance Unit.