Thursday, July 21, 2011

CMS Full Encounter Updates

CMS is currently holding technical assistance meetings for health plans across the country.  SCAN representatives attended the July session in San Diego the week of July 11.

A lot of issues remain up in the air, but we do know a few things.

  • CMS is holding fast on the subject of the 13 month timely filing.  Plans are given an additional month over the 12 month FFS timely filing to account for the submission from provider to plan to CMS.   There is discussion of filing benchmarks and we hope to know more about this after the final session ending the first week of August.
  • Plans cannot make material corrections to claims/encounters, this must be done by the provider of service.  For example, diagnosis codes, procedure codes and other fields involved in pricing the claim (e.g., addresses, modifiers) must be corrected by the provider.
  • Full 9 digit ZIP codes will be required on claims/encounters.
  • CMS has clarified that the only dental claims that will be required are those that are covered by fee-for-service Medicare.  This includes jaw reconstruction after an accident, and examinations (no treatment) prior to kidney transplants and some heart valve implants.  If the services are performed by a hospital based dentist (rare) then the submission must be on the 837 I, and if performed by a dentist in private practice, on the 837P.  No 837D (dental) claims will be accepted by CMS.
  • \CMS has no projected date for a draft of the CMS-HCC model with ICD-10 codes.  There was also no update about a move to the new 87 disease CMS-HCC model.
As we learn more from CMS about full encounter data requirements, we'll post it here.

Please let us know if there are any specific issues you'd like to see in this space.  You can leave us a comment, or email us at

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