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Provider Manual

Encounter Data Policy

Last Updated on August 28, 2018

Security Health Plan shall comply with the reporting requirements in §422.516 and the requirements in §422.310 for submitting data to CMS as set forth below. 42 CFR §422.504(a)(8).

Certification of data that determine payment requirements – As a condition for receiving a related monthly payment from CMS, Security Health Plan agrees that its chief executive officer (CEO), chief financial officer (CFO), or a designee who reports directly to such officer, must request payment under the contract on a document that attests to (based on best knowledge, information and belief, as of the date specified on the certification form) the accuracy, completeness, and truthfulness of relevant data that CMS requests. Such data include specified enrollment/disenrollment information, changes in benefit packages, and other information that CMS may specify.

The CEO, CFO, or a designee who reports directly to such officer, must attest to the fact that each enrollee for whom Security Health Plan is requesting payment is validly enrolled in a Medicare Advantage plan offered by Security Health Plan, and the information relied upon by CMS in determining payment (based on best knowledge, information, and belief as of the date specified on the attestation form) is accurate, complete, and truthful.

The CEO, CFO, or a designee who reports directly to such officer, must attest (based on best knowledge, information and belief, as of the date specified on the attestation form) that the data he/she submits are accurate, complete, and truthful. If such data are generated by a related entity, contractor, or subcontractor of Security Health Plan, such entity, contractor, or subcontractor must similarly attest to (based on best knowledge, information, and belief, as of the date specified on the attestation form) the accuracy, completeness, and truthfulness of the data.

The CEO, CFO, or a designee who reports directly to such officer, must attest (based on best knowledge, information and belief, as of the date specified on the attestation form) that the information in the bid submission is accurate, complete, and truthful and fully conforms to the bid proposal requirements.

This attestation requirement is applicable to all Security Health Plan contractors, including those that are nonrenewing or terminating their contracts.

Encounter Data

Data collection: Basic rule - Security Health Plan must submit to CMS (in accordance with CMS instructions) the data necessary to characterize the context and purposes of each service provided to a Medicare enrollee  by a provider, supplier, physician, or other practitioner. CMS may also collect data necessary to characterize the functional limitations of enrollees of Security Health Plan.

Sources and extent of data

  • To the extent required by CMS, risk adjustment data must account for services covered under the original Medicare program, for Medicare covered services for which Medicare is not the primary payer, or for other additional or supplemental benefits that the MA organization may provide.
  • The data must account separately for each provider, supplier, physician, or other practitioner that would be permitted to bill separately under the original Medicare program, even if they participate jointly in the same service.

Other data requirements

  • Security Health Plan must submit data that conform to the requirements for equivalent data for Medicare fee-for-service when appropriate, and to all relevant national standards. Alternatively, Security Health Plan may submit data according to an abbreviated format, as specified by CMS.
  • The data must be submitted electronically to the appropriate CMS contractor.
  • Security Health Plan must obtain the risk adjustment data required by CMS from the provider, supplier, physician, or other practitioner that furnished the services.
  • Security Health Plan may include in its contracts with providers, suppliers, physicians, and other  practitioners, provisions that require submission of complete and accurate risk adjustment data as required by CMS. These provisions may include financial penalties for failure to submit complete data.

Validation of risk adjustment data - Security Health Plan and its providers and practitioners will be required to submit a sample of medical records for the validation of risk adjustment data, as required by CMS. There may be penalties for submission of false data.

Use of data - CMS uses the data obtained under this section to determine the risk adjustment factor used to adjust payments, as required under §422.304(a)(1), (a)(2), and (a)(3). CMS may also use the data for other purposes except for medical records data.

Deadlines for submission of risk adjustment data - Risk adjustment factors for each payment year are based on risk adjustment data submitted for services furnished during the 12-month period before the payment year that is specified by CMS. As determined by CMS, this 12-month period may include a 6-month data lag that may be changed or eliminated as appropriate.

The annual deadline for risk adjustment data submission is the first Friday in September for risk  adjustment data reflecting services furnished during the 12-month period ending the prior June 30, and the first Friday in March for data reflecting services furnished during the 12-month period ending the prior December 31.

CMS allows a reconciliation process to account for late data submissions. CMS continues to accept risk adjustment data submitted after the March deadline until December 31 of the payment year. After the payment year is completed, CMS recalculates the risk factors for affected individuals to determine if adjustments to payments are necessary. Risk adjustment data that are received after the annual December 31 late data submission deadline will not be accepted for the purposes of reconciliation.