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Encounter and Risk Adjustment Program (Part C)
Encounter and Risk Adjustment Program (Part C)~FAQs
Encounter and Risk Adjustment Program (Part C)
Encounter Data Submission and Processing Guide
Training - Nov. 28 2018
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When will an accepted encounter diagnosis not display on the MAO-004 Report?
Since the transition to the new MBI on April 2, 2018, can MAOs and other entities submit deletions for dates of service (DOS) before April 2, 2018 using the HICN?
How should MAOs report annual wellness visits to CMS?
If an MAO or other entity voids an accepted encounter containing rejected lines, and then submits a new, original encounter containing only the previously rejected (now corrected) lines, will the data submitted on the voided encounter be lost?
How should an MAO submit a linked chart review delete record that has an E code requiring deletion, where the E code is in the primary diagnosis position?
How does the MAO-004 report include diagnosis codes from both the original and replacement EDRs that are risk eligible?
When deleting EDPS data, should plans use the same beneficiary identifiers (i.e. HICN or MBI) used to submit the original data?
Are chart review records with default procedure codes and default NPI eligible for risk adjustment?
Will the updates to the Health Insurance Claim Number (HICN) and social security number (SSN) fields for the 2020 MORs also apply to the 2019 MORs?
Can MAOs and other entities submit End Stage Renal Disease (ESRD) information on behalf of dialysis centers?
Where can MAOs and other entities access the Risk Adjustment for EDS & RAPS User Group materials?
Where can we find guidance on how CMS implemented the MBI initiative for RAPS and EDS?
Can CMS clarify the logic for EDPS error 01405 - Sanctioned Providers?
How are encounter data submissions incorporated into risk score calculations?
Should MAOs and other entities submit subsequent replacement encounters using the ICN of the original encounter or the ICN of the previous replacement encounter?
Does CMS use diagnosis codes submitted via an unlinked chart review for Risk Adjustment payments?
Why do some diagnoses appear on the MAO-004 reports showing as accepted and allowed, but do not appear on the 2019 Initial payment MOR?
What is the process to request a copy of a previously generated MAO-004 Report?
When will the updated mappings for the 2020 CMS -HCC model be posted on the CMS website?
Should MAOs and other entities submit denied claims for processing?
What connectivity options can MAOs and other entities use to submit RAPS and EDS files?
What is the difference between the Monthly Medicaid Status Report and the Medicaid flag on MMR?
Will CMS publish a list of risk adjustment eligible CPT/HCPCS codes?
Does a linked chart review delete need a primary diagnosis code?
How can MAOs or other entities determine which diagnosis codes are accepted on the Phase III MAO-004 Report?
For replacement and void encounter data, if one of the key data fields is different from the original claim submitted, should the encounter be submitted as an original?
What will display in the Allowed/Disallowed Flag field 25 of the MAO-004 report when the Allowed/Disallowed Reason Codes field 27 contains value of Q?
How should an MAO Encounter Data Technical Contact ensure they are registered to receive HPMS communications?
What are the circumstances where a single ICN can have 38 or more diagnoses as defined in field 35 - Additional Diagnosis Codes - of the MAO-004 report layout?
We need to add or delete diagnoses from an already-submitted encounter data record. Are we allowed to change the diagnoses from what was submitted on the bill, or do we need to have the provider rebill the plan?
Where can MAOs and other entities find information on submission deadlines and payment dates?
Are encounter data records and chart review records with default NPIs for atypical providers considered for risk calculation?
Can CMS provide a default NPI for MAOs and other entities to use when submitting unlinked chart review records?
Can a Linked Chart Review Record use either the HICN or MBI when matching to an encounter (if the encounter uses the other beneficiary identifier)?
Are there restrictions on the number of chart review delete records submitted to the EDPS?
What is the cutoff time for RAPS and EDS submission deadlines?
An MAO submitted a CRR Add that was linked to an original EDR. The linked CRR Add was accepted. The MAO then submitted a replacement of the EDR, and it was accepted. Because the linked CRR Add was submitted for the original EDR, will those CRR Add diagnoses now be linked to the replacement EDR?
If MAOs submit an unlinked CRR that corresponds to an accepted EDR, will it result in a duplicate error?
Will the submission of duplicate diagnosis codes in the same EDR generate EDFES edit 255 - Diagnosis Code?
How do MAOs and other entities access the CMS 5010 CEM Spreadsheet?
Where can MAOs locate a complete list of CMS-acceptable HCPCS procedure and modifier codes?
If an encounter data record meets the requirements for risk adjustment, are all diagnoses on the record considered for risk adjustment?
How can MAOs and other entities become certified to submit encounter data?
How does CMS determine a diagnosis code's highest level of specificity for a specific beneficiary when generating edit 255 ‘Diagnosis Code’?
Can the MAO or other entity populate the encounter data record with demographic information related to age, name, and sex that it knows to be correct, or should it only submit data sent to the MAO or other entity by the provider (which might be incorrect)?
If the MAO-002 comes back with the encounter accepted but some of the service lines rejected, should we consider the encounter as rejected, requiring a void and replacement of the whole encounter?
On the MAO-004 Report, does the information in the Additional Diagnosis Codes field 35 apply to the diagnoses in the Current ICN field 9 or the diagnoses in the Prior Record ICN field 13?
How should Medicare Advantage plans submit encounters for a supplemental gym membership?
Do Risk Adjustment filtering rules differ between PACE and typical Medicare Advantage plans?
Will MAOs need to resubmit encounters to account for code set updates, or will CMS reprocess those encounters impacted by these updates?
MAOs are receiving EDFES edit 178 “Submitted Charges” when the charges exceed $99,999.00. Can CMS provide a prevention or resolution strategy for this edit?
How should MAOs report Medicare supplemental dental services to CMS?
What are the submission timelines and deadlines for PACE?
Why would the MAO-004 report list a diagnosis as disallowed?
Can CMS provide a default procedure code for MAOs and other entities to use when submitting unlinked chart review records?
What are the acceptable TOB values for EDS Submissions?
How should anesthesia claims with procedure code 01996 be submitted?
How should submitters identify names containing special characters; for example, a name with the tilde character over the ‘n’?
If the claim submitted by the provider to the MAO or other entity is still an original claim (for example, the provider needed to submit additional pre-authorization information, but the claim is still considered an original or the MAO or other entity has made claims adjustments in our system, but the provider did not submit a new claim), is it acceptable for the MAO or other entity to modify the claim frequency code of the encounter data record?
How can MAOs securely submit PII or PHI so that CMS may research issues?
Where are the ICD-10 to HCC mappings located?
We are receiving error code 502 on RAPS file submissions. Duplicate error is caused by another plan submitting the diagnosis clusters. How can we resolve this issue and/or receive credit for the diagnosis clusters?
How is the EDPS ICN assigned?
Will the MAO-004 report reflect diagnosis codes that are not risk adjustment eligible with a disallowed flag?
How can MAOs and other entities delete diagnosis codes from the Encounter Data System (EDS)?
When viewing the monthly Medicaid Status file, if the MMR and the Medicaid status files display different Medicaid status, which file's data should take precedence?
Where can MAOs submit questions about RAPS and other risk adjustment issues?
Will the MAO-004 report contain DME encounter services?
CMS guidance allows MAOs and other entities, in certain circumstances, to add modifiers to lines within a record to bypass the line-level duplicate check, when each line represents a unique service. Is it acceptable for MAOs and other entities to modify the encounter on the backend for EDPS submission purposes? Or does the billing provider need to rebill with those modifiers?
How can MAOs submit questions regarding MAO-004 reports that they did not receive, but believe they should have?
Will the EDS accept service lines with “S” and “G” procedure codes?
Are all MAO-002 accepted encounter data records included in MAO-004 reports?
Are diagnosis codes submitted on chart review records included in MAO-004 Report data?