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?

Answer:

Since the Encounter Data Record (EDR) is a report to CMS from the MAO or other entity, the MAO or other entity may report information to CMS that was not provided to the MAO or other entity by the provider, per CMS guidance. In the example provided, the provider has submitted one claim to the MAO or other entity, but the MAO or other entity needs to make an adjustment on the EDR that it has sent to CMS. The MAO or other entity may adjust its EDR for this encounter, as it is a report to CMS regarding a specific item or service received by the enrollee. We recognize that plans may want to track their data sources for populating an EDR for data integrity purposes, and for these purposes CMS recommends as a best practice that MAOs or other entities track when and why provider supplied information is modified for submission to the Encounter Data System (EDS). Please see the Health Plan Management System (HPMS) memo entitled Guidance regarding Encounter Data Submission - Edit 98300 – “Exact Inpatient Duplicate” released October 4, 2017, for additional information.

Source: CMS HPMS Memo with subject “Guidance for Encounter Data Submission” (October 30, 2017)