Home       Performance Measurement      Encounter Data Improvement      FAQs

Encounter Data Improvement

What is IHA's work as the Encounter Data Governance Entity (EDGE)?

As the Encounter Data Governance Entity (EDGE), funded through a grant from Health Net LLC’s Encounter Data Improvement Program, IHA is coordinating a statewide effort to coordinate and support encounter data improvement efforts across California.

EDGE is providing education and tools to navigate encounter data complexity and developing standardized solutions to encounter data submission challenges to advance healthcare equity, quality, and affordability across California.

Why and how was EDGE created?

As a contingency of Centene’s acquisition of Health Net, the California Department of Managed Health Care (DMHC) required Health Net to invest $50 million in improving encounter data submissions in California, with a focus on Managed Medi-Cal providers. Health Net launched its Encounter Data Improvement Program (EDIP) in 2015 through a series of grants. In 2019, Health Net oversaw an industry listening process led by Manatt Health. This listening process highlighted the need for a Governance Entity to steward cross-industry alignment. Through a competitive RFP process, Health Net selected IHA as the Governance Entity in March 2021 with the charter of overseeing a multi-year, cross-industry effort to improve the completeness and reliability of encounter data in California.

How is EDGE funded?

IHA’s role as the Encounter Data Governance Entity (EDGE) is funded by Health Net, Inc as part of the California Department of Managed Health Care’s undertakings for Centene Corporation’s acquisition of Health Net. IHA’s work as the Encounter Data Governance Entity is governed through a milestones-based contract with Health Net, Inc.

What problem is EDGE seeking to solve?

Encounter data across California’s healthcare delivery system is fragmented and inconsistent due to the complexity, administrative burden, and a lack of standardization in how the data is submitted and processed. As a result, data gaps, rejections, and duplications threaten the reliability of the many reports and processes that are dependent on encounter data.

The main issues with encounter data in California include the following:

  • Variation in data definitions and submission standards among health plans.
  • Lack of consistent training on the value of submitting complete and accurate encounter data.
  • Due to the highly delegated and complex market in California, there is limited systematic governance and oversight for stakeholder communication and coordination.

Encounter data issues are complicated and impact everyone from patients and individual providers to federal agencies. This is the reason IHA is coordinating efforts across California to improve encounter data.

While this problem is particularly acute in California due to the prevalence of managed care and capitation payment arrangements in the state, encounter data management is a challenge for the healthcare system nationwide, especially as more stakeholders adopt or expand population-based alternative payment models.

Who is IHA working with for Encounter Data Improvement?

To pull off a statewide encounter data improvement effort, we’re working with leading organizations in provider technical assistance, industry collaboration, and those who manage encounter data for their programs. This includes California Medical Association, California Primary Care Association, the Department of Health Care Services, the Department of Managed Health Care, and Health Industry Collaboration Effort.

Learn more about the organizations taking part in this effort.

Is this work only focused on Medi-Cal?

Our work as EDGE has a strong focus on Medi-Cal. However, we seek to implement industry-wide advancements across all product lines and geographies. This is because the challenges associated with poor quality and missing encounter data are not limited to Medi-Cal, and many of the stakeholders that submit and process this data operate across multiple lines of business.

About Encounter Data

What is encounter data?

According to the Centers for Medicare and Medicaid Services, encounter data is “detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form.” A “capitated managed care entity” refers to providers and health plans who receive a per-member-per-month capitated rate to care for an assigned patient population.

What makes up encounter data?

Encounter data is detailed data which generally includes the following.

  1. Patient demographic data such as patient name, DOB, address, gender, etc.
  2. Provider-specific data such as provider name, NPI, location, date of service, etc.
  3. Service code information such as ICD-10 Code, CPT Code, HCPCs, modifiers, etc.
  4. Health plan insurance Information

Additionally, there are several standard electronic transmission formats such as Accredited Standards Committee (ASC) X12 837 (institutional), and X12 837P (professional) that are used to submit encounter data from providers to Managed Care Plans (MCPs) and from MCP’s to the Department of Health Care Services.

If you work at a physician practice and would like to know how you impact encounter data, check out the role-based Encounter Data Impact Guide.

What is encounter data used for?

Many important healthcare processes rely on encounter data, including:

  • Risk-adjustment: Encounter data include diagnoses and other information necessary to understand the risk-level of a given population. This information is then used to determine the appropriate payment levels for both managed care plans and their contracted providers within a capitated healthcare setting.
  • Clinical quality measurement and incentives: In capitated healthcare settings, encounter data serves as the basis for understanding clinical quality performance across prevention, screening, and disease management measures.
  • Consumer cost-sharing: In capitated healthcare settings, encounter data provides information on services provided, which is then used to determine patient cost-sharing and to track accumulation of deductibles and out-of-pocket maximums.
  • Transparency: Encounter data offer information to identify the complete picture of services provided to patients. Whether it’s a self-insured employer tracking utilization and costs for rate-setting, benefit design, and provider selection or a regulator tracking population health outcomes against statewide quality and access goals, transparency into how care is delivered within a capitated healthcare setting depends on encounter data.

What is the encounter dataflow?

The encounter dataflow is the path encounter data takes from when it’s generated at the patient-provider level through its submission to a clearinghouse or to an IPA/PPG or straight to the health plan:

Patient services administered in provider practices are documented in the EHR, translated into an encounter, and directly submitted to an IPA/PPG or through a clearinghouse before being sent to an IPA/PPG. Encounters may be directly submitted to a contracted health plan as well. IPAs/PPGs aggregate and submit encounter files to contracted health plans and or managed care organizations (MCOs).

If you would like to learn more about encounter dataflow, please check out CPCA’s video Encounter Data Made Easy (at 3:42).

What is the difference between encounter and claims data?

Claims data derives from documentation that is supplied by providers and other healthcare professionals during an encounter with a patient for healthcare services. This documentation is then translated into medical coding and applied to an appropriate claim form. This becomes the bill submitted for a patient’s care. Claims data is typically generated by providers who are billing for services provided to a patient. Fee-for-service is most commonly associated with claims.

Encounter data is also based on medical record documentation and data elements that would also be on claims forms. However, it is not tied to a specific claim for services or bill submitted for a patient’s care as the health plan has already reimbursed for services under some form of capitated contract with the provider. Encounter data is typically generated by capitated providers and submitted as a requirement by their health plan contracts.

Although these definitions are broad, the types of basic information a provider would submit for claims or encounters under other payer types (such as commercial HMO, PPO, or Medicare Advantage) is similar. However, each contracted health plan may have different requirements. It’s important to know your contracts and what is required by each.

What is the relationship between Managed Care Organizations (MCOs) and encounter data?

A managed care organization (MCO) is a health plan that has agreed to participate in managed care programs and is paid a capitation rate by the state or federal government to cover all costs of a defined population. MCOs are required, under federal regulations, to collect encounter data for their defined populations from providers and healthcare organizations that are contracted with them under capitated managed care agreements. MCOs that serve Medicaid enrollees in California are referred to as Managed Care Plans (MCPs).

What is the relationship between Managed Care Plans (MCOs), Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs)?

Health Maintenance Organizations (HMOs) typically cover care for patients only within their contracted provider networks. Preferred Provider Organizations (PPOs) typically cover more if care is received in network but may still also cover some out-of-network care.

Both HMOs and PPOs are common examples of Managed Care Organizations (MCOs).

Capitated managed care in California is most commonly seen with Medi-Cal, in which patients are assigned to MCOs by the Department of Health Care Services. MCOs then assign patients to contracted primary care providers who participate in those managed care agreements.

Many MCOs also offer commercial HMO, PPO, POS, and EPO products in addition to their Medi-Cal managed care line of business. 

Medi-Cal managed care is like a commercial HMO in that patients must use only the in-network providers and Medi-Cal covers the basic benefits that all health plans cover in California. Additionally, prescription drugs, vision and hearing care are also covered. Co-pays and annual deductibles do not apply to Medi-Cal managed care. MCOs providing services to California Medi-Cal enrollees are referred to as Managed Care Plans (MCPs).

For more information on the relationship between Medicaid and managed care organizations, check out this video webinar from Center for Health Care Strategies (CHCS) (primary care focused).

Encounter data reporting for providers

What are the requirements for encounter data submissions?

Encounter data requirements may vary depending on health plans. Encounter data is typically submitted in an electronic format in accordance with state and federal regulations. Please check with your affiliated health plans for encounter data submission requirements.

What are some common errors when submitting encounters?

According to the Medicaid Encounter Data Toolkit (2013), these are some of the most common errors when submitting Medicaid (Medi-Cal) claims:

  • Incorrect patient data or demographics.
  • Incorrect provider information (NPI, Tax ID, etc.).
  • Incorrect coding.
  • Claim is not filed on time.

For an introduction to encounter data, see Encounter Data 101.

What are some encounter data reporting challenges for providers?

There are many challenges to the submission of complete, accurate and timely encounter data:

  • Lack of awareness regarding the impact of encounter data throughout a provider practice.
  • High staff turnover and limited training in accurate coding and encounter data submission processes.
  • Outdated EHR systems that are often challenging or impossible to configure to meet a practice’s needs, or reliance on paper-based submissions.
  • Lack of timely or actionable feedback on rejection reports at each submission level from all contracted health plans and/or PPGs.
  • No “standard” data standards, uneven requirements, and poor communication across clearinghouses and health plans that can lead to errors.
  • EHR, billing and transaction system migrations resulting in significant encounter data issues.

As a provider, how do I find out about my encounter data submission performance?

For provider organizations that participate in IHA’s Align. Measure. Perform. (AMP) programs, please visit the Performance Reporting Portal to access your encounter data results along with the rest of your AMP performance results.

For provider organizations that do not participate in AMP, please visit your contracted health plan/IPA or PPG to access information on encounter data report cards and/or rejection feedback.

Managed Care Organizations (MCOs)/Preferred Provider Groups (PPGs): Contact your contracted health plan, IPA, or PPG.

What can providers do to improve encounter data?

We encourage you to visit the Encounter Data Resource Hub to access tools and frameworks for improving encounter data. At a high-level, we recommend providers improve their encounter data through the following:

  • Develop/enhance relationships with MCOs, MCPs, IPAs/PPGs.
  • Always check patient eligibility ahead of patient check-in.
  • Always check credentialing for all providers prior to submitting encounter data.
  • Always check additional authorizations, coverage limits, co-pays, other patient insurance benefit information ahead of patient check-in.
  • Improve check-in and registration processes, optimize workflows.
  • Improve documentation of procedures, treatments, and referrals.
  • Establish and/or improve the coding review process; have a quality audit process to close the loop.
  • Improve data submission processes through review of policies and timelines, tracking of claims, and auditing of denials – establish documentation to reflect processes.
  • Optimize use of systems through configuration options available from your vendors, such as in the EHR.
  • Leverage internal data for tracking and reporting, understand your available internal data sources and what data you can get out of them.

If you would like to know more about how you and your staff can improve Encounter Data, check out this explainer video (at 7:14) from CPCA for providers and healthcare staff.

How do I get new office/billing staff trained?

The Encounter Data Resource Hub offers useful tools to help train new office/billing staff, including: Info sheets, an Onboarding Toolkit (forthcoming), and an Encounter Data 101 presentation (also available for Community Health Centers). For more information on available resources and training, please visit your contracted health plan/IPA or PPG.

For Medi-Cal, fee-for-service, or straight Medi-Cal: Medi-Cal Provider Home Page.

Challenges in encounter data quality

What data challenges has IHA tackled so far?

While limited instructions and formats exist for encounter data, there is a need for additional defined processes, workflows, and consensus-based recommendations to improve how encounter data is collected, reported, aggregated, and analyzed.

Between 2021 and 2023, IHA and the HICE Encounters Team held regular meetings to address the encounter data challenges that would benefit from increased standardization as identified during the 2020 Encounter Data Summit. IHA and the HICE team broke down the scope of each challenge by completing root-cause analyses and key informant interviews, summarizing their findings and recommendations in issue briefs published on the Resource Hub. Finally, the team produced standard sets of codes, processes, and guidelines that can adopted across the healthcare community to streamline encounter data consistency and usability.

Find the industry-backed materials for the following data challenges:

How is IHA helping advance the implementation of data standards for encounter data?

As the Encounter Data Governance Entity, IHA is driving the adoption of standards throughout the data submission chain through the following mechanisms:

  • Under the auspices of our Data Governance Committee, IHA has partnered with the Health Industry Collaborative Effort (HICE) to convene its Encounters Standardization Team. This workgroup is charged with defining and prioritizing a set of guidelines and resources that can accelerate appreciable improvements in encounter data quality.
  • Through a memorandum of understanding with the Department of Health Care Services (DHCS), we are building alignment to ensure that solutions for more standardized encounter data can be put into practice across the industry.
  • Finally, we’re garnering industry stakeholders’ buy-in and commitment to make strategic technical and operational investments that can support the use of the guidelines. We will also facilitate access to the guidelines through our Resource Hub.

Encounter data quality challenges are extensive and require multi-faceted strategies to mitigate inaccurate and incomplete data submissions. A broad commitment among stakeholders, the value proposition for investing in in technical solutions and workflow redesign, and value-based incentive design are all critical to driving meaningful improvement and alignment. We’re pursuing an incremental approach that focuses on areas where there is early agreement, where the proposed remediations are relatively easy to implement, and where adoption can lead to measurable progress.

Do IHA’s performance measurement programs use encounter data measures?

Yes. Since 2007, our Align. Measure. Perform. (AMP) programs have collected and reported encounter data quality measures. Currently, we use the following measures:

  • Encounter Rate by Service Type (ENRST), which measures the number of encounters and claims per member-year, delineated by service type
  • Encounter Format (ENFMT), which assesses for correct coding and formatting of the content included in the encounter submission; and
  • Encounter Timeliness (ENLAG), which assesses the elapsed time in days between the date a patient receives care and the date when the claim/encounter is accepted by the health plan

For provider organizations that participate in IHA’s Align. Measure. Perform. (AMP) programs, please visit the Performance Reporting Portal to access your encounter data results along with the rest of your AMP performance results.

What is IHA’s experience in encounter data performance measurement?

Since 2007, IHA has helped the providers and health plans understand encounter data performance through our Align. Measure. Perform. (AMP) programs. Here are a few significant milestones in IHA’s trajectory:

  • 2007: Collected and reported encounter data volume by service types (ENRST) across all programs (commercial HMO, commercial ACO, Medicare Advantage, Medi-Cal Managed Care).
  • 2015: With funding from the California Health Care Foundation, published an issue brief on encounter data issues within California’s capitated, delegated market.
  • 2016: Convened a multi-stakeholder work group to create a single industry interpretation of the most challenging and non-standard data elements in the 837 encounter forms.
  • 2018: Conducted an encounter data research study to understand market challenges across encounter data exchange in California.
  • 2019: With funding from Aetna, developed additional encounter data quality metrics including encounter data timeliness and completeness measures.
  • 2020-2022: Collected and reported encounter data quality suite of measures (volume, timeliness, completeness) for informational purposes.
  • 2023: For our Measurement Year 2022, we are collecting encounter data quality measures for reporting as “First-Year Measures.” This means we plan to use the results to establish a baseline with the intent of adopting these measures for programmatic purposes in future measurement years.

Encounter data and community health centers (CHCs)

What does the claim and encounter data submission process look like at community health centers?

Claim submission involves sending charge information (documented services rendered) to payors for reimbursement. The revenue cycle team examines charges, CPT codes, and diagnosis codes, ensuring they align with what providers and staff have documented in the system. If documentation is missing or incomplete, then claims and encounter data submissions will also be inaccurate and incomplete.

The revenue cycle team will often engage in some level of claim scrubbing to ensure clean, error-free claims are sent to payors, resulting in quicker payment. This process involves transmitting claims from the EHR or revenue cycle management system to a clearinghouse, which acts as a mailroom, forwarding claims to different payors and/or Independent Physician Associations (IPAs) or sending rejected claims back to the CHC requesting changes before forwarding to the appropriate payor and/or IPA.

The revenue cycle team can use transmission reports to track sent, received, and dropped claims, while the rejections report identifies incorrect codes. These can be used internally as teaching tools to create better training for providers and staff.

What is the difference between a “rejected” claim and a “denied” claim?

Claims go through many gateways that check for common and routine errors before they enter a payor’s system for payment. A claim that has been denied is in the payor’s system awaiting some action like appeal or additional information to prove medical necessity. A rejected claim gets stopped at one of the gateways – either at the clearinghouse or the entry gateway to the payor’s system.

No encounter data will be gathered from rejected claims because they have not entered the payor’s system for payment processing. For rejected claims, CHCs can add additional information to correct and then resubmit.

A denied claim has been reviewed for payment, but the payor has chosen to deny all, or part of the services billed. There are many reasons why a claim would be denied. Payors can take certain encounter data from denied claims even if they are not paid, such as coding that aligns with HEDIS metrics.

Denials can be corrected and/or appealed. Rejections must be corrected and re-submitted.

What is remittance processing and how can it impact the revenue cycle of the CHC?

After claims are submitted, a CHC receives remittances or remittance allowances (RAs), which explain what services they got paid for. RAs help determine “allowables,” which are the agreed-upon payment amounts for services between the CHC and the payor. Sometimes, mistakes occur during this process, such as not reviewing remittances properly, which can lead to missed opportunities for appeals.

RAs also involves write-offs, which can be either contractual (set by contracts with payors) or avoidable (due to process breakdowns). Avoidable write-offs can be prevented by paying attention to reports and catching issues like missing authorizations, referrals, or late claim submissions.

What is “charge capture”?

Charge capture is an important part of the revenue cycle process. Charge capture refers to the process of documenting (capturing) services rendered to patients during a medical visit, converting those services to medical coding, and then submitting those codes and charges to payors for reimbursement. Depending on the Electronic Health Record (EHR) or billing software used, it can also include posting and reconciliation of payments received.

There are two primary methods of capturing services rendered within CHCs:

  • automation, where the EHR system automatically records information into the practice management billing section based on what the provider and staff documents.
  • traditional, where front desk staff manually input the information on a superbill or forward it to the billing department for manual entry.

There is a risk of missing services rendered with either approach. One common oversight involves ancillary services, which can result in unclaimed revenue. To prevent this, it’s essential to ensure accurate documentation capture and coding and accurate submission of services rendered to payors.

What are some of the tools a revenue cycle team can use to look at what’s been paid and what’s not been paid?

Insurance follow-up is an important piece of managing a CHC revenue cycle. This process looks at what has been paid as well as what has not been paid.

What happens to the items that don’t get paid for? The accounts receivable (A/R) report shows everything that is sitting in the insurance and/or patient “buckets” for a specific period. This report can show if insurance follow-up is broken (and which payors) and why it might be taking more time to get reimbursed for services.