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Policies and procedures for practices

December 2022

Developed by CMA Physician Services, this customizable template will help provider practices establish or update their policies and procedures for the encounter data submission process. Establishing and regularly updating your practice’s documentation on policies and procedures for encounter data reporting will ensure your practice consistently submits complete, accurate, and timely data capture, documentation, and coding of encounter data.

Author

California Medical Association Physician Services (CMA PSO)

Why use it

The template helps practices formally document all encounter data submission requirements, staff responsibilities, and the process and tools used to ensure complete, accurate, and timely data capture, documentation, and coding. The exercise of filling out the template will help engage staff while simultaneously clarifying the practice team members’ roles and duties. The template can also help identify critical questions for contracted health plans and IPA/PPGs.

Who it’s for

The Encounter Data Policies and Procedures template is intended for front office, business office, billing, and administrative staff at provider practices and community health centers in California serving patients with commercial, Medi-Cal, and Medicare coverage. The template is useful for onboarding new staff members, semi-annual encounter process reviews, and can be customized to reflect health plan and IPA/PPG contract arrangements.

If you are an encounter data subject matter expert and have edits or additions for this template, please fill out IHA’s Contact Us form so your update may be incorporated.

Key take-aways

This customizable template seeks to comprehensively capture all relevant policies and procedures for encounter data reporting. It includes the following sections:

  • Policy statements, document purpose, and definitions
  • Tables to document procedures by contracted health plan, line of business, and delegated entities
  • Encounter data submission schedule
  • Encounter data acceptance and validity rates by health plan or delegated entity
  • Schedule for rejected encounter data submissions
  • Schedule for submitting appeals
  • Links to relevant code sets
  • Compliance guidelines from DHCS and CMS

Have edits or additions for this resource? Please let us know.

IHA’s Resource Hub is made possible through a grant from Health Net, LLC’s Encounter Data Improvement Program.

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