CRC Encounter Data Submission and Processing

Question 1

What is the primary file format used for submitting encounter data to CMS for Medicare Advantage?

Accepted Answer

ANSI X12 837 transaction format

Answer

UB-04 paper form

Answer

HL7 FHIR

Answer

CMS-1500 paper form

Question 2

Which system does CMS use to process and validate encounter data submitted by Medicare Advantage plans?

Accepted Answer

EDS (Encounter Data System)

Answer

FISS (Fiscal Intermediary Shared System)

Answer

PECOS

Answer

NPPES

Question 3

What happens when an encounter data record is rejected by CMS?

Accepted Answer

The plan must correct and resubmit the record to ensure the diagnoses are counted for risk adjustment

Answer

The plan automatically receives reduced payment

Answer

The provider is penalized

Answer

The enrollee is disenrolled

Question 4

What is a common reason encounter data records are rejected by CMS?

Accepted Answer

Invalid or missing NPI numbers

Answer

Using ICD-10-CM codes correctly

Answer

Including the enrollee's date of birth

Answer

Submitting records electronically

Question 5

What was the purpose of the Risk Adjustment Processing System (RAPS)?

Accepted Answer

To receive risk adjustment diagnosis cluster submissions from MA plans for risk score calculations

Answer

To process pharmacy claims only

Answer

To manage provider credentialing

Answer

To calculate quality star ratings

Question 6

In encounter data submission, what does '837P' refer to?

Accepted Answer

Professional claims format used for physician services

Answer

Pharmacy claims format

Answer

Institutional claims format for hospitals

Answer

Dental claims format