CRC Encounter Data Submission and Processing 1 — Questions and Answers
Question 1: What is the primary file format used for submitting encounter data to CMS for Medicare Advantage?
- ANSI X12 837 transaction format (Correct answer)
- UB-04 paper form
- HL7 FHIR
- CMS-1500 paper form
Correct answer: ANSI X12 837 transaction format
MA organizations submit encounter data to CMS using the ANSI X12 837 transaction format, with 837P for professional and 837I for institutional services.
Question 2: Which system does CMS use to process and validate encounter data submitted by Medicare Advantage plans?
- FISS (Fiscal Intermediary Shared System)
- EDS (Encounter Data System) (Correct answer)
- PECOS
- NPPES
Correct answer: EDS (Encounter Data System)
CMS uses the Encounter Data System (EDS) to process, validate, and store encounter data submitted by Medicare Advantage organizations.
Question 3: What happens when an encounter data record is rejected by CMS?
- The plan automatically receives reduced payment
- The plan must correct and resubmit the record to ensure the diagnoses are counted for risk adjustment (Correct answer)
- The provider is penalized
- The enrollee is disenrolled
Correct answer: The plan must correct and resubmit the record to ensure the diagnoses are counted for risk adjustment
When encounter data is rejected, the plan must identify the error, correct it, and resubmit to ensure the diagnosis is captured for risk adjustment.
Question 4: What is a common reason encounter data records are rejected by CMS?
- Using ICD-10-CM codes correctly
- Invalid or missing NPI numbers (Correct answer)
- Including the enrollee's date of birth
- Submitting records electronically
Correct answer: Invalid or missing NPI numbers
Missing or invalid National Provider Identifier (NPI) numbers are a common cause of encounter data rejection by CMS.
Question 5: What was the purpose of the Risk Adjustment Processing System (RAPS)?
- To process pharmacy claims only
- To receive risk adjustment diagnosis cluster submissions from MA plans for risk score calculations (Correct answer)
- To manage provider credentialing
- To calculate quality star ratings
Correct answer: To receive risk adjustment diagnosis cluster submissions from MA plans for risk score calculations
RAPS was CMS's original system for receiving diagnosis cluster submissions from MA plans used in risk score calculations, though EDS has largely replaced it.
Question 6: In encounter data submission, what does '837P' refer to?
- Professional claims format used for physician services (Correct answer)
- Pharmacy claims format
- Institutional claims format for hospitals
- Dental claims format
Correct answer: Professional claims format used for physician services
The 837P is the ANSI X12 electronic transaction format for professional physician services claims and encounter data submissions.
CRC Encounter Data Submission and Processing 1
What is the primary file format used for submitting encounter data to CMS for Medicare Advantage?