CRC Encounter Data Submission and Processing 1

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

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?

Accepted Answer

EDS (Encounter Data System)

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

Invalid or missing NPI numbers

Answer

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)?

Accepted Answer

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

Answer

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.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Encounter Data Submission and Processing 1