Institutional Encounter Data Submission Requirements

Capitated facilities and dual-risk participating physician groups (PPGs) are contractually required to submit data electronically for all institutional encounters. Health Net accepts institutional encounter data in ANSI 837 5010 X 12 format. Providers may use an authorized electronic data interchange (EDI) vendor or clearinghouse to report encounters.

In Los Angeles County, Medi-Cal providers rendering services to Molina Healthcare-linked members continue to send encounter data to Molina Healthcare. Contact the Capitated Claims/Encounter Department for a list of acceptable clearinghouses.

Institutional services, when covered through capitation, include, but are not limited to:

• Inpatient
• Ambulance
• Home health
• Emergency room
• Outpatient surgery
• Out-of-area
• Skilled nursing facility (SNF)

All data should be submitted according to the terms of the Provider Participation Agreement (PPA) to meet governmental and regulatory timeliness requirements. Failure to do so may impact the revenues received under capitation. For additional information about how to submit encounters electronically, refer to 837 5010 Professional and Institutional Standards (PDF) or 837 Institutional Companion Guide (PDF).