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Encounter Reporting MEDICARE CMC

Provider Type

  • Physicians (does not apply to Cal MediConnect)
  • Participating Physician Groups (PPG)
    (does not apply to HSP)
  • Hospitals
  • Ancillary

Reporting of encounter data is extremely important. Health Net is required to provide encounter data to regulatory agencies. Default enrollment is also based on complete and accurate submissions of encounter data. The following procedures are required for encounter reporting:

  • Reporting of services must be on a per member, per visit basis, rather than a monthly summary. An accounting of all services rendered by date and member must be submitted to Health Net. The encounter data should be submitted via electronic transmission in the HMO's Western Region HMO/Information Services Standards ANSI 837 5010 X12 format. Encounter records must include the same data elements as would be required on a fee-for-service (FFS) claim form. An authorized electronic data interchange (EDI) vendor or clearinghouse may also be used for encounter reporting purposes. Contact the Capitated Claims/Encounter Department for additional information.
  • Health Net does not accept encounter and encounter summary reports on paper. Providers must submit them electronically. For additional information about how to submit encounters electronically, refer to 837 5010 Professional and Institutional Standards (PDF)837 Institutional Companion Guide (PDF) and 837 Professional Companion Guide (PDF).The Department of Health Care Services (DHCS) dictates that Health Net report services within 90 days from the month of service. Participating providers are required to report services according to the terms of the Provider Participation Agreement (PPA).
  • PPGs are required to submit electronic encounter files at least once a month.
  • All encounter reporting must identify members by their Health Net identification (ID) number. This number is on each member's ID card. Submission of encounter data without the member ID number is not acceptable and is returned for correction.

Provider NPI Validation

Per the requirement of the Centers for Medicare & Medicaid Services (CMS), Health Net validates submitted billing provider National Provider Identifiers (NPIs) against the National Plan and Provider Enumeration System (NPPES) database for all dates of service. If the billing NPI is not found or is inactive, capitated encounter claims will be rejected.

Capitated encounter claims rejected will receive an edit with the reason for rejection. The edit reads, "NPPES BILLING PRV NPI IS MISSING OR INACTIVE."

This process applies to professional and institutional Cal MediConnect capitated encounter claims for all dates of service.

The following three default NPIs will be excluded from the validation process:

  • Professional: 1999999984
  • Institutional: 1999999976
  • Durable medical equipment (DME): 1999999992

Contact the Capitated Claims/Encounters Department for assistance in developing or modifying procedures to accomplish complete encounter data submission.

Capitated providers are asked to produce a corrective action plan if the format, quality, timeliness, or expected volume of encounters is not in compliance with Health Net standards. Capitated providers may be sanctioned if they continue to demonstrate noncompliance. Sanctions may include requiring the capitated provider to use an encounter vendor at their own expense, freezing new enrollment and can ultimately result in termination of the capitation contract.

Last Updated: 12/23/2019