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26-893 Action Required: Comply with QMED 2.0 Encounter Submission Requirements

Date: 07/21/26

Failure to meet DHCS QMED thresholds will impact provider performance

Capitated participating physician groups (PPGs) and capitated hospitals are required to submit complete and accurate encounter data within defined timeframes and correct denied encounters promptly to comply with Department of Health Care Services (DHCS) Quality Measures for Encounter Data (QMED 2.0) standards.

Failure to meet these requirements will directly impact provider performance reporting and may contribute to Plan non-compliance and corrective action.

QMED 2.0 (PDF) measures encounter data performance at both the Plan and provider level across:

  • Timeliness of submission
  • Accuracy (correction of DHCS denied encounters)
  • Completeness of data
  • Uniqueness (duplicate submissions)
  • Reasonability

Capitated provider performance is actively monitored against these standards.

Required provider actions

PPGs must:

  • Submit and ensure acceptance of encounters within 90 days of the date of service.
  • Ensure all encounter data is complete and accurate, including Type 1 (individual) rendering provider National Provider Identifier (NPI).
  • Ensure NPI matches National Plan and Provider Enumeration System (NPPES) Type 1 or Type 2 and is valid on date of service (DOS).
  • Review denial reports and correct errors within 10 calendar days of the date of DHCS denial.
  • Resubmit all corrected encounters within the reporting quarter.
  • Prevent duplicate submissions by following established billing practices.
  • Monitor performance reports and take immediate action to resolve identified issues.

Key requirements

1 Timeliness of submission:

  • Effective October 1, 2026, to meet DHCS’s requirement that data be accepted within 120 days, the Plan requires at least 90% of encounters to be submitted and accepted within 90 days of the DOS.
  • Effective October 1, 2026, to meet DHCS’s requirement that denied encounters be corrected within 15 calendar days, the Plan requires at least 97.5% of DHCS-denied encounters to be corrected within 10 calendar days of the denial.

2 Accuracy (correction of DHCS denied encounters):

  • At least 99.5% of DHCS denied encounters must be corrected within the reporting quarter.

3 Completeness of data:

  • At least 90% of encounter service lines must include a Type 1 (individual) rendering provider NPI.

4 Uniqueness (duplicate submissions):

  • Duplicate encounters must remain below 0.5%.
  • Duplicate service lines must remain below 5% for Institutional encounters and 0.5% for Professional encounters.

5 Reasonability

  • Total DHCS denied encounters must remain below 2%.

How performance will be evaluated

Encounter data quality will be evaluated using defined QMED 2.0 performance measures, which include timeliness, accuracy, completeness, uniqueness and reasonability requirements.

Additional details will be provided in future communication(s).

Common causes of performance issues

  • Missing or invalid provider information such as:
    • NPIs.
    • Use of Type 2 (organizational) NPIs for rendering/attending provider instead of required Type 1 (individual) NPIs.
    • NPPES NPI validation: Submitted NPI data is required to match the NPI and qualifier submitted in 837 file.
    • Duplicate encounter submissions.
    • Delays in correcting DHCS denied encounters.
  • Billing errors, including:
    • Invalid diagnosis-related groups (DRGs).
    • Invalid or missing National Drug Codes (NDCs) (numbers, units of measure, quantity).
    • Invalid or missing Bill Types.

Impact to providers

Failure to meet QMED 2.0 requirements will result in:

  • Negative impact to provider performance reporting.
  • Increased risk of Plan-level non-compliance.
  • Required remediation and corrective action, including performance monitoring and escalation.

Questions or support

For additional information, refer to DHCS APL 26-003 (PDF) and QMED 2.0 (PDF), or contact your Plan provider representative.

Additional information

We will continue to provide reporting and targeted education to support compliance with these requirements.

 

This information applies to Participating Physician Groups (PPGs) and Hospitals.

This information applies to Medi-Cal in Imperial County.



Last Updated: 07/20/2026