Medicaid Encounter Data – Project Spotlight

Submission Implementation for Medicaid and Medicare

Client Challenge:

Cirdan was retained to submit encounter data to CMS and the State Agency for a Dual Medicaid/Medicare Advantage plan. The submissions were to commence concurrent with the client’s transition to a new claim processing system.

Our Solution:

To define the required claim data extract to support the creation of the Encounter Data Submissions (EDS) files, Cirdan requested various claim scenarios including situations that are typically problematic. One key aspect of this transition was the need to complete submissions for the new claims system and run-out submissions for the prior claims systems.

Cirdan developed processes to complete the submissions under the two claims systems.

Cirdan reviewed examples of processing of large claims under each system.

Cirdan implemented its Encounter Data and Analysis Oversight tool.

The Result:

In the process of establishing the EDS files, Cirdan found issues with the prior claims payment and helped the client recover past over-payments. Process improvements and the oversight tool resulted in a reduction to the client’s internal staffing needs. The error rates for both CMS and the State Agency were dramatically reduced.