Encounter Processing

Centers for Medicare and Medicaid Services (CMS) collects diagnosis data from Medicare Advantage (MA) plan providers for actuarial purposes - to determine the risk adjustment factors used to adjust plan payments and update risk adjustment models for plan payment.

Based on a  new rule, CMS is requiring additional MA encounter data to be collected to establish risk adjustment models based on MA cost and utilization as well as synchronize that with Part D prescription drug utilization data.the submission of encounter data in 2012 from Medicare Advantage Organizations to more accurately calibrate the risk adjustment model and to analyze utilization and costs.

This will allow CMS to analyze the quality, quantity, and kinds of health care services Medicare beneficiaries are receiving within the MA plans.

CNSI has provided solutions and project teams to design and build the entire Encounter Data Processing System to facilitate CMS in conducting MA provider systems end-to-end testing and certification beginning January 3, 2012.