CMS Encounter Data – Project Spotlight

Submission Implementation Concurrent with New Claims System

Client Challenge:

Cirdan was retained to submit encounter data to CMS for a 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 Submission (EDS) files, Cirdan requested various claim scenarios including situations that are typically problematic:

• Cirdan reviewed results of prototype claims processing.
• Cirdan reviewed provider warehouse detail generated from claims data.
• Cirdan reviewed examples of processing of large claims.

The Result:

In the process of establishing the EDS files, Cirdan helped our client to improve its claim processing results and its data warehouse. Cirdan identified claim processing issues that would have resulted in certain types of claims being significantly overpaid, identified process work arounds to ensure that the provider data included in the EDS files would be accurate, and identified data loss issues in the client’s warehouse before the client was aware of the problem. By working with Cirdan, the client’s claim processing implementation was improved, and the encounter data submission was launched successfully. With the transition to Cirdan, the client’s encounter error rate dropped by more than 90%.