About EDS

EDS (Encounter Data System) is the system required by MAOs (Medicare Advantage Organizations) to submit claims for Medicare Advantage (MA) encounters to CMS for reimbursement. Encounter data is used to determine the risk scores used in payment, calibrating the risk adjustment model, analyzing Medicare coverage, and conducting quality review and improvement activities. Overall, EDS processes MA claims in a specific file format for reimbursement.

1. What is EDS/EDPS?

2. Why is EDS being implemented?

3. What is the encounter data used for?

4. Who needs to use EDS?

1. What is EDS/EDPS?

• EDS (Encounter Data System) is the system required by MAOs to submit claims for Medicare Advantage encounters to CMS for reimbursement.
• EDPS (Encounter Data Processing System) is a part of the EDS system that does the processing of these claims.

2. Why is EDS being implemented?

• Encounter data is designed to improve the risk adjustment and MA payment system by providing complete and accurate data, which allows CMS to accurately measure and analyze MA utilization and costs.
• CMS requires Medicare Advantage Organizations (MAOs) to submit encounter data that will be analyzed for the purpose of determining beneficiary utilization, while ensuring accurate payment and appropriate program oversight.

3. What is the encounter data used for?

• Encounter data is used to determine the risk scores used in payment, calibrating the risk adjustment model, analyzing Medicare coverage, and conducting quality review and improvement activities.

4. Who needs to use EDS?

• All MAOs that will submit encounter data.
  • Medicare Advantage (MA) Plans
  • Medicare Advantage-Prescription Drug Plans (MA-PDPs)
  • Health Maintenance Organizations (HMOs)
  • Special Needs Plans (SNPs)
  • Local Preferred Provider Organizations (PPOs)
  • Regional PPOs
  • Employer Group Health Plans (EGHP)
  • Programs for All-Inclusive Care for the Elderly (PACE) Plans
  • Cost Plans (1876 Cost HMOs/CMPs and 1833 HCPPs)
  • Medical Savings Account (MSA) Plans
  • Private Fee-For-Service (PFFS) Plans
  • Religious Fraternal Benefit Plans (RFBs)
  • Provider Sponsored Organizations (PSOs)

5. What encounters and claims are submitted?

• Medicare Advantage Organizations
  • Submit all accepted and denied adjudicated claims data according to CMS guidelines
• Cost Plans
  • Cost HMOs/CMPs and HCPPs will only be required to submit encounter data for Medicare covered items/services for which plans claim Medicare costs on their CMS Cost Reports. Virtually all Cost HMOs/CMPs and HCPPs (with the exception of one “billing option 2” Cost HMO/CMP) will only need to collect and submit Professional and DME encounters according to CMS guidelines. Since Institutional encounter data will generally not be required, virtually all Cost Plans will not need to perform front-end or end-to-end Institutional testing (identified in Module 8 – Special Considerations).
• Program of All-Inclusive Care for the Elderly (PACE) Organizations
  • For 2013, PACE will submit claims based encounters only.
• Special Needs Plans (SNPs)
  • Submit only Medicare services according to EDS guidelines

6. Where does the encounter data come from?

1. Provider claims
   • Primary source…?
2. Chart reviews
   • Chart reviews may be performed by MAOs for the purpose of diagnosis code validation. Because diagnoses drive risk adjustment, all chart review encounters must be supported by the medical record.
   • MAOs may submit chart reviews that are linked to an original encounter stored in EDS (linked ICN chart reviews) or chart reviews that are not linked to an original encounter stored in Encounter Operational Data Store (EODS) (unlinked ICN chart reviews).
   • All chart review encounters should be flagged by MAOs.
3.  Home Health
   • MAOs should submit Home Health (HH) services to the EDS submitted by HH provider with Type of Bill 32X (TOB 32X).
   • Please reference slide 48 of the 2014 Encounter Data National Technical Assistance Webinar from August 8, 2014. The webinar slides can be found on the CSSC website at http://www.csscoperations.com/internet/cssc3.nsf/DocsCat/CSSC~CSSC%20Operations~Medicare%20Encounter%20Data~Training%20Information~9N4QEK8673?open&navmenu=Medicare^Encounter^Data||||

7. When do I submit the encounters?

• The timely submission of encounter data refers to submitting encounter data within certain time frames and deadlines. CMS has established timeliness compliance standards for the following types of data:

1. Full Encounter
   • 13 months from the DOS submitted on the encounter
2. Correct/Replace or Void/Delete Encounter
   • 13 months from the DOS and not to exceed 30 days after the adjustment date
3. Chart Review Encounter
   • Within 25 months of the data collection period

Dates of Service

1/1/2011 – 12/31/2011

1/1/2012 – 12/31/2012

1/1/2012 – 12/31/2013

1/1/2014 – 12/31/2014

8. How do I set up EDS Connectivity?

• Prior to submitting encounter data, MAOs must establish a secure connection to CMS systems. MAOs use the electronic connection not only to submit encounter data to CMS, but also to receive EDFES acknowledgement and EDPS processing status reports.
• New submitters must complete an Encounter Data Electronic Data Interchange (EDI) Agreement with CMS and submit to CSSC prior to submitting encounter data. The EDI Agreement is a contract between the MAO and CMS attesting to the accuracy of the data submitted. An officer (e.g., CEO) that represents the MAO must sign this document.