EncounterFlow™

Streamlined Encounter Submissions & Response Management for Medicare Advantage

Every encounter matters. Every diagnosis counts. With EncounterFlow™, manage all your Medicare Advantage (MA) risk adjustment encounters—from creation to submission to CMS response—without confusion or delays. Reduce errors, improve first-pass acceptance, and stay audit-ready with a solution built for efficiency and compliance.

Who This Is For

EncounterFlow™ is perfect for:

  • Medicare Advantage health plans

  • Delegated entities (TPAs, coding partners)

  • Risk adjustment and coding teams managing retrospective or prospective chart reviews

  • Organizations seeking full visibility from encounter creation to HCC eligibility

If you handle MA encounters and want clarity, compliance, and efficiency, this solution is built for you.

The Challenges We Solve

Organizations face common frustrations with MA encounter submissions:

  • Accepted 837s fail CMS companion-guide rules

  • MAO-002 & MAO-004 responses are difficult to interpret for HCC eligibility

  • Manual reconciliation between submissions, provider charts, and coding decisions

  • Tracking first-pass acceptance rates and payment-impacting diagnoses takes hours

EncounterFlow™ eliminates these issues by providing a single, streamlined workflow with real-time insights.

How EncounterFlow™ Works: End-to-End

1. Ingest & Normalize

  • Accept professional, facility, and chart-review encounters

  • Convert to CMS-compliant 837 formats

  • Validate NPI, taxonomy, POS, and plan-specific companion rules

  • Automatically detect missing or inconsistent fields to prevent rejections

2. Pre-Edits & Compliance Checks

  • HIPAA/SNIP validations for every encounter

  • Companion-guide rules applied automatically

  • Risk-adjustment plausibility checks to ensure RAF accuracy

3. Submit & Track

  • Securely send encounters to CSSC/EDPS

  • Real-time parsing of TA1, 999, 277CA acknowledgments

  • Visual dashboards show which encounters passed and which need attention

  • Alerts highlight critical errors before they affect payment

4. Response & Reconciliation

  • Map MAO-002 acceptance/rejection details

  • Evaluate MAO-004 risk-adjustment eligibility

  • Flag diagnoses that don’t make it through and guide corrective action

  • Link each response back to the original chart and coding decision

5. Close the Loop

  • Connect HCC-eligible diagnoses to analytics dashboards

  • Provide insights for provider education, coding QA, and supplemental submissions

  • Maintain full audit-ready traceability for RADV and compliance

Key Capabilities

  • 837 Encounter Builder: Build professional, facility, and chart-review encounters with intelligent validation rules

  • Automated Response Engine: Parse TA1, 999, 277CA, MAO-002, and MAO-004 files instantly

  • HCC Lens: Quickly see which accepted encounters are RA-eligible

  • Exception Workbench: Guided fixes, one-click resubmission, bulk corrections

  • RADV-Aware Traceability: Evidence linking encounters to chart and coding decisions

  • Dashboards & Reporting: Visualize trends, acceptance rates, top reject codes, and payment-impacting diagnoses

  • Custom Alerts & Notifications: Notify teams of high-priority issues immediately

  • Historical Comparison Tools: Track changes in acceptance/rejection trends over time

Expanded Benefits

  • Higher First-Pass Acceptance: Catch errors before submission

  • Faster Cash Accuracy: Prevent delayed payments from blocked or rejected diagnoses

  • Audit-Ready Documentation: Maintain evidence linking every encounter to supporting charts

  • Operational Efficiency: Reduce manual effort and error-prone reconciliation

  • Team Clarity & Collaboration: Centralized visibility for coding, submissions, and CMS responses

  • Continuous Learning: Track recurring errors and implement process improvements

  • Better Provider Engagement: Identify common issues and provide feedback to improve coding accuracy

KPIs Tracked

  • First-pass acceptance rate (TA1/999/277CA)

  • MAO-002 acceptances and reject trends

  • MAO-004 eligibility yield (% of accepted encounters producing RA-eligible diagnoses)

  • Time-to-resolution for common reject patterns

  • RADV exposure and unsupported codes

  • Number of corrected submissions after exceptions are resolved

Compliance & Security

EncounterFlow™ is HIPAA-ready, aligns with CMS submission protocols, and ensures audit-ready traceability. Maintain regulatory compliance while optimizing risk-adjustment performance.

Implementation Options

  • SaaS Cloud Deployment: Secure, scalable, low IT overhead

  • API / Batch Integration: Connect with claims systems, coding tools, and data lakes

  • Delegate-Friendly Workspaces: Manage submissions for TPAs, coding partners, and other delegates

  • Custom Configuration: Tailor workflows, dashboards, and alerts to your organization’s needs

Why HDM EncounterFlow™?

  • Unified Risk Adjustment Stack: Works seamlessly with other HDM solutions like ProspectIQ™ and HDM ChartCopilot™

  • HCC-First Approach: Not just accepted vs. rejected—see which encounters actually impact RAF

  • Plain-English Guidance: Built-in tips and training consistent with HDM’s blogs and EDPS explainer content

  • Actionable Insights: Translate CMS responses into clear, prioritized action items