Claims Processing Terms
EDS
EODS
FISS
MCS
VMS
EDCWF
EDDPPS
EDFES
EDIPPS
EDPPPS
EDPS
1. Encounter Data Common Working File (EDCWF)
The EDCWF is a central database containing eligibility and claims history for all Medicare beneficiaries for encounter data purposes. For claims processing, the EDCWF verifies beneficiary enrollment and eligibility for the dates of service of the claim.
2. Encounter Data DME Processing and Pricing Sub-system (EDDPPS)
The Encounter Data DME Processing and Pricing Subsystem will process and price DME encounter data. The EDDPPS is based on VMS processing.
3. Encounter Data Front-End System (EDFES)
The Encounter Data Front-End System includes the Electronic Data Interchange (EDI) Commercial Off-the-Shelf (COTS) Translator, the Institutional Common Edits and Enhancements Module (CEM), the Professional CEM, and the Durable Medical Equipment (DME) CEM.
4. Encounter Data Institutional Processing and Pricing Sub-System (EDIPPS)
The Encounter Data Institutional Processing and Pricing Subsystem will process and price Institutional encounter data. The EDIPPS is based on FISS processing.
5. Encounter Data Professional Processing and Pricing Sub-System (EDPPPS)
The Encounter Data Professional Processing and Pricing Subsystem will process and price Professional encounter data. The EDPPPS is based on MCS processing.
6. Encounter Data Processing System (EDPS)
The Encounter Data Processing System is comprised of the Encounter Data Institutional Processing and Pricing Sub-System (EDIPPS), the Encounter Data Professional Processing and Pricing Sub-System (EDPPPS), and the Encounter Data DME Processing and Pricing Sub- System (EDDPPS).
7. Encounter Data System (EDS)
A data collection system used for the collection, processing, pricing, and storage of encounter data.
8. Encounter Operational Data Store (EODS)
The CMS repository for encounter data submissions. All encounter data is stored in the EODS.
9. Fiscal Intermediary Shared System (FISS)
The standard Medicare claims processing system used for all Institutional claims. The EDIPPS is based on FISS processing.
10. Multi-Carrier System (MCS)
The standard Medicare claims processing system for physician and supplemental services (i.e., lab) claims. The EDPPPS is based on MCS processing.
11. ViPS Medicare System (VMS)
The standard Medicare claims processing system that processes Durable Medical Equipment (DME) claims from DME suppliers. The EDDPPS is based on VMS processing.
Encounter Data Acronyms
A
ACA - Affordable Care Act
ANSI - American National Standards Institute
ASCA - Administrative Simplification Compliance Act
C
CAS -Claims Level Adjustment Segment
CEM - Common Edits and Enhancement Module
CMP - Competitive Medical Plan
COTS - Commercial Off-the-Shelf
CPT - Current Procedural Terminology
D
DME - Durable Medical Equipment
DMEPOS - Durable Medical Equipment Prosthetics, Orthotics, and Supplies
E
EDCWF - Encounter Data Common Working File
EDDPPS - Encounter Data DME Processing and Pricing Sub-System
EDFES - Encounter Data Front-End System
EDFESC - Encounter Data Front-End System Contractor
EDI - Electronic Data Interchange
EDIPPS - Encounter Data Institutional Processing and Pricing Sub-System
EDPPPS - Encounter Data Professional Processing and Pricing Sub-System
EDPS - Encounter Data Processing System
EDPSC - Encounter Data Processing System Contractor
EDS - Encounter Data System
EODS - Encounter Operational Data Store
F
FFS - Fee-For-Service
FISS - Fiscal Intermediary Standard System
FS - Fee Schedule
FTP - File Transfer Protocol
H
HCPC - HCFA Common Procedure Code
HCPCS - Healthcare Common Procedure Coding System
HCPP - Health Care PrePayment Plan
HIPAA - Health Insurance Portability & Accountability Act of 1996
HIPPS - Health Insurance Prospective Payment System
HMO - Health Maintenance Organization
I
IG Edits - Implementation Guide Edits
I/OCE - Integrated/Outpatient Code Editor
M
MA - Medicare Advantage
MAO - Medicare Advantage Organization
MCE - Medicare Code Editor
MCS - Multi-Carrier System
MUE - Medically Unlikely Edits
N
NCCI - National Correct Coding Initiative
NPI - National Provider Identifier
NPPES - National Plan and Provider Enumeration System
NUCC - National Uniform Claim Committee
O
OASIS - Outcome and Assessment Information Set
P
PACE - Program for All-Inclusive Care for the Elderly
PDE - Prescription Drug Event
POS - Place of Service
PPACA - Patient Protection and Affordable Care Act
PPS - Prospective Payment System
R
RAPS - Risk Adjustment Processing System
S
SNF - Skilled Nursing Facility
T
TOB - Type of Bill
TOS - Type of Service
V
VMS - ViPS Medicare System
W
WPC - Washington Publishing Company
Technical Information
Our technical information page is updated daily with all of the latest requirements from CMS. Use this as your one stop shop for technical guidelines.
5. How often do I submit the encounters?
6. What are the file size limitations?
7. What will CMS be monitoring regarding the submission of encounters?
8. What about Part B Drug Data?
1. What is the EDS process?
2. What happens to the claims after they are submitted?
3. What are the claim disposition codes?
4. What format do I submit the encounters?
1. What is the EDS process?
Providers submit claims data to the MAO.
MAO submits the encounter data in the HIPAA compliant version 5010 837X format transaction file to CMS.
Data is sent to the EDFES to process through the COTS EDI Translator, and then to the CEM module for editing.
Submitter receives acknowledgement reports based on various levels of editing performed in the EDFES.
After encounters successfully process through the EDFES, they are sent to the EDPS for detailed editing and validation.
Once processed, the encounters may take various paths. If the data is able to be priced, the data is priced and stored in EODS.
If the data falls into exception categories (i.e. capitated claim, atypical provider), the data will bypass pricing edits and move to storage. NOTE: This is not depicted in graphic
Submitters receive encounter data transaction and management reports based on the results of the EDPS edit checks.
The EODS stores all encounter data.
Model diagnoses are extracted from accepted encounters and sent to RAS for risk score calculation.
MARx is used to calculate and determine plan payments.
2. What happens to the claims after they are submitted?
MAOs must collect and adjudicate claims in the MAO entities’ claims processing systems prior to submission to EDS. Although claims may have a final disposition of “accepted”, “denied”, or “rejected” in the MAO claims processing systems, for the purposes of encounter data processing, only fully adjudicated claims with a final disposition of “accepted” or “denied” may be submitted to EDS. Adjudicated claims with a denied status must also include the reason for the denial.
Claims deemed rejected in encounter data terms will not pass EDFES edits and will be rejected back to the submitter for correction and resubmission. MAOs may not submit claims in a pending status.
3. What are the claim disposition codes?
Accepted - Claims/lines deemed “processable” and given a final disposition of “payment” within the MAO’s claims processing system
Denied - Claims/lines deemed “processable” and given a final disposition of “no payment” within the MAO’s claims processing systems
Rejected - Claim s/lines deemed “unprocessable” (i.e., Invalid HCPCS or diagnosis code) at any stage in the MAO’s adjudication process
4. What format do I submit the encounters?
In accordance with HIPAA regulations and to facilitate encounter data processing and reduce burden, MAOs must ensure that data is submitted using the appropriate HIPAA compliant standard Health Care Claims ANSI X12 V5010 format. All required data elements specific to the collection of encounter data must be populated on the 837-I (Institutional) or 837-P (Professional and DME Supplier) 5010 format.
5. How often do I submit the encounters?
MAOs are required to submit data at the frequency specified according to a tiered scale determined by the number of Medicare enrollees per Contract ID. MAOs must adhere to the minimum frequency standards established by the tiered scale, but are encouraged to submit encounter data more often. More frequent submission will help the EDS maintain its systematic capabilities to process encounter data.
Minimum Submission Frequency
Weekly
Bi-weekly
Monthly
Number of Medicare Enrollees
Greater than 100,000
50,000 – 100,000
Less than 50,000
6. What are the file size limitations?
Due to system limitations, the combination of all ST-SE transaction sets per file cannot exceed certain thresholds depending upon the connectivity method of the submitter. FTP and NDM users cannot exceed 85,000 encounters per file. Gentran users cannot exceed 5,000 encounters per file. For all connectivity methods, the TR3 allows no more than 5000 CLMS per ST-SE. Table 1C provides the file size limits due to connectivity methods:
Maximum # of Encounters
85,000
5,000
Type of Connection
FTP/NDM
Gentran
Maximum # of ST-SE
5,000
5,000
7. What will CMS be monitoring regarding the submission of encounters?
CMS will be monitoring individual submitters with regard to plan specific submission issues to address serious problems as they arise. Areas of monitoring will include the following:
Timeliness of submission
Quantity (volume) of submission
Quality of submission
Accuracy of submission
Timeliness of submission
See question 5 above
Quantity of Submission
EDS specifications require that the volume of encounters submitted to the system align with the number of enrollees per contract ID. Specific metrics include, but are not limited to, submission rates, proportions of claims in particular service categories, and overall volume of submission.
It is MAOs responsibility to ensure the volume of encounters submitted is appropriate in relation to the frequency standards established.
CMS will confirm the anticipated volume annually and will run submission quantity analyses on a quarterly basis. CMS will also perform analyses on the quantity of encounters submitted to EDS against the volume of RAPS submissions for each Contract ID.
MAOs are strongly encouraged to evenly distribute the volume of encounters submitted according to the required frequency requirements.
Quality of Submission
Quality standards allow CMS to analyze encounter data submission to ensure that EDS collects accurate and complete data. Adherence to quality standards requires that MAOs collect and submit all encounter data in the appropriate ANSI V5010 X12 format.
The quality of encounter data submitted is partially evidenced by the number of errors returned to the submitter and the number of duplicates submitted per Contract ID.
CMS will develop error frequency benchmarks and will monitor resubmission and duplicate rates on a quarterly basis.
Accuracy of Submission
MAOs are responsible for the accuracy of all encounter data submitted and must ensure that every submission can be supported by an original source document (i.e. a medical record).
MAOs must also attest that the data submitted is based on best knowledge, information, and belief and be accurate and truthful.
8. What about Part B Drug Data?
Many drugs and biologics are further identified by the National Drug Code (NDC) assigned. NDC is a system created to identify drugs intended for human use. Originating from the Drug Listing Act of 1972, Section 510 requires the Food and Drug Administration (FDA) to list all current drugs manufactured, prepared, propagated, compounded, or processed by it for commercial distribution. The NDC codes, when available, must be submitted; however, it is not required for Part B drug data submission on the encounter.
MAOs may receive drug data from Pharmacy Benefit Managers (PBMs) in the National Council for Prescription Drug Programs NCPDP D.0 format, which is not compatible with the 837. Due to the incompatibility of the NCPDP D.0 format to the 837 format in the EDS, MAOs must only submit Part B drug data that can be processed through their claims processing system and submitted on the 837. Part B drug data received by the MAO on the NCPDP D.0 format must be excluded from encounter data submission. CMS is currently reviewing alternative options for the submission of Part B drug data collected from a PBM that is in the NCPDP D.0 format.
CMS RESOURCES
1. CMS Health Plan Management System Memos
CMS publishes HPMS memos for communicating important plan-level Part C and Part D information to interested stakeholders.
2. Customer Service and Support Center (CSSC)
The CSSC website is the gateway to EDS. Visitors to the site can access information about the EDS, including opportunities for enrollment to submit encounter data and obtain comprehensive information about encounter data submission and EDS testing requirements. In addition, the site provides valuable links to CMS instructions and other official resources. Work Group and other training information is regularly posted.
The toll free help line (1-877-534-2772) is available Monday – Friday, 8:00 A.M. EST to 7:00 P.M. EST to provide assistance. CSSC provides ongoing encounter data assistance.
3. Technical Assistance Registration Service Center (TARSC)
The website includes information about trainings and work groups, training dates, locations, online registration, and encounter data FAQs.
4. A. Reddix & Associates (ARDX)
Provides project integration, industry outreach, business requirements, systems specifications and is the training contractor responsible for encounter data training initiatives, including regional training programs and work groups.
EDS Inbox: EDS@ar