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. 

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?

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?

1. Providers submit claims data to the MAO.

2. MAO submits the encounter data in the HIPAA compliant version 5010 837X format transaction file to CMS.

3. Data is sent to the EDFES to process through the COTS EDI Translator, and then to the CEM module for editing.

4. Submitter receives acknowledgement reports based on various levels of editing performed in the EDFES.

5. After encounters successfully process through the EDFES, they are sent to the EDPS for detailed editing and validation.

6. Once processed, the encounters may take various paths. If the data is able to be priced, the data is priced and stored in EODS.

7. 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

8. Submitters receive encounter data transaction and management reports based on the results of the EDPS edit checks.

9. The EODS stores all encounter data.

10. Model diagnoses are extracted from accepted encounters and sent to RAS for risk score calculation.

11. MARx is used to calculate and determine plan payments.

 
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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:

Type of Connection

FTP/NDM

Gentran

Maximum # of Encounters

85,000

5,000

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:
  1. Timeliness of submission
  2. Quantity (volume) of submission
  3. Quality of submission
  4. Accuracy of submission
  1. Timeliness of submission
    • See question 5 above
  2. 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.
  3. 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.
  4. 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.