§ 422.257 - Encounter data.

(a) Data collection: Basic rule. Each M+C organization must submit to CMS (in accordance with CMS instructions) all data necessary to characterize the context and purposes of each encounter between a Medicare enrollee and a provider, supplier, physician, or other practitioner.

(b) Types of service and timing of submittal. M+C organizations must submit data as follows:

(1) Beginning on a date determined by CMS, inpatient hospital care data for all discharges that occur on or after July 1, 1997.

(2) CMS will provide advance notice to M+C organizations to collect and submit data for services that occur on or after July 1, 1998, as follow:

(i) Physician, outpatient hospital, SNF, and HHA data beginning no earlier than October 1, 1999; and

(ii) All other data CMS deems necessary beginning no earlier than October 1, 2000.

(c) Sources and extent of data. (1) To the extent required by CMS, the data must account for services covered under the original Medicare program, for Medicare covered services for which Medicare is not the primary payor, or for other additional or supplemental benefits that the M+C organization may provide.

(2) The data must account separately for each provider, supplier, physician, or other practitioner that would be permitted to bill separately under the Medicare fee-for-service program, even if they participate jointly in the same encounter.

(d) Other data requirements. (1) M+C organizations must submit data that conform to the requirements for equivalent data for Medicare fee-for-service when appropriate, and to all relevant national standards.

(2) The data must be submitted electronically to the appropriate CMS contractor.

(3) M+C organizations must obtain the encounter data required by CMS from the provider, supplier, physician, or other practitioner that rendered the services.

(4) M+C organizations may include in their contracts with providers, suppliers, physicians, and other practitioners, provisions that require submission of complete and accurate encounter data as required by CMS. These provisions may include financial penalties for failure to submit complete data, or for failure to submit data that conform to the requirements for equivalent data for Medicare fee-for-service.

(e) Validation of data. M+C organizations and their providers and practitioners will be required to submit medical records for the validation of encounter data, as prescribed by CMS.

(f) Use of data. CMS uses the data obtained under this section to determine the risk adjustment factor that it applies to annual capitation rates under § 422.256(c). CMS may also use the data for other purposes.

(g) Deadlines for submission of encounter data. Risk adjustment factors for each payment year are based on encounter data submitted for services furnished during the 12 month period ending 6 months before to the payment year (for example, risk adjustment factors for CY 2000 are based on data for services furnished during the period July 1, 1998 through June 30, 1999).

(1) The annual deadline for encounter data submission is September 10 for encounter data reflecting services furnished during the 12 month period ending the prior June 30 (for example, the deadline for submission of data for the period July 1, 1998 through June 30, 1999 is September 10, 1999).

(2) CMS allows a reconciliation process to account for late data submissions. CMS continues to accept encounter data submitted after the September 10 deadline until June 30 of the payment year (for example, until June 30, 2000 for data from the period July 1, 1998 through June 30, 1999). After the payment year is completed, CMS recalculates the risk factors for affected individuals to determine if adjustments to payments are necessary.