Program_Memos / 2000 / B-00-23

Why This Topic Matters

The memorandum defines how physician encounter data must be accepted and processed, which affects system configuration, data validation, and reporting for Medicare+Choice operations. It also identifies the format and data elements needed for electronic encounter submissions, making it important for organizations responsible for implementation and compliance.

Article Sections

1. Background

   Provides the policy and operational context for encounter data submission and the transition timeline for physician encounter processing.

2. General Requirements

   Summarizes the submission environment, transaction volume expectations, definitions used for physician encounters, and the electronic format requirements.

3. Transaction Processing

   Describes support responsibilities for the processing environment and the role of the contractor supporting transaction handling.

4. Receipt of Transactions

   Explains how encounter transactions are verified on receipt and how incomplete or invalid submissions are handled at a high level.

5. Editing of Data - General

   Outlines broad categories of system edits applied to encounter data, including validation of required fields and lookup-based checks.

6. Functions/Edits to Eliminate, By-pass, or Turn Off

   Identifies the types of review-related functions that are not to be applied in this processing environment.

7. Functions/Editing that Shall Occur

   Covers pricing-related processing, locality handling, code acceptance rules, and other edits that remain active in the system.

8. Diagnosis and Procedure Code Editing

   Discusses logical diagnosis/procedure edits and the application of coding-related edit logic for pricing purposes.

9. Duplicate Transactions

   Describes the handling of duplicate and potential duplicate encounter transactions within the processing workflow.

10. Beneficiary Eligibility

    Addresses eligibility validation and enrollment checks performed against the submitting organization.

11. Remittance Advice Generation

    Summarizes the electronic remittance output produced for processed encounter transactions.

12. Adjustment Processing

    Explains the ability to manually adjust accepted transactions and reprocess them after changes are made.

13. History Retention

    Covers storage of encounter history across processing systems and retention expectations.

14. Provider File Maintenance

    Describes the provider file sources, maintenance approach, and data maintenance cycles for participating organizations and individual practitioners.

15. Reports

    Outlines routine reporting needs for the support center and HCFA, including transaction status and usage reporting.

16. Attachment A

    Contains the National Standard Format record layout for physician encounter data and related field structure information.