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The policy explains provider obligations to understand plan-specific requirements and submit encounters within defined deadlines after the date of service, using current diagnosis, procedure, and place of service codes at appropriate specificity. It outlines data submission schedules, acceptance/validity rate expectations, handling of rejected submissions through resubmission timelines, and appeal processes for denied claims, supporting regulatory reporting to DMHC and NCQA-HEDIS requirements.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/encounter-data-submission-policy-and-procedures-all-plans/172871/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/encounter-data-submission-policy-and-procedures-all-plans/172871.png","ImageObject",442,249,{"name":88,"@type":89},"Margaret","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-19","2026-09-01",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What is the purpose of [INSERT CHC NAME]’s encounter data submission policy?","Question",{"text":109,"@type":110},"The policy enables contracted health plans to meet regulatory requirements, accurately capture data for medical programs, and improve medical and financial performance. It also requires certification of completeness and truthfulness for DMHC-related reporting.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What deadlines and scope apply to encounter data submitted by providers?",{"text":114,"@type":110},"Providers must submit encounter data for all covered services delivered to assigned capitated members, including PCP visits and sub-capitated services, within the defined timeframe from the date of service. Specific deadlines depend on the contracted health plan, PPG, or IPA requirements.",{"name":116,"@type":107,"acceptedAnswer":117},"How does [INSERT CHC NAME] handle rejected encounter submissions and denied claims?",{"text":118,"@type":110},"For rejected submissions, [INSERT CHC NAME] corrects the rejections and resubmits within the designated time frame/claim file limit after receiving the rejection notice. For denied claims, [INSERT CHC NAME] files appeals when necessary within the specified time frame after the date of service, unless otherwise stated by contracted PPGs/IPAs.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},172871,1788297305,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":126,"read_time":76},137451207643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","[Insert Community Health Center (CHC) Name and/or Logo]\nEncounter Data Submission Policy and Procedures (ALL PLANS)\nPOLICY:\nIt is the policy of [INSERT CHC NAME] to ensure complete, accurate, reasonable, and timely submission of encounter data to all contracted health plans, for all items and services furnished to its members, whether directly or through clearinghouses, IPAs, or PPGs, including capitated providers.\nIt is the policy of [INSERT CHC NAME] to understand encounter data submission requirements for each contracted health plan and that providers submit encounter data within the defined deadline (e.g., 90 days) from the date of service. Encounter data must be submitted for all covered services provided to assigned capitated members.\nIt is the policy of [INSERT CHC NAME] to recognize how imperative it is that all capitated services be submitted on a regular basis. We hold all providers accountable for the information regarding their patient populations, even more so when evaluating prevalent diseases, treatment outcomes, preventive medicine, etc.\nPURPOSE:\n[INSERT CHC NAME] is required to submit encounter data to enable contracted health plans to comply with regulatory requirements, accurately capture data for various medical programs, and help improve medical and financial performance. We must certify the completeness and truthfulness of our encounter data submissions, as required by the Department of Managed Health Care (DMHC).\n[INSERT CHC NAME] is required to comply with regulatory reporting requirements of the DMHC and comply with NCQA-HEDIS reporting requirements.\nDefinitions:\nEncounter Data: Records of services delivered to beneficiaries enrolled in managed care plans that receive a capitated, per-member-per-month payment. They are the primary source of information about the delivery of services provided by healthcare or atypical providers to capitated members.\nCapitation Payment: A lump sum payment received each month to cover the cost of healthcare services for each beneficiary from the capitated payer, regardless of the amount or type of services rendered.\nIndependent Physician Association (IPA): A business entity organized and owned by a network of independent physician practices for the purpose of reducing overhead or pursuing business ventures such as contracts with employers, accountable care organizations (ACO) and/or managed care organizations (MCOs).\nParticipating Physician Group (PPG): Physician groups that contract with health plans on a capitated basis, where the health plan negotiates a monthly fixed dollar amount with providers based on a Per Member Per Month (PMPM) rate schedule.\nManaged Care Organization (MCO): A managed care organization is a health care company or a health plan that is focused on managed care as a model to limit costs, while keeping quality of care high. Health insurance contracts for health care services through established networks of organized systems of care, which emphasize primary and preventive care. Common MCO types include but are not limited to: Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), or Point of Service (POS).\nProcedures:\nWe are required to submit encounter data in accordance with all contracted health plans and PPGs/IPAs, which are listed below. For providers with large patient panels, it’s advised to submit encounter data more frequently [INSERT CADENCE].\nWe must submit data for all covered services provided to a member (include all services for which the practice is responsible), including Primary Care Physician (PCP) visits and sub-capitated services.\nAll data records must include the most current industry standard diagnosis, procedure, and place of service codes. All diagnosis codes must be reported to an accurate level of specificity that reflects the patient’s current condition.\nAll encounters from contracted providers are required to be submitted within the designated number of days from the date of service in which care ","cbCaib1sdK2j1EGT","https://ap.wps.com/l/cbCaib1sdK2j1EGT","docx",223613,8,"English","# Policy\n## Purpose\n## Definitions\n# Procedures\n## Encounter Data File Submission Schedule\n## Acceptance or Validity Rates\n## Schedule for Rejected Submissions\n## Schedule for Submitting Appeals\n## Code Sets","[{\"question\":\"What is the purpose of [INSERT CHC NAME]’s encounter data submission policy?\",\"answer\":\"The policy enables contracted health plans to meet regulatory requirements, accurately capture data for medical programs, and improve medical and financial performance. It also requires certification of completeness and truthfulness for DMHC-related reporting.\"},{\"question\":\"What deadlines and scope apply to encounter data submitted by providers?\",\"answer\":\"Providers must submit encounter data for all covered services delivered to assigned capitated members, including PCP visits and sub-capitated services, within the defined timeframe from the date of service. Specific deadlines depend on the contracted health plan, PPG, or IPA requirements.\"},{\"question\":\"How does [INSERT CHC NAME] handle rejected encounter submissions and denied claims?\",\"answer\":\"For rejected submissions, [INSERT CHC NAME] corrects the rejections and resubmits within the designated time frame/claim file limit after receiving the rejection notice. For denied claims, [INSERT CHC NAME] files appeals when necessary within the specified time frame after the date of service, unless otherwise stated by contracted PPGs/IPAs.\"}]","Encounter Data Submission Policy and Procedures - ALL PLANS | DOCX"]