Envolve's ability to receive accurate and complete claims (as well as inbound encounters for sub-capitated services) from providers on the "front end" of the encounter data submission process is a critical factor in ensuring timely, accurate, and complete encounter data production.
We understand that good claims in means a good encounter out. We make sure our medical claims processing is efficient, effective, and accurate to support downstream encounter data production.
Our process includes:
Our integrated encounter system is configured to systematically extract claim data from our EDW into the encounter repository based on the claim paid date to minimize bottlenecks and the need for manual intervention, as well as ensure we meet timeliness requirements for encounter data submission. The encounter system is configured to submit encounter data that complies with all standards for electronic file submission. We also adhere to HIPAA, NCQA, AMA coding, UB-04 editor, and NCCI standards regarding the definition and treatment of critical data elements captured on claims. The encounter solution produces Professional and Institutional Encounter files for the MMIS in HIPAA compliant 837P (Professional) and 837I (Institutional).
Envolve's encounter solution includes a module which provides a ‘pre-submission scrub’ mechanism to customize and apply edits to encounters prior to State submission as a final check for encounter accuracy prior to submission to the state. Envolve configures scrubs to recognize conditions that could cause an encounter to deny and hold the claim for review. If errors are identified, we work with providers to correct any issues and/or reprocess the claims for a valid encounter submission.
If an erred encounter file requires the claim to be reprocessed, corrections are made at the source and resubmitted through the encounter solution. If an identified systematic error requires a system configuration change, we submit a configuration change request to correct program logic issues. Encounter submission errors processed by our subcontracted vendors are corrected by the vendor in collaboration with Envolve. Once corrected, those encounters are batched and are resubmitted for the next encounter cycle. Weekly encounter data from EDW is combined with corrected, repairable encounters that need to be resubmitted.