Encounters Processing Solutions

Partner with Envolve for Encounters Processing

Envolve Health understands that good claims in mean a good encounter out. We make sure our medical claims and encounters processing solutions are efficient, effective, and accurate to support downstream encounter data production.

Our Encounters Processing capabilities include:

  • Financial Encounter Balancing and Reconciliation Tracking
  • Claims to Encounter Support 
  • Reconciliation Review
  • Monitoring Encounter Submissions
  • Acceptance and Rejection Review
  • Vendor Status Reports

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 for MCOs.

Encounter Data Extraction and Preparation

Our integrated encounter system is configured to systematically extract Medicaid and Medicare claim data from our Enterprise Data Warehouses (EDW) into the encounter repository based on the claim paid date.

This encounter data management system minimizes bottlenecks and the need for manual intervention and ensures we meet our customer’s timeliness requirements for encounter data submission.

When encounter data is submitted electronically, we adhere to strict data privacy standards, as our system is designed to comply with all industry standards and regulations.

We Keep Claims and Encounter Data Safe

We adhere to HIPAA, NCQA, AMA coding, UB-04 editor, and NCCI standards regarding the definition and treatment of critical data elements captured on claims.

We produce both Professional and Institutional Encounter files for the MMIS in HIPAA compliant 837P (Professional) and 837I (Institutional) formats.

Encounter Pre-Submission Scrub and Accuracy Validation

Envolve's encounter solution includes a module which provides a ‘pre-submission scrub’ mechanism to customize and apply edits to Medicaid and Medicare encounters data prior to State submission as a final accuracy check.

Envolve configures scrubs to recognize conditions that could cause a payer to deny the encounter and hold the claim for review.

If errors are identified, we work with the member’s healthcare providers to correct any issues and/or reprocess the claims for a valid encounter submission.

Encounter Processing Correction and Resubmissions

If an erred encounter file requires claim reprocessing, 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 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 our EDW is combined with corrected, repairable encounters that need to be resubmitted.

Encounters Processing Solutions with Envolve

Envolve offers an efficient, effective & accurate healthcare encounters processing solution for healthcare payers. Improve the effectiveness of member care and deliver cost savings with support from Envolve Health. Contact us today!

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