The Volume of Encounter Claim Records from Comprehensive Managed Care Organizations in 2017 (Brief)

T-MSIS Analytic Files Data Quality Brief #5162
Publisher: Baltimore, MD: Centers for Medicare & Medicaid Services
Oct 24, 2019
Authors
Julia Baller, Andres Arguello, Mary Allison Geibel, Brenda Natzke, Kimberly Proctor, and Jessie Parker

Key Findings:

  • States are required to report in T-MSIS encounter records that reflect services provided to Medicaid and CHIP beneficiaries by managed care organizations. These encounter records include one header and one or more associated line records per claim. Header records summarize information about the entire claim, and line records provide details about the individual goods and services billed as part of the claim. This brief examines the number of header- and line-level encounter records from comprehensive plans relative to the size of a state’s comprehensive managed care program. The analysis is conducted separately for the 2017 IP, LT, OT, and RX files. The purpose of this analysis is to identify states with completeness or quality problems in their managed care encounter data.
  • Of the 35 states and the District of Columbia that reported beneficiaries enrolled in comprehensive managed care programs in T-MSIS, 2 states fell into the low-concern category with respect to the volume of encounter records across all four claims files. Seven states fell into the low-concern category with respect to the volume of encounter records in the IP file, 6 states fell into this category with respect to the volume of encounter records in the OT file.
  • One states—North Dakota—did not have any encounter data in the T-MSIS Analytic Files; as a result, its claims data are unusable for research requiring encounter claims data. Iowa (IP and OT), South Carolina (LT), Tennessee (RX), and Wisconsin (RX) had no encounter data in one or more files, and therefore had unusable encounter claims data for some files.