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Encounter Data Validation

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Pursuant to Title 42 of the Code of Federal Regulations (42 CFR) §438.242, Oregon Health Authority (OHA) must ensure that each of its coordinated care organizations (CCOs) maintain a health information system that collects, analyzes, integrates, and reports data on areas including, but not limited to, utilization, claims, grievances and appeals, and disenrollment. OHA must also review and validate encounter data collected, maintained, and submitted by the CCOs to ensure that they are a complete and accurate representation of the services provided to its Medicaid members. OHA relies on the quality of these encounter data submissions to accurately and effectively monitor and improve the program’s quality of care, generate accurate and reliable reports, develop appropriate capitated rates, and obtain complete and accurate utilization information.

HSAG’s approach to conducting EDV studies is tailored to address the specific needs of its clients by customizing elements outlined in the Centers for Medicare & Medicaid Services (CMS) External Quality Review (EQR) Protocol 5, Validation of Encounter Data Reported by the MCO. In accordance with the protocols, HSAG incorporates the following activities in its reviews:

  1. Review of state requirements for collecting and submitting encounter data.
  2. Review of health plans’ capacity to produce accurate and complete encounter data.
  3. Analysis of health plans’ electronic encounter data for accuracy and completeness.
  4. Review of medical records for confirmation of findings of encounter data analysis.
  5. Submission of findings.

Since CY 2020, HSAG has conducted one or more of the following activities to support OHA’s validation of encounter data:

  • Information systems (IS) review—Assessment of the State’s and/or CCOs’ information systems and processes.
  • Administrative profile—Analysis of the State’s electronic encounter data completeness, accuracy, and timeliness.
  • Comparative analysis—Analysis of the State’s electronic encounter data completeness and accuracy through a comparison between the State’s electronic encounter data and the data extracted from the CCOs’ data systems.
  • Medical record review (MRR)—Analysis of the State’s electronic encounter data completeness and accuracy by comparing the State’s electronic encounter data to the information documented in the corresponding members’ medical records.

The following table highlights the EDV activities HSAG conducted, or will conduct, by contract year:

For questions related to the compliance monitoring review activity, please contact:

       Eliza Buyong, MS
       Senior Analyst, Data Science & Advanced Analytics
       Telephone: 602.575.7445
       Email: EBuyong@hsag.com

Oregon Medicaid EQRO