Medicaid Program Oversight (MPO)
The mission of the Medicaid Program Oversight Unit (MPO) is to monitor, analyze and validate encounter data submissions from Medicaid Health Plans to enhance system processes for collecting and reporting encounter data, to determine Health Plans’ compliance with contractual requirements, and to measure health outcomes. To that end, MPO collects, processes, stores, reports and analyzes the encounter data from managed care service activities and prescription drug utilization for all Florida Medicaid capitated Health Plans. MPO also supports rate development and the risk model computations that set capitated payments for managed health care entities as defined in the Florida Medicaid Reform contracts.
The Agency for Health Care Administration is required to capture encounter data for all Medicaid managed care services in compliance with Title XIX of the Social Security Act, the Balanced Budget Act of 1997, 42 CFR 438, and Chapters 409 and 641, Florida Statutes.
HIPAA 5010 and NCPDP D.0 Encounter Claims Submissions
The Florida Medicaid Program now requires version 5010 of X12 837 encounter claims, and version D.0 of National Council for Prescription Drug Programs (NCPDP) encounter transactions.
X12 5010 Encounter Claims -
- Requirements for X12 837 encounter claims are documented in the national Implementation Guides, which may be obtained through the Washington Publishing Company’s website. Florida’s specifications are in the Florida Companion Guides. Please consult these Guides frequently for the technical specifications regarding proper formatting and presentation of your X12 837 encounters.
- Please also refer to the Managed Care page on the Florida Medicaid public provider portal for additional details about the 5010 versions of X12 837 encounter transactions.
For example, here are some common errors/issues to be aware of:
- All plans should use Ramp Manager as a testing mechanism to ensure that their encounter claims will pass the syntax requirements for 5010 transactions.
- Failure to submit information correctly in the CN1 segment, the ISA segment, and the COB segment will result in a header level failure, thus requiring remediation of the claims.
- All plans are now required to submit X12 837 encounters in separate files by county according to the 9-digit, county-specific Medicaid Provider ID in field ISA02 of the Interchange Header.
- Clarification regarding Loop 2320 (required on all encounter claims) is provided in the 837 Companion Guides: “For encounter claims, the MCO should always be reported as one of the other payers. For example, when there is TPL, the TPL is primary and the MCO is secondary. When there is no TPL, the MCO is primary.”
- Values portrayed in the CN101 segment are not restrictive. All values associated with the CN101 in the 5010 Implementation Guides are permissible.
NCPDP D.0 Encounter Claims -
- Requirements for NCPDP encounter claims are documented in the national Implementation Guide, which may be obtained through the
NCPDP website. Florida-specific requirements are in the “Encounter D.0 Specs” on Florida Medicaid’s Pharmacy Information page. Please review these guides frequently for the most current technical specifications for formatting and presenting your NCPDP encounter claims.
- Please refer to the Pharmacy Information page on the Florida Medicaid public provider portal for details about NCPDP D.0 encounter specifications.
Please contact the appropriate party for help in the following areas:
- Contact the HP EDI Team at 1-866-586-0961 or firstname.lastname@example.org for information on the following topics:
- X12 submissions (837s)
- X12 processing reports (997s, 835s, etc.)
- Mass Registration
- Ramp Manager testing
- Encounter Trading Partner Agreements (TPIDs)
- Contact the HP Provider Service Call Center (PSCC) at 1-800-289-7799, Option 7, for help with the following:
(PLEASE NOTE: When calling the PSCC, please identify yourself as a plan representative. Have the ICN available for the claim you are calling about and the TPID under which the claim was submitted. This will assist the call center representative in identifying that your call is about encounter claims.)
- Clarification of different claim-specific EOB/error codes
- Clarification of why certain EOB/error codes were given
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