Local Navigation

• Florida Medicaid Home Page
• Abuse & Overpayment
• Area Offices
• Assistive Care Services
• Behavioral Health
• Child Health Services
• Cost Reimbursement
• Disease Management
• Draft Handbook Review
• Durable Medical Equipment (DME)
• Family Planning
• HCBS Waivers
• HIPAA
• Intergovernmental Transfer (IGT) Workgroup
• Long-Term Care Partnership
• Medicaid Encounter Data System (MEDS)
• Medicaid HMOs
• Medicaid Privacy Notice
• Medicaid Procurements
• Medicaid Reform
• Medicaid Research Contracts and Evaluations
• Medicaid State Plan
• MediKids
• MediPass
• Newborn Eligibility
• Nursing Facility Provider Information
• Nursing Home Transition
• Organ Transplant Advisory Council
• Payment Error Rate Measurement (PERM)
• Pharmacy Services
• Preferred Drug List
• Provider Service Network (PSN)
• Provider Training e-Library
• Quality in Managed Care
• Recent Presentations
• Reimbursement Workgroups Meetings
• Report Medicaid Fraud
• Statewide Medicaid Managed Care Program
• Substance Abuse Services
• Utilization Review

Medicaid Encounter Data System (MEDS)

The Medicaid Encounter Data System (MEDS) collects, processes, stores, and reports managed care service activities and prescription drug utilization for all Florida Medicaid capitated health care providers.  MEDS 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 no longer accepts versions 4010 of X12 837 encounter claims or version 5.1 of NCPDP transactions.  March 1, 2012, through June 30, 2012, is the period designated for health plans to complete software and business changes, and to finalize testing activities and complete the transition to 5010 and D.0 formatting.

Pharmacy Encounters

Please refer to the “Encounters Testing” document located on the website for details about NCPDP testing:

Pharmacy Encounters Testing Companion Guide

X12 837 Encounters

Effective April 18, 2012, all encounter trading partner IDs (TPIDs) were deactivated. There are two tasks each plan must complete before the Agency will reactivate TPIDs and authorize the plan to submit 5010 X12 encounters in the production environment. 

1. Register any provider that will be present on encounter claims in FMMIS.  There are two tools for doing so, namely the two-page Registration Form and the Mass Registration electronic file process.  The Mass Registration process may be used for any provider (in-state or out-of-state) with a valid Florida license.  Please use the two-page Managed Care Treating Provider Registration form to register providers not licensed in Florida.  Failure by the plans to register/enroll all their service providers will cause encounter claims to fail the system’s provider checks.
   
   
2. Successfully test 5010 encounter claim submissions through Ramp Manager.  Please follow the instructions provided at this site, under “Managed Care Plan X12 Testing”:  X12 5010 Testing

Additional instructions for Ramp Manager may be found on the Florida Medicaid public portal:  Ramp Manager Information Sheet

837 Companion Guides Clarifications

Validation requirements for encounter claims have been documented in the Companion Guides located on the website:  EDI Companion Guides.  These guidelines are not being adhered to with the submissions of recent 5010 production encounter claims.  Here are some common errors:

• As noted above, all plans are required to use Ramp Manager as a testing mechanism to ensure that claims will pass the syntax requirements for the 5010 transaction.  These tests should include the following segments:  the CN1 segment, the ISA segment, and the COB segment.  Failure to submit these required segments will result in a header level failure, thus requiring remediation of the claims.
  
  
• The recently published 837 Companion Guides specify: ‘For encounter claims, MCO is the primary and secondary payer.’ The guides are being updated with a clarification.  The health plan should always be reported as one of the payers. When there is another payer, third party liability (TPL), the TPL is primary and the health plan is secondary.  When there is no TPL the health plan is primary.
  
  
• Values portrayed in the CN101 segment are not restrictive.  All values associated with the CN101 in the 5010 Implementation Guides are permissible. 

Submission and Enforcement Timeline

By July 1, 2012, all health plans will be expected to have completed readiness activities and resume submission of encounter claims according to contract requirements.  Completeness, Accuracy and Timeliness measures will be applied to encounter claims according to the following timelines. 

• X12 encounter claims with health plan paid dates through 5/31/2012 must be submitted by 8/1/2012.

• X12 encounter claims with health plan paid dates of 6/1/2012 and after are to be submitted on the normal routine (due within 60 days following the end of the month in which the payment was made). 

• Pharmacy encounter claims with dates of service through 6/30/2012 must be submitted by 7/15/2012. 

EDI Contact Information

For technical questions and/or clarifications of the 5010 encounter Companion Guides, please contact the HP EDI Helpdesk at 1 (866) 586-0961.  If you have policy/contract questions, contact the MEDS Team via email at: medsmailbox@ahca.myflorida.com.

Current Information

MEDS Archive

Reports and Presentations

RSS Feed to subscribe to document updates

Email your comments and suggestions on the Medicaid Encounter Data System to:

medsmailbox@ahca.myflorida.com