Response to Comment Document (60-day)

Docket: CMS-2023-0200 Response

Collection of Encounter Data from MA Organizations, Section 1876 Cost HMOs/CMPs, MMPs, and PACE Organizations (CMS-10340)

Comment On: CMS-2023-0200-0001
Collection of Encounter Data from MA Organizations, Section 1876 Cost HMOs/CMPs, MMPs, and PACE Organizations (CMS-10340)

Document: CMS-2023-0200-0002
Comment on CMS-2023-0200-0001

Submitter Information

Name: Hope Ray
Address: United States 
Email: hope_ray@sharedhealth.com

General Comment

Shared Health does not have claims data to generate an encounter for dental services submitted through our supplemental benefit card.

Response

CMS has been collecting MA encounter data starting with 2014 dates of service, and MA organizations have been submitting these data reliably for many years now. While collecting encounter data for Medicare-covered items and services (basic benefits) has thus far been the focus of our data quality improvement work with plans, CMS requires that MA organizations submit to CMS all items and services, including supplemental benefits.

Regulation 42 CFR 422.310(b) states, “Each MA organization must submit to CMS (in accordance with CMS instructions) the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee by a provider, supplier, physician, or other practitioner. CMS may also collect data necessary to characterize the functional limitations of enrollees of each MA organization.”

We understand that some submitters employ capitated or allowance types of payment arrangements in which the submitter does not receive claims data for dental services. CMS expects that, in these circumstances, MA organizations will work with their vendors to gather the data necessary to populate an 837D.   

Docket: CMS-2023-0200 Response

Collection of Encounter Data from MA Organizations, Section 1876 Cost HMOs/CMPs, MMPs, and PACE Organizations (CMS-10340)

Comment On: CMS-2023-0200-0001
Collection of Encounter Data from MA Organizations, Section 1876 Cost HMOs/CMPs, MMPs, and PACE Organizations (CMS-10340)

Document: CMS-2023-0200-0003
Comment on CMS-2023-0200-0001

Submitter Information

Name: Jeremiah McCoy
Address: United States 
Email: jeremiah.mccoy@elevancehealth.com

General Comment

(Full Comments in Attachment)

As CMS is aware, the Encounter Data Processing System (EDPS) has been unable to accept dental encounters unless they ore submitted in one of two formats: professional encounters (837P) and institutional encounters (8371). We appreciate that CMS is working to increase standardization across payers by requiring MA organizations to submit data on routine dental services in the industry standard dental claim format, 837-D. This shift would replace the current process to submit under 837P or 8371. Elevance Health recently implemented 837-D submission in our Medicaid plan in West Virginia. Based on this experience, we strongly urge

CMS to allow nine months to implement the new format, and ensure all stakeholders have timely encounter data specification materials for 837-D, in support of beneficiary care.

Response

CMS will notify submitters when the EDS begins accepting dental encounters using the 837D format; we expect that this will be around June 2024. At that time, we expect that MA organizations will begin to submit supplemental dental benefits for dates of services beginning January 1, 2024, and we expect submissions (notwithstanding runout) to be caught up by the end of 2024.

Draft instructions for submission of supplemental dental services were released with the PRA package and will be updated prior to implementation of dental services collection.

Thank you for your comment supporting the use of the 837D for collecting dental services in the encounter data system.