Encounter Data and MCO Reporting

The encounter data and Managed Care Organization (MCO) reporting webpage contain information to assist MCOs in reporting and receiving data associated with their Department of Health Services (DHS) contract.

Questions regarding these files should be directed to VEDS HMO Support at VEDSHMOSUPPORT@wisconsin.gov

Index

Document	Last Update
Enrollment Cycles and Capitation Payment Reporting Schedule	12/6/2021
Encounter Technical Workgroup Conference Call Schedule	01/13/2023
Encounter User Guide	12/18/2023
EOB Cheat Sheet	02/27/2024
MCO Toolkit	07/05/2016
Provider Service Hierarchy
Forward Health MCO Pricing Administration Guide	04/05/2024
Forward Health APR DRG MCO Documentation
Quarterly Progress Report	06/27/2017
Report Matrix	06/05/2021
WI BCP Financial Template and Synopsis	03/21/2023
Annual HMO Financial Audit Guide	06/26/2018
x12 Companion Documents
Clinical Laboratory Improvement Amendments (CLIA) Guide	09/01/2014
Care Coordination Reports - PA File
HMO Provider Network Universe
Third Party Liability 101	06/28/2018
HMO Periodic Audit Round One (Year Ending 2017) Findings, in Compliance with CFR 42 438.602(e)	06/04/2020
HMO Periodic Audit Round Two (Year Ending 2018) Findings, in Compliance with CFR 42 438.602(e)	01/12/2022
HMO Periodic Audit Round 3 (Year Ending 2019) Findings, in Compliance with CFR 42 438.602(e)	01/12/2022

Enrollment Cycles and Capitation Payment Reporting Schedule

This document contains the enrollment cycles and capitation payment reporting schedule as released by ForwardHealth.

• CY22 Enrollment Cycles and Capitation Payment Reporting Schedule

Encounter Technical Workgroup Conference Call Schedule

This document contains the schedule for the Encounter Technical Conference Calls.

• Encounter Technical Meeting Schedule 2022

Encounter User Guide

The DHS Medicaid Contract requires MCOs to report encounter data to ensure quality of care for rate setting purposes. The Encounter User Guide contains the reference materials necessary to report encounter data to the Department.

• Encounter User Guide

EOB Cheat Sheet

The EOB Cheat Sheet is a guide for MCOs to understand the reasons why an encounter has been denied by Medicaid Management Information Systems (MMIS).

• EOB Cheat Sheet

MCO Toolkit

The MCO Toolkit is training material for new MCO employees to educate on the MMIS system and the State encounter processing.

• MCO Toolkit

Provider Service Location Hierarchy

This document details the HCPCS procedure code range and what service area it applies to.

• Provider Service Location Hierarchy

Forward Health MCO Pricing Administration Guide

This guide is developed to help interpret the Max Fee extract and to assist MCOs in understanding MMIS reimbursement policy.

• Forward Health MCO Pricing Administration Guide

Forward Health APR DRG MCO Technical Documentation

This guide is developed to assist MCOs in understanding APR DRG pricing and policies.

• Forward Health MCO APR DRG Technical Documentation

Quarterly Progress Report

MCOs are required to report the status of encounter data submissions to DHS on a quarterly basis. The Quarterly Progress Report contains the instructions on how that reporting is to be performed.

• Quarterly Progress Report

Report Matrix

The link below contain all reports and layouts sent by DHS to MCOs.

• Report Matrix

WI BCP and SSI Financial Template and Synopsis

MCOs are required to submit historical financial information for Medicaid services provided to support the rate setting process.
The enclosed file, entitled “WI BCP Financial Template” is the template that should be used to report member months, revenue, payments to providers for medical services, and administrative costs. The file contains an instructions tab for directions on completing the template.

• WI BCP Financial Template Version 8.0
• WI Medicaid HMO Financial Template Synopsis
• WI BCP and SSI Financial Template Q&A
• HMO Financial Template Training Information

Annual HMO Financial Audit Guide

• Annual HMO Financial Audit Guide

ASC X12 Implementation Guides

The link below will direct you to the HIPAA Version 510 Companion Guides and NCPDP D.0 Payer Sheets and ASC x12 Implementation Guides

• ASC x12 Implementation Guides

CLIA Guide

This guide contains all relative HCPCS Procedure Codes related to CLIA and the components required for reimbursement.

• CLIA Guide

Care Coordination Reports - PA File

The following links contain Prior Authorization data definitions and File Layouts sent by DHS to HMOs.

• HMO PA Data Definition V2.2
• HMO PA Error Reasons V1.5
• HMO PA Response File V1.0

HMO Provider Network Universe

The following links contain file submission specifications and data dictionaries sent by DHS to HMOs.

• 25739 file submission specs v6 3.5
• 25739 hmo provider network data dictionary v001 release v3 2 5 - standard final release 20220901
• 25739 hmo provider network data dictionary v002 release v3 2 5 - coe final release 20220901
• HPN Response File Data Dictionary v3 1.0
• Provider Network Upgrade – FAQ

Third Party Liability 101

• Third Party Liability 101

HMO Periodic Audit Round One (Year Ending 2017) Findings, in Compliance with CFR 42 438.602(e)

• HMO Periodic Audit Round One (Year Ending 2017) Findings, in Compliance with CFR 42 438.602(e)

HMO Periodic Audit Round Two (Year Ending 2018) Findings, in Compliance with CFR 42 438.602(e)

• HMO Periodic Audit Round Two (Year Ending 2018) Findings, in Compliance with CFR 42 438.602(e)

HMO Periodic Audit Round 3 (Year Ending 2019) Findings, in Compliance with CFR 42 438.602(e)

• HMO Periodic Audit Round 3 (Year Ending 2019) Findings, in Compliance with CFR 42 438.602(e)