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
This document contains the enrollment cycles and capitation payment reporting schedule as released by ForwardHealth.
This document contains the schedule for the Encounter Technical Conference Calls.
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.
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).
The MCO Toolkit is training material for new MCO employees to educate on the MMIS system and the State encounter processing.
This document details the HCPCS procedure code range and what service area it applies to.
This guide is developed to help interpret the Max Fee extract and to assist MCOs in understanding MMIS reimbursement policy.
This guide is developed to assist MCOs in understanding APR DRG pricing and policies.
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.
The link below contain all reports and layouts sent by DHS to MCOs.
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.
The link below will direct you to the HIPAA Version 510 Companion Guides and NCPDP D.0 Payer Sheets and ASC x12 Implementation Guides
This guide contains all relative HCPCS Procedure Codes related to CLIA and the components required for reimbursement.
The following links contain Prior Authorization data definitions and File Layouts sent by DHS to HMOs.
The following links contain file submission specifications and data dictionaries sent by DHS to HMOs.
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