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Encounter and Reporting

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 6/3/2020
Encounter Technical Workgroup Conference Call Schedule 01/17/2020
Encounter User Guide 07/29/2020
EOB Cheat Sheet 04/29/2020
MCO Toolkit 07/05/2016
Provider Service Hierarchy
Forward Health MCO Pricing Administration Guide 07/20/2020
Forward Health APR DRG MCO Documentation
Quarterly Progress Report 06/27/2017
Report Matrix 02/12/2020
WI BCP Financial Template and Synopsis 03/08/2019
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

Enrollment Cycles and Capitation Payment Reporting Schedule

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

Encounter Technical Workgroup Conference Call Schedule

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

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.

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).

MCO Toolkit

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

Provider Service Location Hierarchy

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

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 APR DRG MCO Technical Documentation

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

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.

Report Matrix

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

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.

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

CLIA Guide

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

Care Coordination Reports - PA File

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

HMO Provider Network Universe

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

Third Party Liability 101

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

 
 
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