Brief Issue Description
The ability of a state to submit complete and accurate encounter data is critical to Medicaid and CHIP program analysis. This guidance document outlines the legislative background and CMS’s expectations for reporting complete and accurate encounter data in Transformed Medicaid Statistical Information System (T-MSIS).
Background Discussion
Since the implementation of MSIS in 1999, states have been required by federal law to report encounter data to CMS and this requirement continues to be applicable for states submitting data to CMS using the T-MSIS process. The Affordable Care Act outlined provisions about reporting encounter data to CMS as a condition for receiving federal matching payments for medical assistance provided through the Medicaid program. Sections 6402(c)(3) amended Social Security Act (SSA) §§ 1903(i)(25) and 6504(b)(1) amended SSA §§ 1903(m), both stipulate that federal matching payments should not be made for individuals for whom a state does not report enrollee encounter data to CMS. With 55 million people1 enrolled in managed care, encounter data are critical to monitoring and assessing the impact of programs on the states in which they operate and for the people whom the state programs serve.
In support of these policy actions, state Medicaid agencies have been (1) modifying managed care plan contracts to require reporting of the requisite data to state agencies, (2) making significant investments in their encounter data reporting systems to accept encounter data, and (3) reporting these data to CMS via MSIS and now T-MSIS.
CMS Guidance
With the transition to T-MSIS, CMS provides supplementary guidance to support states in their efforts to report data to CMS and clarify the T-MSIS threshold for reporting complete and accurate data.
- Submit all applicable data. In each T-MSIS reporting month, states should include both managed care program and encounter data with each file as noted in the “High-level Summary Data by T-MSIS File Type” below. This includes adhering to all T-MSIS data dictionary specifications for file integrity.
- Submit records in compliance with business rule validation. All records must pass business rule validation without error. States can access the complete list of business rules on the Confluence State Support Site , which are noted in the “Summary of Error Types” list from the CMS operations dashboard below.
High-level Summary Data by T-MSIS File Type
- Eligible File
- Enrollment for each beneficiary enrolled in managed care for a given timespan
- Managed care plan identifier for the beneficiary that can be linked to the Managed Care file
- Waiver-Id for each waiver2 through which managed care programs are authorized.
- Claim OT
- Capitation payments issued to all managed care plans for beneficiaries enrolled in the respective plan
- Managed care plan identifier for the enrolled managed care plan that can be linked to the Managed Care file and linked to the beneficiary’s managed care enrollment
- MSIS identification number for the enrolled beneficiary that can be linked to the Eligible file
- Waiver-Id, if the state’s managed care program is authorized through a waiver
- Claim IP, LT, OT and RX
- Encounter data for each service the beneficiary received while enrolled in managed care
- Managed care plan identifier that can be linked to the Managed Care file and linked to the beneficiary’s managed care enrollment on the date of service
- MSIS identification number for the enrolled beneficiary that can be linked to the Eligible file
- Waiver-Id, if the state’s managed care program is administered through a waiver
- Managed Care File
- Record for every managed care plan contracted with the state Medicaid agency for a given timespan
- Managed care plan identifier for each authorized managed care plan that can be linked to both the Eligible and Claims files
- Waiver-Id, if the state’s managed care program is administered through a waiver
- Provider File
- Record for each provider participating in managed care for a given timespan
- Provider identifier and provider identifier type that can be linked to encounter data
- Affiliated program identifier showing provider’s association with a managed care plan using the managed care plan ID number.
Summary of Error Types
File specification error
- Duplicate record identifier (RECORD-NUM or primary key values)
Formatting Error
- Value illegal for specified data type
Relational error
- Missing corresponding record (multi-file) (for example, missing eligibility record for claim header)
- Missing parent record (single file)
- Values inconsistently specified (multi-record, multi-file)
- Values inconsistently specified (multi-record, single file)
- Values inconsistently specified (single record type, multiple records)
- Values inconsistently specified (single record type, single record)
Value Error
- Value does not match specification
- Value not in specified valid value set
- Value not valid for state-supplied format (format or valid values)
States should consider revisiting source to target mapping documents and internal specifications documents to refresh themselves on those data elements being reported for managed care program and encounter data. This review will help states use the T-MSIS dashboard edits to identify necessary changes. States can continue to use the T-MSIS dashboard to see which records contain errors and resubmit files, records, or both as required to correct data with errors. If states require assistance collecting, validating, and reporting Medicaid managed care encounter data to CMS, they can reference the Medicaid Encounter Data Toolkit (PDF, 1.02 MB) (PDF 1.02 MB) to help with this process.