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8.1.1
Introduction
The Centers for Medicare and Medicaid Services (CMS) requires the Arizona Health Care Cost Containment System (AHCCCS) to conduct encounter validation studies as a condition for receiving Federal Medicaid funding. The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) requires the Regional Behavioral Health Authorities (RBHAs) to conduct encounter validation studies of their providers. For guidelines on the RBHA data validation process, see the
Office of Program Support Operations and Procedures Manual.
The purpose of encounter validation studies is to compare recorded utilization information from a clinical record or other source with submitted encounter data. The review “validates” or confirms that covered services are encountered timely, correctly and completely.
The purpose of this section is to:
- Inform behavioral health providers that encounter validation studies may be performed by AHCCCS, RBHAs and/or ADHS/DBHS staff; and
- Convey ADHS/DBHS’ expectation that behavioral health providers cooperate fully with any encounter validation review that AHCCCS, the RBHAs and/or ADHS/DBHS may conduct.
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8.1.2
References
The following citations can serve as additional resources for this
content area:
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8.1.3
Scope
To whom does this apply?
All behavioral health providers under
contract with a RBHA or a RBHA network that deliver covered behavioral health services to
eligible persons.
8.1.4
Did you know…?
- The majority of correctness errors found are caused by invalid procedure or revenue codes and by not coding the diagnosis to the correct level of specificity. Coding from the ICD-9 is required on all encounter submissions.
- RBHAs are required to conduct encounter validation studies of their providers on a quarterly basis.
- If determined appropriate, ADHS/DBHS and the RBHAs can pass down sanctions for non-compliance with encounter submission requirements to behavioral health providers.
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8.1.5
Objectives
To communicate an overview of data validation studies and the expectation for
behavioral health providers to cooperate with all activities associated with AHCCCS’ or
ADHS/DBHS’ data validation review.
8.1.6
Procedures
8.1.6-A.
Criteria used in encounter validation studies
The criteria include timeliness, correctness and omission of encounters. These criteria are defined as follows:
- Timeliness-The time elapsed between the date of service and the date that the encounter is received;
- Correctness- A correct encounter contains a complete and accurate description of a covered behavioral health service provided to a person. Correctness errors frequently identified include, but are not limited to, invalid procedure or revenue codes and ICD-9 diagnoses not reported to the correct level of specificity; and
- Omission- Provider documentation shows a service was provided, however, an encounter was not submitted.
In addition, assessment compliance must be monitored by the RBHA in accordance with
Section 3.9, Assessment and Service Planning.
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8.1.6-B.
Behavioral health provider responsibilities
Behavioral health providers must deliver covered services in accordance with the
ADHS/DBHS Covered Behavioral Health Services Guide. Behavioral health providers must document adequate information in the clinical record and submit encounters in accordance with
Section 6.2, Submitting Claims and Encounters to the RBHA.
8.1.6-C.
Encounter validation study findings
RBHAs are required to
report the data validation findings to the provider. [RBHA
insert RBHA specific language here]
8.1.6-D.
AHCCCS Encounter Data Validation
AHCCCS performs yearly data validation studies. All AHCCCS contractors and subcontractors are contractually required to participate in this process. In addition, the data validation studies enable AHCCCS to monitor and improve the quality of encounter data. Information regarding AHCCCS Encounter Data Validation Study procedures can be found in the
Office of Program Support Operations and Procedures Manual.
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8.2 Independent Case Review
Last Revised: 12/08/2005
Effective Date: 06/01/2006 |
