Encounters & Claims Submission

Optimize through put and submission accuracy by leveraging our data transformation and submission tools to meet CMS EDPS, EDGE server or state Medicaid requirements.

Our fully certified products support the entire life cycle of encounter and claims submission. Receive health plan source data, transform and analyze data counterpart requirements, pre-validate data for pre-submission errors, receive, transform and analyze response files, prioritize errors, process corrections, adjustments and resubmissions and track the status of claim, encounter and enrollment data throughout the process.

Solutions: ENCOUNTER Complete & EDGE Complete

Our deep domain expertise and leading web-based technology application – ENCOUNTER Complete TM and EDGE Complete TM – enable health plans to report encounter, claims and enrollment data in a cost effective and efficient manner.

Our technology optimizes the throughput of required encounter data, facilitating accurate and timely submissions. Our programs allow healthcare organizations to submit all required data elements to contracted counter-parties such as the Center for Medicare and Medicaid Services (CMS) for Medicare’s Encounter Data Processing System (EDPS), ACA Edge Server, and state-specific Medicaid programs.


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Solution Features

  • Collection Process Tracking – Control the data being submitted with visible status displays of inbound processing and validation. Displayed information includes: process from-through dates, claim/enrollment lines and dollars, included and excluded dates, hold or queue statuses and views for EDGE sever test and production process tracking.
  • Pre-validation Error Identification – Manage errors on the front-end to improve through-put and reduce rework by using our pre-validation rules based on specific business and submission rules. Customize the pre-validation rules based on your claims system and business needs.
  • Outbound File Process Monitoring – Monitor and review file status. The system displays information related to submitted, pend, sent, accepted and rejected statuses. This view assists users in identifying and resolving submission choke points.
  • Enrollment Preprocessing for EDGE Server – Manage enrollment data and promote consistency between member demographic and enrollment data files. Look for potential enrollment data issue including duplicate members, new or dropped IDs, unexpected masked ID and prevent data drop-off while minimizing orphaned claims.
  • Examine Data Details – View all details via hyperlinks, including claim, summary and line-level claim and enrollment data, including the submission audit trail at the derail level. Member level data summarizes claims and errors. EDPS tool to facilitate provider level data and error details.
  • Error Management – Sort, filter and summarize errors by error type, data type or error status criteria.
  • Submit and Resubmit – Submit and re-submit functions for rejected data management and the re-submission process for error reconciliation. As source data is corrected and re-submitted, results of the correction at the line item level and rolls up to member, claim, and error-type levels.
  • Receive and Process Return Response Files – Gain reports for use in data quality, risk adjustment and reinsurance. Each counterparty produces response files which are received, translated, and analyzed. For example, EDPS MA-004 reports and EDGE server reports for data quality, risk adjustment and reinsurance.
  • Filtering and Exporting – Perform multiple sorts and filters using hyperlinks that allow data to be exported for additional review and error reconciliation.