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Claims/Encounters Data Exchanges. May 2013. Purpose & Types of Data Exchange. AHCCCS will manage exchange of encounter and claims data to Contractors in order to eliminate “blind spots” for services provided to a member shared by multiple programs In compliance with Federal privacy regulations

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Purpose types of data exchange
Purpose & Types of Data Exchange

  • AHCCCS will manage exchange of encounter and claims data to Contractors in order to eliminate “blind spots” for services provided to a member shared by multiple programs

  • In compliance with Federal privacy regulations

  • Contractors should use this information to develop short- and long-term strategies to improve care coordination

  • Historical – provide up to 3 years of data

  • Ongoing – provide at least quarterly


Historical data exchange
Historical Data Exchange

  • Who does this apply to?

    • New SMI Integrated Contractor

    • New CRS Integrated Contractor

    • New Acute Contractor

    • Incumbent Contractors New to a GSA

    • ALTCS Contractors for CRS Eligibles


Historical data exchange cont
Historical Data Exchange, cont.

  • What Data will be provided?

    • SMI Integrated Contractor

      • FFS Claims from I.H.S and 638 Providers; FFS Claims from TRBHA Providers; Any other FFS Claims; Acute Contractor, DDD and CMDP Encounters

    • CRS Contractor, for each type of coverage

      • FFS Claims from I.H.S and 638 Providers; FFS Claims from TRBHA Providers; Any other FFS Claims; Acute Contractor, BHS, DDD and CMDP Encounters


Historical data exchange cont1
Historical Data Exchange, cont.

  • Incumbent Contractor New to a GSA or New Acute Contractor

    • FFS Claims from I.H.S and 638 Providers; FFS Claims from TRBHA Providers; Any other FFS Claims; Acute Contractor and BHS Encounters

  • ALTCS Contractor for CRS eligibles

    • FFS Claims from I.H.S and 638 Providers; CRS Contractor Encounters

    • A draft format for the data exchange has been provided to Contractor technical staff for comment and we are in the process of updating now


Ongoing data exchange
Ongoing Data Exchange

  • Who does this apply to?

    • Acute Contractors

    • SMI Integrated RBHA and BHS for each RBHA

    • CMDP

    • DDD

    • CRS Contractor, for each type of coverage


Ongoing data exchange cont
Ongoing Data Exchange, cont.

  • What Data will be provided?

    • Acute Contractors

      • FFS Claims from I.H.S and 638 Providers; FFS Claims from TRBHA Providers; BHS Encounters

    • SMI Integrated Contractor (via BHS)

      • FFS Claims from I.H.S and 638 Providers

    • BHS

      • FFS Claims from I.H.S and 638 Providers; Acute Contractor, DDD and CMDP Encounters

    • CMDP and DDD

      • FFS Claims from I.H.S and 638 Providers; FFS Claims from TRBHA Providers; BHS Encounters; CRS Partially Integrated – BH and CRS Only Encounters


Ongoing data exchange cont1
Ongoing Data Exchange, cont.

  • CRS Contractor, for each type of coverage

    • Fully Integrated: FFS Claims from I.H.S and 638 Providers

    • CRS Partially Integrated - Acute: FFS Claims from I.H.S and 638 Providers; FFS Claims from TRBHA Providers

    • CRS Partially Integrated - BH: FFS Claims from I.H.S and 638 Providers; DDD and CMDP Encounters

    • CRS Only: FFS Claims from I.H.S and 638 Providers; FFS Claims from TRBHA Providers; FFS Claims from Tribal Contractor Providers; Any other FFS Claims; BHS, CMDP and DDD Encounters


Ongoing data exchange cont2
Ongoing Data Exchange, cont.

  • A draft format for the data exchange has been provided to Contractor technical staff for comment and we are in the process of updating now

  • Planned Future Data Exchange

    • Medicare Paid Claims Data – Targeted for early 2014


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