HPSJ 2022-2023 Encounter Data Validation Study
| Date: | February 21, 2024 |
| From: | Health Plan |
| To: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) Provider Network |
| Type: | Informational |
| Subject: | HPSJ 2022-2023 Encounter Data Validation Study |
| Business: | Medi-Cal Managed Care |
The Department of Health Care Services (DHCS) contracts with Health Services Advisory Group (HSAG) annually to conduct an Encounter Data Validation (EDV) study. The EDV study evaluates the completeness and accuracy of encounter data through medical record review. DHCS provided the following results of the 2022-23 EDV study for Health Plan of San Joaquin (HPSJ). For most of the areas, HPSJ met the EDV study standards and had better rates than the statewide rates. We hope the helpful tips provided will be beneficial in improving the accuracy and completion of your encounters.
Medical Record Procurement Status
| Plan | Initial Sample Size | Number of Records Submitted | % of Records Submitted |
|---|---|---|---|
| HPSJ | 411 | 393 | 95.6%+ |
| Statewide Total | 10.590 | 9,358 | 88.4% |
Note: Medical record procurement rates greater than 90% are shaded in gray to show
that the EDV study standard was met.
Encounter Data Completeness
HSAG evaluates encounter data completeness by identifying differences between the electronic encounter data and the member’s medical records.
- Medical record omission rate: the percentage of dates of service identified in the electronic encounter data that were not found in the members’ medical records
- Encounter data omission rate: the percentage of dates of service from members’ medical records that were not found in the electronic encounter data
Medical Record Omission
| Key Data Elements | Denominator | HPSJ Rate | Statewide Rate |
|---|---|---|---|
| Date of Service | 533 | 5.4%+ | 8.6%+ |
| Diagnosis Code | 1,418 | 7.1%+ | 11.5% |
| Procedure Code | 1,119 | 10.8% | 19.4% |
| Procedure Code Modifier | 486 | 16.5% | 28.3% |
| Rendering Provider Name | 533 | 6.0%+ | 9.1%+ |
Encounter Data Omission
| Key Data Elements | Denominator | HPSJ Rate | Statewide Rate |
|---|---|---|---|
| Date of Service | 521 | 3.3%+ | 3.7%+ |
| Diagnosis Code | 1,338 | 1.5%+ | 2.1%+ |
| Procedure Code | 1,047 | 4.7%+ | 8.5%+ |
| Procedure Code Modifier | 410 | S+ | 5.0% |
| Rendering Provider Name | 517 | 3.1%+ | 3.6%+ |
Note: For both omission rates, lower values indicate better performance. Omission rates of less than 10% are shaded in gray to show that the EDV study standards were met.
- Areas of Opportunity: Rendering Provider Name, All-Element Accuracy, and All Element Accuracy Excluding Rendering Provider Name
- Helpful Tips:
– Ensure appropriate Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) codes are used
– Ensure that the rendering provider name submitted to HPSJ matches the rendering provider name on the medical record
– Ensure the rendering provider name is legible in the medical record
– Ensure encounter data accuracy for all key data elements (i.e., Diagnosis Code, Procedure Code, Procedure Code Modifier, and Rendering Provider) to improve the all-element accuracy rate
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG