OIG Provider Claims Data Request Process for MCOs

HHSC MCO Encounter Requirements

On a monthly basis, MCO/DMOs are required to submit encounter data to TMHP's encounter data warehouse known as Vision21. MCO/DMOs must comply with encounter data submission requirements to meet federal and state regulations as well as contractual requirements. The managed care contract includes several MCO/DMO requirements related to encounter data submission:

• MCO/DMOs must provide accurate and complete encounter data that is consistent and verifiable for all covered services, including value-added services.
• MCO/DMOs establish and apply their own claims filing requirements for their managed care network providers. These requirements must be clearly set out in the MCO/DMO Provider Manual.
• The Data Certification Form must be certified by the MCO/DMO’s Chief Executive Officer, Chief Financial Officer, or Delegated Representative, who must attest, based on best knowledge, information, and belief, that data is complete, accurate, and truthful and complies with 42 CFR Sections 438.604 and 438.606.

OIG Process

• MCO Encounter data is analyzed to identify potential concerning provider billing patterns within the Texas Medicaid program.
• For any OIG investigations or audits that include MCO/DMO services, OIG Data and Technology (DAT) utilizes encounter data to establish a dataset related to the potential concerning provider billing behavior.
• Once the encounters are reviewed and the determination is made to include the data within the scope of an audit or Medicaid Program Integrity (MPI) investigation, DAT will request paid claims data directly from the MCO/DMOs in a standard file layout.
• The MCO/DMO is required to provide the paid claims data to DAT within five-business days from the date of request, per contractual requirement.
• DAT reviews the paid claims data provided by the MCO/DMO and validates the dataset against the encounter file. If variances are identified between the submitted paid claims data and the encounter file, DAT will communicate with the MCO/DMO and request additional information for the variances. After review of the variances and additional information or submission of an updated paid claims file, DAT will issue approval to the MCO/DMO and direct them to provide the final dataset on a CD and submit the Business Record Affidavit that stipulates the accuracy and completeness of the submitted data.
• The MCO Paid Claims data is utilized thereafter in the further development of the audit or Medicaid Program Integrity (MPI) investigation.