Questions Submitted by the Public, by Date Posted to the Website. Encounter transaction in shared information systems

11/02/2001

Our medical care program consists of three closely cooperating organizations, a health plan, a hospital holding company, and a medical group, that share a commonly owned and operated information systems infrastructure. Analytical staff of each of the program's organizations extract encounter data from our shared data repositories as appropriate in connection with their analytical or reporting duties. Does this retrieval of encounter information constitute a standard transaction under § 162.1101 - Health Care Claims or Equivalent Encounter Information Transaction?


5/14/2001:

Under § 162.1101, the health care claims or equivalent encounter transaction is defined as follows:

The health care claims or equivalent encounter information transaction is the transmission of either of the following:

(a) A request to obtain payment, and the necessary accompanying information from a health care provider to a health plan, for health care.

(b) If there is no direct claim, because the reimbursement contract is based on a mechanism other than charges or reimbursement rates for specific services, the transaction is the transmission of encounter information for the purpose of reporting health care.

The definition under paragraph (a) describes the situation where the transmission of encounter information is a request for payment for health care delivered. In the situation described, the extracting of encounter data from a shared data repository is for analytical or reporting purposes and is not part of a payment request. Therefore, it would not meet the definition in paragraph (a).

The definition in paragraph (b) describes the situation where a direct claim for payment is not involved, but encounter information is transmitted "for the purpose of reporting health care." In the situation described, the information is extracted from the database, not reported to the database. Thus, the activity would not meet the definition of paragraph (b).

Since the activity described does not meet the definition of either paragraph (a) or paragraph (b) of § 162.1101, it would not be required to be conducted as a standard transaction.