External Quality Review of Medicaid MCOs and Supporting Regulations in 42 CFR 438.360, 438.362, and 438.364

EQR PROTOCOL 4 – Validation of Encounter Data Submitted by the MCO
Attachment A: Encounter Data Tables
Table 1: Acceptable Rates
Instructions:
Acceptable Error Rate: For each encounter type and each error type, document the State’s
tolerance for errors. The table expresses the acceptable error rate as a percent missing, surplus
or erroneous, below which is acceptable. For example, for office visits, the State may allow less
than 10 percent missing encounters, less than 2 percent surplus encounters and less than 5
percent encounters reflecting erroneous information. If the State expresses its error tolerance in
a different way, the EQRO should adjust the table accordingly.
Area of Concern: Based on the Information Systems Capabilities Assessment (ISCA) and any
other information available to the EQRO, for example, from work performed on Protocol 2, the
EQRO should indicate whether there are particular encounter types and error types that are
suspected for which it determines there is a reasonable potential. The EQRO will use this
indicator to focus its later review activities.

EQR Protocol 4 Attachment A
Encounter Data Tables
December 2011

1

Acceptable Error Rates Specifications and Identified Areas of Concern Form
Encounter Type

Office Visit - (excludes
dental and mental health /
substance abuse visits)

Office Visit - mental health /
substance abuse

Office Visit – dental

Inpatient admission (excludes mental health /
substance abuse visits)

Inpatient admission mental health / substance
abuse

Other types of encounters
as specified by the State
(e.g., laboratory, pharmacy,
physical therapy).

Error Type

Acceptable Error
Rate

Missing

<

%

Surplus

<

%

Erroneous

<

%

Missing

<

%

Surplus

<

%

Erroneous

<

%

Missing

<

%

Surplus

<

%

Erroneous

<

%

Missing

<

%

Surplus

<

%

Erroneous

<

%

Missing

<

%

Surplus

<

%

Erroneous

<

%

Missing

<

%

Surplus

<

%

Erroneous

<

%

Area of Concern
(Yes/No)
Describe

Note: The EQRO should add additional rows as necessary to incorporate all types of encounters
specified by the State.
Definitions:
Missing - Encounters that occurred but are not represented by an electronic record.
Surplus - Encounter records for which an encounter did not occur or which duplicated
other records.
Erroneous - Encounters that occurred and are represented by an electronic record that
contains incorrect data elements.
Acceptable Error Rate - The maximum percentage of missing, surplus, or erroneous
records that the State accepts.
EQR Protocol 4 Attachment A
Encounter Data Tables
December 2011

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Table 2: Data Element Validity Requirements
Instructions:
For each data element required for the types of encounter data to be validated, the EQRO
should document the State’s requirements for validity. The EQRO will analyze the encounter
data set to determine the validity of specific data elements in the set.
Expectation: The EQRO should use this column to describe the characteristics of, or the
test for, validity of each data element.
Validity Criteria: The EQRO should use this column to document the threshold for
determining a data element is valid. Typically, this column will hold a quantitative
expression of the description in the Expectation column.
Encounter Type
Data Element

Expectation

Validity Criteria

Enrollee ID

This should be a valid ID as found
in the State’s eligibility file. Use the
State’s ID unless State also
accepts SSN

100% valid

Date of Service

Dates should be evenly distributed
across time

If looking at a full year of data, X% of
the records should be distributed
across each month

Unit of Service
(Quantity)

The number should be routinely
coded

X% non-zero
< Y% should be 1 if CPT code in range
99200-99215, 99241-99291

Procedure Code

This is a critical data element and
should always be coded

100% present (not zero, blank, 8- or 9filled). 100% should be current, valid,
State-approved codes, with X numbers
of digits. The frequency and
distribution of procedure codes should
be consistent with those previously
reported.

Revenue Code
If the facility uses a UB04 claim
100% valid
(Hospital)
form, this should always be present
Note: The EQRO should add additional rows as necessary to incorporate all data elements for
which the State specifies specific validity requirements.

EQR Protocol 4 Attachment A
Encounter Data Tables
December 2011

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TABLE 3: Evaluation of Submitted Fields
Instructions:
In its review of individual encounter records, for each data element that requires validation, the
EQRO should document its findings on a standard form similar to Table 3:

1

Is there information in the field, and is that information of the type requested? The
EQRO must check each data field to determine whether the information is of the
correct type and size in relation to the State’s data dictionary. For example, if
CPT-4 codes are requested, the field should have 5 digits. If the State’s
Medicaid/CHIP beneficiary ID is requested, the field should contain the correct
number of letters and digits.

2.

Are the values valid? When compared to an external standard, are the values in
the field valid? For instance, if ICD-9 diagnosis codes have been requested, are
the values in the diagnosis field current and valid ICD-9 diagnosis codes?

Sample Form for Recording Evaluation of Submitted Fields

Required
Field

Information
present
#

%

Correct
Correct
Presence
type of
size of
of valid
information information
value?
%
#
%
#
% #

Enrollee ID
Plan ID
Provider ID
Principal
Diagnosis
Procedure
Code
Date of
Service
Units of
Service

EQR Protocol 4 Attachment A
Encounter Data Tables
December 2011

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Required
Field

Information
present

Correct
Correct
Presence
type of
size of
of valid
information information
value?

Others
(continue
adding fields
as
appropriate).
..

EQR Protocol 4 Attachment A
Encounter Data Tables
December 2011

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TABLE 4 – Benchmark Utilization Rates
Instructions:
Use this Table to compare findings to State-identified benchmarks. Revise the column headings
to reflect the benchmarks identified by the State.
TABLE OF BENCHMARK UTILIZATION RATES (for services incurred between XX/20XX and
YY/20YY)

Measure

MCO
Rate

Value from
FFS or
PCCM

Value from
Comparable State
or States

Other
Comparison
Value

Inpatient Discharges
Inpatient LOS
Overall
By high volume MSDRGs
By eligibility category/patient
cohort
Ambulatory Surgeries
Total # surgeries
By high volume CPT codes or
by ambulatory surgery
categories
Total # surgeries/1,000
enrollees
By high volume CPT codes or
by ambulatory surgery
categories
Number of Providers
Primary care physicians
Specialists
Other (e.g., mental health
providers)
Number of Enrollees
Total #
By eligibility category
By age/sex categories
Number of Users (i.e.,
enrollees who used services)
Total #
By eligibility category
By age/sex categories

EQR Protocol 4 Attachment A
Encounter Data Tables
December 2011

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Measure

MCO
Rate

Value from
FFS or
PCCM

Value from
Comparable State
or States

Other
Comparison
Value

Visits
Total #
#/enrollee
#/user
by visit categories (e.g., well
child, well adult, ob/gyn, mental
health, substance abuse, etc.)
Other Services (e.g., prescription
drug)
Total #
#/enrollee
#/user
by service category

END OF DOCUMENT

EQR Protocol 4 Attachment A
Encounter Data Tables
December 2011

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