Collection of Encounter Data from MA Organizations, Section 1876 Cost HMOs/CMPs, MMPs, and PACE Organizations (CMS-10340)
Revision of a currently approved collection
No
Regular
05/03/2021
table that charts list comparision
Requested
Previously Approved
36 Months From Approved
05/31/2021
1,068,205,855
769,396,692
35,618,759
19,481
0
0
CMS uses the risk adjustment data to develop individual risk scores for risk adjusted payment under Part C. As required by law, CMS also establishes the risk adjustment methodology and annually publishes the risk adjustment factors for MA organizations and other interested entities in the Advance Notice of Methodological Changes for MA Payment Rates (every February) and the Announcement of Medicare Advantage Payment Rates (every April). Risk adjustment data in particular is used to calibrate the CMS-HCC risk adjustment models using MA patterns of diagnoses, utilization, and expenditures.
While establishing a risk adjustment model appropriate for the MA program is the paramount reason for collecting MA risk adjustment, there are other important uses of the data that will improve other key functions undertaken by CMS. Data is used for the calculation of Medicare Disproportionate Share Hospital (DSH) payments. CMS collects inpatient stay information for the Medicare managed care enrollees. In particular, we collect the admission date, discharge date, Health Insurance Claim Number (HICN), and Medicare hospital number/CCN. Further, we also use the data for quality review and improvement activities. For example, MA risk adjustment data may be used in the development and calculation of quality measures for MA organizations. Other uses for the data include geographical acuity studies, utilization trends and detection of abuse as defined in the False Claim Act. Additional uses for the data include verifying the accuracy and validity of the reasonable costs claimed on Cost Reports submitted by section 1876 Cost HMOs/CMPs and section 1833 HCPPs. Finally, as stated in the regulation, we use the data for Medicare coverage purposes. For example, we can use risk adjustment data for the determination of whether day limits have been exhausted and, if not, how many such days are left.
The updated estimate is 35,606,814 total transaction hours. The total annual transaction hours have increased concurrent with significant enrollment growth in the MA program. There has been an overall increase in the number of encounter data submissions (1,068,204,429 in 2019 compared to an average of 769,389,091 (2015-2017)).
CM replaced the Institutional, Professional, and DME companion guides with the Encounter Data Submission and Processing Guide, and update language within the package to reduce duplication and improve clarity. In addition, all Part D sponsors were required to complete a Payment Reconciliation System (PRS) Contract and Contact Verification Form to verify contracts and the appropriate contacts for receipt of the PRS reports. This form is no longer used, therefore, we have removed this form from this PRA package.
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Form CMS-10340 Submitter Authorization Form
CMS-10340 - Supporting Statement A_Encounter Data PRA.docx
United BCBSA_Response to Public Comments - CMS-10340_final.pdf
PRA Forms Revisions - Crosswalk_020121.csv
Complete Certification