Appendix R Update


In July, the Pennsylvania Department of Human Service (DHS) implemented revisions to Appendix R, Encounter Data Submissions Requirements and Accompanying Sanctions for Noncompliance.

The focus of Appendix R is two-fold: DHS is interested in both the timeliness and acceptance, as well as the accuracy and completeness of HIPAA-compliant file submissions.

Recently, DHS responded to inquiries with additional information on outstanding items listed in a previous post on the subject:

The revisions went into effect on July 1st, however, it was not clear if the effective date applied to the dates of service on encounters, the date encounters were submitted, the dates they were adjudicated.
DHS clarified that the effective date applies to the date encounters are accepted in PROMISe™. DHS considers acceptance to be the date at which an encounter has been submitted and has passed PROMISe™ edits.

It was unclear if timeliness percentages would apply to claims or claim lines.
DHS clarified that percentages apply to claims, not claim lines.

It was not stated if denied encounters would be included in acceptance counts. Typically, when adjustments are required to an encounter previously accepted by PROMISe™, a void is submitted to back out the original, and a replacement claim is submitted. PROMISe™ communicates the acceptance of the void as a “denial”.
DHS clarified that voids are excluded from acceptance calculations.

For assessing accuracy and completeness, how will DHS consider claims history?
DHS stated that distinct ICNs will be counted as many times as they are submitted in the month. For example, if 100,000 claims are submitted and denied, and those claims are then resubmitted and approved within the same month, the acceptance rate for the month would be 50%.

Given these recent clarifications, ACA is working with BH-MCOs and oversight entities with which it contracts to determine how to best adjust its reporting to most accurately reflect both encounter submission timeliness and acceptance, as well as accuracy and completeness.