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Identifying Denied Claims in Medicare Advantage Encounter Data

CMS requires Medicare Advantage organizations (MAOs) to submit records of all services provided to beneficiaries to CMS's Medicare Advantage (MA) Encounter Data System. These records often (although not always) begin as claims for payments that health care providers submit to MAOs. MAOs must submit all records of services to CMS, including records of denied claims-i.e., claims for which an MAO determines it had no responsibility to pay the health care provider. CMS does not require MAOs to differentiate between paid and denied claims when submitting encounter records. In the absence of requiring a denied claims indicator, CMS requires each MAO to submit claim adjustment reason codes that contain information about how the MAO processed the claim and may be a helpful, but not definitive, method for identifying denied claims. The lack of a definitive method to identify denied claims in the MA encounter data may limit the use of these data to ensure MA program integrity and quality of care. This work will: (1) determine the extent to which the MA encounter data contained potentially denied claims and (2) identify any challenges to MA program oversight that result from the lack of a denied claim indicator on services in the MA encounter data.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
Revised Centers for Medicare and Medicaid Services Identifying Denied Claims in Medicare Advantage Encounter Data Office of Evaluation and Inspections OEI-03-21-00380 2023