Medicaid Encounter Data

MCOs are required to maintain records (encounter data) of the services that are delivered to Medicaid beneficiaries enrolled in their managed-care plans and the payments the MCOs make to providers for those services (42 CFR § 438.242). The encounter data typically comes from the claims that providers submit to the MCOs for payment. This data is required to be transmitted to the State to allow the States to track the services received by members enrolled in Medicaid managed-care plans (42 CFR § 438.604). States, in turn, are required to use the encounter data when setting capitation payment rates for MCOs (42 CFR § 438.6(c)). Effective July 5, 2016, States are required to use encounter data for at least the 3 most recent years when developing the capitation payment rates for MCOs (42 CFR § 438.5(c)(1)).