Welcome to the Blue Shield of California and Blue Shield of California Promise Health Plan Encounters Resources page. The information here can help you stay updated on the requirements and guidelines for submitting compliant encounters resulting from services provided to our members.
How encounters work
Blue Shield and Blue Shield Promise receive encounter data submitted by participating independent physician associations (IPAs). The data provides records of payments made to practitioners for services provided to Blue Shield commercial HMO plan members and Medicare Advantage HMO plan members, and to Blue Shield Promise Medi-Cal members, when the IPA is financially responsible for reimbursement in accordance with their provider agreement.
State regulations require the IPAs to submit accurate and timely encounters to the member’s health plan. Receiving all encounters correctly and on time also helps IPAs, their affiliated healthcare providers, and the health plan comply with measures included in the Healthcare Effectiveness Data and Information Set (HEDIS).®
Importance of Monthly Performance Summary Reports
Blue Shield and/or Blue Shield Promise send monthly Performance Summary Reports (PSRs) to all participating IPAs and management service organizations (MSOs). The purpose for these reports is to track accuracy and timeliness against the requirements and goals of Blue Shield and/or Blue Shield Promise.
The PSR reflects electronic data interchange (EDI) inbound encounter volumes based on the measurements displayed below, which are based on regulatory expectations. It does not include encounters for members who were not eligible at the time services were provided.
The accuracy and timeliness described below are required to meet the goals.
Acceptance rate is based on the encounters by receipt date, file type and line of business.
Total accepted encounters/total received encounters goal: 95%
- Calculated for 0-30, 0-60, 0-180 days between the service end date and the encounter EDI inbound received date (by Blue Shield or Blue Shield Promise)
- Total acceptance encounters received within N (N=0-30, 0-60, 0-180 days between the service end date and the encounter)
- Medi-Cal LA: 65% received by Blue Shield Promise within 30 days from the date of service
- Medi-Cal SD: 65% received by Blue Shield Promise within 60 days from the date of service
- Cal MediConnect 65% received by Blue Shield Promise within 180 days from the date of service
- Medicare, Commercial: 65% received by Blue Shield within 180 days from the date of service