26-892 Action Required: Comply with QMED 2.0 Encounter Submission Requirements

REQUIREMENTS: Immediate Actions (Now through September 30, 2026): - Billing team must audit all encounter submission processes to ensure compliance with QMED 2.0 standards - Verify that 100% of submitted encounters include valid Type 1 (individual) rendering provider NPIs that match NPPES records and were active on date of service - Implement system validations to prevent duplicate encounter submissions (target: <0.5% duplicate encounters; <5% duplicate service lines for institutional; <0.5% for professional) - Establish denial management workflow to correct DHCS-denied encounters within 10 calendar days of denial notification - Configure billing software to track and report: submission timeliness, denial rates, NPI validity, and duplicate submissions - Train all billing and coding staff on common causes of denials: missing/invalid NPIs, use of Type 2 instead of Type 1 NPIs, invalid DRGs, missing/invalid NDCs, invalid bill types - Create monitoring dashboard to track performance against all five QMED 2.0 measures By October 1, 2026: - Ensure at least 90% of all encounters are submitted and accepted within 90 days of date of service - Ensure at least 97.5% of DHCS-denied encounters are corrected within 10 calendar days of denial - Ensure at least 99.5% of DHCS-denied encounters are corrected within the reporting quarter - Ensure at least 90% of encounter service lines include valid Type 1 rendering provider NPI - Maintain duplicate encounters below 0.5% and duplicate service lines below specified thresholds - Maintain total DHCS denied encounters below 2% Ongoing (Quarterly): - Billing team must review QMED 2.0 performance reports provided by Health Net - Take immediate corrective action on any identified compliance gaps - Resubmit all corrected encounters within the reporting quarter Consequences of Non-Compliance: - Negative impact to provider performance reporting - Increased risk of plan-level non-compliance - Required remediation and corrective action - Performance monitoring and escalation by Health Net Applies to: Participating Physician Groups (PPGs) and Capitated Hospitals in Fresno, Kings, and Madera counties billing to Medi-Cal through Health Net California