CA Encounter Report

Provider Services at Anthem Blue Cross (Anthem) is glad to announce that we are now generating a CA Encounter Report for all of our HMO medical groups in the state of California. This report captures the encounters participating medical groups (PMG) have submitted to Anthem where member cost share has changed due to adjustments made on those encounters by Anthem based on member benefits. We believe this is an important step to partner with our medical groups to ensure member cost share is not being overapplied. We continue to review and assess the opportunities to partner with our medical groups to ensure accuracy of encounter data.

Here are the details about the report that can be found on Availity Essentials:*

Report name: CA Encounter Report

Frequency: This is a weekly report generated every Tuesday of the week to include the encounters processed in the previous week based on the process date for the encounter claim.

Format: PDF and XLS format

This report is available for all PMGs at the main site code level.

Point of contact in case of any questions:

The Provider Relationship Managers at Anthem assigned to the respective medical group will be able to support you with any questions related to this report.

How to access the report:

Medical groups can access this report by registering on https://availity.com. Once registered, log on to https://availity.com and then run a search by report name. Here are the steps:

• Log on to Availity Essentials.
• Go to Provider Online Reporting under Anthem.

• Select your organization tax ID XXXXXXXXX:

• Register your organization for the CA Encounter Report:

• Select Register Tax ID(s):

• Check the tax ID off and choose Save:

• Go to Maintain Users and check off users, then assign access for eligible tax IDs:

• Search by tax ID XXXXXXXXX and PMG site code YYY000.
  • Select the month, file type, and choose Search button.

• You will then see the download for the CA Encounter Report. First page is the type of notification, and following pages will have a list of mismatched/adjusted encounters along with member details when the report is downloaded in PDF format. If the report is downloaded in the XLS format, it will only have the list of mismatched/adjusted encounters and corresponding member details in order for our groups to automate the process at their end if they wish to do so. Here is the sample screenshot of the CA Mismatch Report in PDF format:

• Here is the sample screenshot of the CA Mismatch Report in XLS format:

Next steps:

These adjustments may have caused a change to the amount the member owes for this service:

• If the member has already paid and the cost shares decreased, they are due a refund by the entity who collected the payment.
• If the member already paid and the cost shares increased, they are responsible for paying the remaining balance.

We ask that PMGs reconcile their records to reflect the information provided on the CA Encounter Report. PMGs can check a member’s Eligibility and Benefits by logging on to https://availity.com and running an Eligibility and Benefits Inquiry on the Patient Registration tab.