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CMS Compliant Encounter Processing Risk Adjustment

Data Driven, Scalable & Intelligent SaaS Platform

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Wipro's Encounter Data Processing System (EDPS) assists Plans in submitting accurate encounter data to the Centers for Medicare and Medicaid (CMS). EDPS is a CMS and HIPAA-compliant processing solution that manages front-end testing, end-to-end testing and certification logistics. EDPS receives the les, transforms the data, and transmits complete and compliant 5010 encounters to CMS.

Wipro offers this solution to the Health Plans looking for assistance in any of the areas, i.e. converting claims data to HIPAA Outbound X12 837 (5010 format); Encounter correction and resubmission to CMS; Reconciliation between RAPS and Encounters. This Encounter Correction and Resubmission system allows plans to reconcile encounters to claim adjudication system, perform correction of Encounter data and to resubmit outside their claim processing system.

EDPS-GT360 platform - Process flow

Leveraging Wipro’s RAPS-Expert, RA-Expert, and Recon+ systems, Wipro also provides a service which reconciles RAPS HCCs and encounter submissions. Claims data is transformed and formatted into RAPS.
Wipro takes a standardized, cost-effective pricing approach that includes:

How will EDPS benefit your plan?
  • 5010 Encounters are created, edited and transformed by Wipro
  • Encounters are transmitted to CMS accurately formatted and on time
  • Reduces errors and rework
  • Controls and reduces staffing costs

Solution Benefits

Software as a Service (SaaS) Delivery

Reliable Technology

CMS Compliance

Software as a Service (SaaS) Delivery
  • No hardware, software, or installation required on the customer side
  • Fast implementation timeframes
  • Utilizes customer proprietary claim formats
  • Data storage for both inbound and outbound les and reports
  • Standard reports and extracts furnished to client
  • Query, decode and correct errors via online system
Reliable Technology
  • Average response Time < 3 seconds
  • Security (SSL, HTTPS, Application security on Web Server)
  • Secure FTP, site-to-site VPN; Worldwide accessibility
  • Leverages the value of legacy systems; Error Management System
  • X12 4010/5010 and IBM WTX ETL experience for encounter data
  • Maps inbound claim and adjudication data
  • Maps customer claim formats to 5010 loops/segments
  • Tracks and reports submission statistics and drill down capable via dashboard
CMS Compliance
  • Compliance checker adds CMS and HIPAA edits/logic to ensure accepted transactions
  • Creates custom extracts of CMS responses, identifying named errors in plain language for correction
  • Uses existing claim formats and transforms through an ETL process to produce CMS-compliant outbound 5010 encounters
  • Complies with EDPS mandated deadlines and regulations
  • Complies with industry and regulatory standards for exchange of complex data
  • Leverages industry standard ETL Products to produce 5010 x12 claim encounters
  • Can be configured to comply with Duals requirements


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