Submission Services

Submission is the process of preparing, validating and submitting risk adjustment data to CMS, HHS or state programs. Submission services can include data intake, validation, error correction workflows, submission tracking, reporting and reconciliation to help improve submission accuracy and efficiency. It is essential to close the loop by making sure that complete and accurate information is accepted by CMS, HHS and state programs.

Encounter data is information about the care a member received, including claim-level details such as diagnosis codes, procedure codes, provider information and dates of service. Encounter Data Processing System (EDPS) is the platform used by CMS for Medicare Advantage plans to process encounter data. CMS requires health plans to submit detailed records for every medical service provided to their Medicare Advantage members.

External Data Gathering Environment (EDGE) server data refers to enrollment, claims and encounter information submitted to HHS through the EDGE server for ACA members.

These data sources help support accurate, complete submissions to CMS, HHS and state programs.

Accurate and complete submissions help reduce rework, improve acceptance rates and support more reliable risk adjustment outcomes. Pre-filtering logic can help detect errors before submission, while custom validation and ongoing monitoring of CMS guidance help keep edits aligned with changing requirements. With the right support, health plans can work to improve submission accuracy, support compliance and help ensure data is submitted in a timely, complete and usable format.

Health plans and provider groups often lack visibility into the errors that exist within their encounter data. Without a means to identify and rectify these errors, they lack the ability to provide complete submissions on their own. Also, CMS, HHS and state requirements are frequently changing, which can create rework, delay corrections and make it harder to maintain accuracy, throughput and acceptance.

Health plans should look for a submissions partner that combines consultative services and technology to provide transparency, workflow tools and personalized support. The right partner should avoid a one-size-fits-all approach and be able to intake, transform and submit data in a way that helps meet the plan’s unique data needs. They should also offer a self-service portal, timely reporting, expert guidance, ongoing monitoring of CMS guidance and support for error correction and resubmission.

Working with a submissions partner can help reduce operational burden by giving health plans access to a structured process for intake, validation, submission, error correction and reporting. A vendor that provides a self-service portal will allow users to view and track submissions, drive error correction and access dashboard reporting. This helps reduce manual tracking, supports faster remediation and gives teams a clearer view of submission activity across files, claims and errors for intake, validation, submission, error correction and reporting.

Optum offers Submission Services to help support CMS, HHS and state managed Medicaid requirements by aligning data preparation, validation and submission activity to required formats and program guidance. For state-managed Medicaid programs, we manage encounter submissions through our proprietary National Encounter Management Information System (NEMIS). NEMIS is designed to provide the flexibility required to support varying state regulatory requirements and rapidly adapt to changes in submission specifications. The platform offers robust monitoring and reporting capabilities, providing visibility into encounter non-acceptances and rejection trends, which enables timely identification, remediation and resubmission of impacted records.

Complementing the technology, our Medicaid SMEs maintain strong working relationships with state agencies and possess extensive knowledge of individual state requirements. They work collaboratively with state partners and the Health Plan to address operational issues, interpret regulatory changes and ensure ongoing compliance. Together, NEMIS and our Medicaid expertise provide a scalable, responsive and compliant encounter management solution.

Health plans can improve their submission acceptance rate by using a fully comprehensive submissions platform that works to catch and correct errors before they reach CMS, HHS or states. On intake, custom validation edits and pre-filtering logic screen the data so accurate, complete records are submitted. When errors are flagged, the exact fields in error are identified and immediate feedback is sent, supporting fast, self-service remediation and resubmission through the portal. Continuous monitoring of governing agency guidance means clients are notified and data is resubmitted whenever rules change to help minimize rejections, while weekly expert insights, reconciliation and dashboard reporting support ongoing improvement in accuracy over time, all delivered with quick turnaround.

Yes, health plans can correct submission errors themselves with our Optum submissions platform. Through our self-service portal, health plans can view, track, edit and resubmit their claims directly. Errors are highlighted and plans receive immediate custom feedback. This visibility into errors, paired with a customized approach to self-service correction, supports timely error correction while plans still have the option to lean into our team’s available submissions support.

Optum continually monitors CMS, HHS and state submission guidance for updates, constantly evaluating changes to keep submissions aligned with the latest requirements. When a change affects your data, our team proactively notifies you and resubmits the data to minimize rejections, helping prevent incorrect data from reaching CMS or HHS. This helps your organization maintain accuracy throughout the submission cycle.

Optum can submit data to CMS multiple times per day, within the same day of receipt. This includes a 99% CMS acceptance rate and the capacity to process 14M records per day, allowing the submission process to move quickly and accurately. 

Optum accepts the 837 claim format and the Optum proprietary claim format for appropriate products. Optum can also review current client file formats to determine whether they include the required data elements for submission.