MEDICARE ADVANTAGE & ACA ENCOUNTER SUBMISSIONS
Encounter submissions, integrated with risk analytics and your coder workbench
Invent Health puts encounter intelligence at the center and connects it to risk analytics and the coder workbench — so plans prioritize the right encounters, reconcile data with CMS, flag encounters carrying risk-impacting conditions, and link encounters back to the charts coders worked.
Overview
Prioritize the right encounters
Risk analytics ranks encounters by risk impact and revenue value, so teams work what matters most first.
Reconcile data end to end
Match submitted encounters against CMS outcomes (MAO / Edge reports) and internal records to surface every discrepancy.
Flag risk-impacting conditions
Automatically flag encounters that carry — or are missing — risk-impacting diagnoses before they reach CMS.
Link encounters to coded charts
Connect each encounter to the charts coded in the coder workbench (CWB) for full traceability and audit defense.
Encounter intelligence at the core
Encounter submission at the center, integrated with risk analytics and the coder workbench.
Encounters at the center, integrated with risk analytics and the coder workbench — no exports, no handoff gaps.
Everything the encounter lifecycle needs
From generation to CMS reconciliation — for Medicare Advantage and ACA risk adjustment in a single platform.
Encounter & Edge Server Generation
Generate compliant submission files for every program and provider model.
- 837P, 837I & DME generation
- ACA Edge Server medical & supplemental XML
- Linked & unlinked encounters
- Capitated, VBC & encounter-only models
Validation & Rejection Detection
Catch issues before CMS does, with pre- and post-processing edits.
- 837 format & XML schema validation
- Missing / invalid diagnosis detection
- NDC validation for RXC scoring
- Flags claims likely to be rejected
CMS Reconciliation & Monitoring
Reconcile what you submitted against what CMS accepted.
- MAO-002 & MAO-004 reconciliation
- RARSD, RACSD & ECD analysis
- Accepted / rejected / deleted diagnoses
- Orphan & coverage issue detection
Prospective Coding & Gap ID
Find documentation gaps earlier and reduce retrospective chart chase.
- Missing diagnosis detection pre-submission
- Suspect conditions from clinical & pharmacy data
- EMR-integrated CCD / FHIR context
- Flagging for prospective chart review
Medical + Pharmacy Risk Scoring
Combined visibility across both risk-adjustment drivers.
- HCC RAF from diagnosis codes
- Pharmacy RXC from NDC codes
- Combined medical + pharmacy score view
- Score movement across CMS cycles
Financial Impact & Projection
Quantify revenue at stake and prioritize the work that matters.
- Revenue impact of rejected diagnoses
- RAF progression across payment cycles
- High-risk member prioritization (HCRPDE)
- Corrections ranked by RAF / RXC value
A closed loop from data to dollars
Every encounter flows through the same intelligent pipeline — nothing falls through the cracks between systems.
Rejections feed back. The AI drafts a rule, your analyst approves it.
Forward encounter flow
Agentic AI feedback loop
What sets Invent Health apart
Encounter submission that is accurate, low-maintenance, and built for both Medicare and ACA.
More than 99% accepted the first time
The platform auto-corrects errors and runs CMS-grade checks before a file leaves, so encounters clear on the first pass across Medicare and ACA.
Built for the messy cases
Voids, interim bills, denials, orphan holds, MMR reconciliation, new-to-plan members. The submissions that break other systems run through this one without special handling.
AI drafts the fix, your analyst approves it
When the same rejection keeps happening, the AI finds the pattern and writes a rule to stop it. Your analyst approves it in one click, so nothing changes without a person saying yes.
Change a rule in minutes, not a release
Every CMS edit and plan rule is a setting in the interface. Your team updates it directly, with no code deploy and no engineering ticket, which cuts hours per thousand encounters.
Start with the Core alone
Run encounter submission as your system of record on day one. Add Risk Analytics and the Coder Workbench later, with no rebuild and no migration.
One engine for both programs
The same validation logic runs Medicare EDPS and the ACA Edge Server, each with its own program rules. Your team learns one system, not two.
Complex cases, handled
The submissions that stall other systems run through Invent Health without special handling.
Voids & new members
Voids and interim bills get rebilled by hand, and new members arrive with no history.
Orphaned encounters
There is no parent record to link to, so encounters sit in limbo.
MMR reconciliation
Reconciled by hand in spreadsheets, so payment and risk gaps slip through.
ACA plan changes
Plan-ID changes and member moves break the audit trail.
Void, replacement, and interim logic is built in. New members are found and sequenced automatically.
Orphans are held and tracked, then released the moment the parent record appears.
Reconciled automatically against what was submitted, and every gap surfaces with a dollar value.
Full plan-ID history is kept across moves, so every Edge Server submission stays traceable.
The result: one governed submission lane.
Outcomes health plans care about
Cleaner submissions, earlier gap closure, and clearer visibility into the revenue drivers behind every risk score.
More accurate, complete 837 & Edge Server submissions
Risk-impacting gaps identified before submission
Operational burden from errors & reconciliation rework
Visibility into RAF / RXC revenue drivers for actuarial teams
One platform, mapped to every stakeholder
Each role gets the same connected data — pointed at the outcome they own.
Encounter / EDI Operations
Goal: Clean, complete, on-time submissions with fewer CMS rejections.
- Pain: High 277CA / MAO rejections & manual rework
- We solve it: CMS-grade validation + risk-impact prioritization
- Message: Catch rejections before CMS, fix the highest-impact encounters first
Risk Adjustment / Stars
Goal: Accurate RAF and closure of risk-impacting gaps.
- Pain: Risk-impacting conditions missed; gaps found late
- We solve it: Risk analytics integration + risk-impacting flagging
- Message: Encounters driven by risk impact — flag and reconcile every condition
Coding / HCC Leadership
Goal: Productive, audit-ready coding tied to submitted encounters.
- Pain: No traceability between coded charts and encounters
- We solve it: Coder workbench linkage + chart-to-encounter lineage
- Message: Every encounter linked to the chart your coders worked
Actuarial / Finance
Goal: Reliable revenue projection and visibility into score drivers.
- Pain: Limited visibility into revenue impact & reconciliation gaps
- We solve it: Financial impact analytics + RAF / RXC reconciliation
- Message: A clear line from each encounter to RAF / RXC revenue
See the integrated platform in action
Walk through encounter generation, CMS-grade validation, reconciliation, and the coder workbench — on your own data scenarios.
