Understanding Medicaid Claims and Encounter Data and Their Use in Payment Reform
States across the country are fully engaged in delivery system and payment reform efforts to improve care and lower costs in their Medicaid programs. Data is a critical component of these efforts. This NASHP brief provides an introduction to two types of Medicaid utilization data—fee-for-service claims data and managed care encounter data—and, based on examples from leading states (Arkansas, Michigan, and Missouri), discusses their use in 1) identifying high-need, high-cost patients for care coordination; and 2) measuring, supporting, and rewarding provider performance. This brief also identifies challenges faced in collecting, analyzing, and reporting this data, as well as strategies for addressing them, based on interviews with state officials.