Encounter Processing System
Every Medicaid encounter, validated and compliant by design.
The Problem
Encounter data is one of the highest-volume, highest-stakes data operations in any state Medicaid program, and most states still run it on aging, proprietary systems.
Validation happens in slow 30, 60, 90, 180, and 365-day cycles, formats drift across MCOs, and licenses cost a fortune, all while inaccurate encounter data quietly distorts capitation rate-setting, program integrity, and federal reporting.
What EPS Does
The Encounter Processing System (EPS) is a modern, modular platform for the way state Medicaid agencies work with encounter data. It ingests encounter files from managed care organizations, validates them against your rules, flags and explains every problem record, and produces clean output that is compliant with CMS by design, not by after-the-fact cleanup.
Under the hood, an Encounter Processing Engine coordinates a compliance checker that validates EDI transactions, a business rules engine carrying roughly 250 configurable rules, and a service orchestrator that keeps the pipeline moving, all reachable through a role-based web portal and a full reporting layer. Rules adapt to each state's requirements, without a rewrite.
EPS is built to last: an open-source foundation with no proprietary licenses, a cloud-native design that also runs on-premises, and open standards that keep you free of vendor lock-in.
Credentials
| ✓ | CMS T-MSIS encounter specification aligned |
|---|---|
| ✓ | Compliant by design |
| ✓ | Role-based and least-privilege access control |
| ✓ | Open-source foundation, no vendor lock-in |
| ✓ | Cloud or on-premises deployment |
How It Flows
From MCO File to Compliant Submission
How every encounter batch moves through EPS, and why the output can be trusted.
- STEP 1IngestMCO encounter files land securely over SFTP, any source, any format
- STEP 2CheckThe compliance checker validates every EDI transaction
- STEP 3Apply RulesThe business rules engine runs approximately 250 configurable, state-specific rules
- STEP 4SubmitClean, CMS-compliant output, with problem records flagged and explained
How It Works
Key Capabilities
- Encounter Processing EngineA central engine coordinates ingestion, validation, orchestration, and reporting as one pipeline instead of a patchwork.
- 250+ configurable business rulesInstead of hard-coded logic buried in a legacy system, we offer a baseline rule pack you can configure for your state.
- Multi-level validationEDI compliance checks plus business-rule validation catch, flag, and explain problem records before they reach CMS.
- Compliant by designOutput is built to meet CMS encounter requirements from the start, so compliance is the default, not a cleanup project.
- Role-based web portal and reportingStakeholders get intuitive access to encounter data, error trends, and reports, with role-based and least-privilege access control.
- Open-source, no lock-inAn open-source foundation with no proprietary licenses, deployable in your cloud or on-premises, and free of vendor lock-in.
How We Compare
Legacy Encounter Systems vs. EPS
| Legacy Encounter Systems | EPS |
|---|---|
| Slow 30/60/90/180/365-day validation cycles | Continuous, multi-level validation on every batch |
| Expensive proprietary tools and licenses | Open-source foundation, no license fees or lock-in |
| Errors surface downstream, after submission | Problem records flagged and explained before CMS |
| Rigid logic hard-coded per vendor | More than 250 rules you configure and extend per state |
| Compliance is an after-the-fact cleanup | Compliant by design, from ingestion to submission |
Why It Wins
The Differentiator
Most states run encounter processing on legacy MMIS modules or manual spreadsheets, where accuracy is fragile and every change means a vendor ticket. EPS is a purpose-built alternative: modular and open-source by design, it makes encounter data compliant by design, puts the rules in your hands, and runs wherever you need it, so the data behind capitation rates and program integrity is finally something you can trust.
Works Well With
Complementary Products
TorQE
T-MSIS Outcome Review and Quality Engine. Catch errors before they reach CMS.
Learn moreTessarix™
The cloud-native data lakehouse that unifies Medicaid, CHIP, Medicare, and waiver data.
Learn moreLighthouse
An API-first validation engine: your pipeline calls Lighthouse mid-run, it checks the batch against your rule library where the data lives, and returns a clear gate: proceed or stop.
Learn moreTrust Every Encounter.
A working session with the engineers behind EPS: bring your encounter challenge, see how compliant-by-design changes the math.