Claims Processing Reporting Requirements
C. Instructions for Monthly Claims Processing Reports
The Monthly Claims Processing Reports are due on the fifth calendar day of the second subsequent month. If a due date falls on a weekend or state holiday, reports will be due the next state business day. The due date is the date the reports are to be accepted by the DPW Electronic Reporting System.
The MCO shall provide the Department with monthly reports using the report format provided by the Department and specified in this requirement document. If one or more Subcontractors process claims, the MCO shall provide information distinct to each entity that processes claims.
The monthly reports submission consist of three parts:
Report #1 (Claims Processing Report). The purpose of this is to report adjudication timeliness for all types of claims (Inpatient Clean Claims, Inpatient All Claims, Other than Inpatient or Drug Clean Claims and Other than Inpatient or Drug All Claims) processed by the MCO and/or subcontractors. This report consists of 5 Excel spreadsheets (5 tabs in one workbook) and provides processing information for all types of claims by month (1 tab for
each month) for claims received during the 2nd previous month and each of the previous four
months. The header labeled Month of Claim Receipt in the first tab in the report template
provided by the Department should reflect the most recent month (2nd previous month).
Month of Claim Receipt header in the four remaining tabs will automatically populate the appropriate prior four months for which claims information needs to be entered for each month individually.
The MCO will provide information on claims identified as clean claims or all claims as of the date the report is prepared. Counts of clean or all claims received during a particular month may change on subsequent monthly submission for same month as the MCO identifies additional clean claims. However, the Department does not expect to see major changes to significantly affect claims processing results in the fourth prior month from the same time period in the previous submission.
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The MCO will provide the following information on Report #1:
Name of the MCO (in the first tab only);
Zone (in the first tab only). Reporting is by zone and cannot be combined;
Month of Claim Receipt (in the first tab only);
Information Available to the MCO through Month/Day/Year (in the first tab only);
The name of the individual who prepared the report (in the first tab only);
The date the report was prepared (in the first tab only);
Submission Date (in the first tab only). This field will be validated by the system;
Member Months as of the 3rd prior month (in the first tab only);
Name of Subcontractors processing claims (in all tabs);
Number of claims received (in all tabs);
Number of claims paid within 30 days (in all tabs);
Number of claims denied within 30 days (in all tabs);
Number of claims paid in 31-45 days (in all tabs);
Number of claims denied in 31-45 days (in all tabs);
Number of claims paid in 46-90 days (in all tabs);
Number of claims denied in 46-90 days (in all tabs);
Number of claims paid more than 90 days after receipt (in all tabs);
Number of claims denied more than 90 days after receipt (in all tabs);
Number of rejected claims (in all tabs); and
Number of claims in the inventory not adjudicated (in all tabs).Report #2 (A) – Claims Payment Report. This report provides summary information of fee for service provider payments made during the month without regard to claim type.
Quality/provider incentives paid to fee for service providers should also be included on Part A. The MCO must use the appropriate report templates as provided by the Department. Report #2 (B) – Capitation Payment Report. This report provides summary information on capitation payments made by the MCO during the month. Capitation payments made by the subcontractors are not to be included. Incentives paid to capitated providers should also be included on Part B. MCO must use the appropriate report template as provided by the Department.
It is not necessary to include on Reports #2 (A) and (B) a check that makes a payment only for interest on an untimely payment of a claim. This report provides information on check dates and check mailing dates, total amount of the checks mailed, remittance dates and remittance mailing dates.
The date an electronic transfer of funds is made should be used as the check mailing date.
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The MCO will provide the following information on Report #2:
Name of the MCO (in the first tab only);
Program (in the first tab only). HealthChoices or Voluntary or both;
Month ended Month/Day/Year (in the first tab only);
The name of the individual who prepared the report (in all tabs);
The date the report was prepared (in all tabs);
Name of Subcontractors making the payments (in all tabs where subcontractorinformation is being entered);
Member Months as of the 2nd prior month (in the first tab only);
The check or MCO bank notification date for an electronic payment date (in all tabs);
The check mailing or Electronic Funds Transfer date (in all tabs);
The number of work days between the processing date and the mailing date (in all tabs);
The number of checks mailed or the number of electronic payments (in all tabs);
The amount paid (in all tabs);
The remittance advice date (in all tabs);
The remittance advice mailing date (in all tabs); and
For Report #2 (B) only, the type of service (Provider, Vision, Dental, Pharmacy, Other)and indication if Service Provider paid FFS? by selecting (Yes or No).
The MCO manager responsible for claims processing who reports directly to the Chief Executive Officer must sign a certification statement. The certification statement must be included with all reports being sent to the Department. The name of the preparer on this certification is the person who can be contacted by the Department with any concerns or questions.
Note: An encounter form is not a claim for the purpose of claims processing reporting requirements, even if the MCO pays a modest fee to the provider to encourage submission of the form.
D. Sanctions
Failure to submit a claims processing report timely that is accurate and fully compliant with the reporting requirements shall result in the following penalties: $200 per day for the first ten (10) calendar days from the date the report is due, and $1,000 per day for each calendar day thereafter.
The Department will utilize the monthly report that is due on the fifth (5th) calendar day of
the fifth (5th) subsequent month after the Claim is received to determine Claims processing
penalties. For example, the Department will utilize the monthly report that is due January 5th, to determine claims processing penalties for claims received in the previous August.
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The Department shall utilize the monthly report that is due February 5th, to determine Claims
processing penalties for claims received in the previous September, and so on. All claims received during the month for which a penalty is being computed, that remain unadjudicated at the time the sanction is being determined, shall be considered a clean claim.
If a Commonwealth audit, or an audit required or paid for by the Commonwealth, determines claims processing timeliness data that are different than data submitted by the MCO, or if the MCO has not submitted the required claims processing data, the Department will use the audit results to determine the penalty amount.
The penalties included in the attached charts below will apply separately to:
(1) Inpatient Claims
(2) Claims other than Inpatient or Drug
The penalties provided by this Section apply to all claims included in each of the two (2) claim categories specified above, including claims processed by any Subcontractor.
The MCOs will be considered in compliance with the requirement for adjudication of 100.0% of all Inpatient Claims if 99.5% of all Inpatient Claims are adjudicated within ninety (90) days of receipt. The MCO will be considered in compliance with the requirement of adjudication of 100.0% of All Claims other than Inpatient or Drug if 99.5% of all Claims other than Inpatient or Drug are adjudicated within ninety (90) days of receipt.
Penalties in the chart below shall be reduced by one-third if the MCO has 25,000-50,000 recipients. Penalties in the charts below will be reduced by two-thirds if the MCO has less than 25,000 recipients.
Effective with the claims processing report due on January 5, 2007 from the MCO, the total penalty for the current month will increase to $10,000 if the following conditions exist.
MCO fails to comply with any adjudication timeliness requirement for claims
received in the seven (7) of the nine (9) previous months; and
The sum of adjudication timeliness penalties for the current month is greater than
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