COMPARISON OF MANAGED CARE ENCOUNTER …...Comparison of Managed Care Encounter Data to Accounting...

Comparison of Managed Care Encounter Data to Accounting System Data for PHP TFebruary 17, 2017

Appendix C-1: Initial Encounter Reconciliation Report-April 7, 2017

JANUARY 1, 2014 THROUGH APRIL 30, 2016

COMPARISON OF MANAGED CARE ENCOUNTER DATA TO ACCOUNTING SYSTEM

DATA FOR PRESBYTERIAN HEALTH PLAN, INC.

APRIL 7, 2017

Comparison of Managed Care Encounter Data to Accounting System Data for PHP

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EXECUTIVE SUMMARY ................................................................................................. 3

DEFINITIONS AND ACRONYMS ................................................................................... 5

STUDY PURPOSE .......................................................................................................... 7

DATA SOURCES ............................................................................................................ 8

ANALYSIS ...................................................................................................................... 9

POTENTIAL DATA ISSUES AND ANALYSIS ASSUMPTIONS ................................... 10

PHP – ENTIRE PLAN .................................................................................................... 13

CALCULATED VOID AND DUPLICATE SUMMARY ................................................... 15

SUMMARY REPORTING CHARTS .............................................................................. 16

PHP – DENTAL SERVICES ......................................................................................... 17

PHP – PHARMACY BENEFITS ................................................................................... 18

PHP – PLAN PROCESSED AND OTHER VENDORS ................................................. 19

RECOMMENDATIONS ................................................................................................ 20

TABLE OF CONTENTS


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New Mexico MCO Encounter and ASD Comparison The New Mexico Human Services Department (HSD) has contracted with HealthInsight New Mexico (HealthInsight) as the external quality review organization (EQRO). Myers and Stauffer LC (Myers and Stauffer) is subcontracted and under the direction of HealthInsight New Mexico for the encounter data validation (EDV) project. HSD requires that each Managed Care Organization (MCO) submit encounter data to HSD’s fiscal agent (FA), Conduent, Inc. (known as Xerox Health Solutions prior to January 2017). As part of the External Quality Review (EQR) Protocol 4 process, Myers and Stauffer analyzed Medicaid encounter data that had been submitted by the MCOs to the FA and completed a comparison of the encounters to accounting system data (ASD) provided by each MCO. Validated encounter data have many uses in rate setting analyses by actuaries, as well as in fulfilling the federal reporting requirements related to the Medicaid Managed Care Final Rule, in providing program management and oversight, and other ad hoc analyses. This encounter reconciliation will help fulfill part of the work requirements set forth in activity number 3 of the Centers for Medicare & Medicaid Services (CMS) EQR Protocol 4, which requires a determination of the completeness, accuracy and quality of the encounter data being submitted by each MCO. CMS’s EQR Protocol 4, is a way to assess whether the encounter data can be used to determine program effectiveness, accurately evaluate utilization, identify service gaps and make management decisions. In addition, the Protocol requires an evaluation of both departmental policies, as well as the policies, procedures and systems of the health plans to identify strengths and opportunities to enhance oversight. The full results of our Protocol 4 work will be issued as a separate report. The April 2017 New Mexico Encounter Reconciliation report is an analysis of the encounter data compared to the payments to service providers in the MCO’s and delegated vendor’s accounting system data. Below is a summary of the cumulative completion percentages for all paid encounters submitted to Conduent, Inc. (Conduent), the FA, by Presbyterian Health Plan, Inc. (PHP) for the reporting period of January 1, 2014 through April 30, 2016. Included with this report, are the potential data issues and assumptions utilized during the completion of this report, as well as our recommendations to the MCO, FA, and HSD to help identify and correct the root causes of the issues identified. HealthInsight and Myers and Stauffer recommend that the Human Services Department utilize this report as a management oversight tool to track the progress made by the MCO over time and to monitor the MCO’s contract compliance with providing complete and accurate encounter information. This report consists of PHP’s encounters and ASD.

EXECUTIVE SUMMARY


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Table A PHP ― Cumulative Completion Percentages PHP/Delegated Vendor % of Cumulative Total Entire Plan 112.21% Dental Services 90.49% Pharmacy Benefits 49.89% Plan Processed and Other Vendors 121.58%

Potential issues that may impact the completion percentages are listed below (a full list and description of all potential are included in the main report):

1) There may be encounters included without a matching ASD transaction. 2) It is possible that there were duplicate encounters in the encounter data that we

were unable to identify and remove. 3) Some ASD transaction dates may not have matched the payment dates that

were reported in the encounter data resulting in potential timing issues. 4) The ASD transaction total is low for January 2014. The completion percentage

could be overstated as a result of the low transaction totals in the ASD. 5) The pharmacy encounters for February through May 2014 show very low paid

amounts. The absence of paid encounters for that time period may explain the overstated completion percentage of pharmacy encounters noted for July 2014.

EXECUTIVE SUMMARY


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The following terms are used throughout this document:

• Accounting System Data (ASD) Monthly Reported Total – The sum of all payments from an MCO or delegated vendor to service providers for a given month as reported by the MCO to HSD.

• ASD Cumulative Reported Total – The sum of all payments from an MCO or delegated vendor to service providers for the reconciliation period as reported by the MCO to HSD.

• Calculated Void Encounter (CV) – An encounter that Myers and Stauffer has identified as being a replacement or adjustment that does not appear to have a corresponding void of the original encounter in the FA’s data warehouse.

• Conduent, Inc. (Conduent) – State fiscal management agent (Formerly known as Xerox Health Solutions).

• Cumulative Encounter Total – The sum of all encounter submissions stored in the fiscal agent contractor’s encounter data warehouse. This amount is inclusive of all amounts submitted in prior months.

• Cumulative Variance – The difference between the cumulative encounter total and the ASD cumulative reported total.

• Denied Encounter- An encounter, which has met all Health Insurance Portability and Accountability Act (HIPAA) front end data checks and was accepted by the FA; however, once the encounter was checked against the MMIS business rules, was denied due an exception in a business rule. These denied encounters may be resubmitted by the MCO to correct the issue which caused the denial by the FA.

• Fiscal Agent (FA) – A contractor selected to design, develop and maintain the claims processing system (Medicaid Management Information System); Conduent, Inc (known as Xerox Health Solutions prior to January 2017) is the current FA.

• FOCoS Online (FOCoS) – A subcontractor of Conduent, Inc. • Human Services Department (HSD) – The division in the Office of the Governor

that is responsible for administering Medicaid in New Mexico. • Medicaid Management Information System (MMIS) – The claims processing

system used by the FA to adjudicate New Mexico’s Medicaid claims. MCO submitted encounters are loaded into this system and assigned a unique claim identifier.

DEFINITIONS AND ACRONYMS


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• Managed Care Organization (MCO) – A private organization, or health plan, that has entered into a risk-based contractual arrangement with the New Mexico Human Services Department (HSD) to obtain and finance care for enrolled Medicaid members. MCOs receive a capitation or per member per month (PMPM) payment from HSD for each enrolled member. There are four MCOs operating in New Mexico under a contract that was effective February 1, 2013: Blue Cross and Blue Shield of New Mexico, Molina Healthcare of New Mexico, Presbyterian Health Plan, Inc. and United Healthcare of New Mexico, Inc.

• Monthly Encounter Total – The sum of all encounter submissions for a given month stored in the FA’s encounter data warehouse.

• Monthly Variance – The difference between the monthly encounter total and the ASD monthly reported total.

• Plan Processed Encounters- All encounters processed by the health plan, which would include the encounters that represent medical (institutional and professional) claims and all other claims processed by the plan, which were not subcontracted or delegated to a vendor (i.e., vision, dental, pharmacy, transportation).

• Potential Duplicate Encounter (PDUP) – An encounter that Myers and Stauffer has identified as being a potential duplicate of another encounter in the FA’s data warehouse.

• Rejected encounter - An encounter that has been submitted to the FA but did not meet HIPAA or other front end data checks and was not accepted into the MMIS.

• Xerox Health Solutions (Xerox) – Former name of Conduent, Inc., the state’s fiscal agent contractor. The name change went into effect in January 2017.



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HealthInsight New Mexico (HealthInsight) engaged Myers and Stauffer to analyze Medicaid encounter data that has been submitted by the MCOs to the FA and complete a comparison of the encounters to accounting system data provided by PHP. For purposes of this analysis, “encounter data” are the set of encounters which represent claims that have been paid by MCOs or delegated vendors (e.g., vision and pharmacy) to health care providers that have provided health care services to members enrolled with the MCO. Such encounters are submitted by the MCOs to HSD via the FA for HSD’s use in rate setting, federal reporting, program management and oversight, tracking, accounting and other ad hoc analyses. Section 4.19.2.2.11 of the contract between HSD and the MCO states, “[The Contractor shall] meet HSD Encounter timeliness requirements by submitting to HSD at least ninety percent (90%) of its Claims, both paid and denied, originals and adjustments within thirty (30) Calendar Days of the date of adjudication, and ninety-nine percent (99%) within sixty (60) Calendar Days of the date of adjudication…whether the Encounter is from a subcontractor, subcapitated arrangement, or performed by the CONTRACTOR.” Subsequently in Section 7.3.1.1, the contract states “In the event that the CONTRACTOR or any person with an ownership interest in the CONTRACTOR, affiliate, parent or subcontractor, fails to comply with this Agreement, HSD may impose, at HSD's discretion, the remedies, sanctions and damages described in this Section [7.3].” HealthInsight, on behalf of HSD, requested that, for this study, we estimate the percentage of each MCO and delegated vendor paid encounters that appear to be included in the FA’s data warehouse. This analysis includes these percentages for all MCO paid claims as well as separate pharmacy and dental vendor encounters paid during the period January 1, 2014 through April 30, 2016.

STUDY PURPOSE


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Myers and Stauffer received encounter data from the FA. The data are in a standardized extract containing MCO institutional, medical, and pharmacy encounters. These encounter data extracts include encounters from the four MCOs: Blue Cross and Blue Shield of New Mexico, Molina Healthcare of New Mexico, Presbyterian Health Plan, Inc. and United Healthcare of New Mexico, Inc., having plan paid dates starting on January 1, 2014. The data used for this report includes encounters received and accepted by the FA through May 31, 2016. Myers and Stauffer also requested ASD from each MCO ranging in dates from January 1, 2014 through April 30, 2016 in a standardized format.

DATA SOURCES


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Encounters from institutional, medical and pharmacy claim types were combined on like data fields. We analyzed the line reported information of each encounter to capture the amount paid on the entire claim. Encounter totals were calculated by summarizing the data by the MCO paid date and MCO identification number. Accounting system data submitted by the MCO were summarized by paid date. These two tables were combined using common fields between the tables and were used to produce the results. Based on criteria provided by the MCO and HSD, we identified the PHP encounters as follows: General criteria for all populations:

Submitter ID For PHP the submitter ID is noted to be 000M1814. Only

encounters with the indicated submitter ID were included in the analyses.

Filing Indicators No filing indicators were excluded from these analyses. Medicare Part A and Medicare Part B crossover claims have been included in analysis.

Criteria for specific populations:

Pharmacy Benefit

Pharmacy encounters were isolated by restricting the data to header type code ‘R’.

Dental Services Dental encounters were isolated by restricting the data to header

type code ‘D’.

Plan Processed Encounters and Other Vendors Plan Processed Encounters and Other Vendors were isolated by

excluding the data with header type code ‘D’ or ‘R’.

ANALYSIS


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In the performance of this analysis, Myers and Stauffer makes the following assumptions and notes regarding potential data issues: 1. We assume that all data provided to Myers and Stauffer is complete and accurate.

2. This analysis only included encounters that were submitted by the MCOs to the FA and loaded into the FA’s data warehouse. Encounters submitted by any MCO that were rejected by the FA for errors in submission or other reasons are excluded from this analysis.

3. We instructed the MCOs to exclude referral fees, management fees and other non-encounter related fees in the ASD data submitted to Myers and Stauffer.

4. We identified potential duplicate encounters. We analyzed the encounters and ASD submissions to conclude that some of these potential duplicates appear to be partial payments, some are actual duplicate submissions and some are replacement claims without a matching void. We have attempted to adjust our totals to reflect the actual payment made and have removed duplicate payments from our analysis.

5. The monthly completion percentages for the entire plan exceeded 100 percent for some months of the reporting period. These overstated monthly completion percentages may be due to a variety of reasons such as encounters included without a corresponding matching ASD transaction or certain claim voids and replacements that were absent from the encounter data, but were accounted for in the ASD. Additionally, duplicate encounters may have existed in the encounter data that we were unable to identify and remove. Also, ASD payment dates may not have matched the payment dates that were reported in the encounter data resulting in potential timing issues.

6. Myers and Stauffer historically codes voided encounters contained within the encounter submissions to match the associated adjustment claim’s paid date. This allows for the proper matching of accounting system data that occurs due to this void transaction. We were unable to assign a paid date to the void transactions that was different than the date of the original submission. It appears PHP used the date of the original submission for the MCO paid date and the MCO received date on all subsequent adjustments, replacements, back outs and voids of an encounter claim.

7. Interest amounts do not appear to be included in the MCO paid amounts. We have therefore excluded the separately itemized interest expense from the ASD totals.

POTENTIAL DATA ISSUES AND ANALYSIS ASSUMPTIONS


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8. Encounters denied by the FA were included and subjected to our potential duplicate encounter logic process which identifies and removes these claims appropriately. This methodology artificially inflates the percentages of claim counts and amounts removed as identified in Table 2 – PHP Calculated Void and Duplicate Summary, since some of these were likely already marked correctly as denied for this duplicate issue. This is currently the only fair and representative way to ensure that the actual MCO paid encounters remain in our analysis.

9. The MCO paid date in the encounters seems to be set to the same date for each original encounter and all of its subsequent adjustments. The MCO received date also seems to be set to the same date for each original encounter and all of its subsequent adjustments. The process of using the same date for the original encounter and all adjustments has the potential to create timing issues and may contribute to the overstated percentages noted in some months of the reporting period.

10. It appears that there are no Waiver encounters in the data that was submitted to Myers and Stauffer, as evidenced by the absence of encounters with header type code “W.”

11. Within the ASD, there are no data with the “self-directed benefit” service type. Myers and Stauffer has noted some claims with the self-directed benefit vendor, FOCoS, in the Service_Name field; however, the service type for these claims is ‘Medical.’

12. Additionally, there are no claims in the ASD with “therapy” or “durable medical equipment” service types. Any missing accounting system data has the potential to affect the completion percentages.

13. It seems that in the pharmacy encounter data there are a significant amount of voids and backouts; however, no voids or backouts seem to be present in the ASDs. This may be a contributing factor to the completion percentages for pharmacy being understated for the first half of calendar year 2014.

14. There are adjustment instances in the encounters where the adjustment backout is successful, but the corresponding replacement transaction is denied by the FA. This is creating a series of problems with the encounter data. First, these instances effectively remove paid encounters from the FA’s data warehouse that the MCO may have intended to replace. Additionally, when an MCO submits subsequent replacement transactions (to replace the replacement encounters), these too are denied due to the original encounter already being considered voided or adjusted. As a result, the plan must send the transaction as a new unrelated original encounter in order to have it accepted by the FA. This process is problematic since it can produce encounters that may not reflect the MCO’s actual encounter adjustment activity.



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15. Analysis of the encounter data and accounting system data, as well as interactions with the MCOs, HSD and the FA have resulted in the identification of opportunities for improving the encounter reconciliation process. While we have attempted to account for these situations, other potential issues within the data may exist that have not yet been identified which may require us to restate this report.


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PHP appears to have submitted approximately 180 percent of their encounter data for this period. Monthly percentages exceeded 100 percent during some months of the reporting period and for the overall study period. Please reference potential data issues for an explanation of the possible causes.

Table 1 ― PHP Entire Plan

Paid Month ASD

Monthly Reported

Total

Monthly Encounter

Total Monthly Variance

ASD Cumulative Reported

Total

Cumulative Encounter

Total Cumulative

Variance % of

Monthly Claims

% of Cumulative

Total

January 2014 $20,443,645 $36,934,407 $16,490,762 $20,443,645 $36,934,407 $16,490,762 180.66% 180.66% February 2014 $44,123,222 $51,093,558 $6,970,336 $64,566,867 $88,027,965 $23,461,098 115.79% 136.33% March 2014 $53,949,502 $78,808,092 $24,858,590 $118,516,368 $166,836,057 $48,319,688 146.07% 140.77% April 2014 $56,763,351 $70,818,583 $14,055,231 $175,279,720 $237,654,639 $62,374,920 124.76% 135.58% May 2014 $60,236,717 $83,332,560 $23,095,843 $235,516,437 $320,987,200 $85,470,763 138.34% 136.29% June 2014 $58,302,180 $120,803,395 $62,501,215 $293,818,617 $441,790,595 $147,971,978 207.20% 150.36% July 2014 $64,458,346 $83,755,630 $19,297,284 $358,276,964 $525,546,225 $167,269,261 129.93% 146.68% August 2014 $66,260,919 $79,095,271 $12,834,352 $424,537,882 $604,641,496 $180,103,614 119.36% 142.42% September 2014 $70,441,938 $82,227,702 $11,785,764 $494,979,820 $686,869,198 $191,889,378 116.73% 138.76% October 2014 $73,229,614 $76,493,761 $3,264,147 $568,209,434 $763,362,959 $195,153,525 104.45% 134.34% November 2014 $74,484,899 $83,502,905 $9,018,005 $642,694,334 $846,865,864 $204,171,530 112.10% 131.76% December 2014 $73,637,301 $78,215,100 $4,577,799 $716,331,634 $925,080,963 $208,749,329 106.21% 129.14% January 2015 $73,812,919 $85,350,203 $11,537,284 $790,144,554 $1,010,431,166 $220,286,612 115.63% 127.87% February 2015 $79,597,450 $92,781,705 $13,184,256 $869,742,004 $1,103,212,872 $233,470,868 116.56% 126.84% March 2015 $83,192,148 $97,541,326 $14,349,178 $952,934,152 $1,200,754,197 $247,820,046 117.24% 126.00% April 2015 $92,619,825 $80,656,317 ($11,963,508) $1,045,553,976 $1,281,410,514 $235,856,538 87.08% 122.55% May 2015 $82,692,876 $77,815,148 ($4,877,729) $1,128,246,853 $1,359,225,661 $230,978,809 94.10% 120.47% June 2015 $81,034,063 $77,946,312 ($3,087,751) $1,209,280,916 $1,437,171,973 $227,891,057 96.18% 118.84% July 2015 $87,744,741 $83,648,775 ($4,095,966) $1,297,025,657 $1,520,820,748 $223,795,091 95.33% 117.25% August 2015 $79,508,079 $84,257,598 $4,749,520 $1,376,533,736 $1,605,078,347 $228,544,611 105.97% 116.60% September 2015 $75,526,751 $78,547,595 $3,020,843 $1,452,060,487 $1,683,625,941 $231,565,454 103.99% 115.94% October 2015 $81,221,142 $84,479,002 $3,257,860 $1,533,281,629 $1,768,104,943 $234,823,314 104.01% 115.31% November 2015 $77,968,284 $84,287,975 $6,319,691 $1,611,249,912 $1,852,392,918 $241,143,006 108.10% 114.96% December 2015 $91,076,191 $90,434,904 ($641,287) $1,702,326,103 $1,942,827,822 $240,501,719 99.29% 114.12%

PHP – ENTIRE PLAN

PHP JANUARY 2014 – APRIL 2016


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Table 1 ― PHP Entire Plan (continued)

Paid Month

ASD Monthly Reported

Total

Monthly Encounter



Total


Total Cumulative

Variance

% of Monthly Claims

% of Cumulative

Total

January 2016 $81,927,982 $79,274,943 ($2,653,039) $1,784,254,085 $2,022,102,764 $237,848,680 96.76% 113.33% February 2016 $81,137,763 $81,058,796 ($78,967) $1,865,391,848 $2,103,161,560 $237,769,712 99.90% 112.74% March 2016 $82,786,067 $90,101,191 $7,315,124 $1,948,177,915 $2,193,262,751 $245,084,836 108.83% 112.58% April 2016 $80,511,668 $83,174,924 $2,663,256 $2,028,689,583 $2,276,437,676 $247,748,092 103.30% 112.21%

*Please note that the ASD has been provided to Myers and Stauffer by PHP. Encounter data has been provided by the FA.


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The calculated void (CV) and potential duplicate (PDUP) encounters that have been identified through the encounter reconciliation analysis are indicated below. These claims have been removed from the encounter reconciliation totals.

Table 2 ― PHP Calculated Void and Duplicate Summary

Paid Month Count of Encounters

Total Sum (CCO

Submitted Paid Amount)

Count of CV PDUP

Encounters

CV PDUP Amount

Removed

% of CV PDUP

Encounter Count

% of CV PDUP

Amount Removed

January 2014 251,332 $40,581,242 38,813 $3,646,835 15.44% 8.99% February 2014 250,400 $56,438,405 48,933 $5,344,847 19.54% 9.47% March 2014 338,136 $86,951,763 70,640 $8,143,672 20.89% 9.37% April 2014 311,601 $80,745,132 68,622 $9,926,549 22.02% 12.29% May 2014 342,348 $93,824,635 71,505 $10,492,075 20.89% 11.18% June 2014 506,369 $136,680,698 168,349 $15,877,303 33.25% 11.62% July 2014 1,024,235 $114,956,293 485,502 $31,200,663 47.40% 27.14% August 2014 465,505 $95,138,208 153,057 $16,042,937 32.88% 16.86% September 2014 519,140 $103,165,061 181,795 $20,937,359 35.02% 20.30% October 2014 486,775 $92,624,860 154,002 $16,131,100 31.64% 17.42% November 2014 538,703 $101,333,017 155,794 $17,830,112 28.92% 17.60% December 2014 513,760 $91,355,246 135,639 $13,140,147 26.40% 14.38% January 2015 468,670 $97,576,130 111,612 $12,225,927 23.81% 12.53% February 2015 511,219 $107,853,633 126,139 $15,071,928 24.67% 13.97% March 2015 575,092 $113,467,204 138,893 $15,925,878 24.15% 14.04% April 2015 483,202 $91,098,514 110,115 $10,442,197 22.79% 11.46% May 2015 546,607 $89,759,910 144,215 $11,944,763 26.38% 13.31% June 2015 452,479 $87,020,544 88,776 $9,074,233 19.62% 10.43% July 2015 479,974 $93,288,647 111,180 $9,639,871 23.16% 10.33% August 2015 537,598 $99,023,071 191,093 $14,765,473 35.55% 14.91% September 2015 494,277 $87,517,963 122,306 $8,970,369 24.74% 10.25% October 2015 462,899 $92,824,096 96,057 $8,345,094 20.75% 8.99% November 2015 479,303 $92,655,756 103,710 $8,367,781 21.64% 9.03% December 2015 501,714 $100,883,263 113,655 $10,448,359 22.65% 10.36% January 2016 433,120 $86,825,467 89,014 $7,550,524 20.55% 8.70% February 2016 474,454 $89,955,034 96,238 $8,896,238 20.28% 9.89% March 2016 551,297 $99,217,258 122,436 $9,116,067 22.21% 9.19% April 2016 443,002 $88,805,191 85,277 $5,630,266 19.25% 6.34% TOTALS 13,443,211 2,611,566,241 3,583,367 335,128,567 26.66% 12.83%

Count of Encounters – The number of encounters processed by the FA (including claims marked as denied by the FA). Total Sum (MCO Submitted Paid Amount) – The total paid amount of encounters in a month per the encounter data provided by the FA. Count of CV PDUP Encounters – The number of encounters identified by Myers and Stauffer as potential calculated voids and duplicates. CV PDUP Amount Removed – The paid amount removed from the Monthly Encounter Total based on Myers and Stauffer ’s analysis of calculated void and duplicate encounters. % of CV PDUP Encounter Count – The percentage of CV PDUP encounters out of the total number of encounters. % of CV PDUP Amount Removed – The percentage of paid amount removed from the total MCO submitted paid amount.

PHP CALCULATED VOID AND DUPLICATE SUMMARY


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Figure 1 - PHP’s ASD totals and encounter totals as reported monthly.

Figure 2 - PHP’s cumulative encounter submissions expressed as a percentage of payments submitted to the FA to reported MCO ASD payments.

$0

$20,000,000

$40,000,000

$60,000,000

$80,000,000

$100,000,000

$120,000,000

$140,000,000

ASD Monthly Reported Total

Monthly Encounter Total

100%

125%

150%

175%

% of Cumulative Total

PHP SUMMARY REPORTING CHARTS


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PHP appears to have submitted approximately 90 percent of the dental encounter data for this period, with a cumulative monthly range between 90 percent and 93 percent.

PHP – DENTAL SERVICES

Table 3 ― PHP Dental Services

Paid Month ASD

Monthly Reported

Total

Monthly Encounter



Total


Total Cumulative

Variance % of

Monthly Claims

% of Cumulative

Total

January 2014 $4,059,774 $3,769,377 ($290,397) $4,059,774 $3,769,377 ($290,397) 92.84% 92.84% February 2014 $3,596,463 $3,337,841 ($258,622) $7,656,237 $7,107,218 ($549,019) 92.80% 92.82% March 2014 $3,572,239 $3,361,039 ($211,201) $11,228,477 $10,468,257 ($760,219) 94.08% 93.22% April 2014 $3,570,049 $3,321,052 ($248,997) $14,798,525 $13,789,309 ($1,009,216) 93.02% 93.18% May 2014 $3,764,439 $3,479,589 ($284,850) $18,562,964 $17,268,898 ($1,294,066) 92.43% 93.02% June 2014 $3,402,105 $3,169,417 ($232,688) $21,965,069 $20,438,315 ($1,526,754) 93.16% 93.04% July 2014 $5,051,745 $4,694,116 ($357,629) $27,016,814 $25,132,431 ($1,884,383) 92.92% 93.02% August 2014 $3,862,122 $3,571,298 ($290,825) $30,878,937 $28,703,729 ($2,175,208) 92.46% 92.95% September 2014 $3,507,201 $3,314,880 ($192,321) $34,386,138 $32,018,609 ($2,367,529) 94.51% 93.11% October 2014 $3,682,170 $3,401,270 ($280,900) $38,068,308 $35,419,879 ($2,648,429) 92.37% 93.04% November 2014 $3,555,065 $3,324,184 ($230,880) $41,623,372 $38,744,063 ($2,879,309) 93.50% 93.08% December 2014 $4,826,317 $4,466,610 ($359,707) $46,449,690 $43,210,673 ($3,239,016) 92.54% 93.02% January 2015 $3,339,467 $3,107,327 ($232,140) $49,789,157 $46,318,001 ($3,471,156) 93.04% 93.02% February 2015 $4,108,220 $3,816,667 ($291,553) $53,897,377 $50,134,668 ($3,762,709) 92.90% 93.01% March 2015 $4,091,504 $3,820,045 ($271,459) $57,988,881 $53,954,713 ($4,034,169) 93.36% 93.04% April 2015 $4,069,111 $3,775,554 ($293,558) $62,057,992 $57,730,266 ($4,327,726) 92.78% 93.02% May 2015 $3,891,076 $3,460,238 ($430,838) $65,949,069 $61,190,505 ($4,758,564) 88.92% 92.78% June 2015 $4,015,285 $3,516,264 ($499,021) $69,964,354 $64,706,769 ($5,257,585) 87.57% 92.48% July 2015 $5,904,803 $5,160,246 ($744,557) $75,869,157 $69,867,015 ($6,002,142) 87.39% 92.08% August 2015 $4,144,959 $3,670,777 ($474,182) $80,014,116 $73,537,793 ($6,476,324) 88.56% 91.90% September 2015 $3,876,570 $3,429,224 ($447,346) $83,890,686 $76,967,016 ($6,923,670) 88.46% 91.74% October 2015 $4,066,469 $3,711,201 ($355,268) $87,957,155 $80,678,217 ($7,278,938) 91.26% 91.72% November 2015 $4,186,555 $3,725,137 ($461,417) $92,143,710 $84,403,355 ($7,740,355) 88.97% 91.59% December 2015 $5,622,040 $4,968,989 ($653,050) $97,765,749 $89,372,344 ($8,393,405) 88.38% 91.41% January 2016 $3,628,416 $3,290,980 ($337,436) $101,394,166 $92,663,324 ($8,730,842) 90.70% 91.38% February 2016 $4,418,668 $3,751,826 ($666,842) $105,812,833 $96,415,150 ($9,397,684) 84.90% 91.11% March 2016 $4,364,042 $3,696,082 ($667,960) $110,176,875 $100,111,232 ($10,065,644) 84.69% 90.86% April 2016 $4,573,245 $3,728,162 ($845,083) $114,750,120 $103,839,393 ($10,910,727) 81.52% 90.49%


18

PHP appears to have submitted approximately 49 percent of the pharmacy benefit encounter data for this period, with a cumulative monthly range between -36 percent and 50 percent. Monthly percentages exceeded 100 percent during a month of the reporting period. Please reference potential data issues for an explanation of the possible causes.

Table 4 ― PHP Pharmacy Benefits

Paid Month ASD

Monthly Reported

Total

Monthly Encounter



Total


Total Cumulative

Variance % of Monthly Accounting

Transactions

% of Cumulative

Total

January 2014 $4,791,058 ($1,730,248) ($6,521,306) $4,791,058 ($1,730,248) ($6,521,306) -36.11% -36.11% February 2014 $4,939,410 ($3,311) ($4,942,722) $9,730,469 ($1,733,560) ($11,464,028) -0.06% -17.81% March 2014 $7,634,230 $1,464 ($7,632,767) $17,364,699 ($1,732,096) ($19,096,795) 0.01% -9.97% April 2014 $6,785,674 $122 ($6,785,551) $24,150,372 ($1,731,974) ($25,882,346) 0.00% -7.17% May 2014 $6,558,813 $5,923 ($6,552,891) $30,709,186 ($1,726,051) ($32,435,237) 0.09% -5.62% June 2014 $6,428,407 $3,702,056 ($2,726,352) $37,137,593 $1,976,005 ($35,161,589) 57.58% 5.32% July 2014 $6,205,176 $18,107,506 $11,902,330 $43,342,769 $20,083,510 ($23,259,258) 291.81% 46.33% August 2014 $6,802,752 $3,265,411 ($3,537,341) $50,145,521 $23,348,922 ($26,796,599) 48.00% 46.56% September 2014 $6,768,052 $3,859,158 ($2,908,894) $56,913,573 $27,208,079 ($29,705,493) 57.02% 47.80% October 2014 $6,787,438 $2,839,020 ($3,948,418) $63,701,011 $30,047,099 ($33,653,911) 41.82% 47.16% November 2014 $6,948,964 $3,188,924 ($3,760,040) $70,649,974 $33,236,023 ($37,413,951) 45.89% 47.04% December 2014 $7,402,475 $4,486,396 ($2,916,079) $78,052,450 $37,722,420 ($40,330,030) 60.60% 48.32% January 2015 $7,479,655 $2,876,186 ($4,603,470) $85,532,105 $40,598,605 ($44,933,500) 38.45% 47.46% February 2015 $5,631,725 $4,068,591 ($1,563,133) $91,163,830 $44,667,197 ($46,496,633) 72.24% 48.99% March 2015 $9,335,636 $4,603,355 ($4,732,281) $100,499,465 $49,270,551 ($51,228,914) 49.30% 49.02% April 2015 $7,948,593 $3,363,764 ($4,584,829) $108,448,058 $52,634,315 ($55,813,743) 42.31% 48.53% May 2015 $7,687,197 $6,106,974 ($1,580,223) $116,135,256 $58,741,290 ($57,393,966) 79.44% 50.58% June 2015 $7,733,919 $3,293,431 ($4,440,488) $123,869,175 $62,034,721 ($61,834,454) 42.58% 50.08% July 2015 $7,646,815 $4,642,959 ($3,003,856) $131,515,990 $66,677,680 ($64,838,310) 60.71% 50.69% August 2015 $7,903,829 $2,880,357 ($5,023,471) $139,419,819 $69,558,038 ($69,861,781) 36.44% 49.89% September 2015 $8,848,334 $4,960,579 ($3,887,755) $148,268,152 $74,518,617 ($73,749,536) 56.06% 50.25% October 2015 $8,916,088 $3,793,236 ($5,122,852) $157,184,240 $78,311,853 ($78,872,388) 42.54% 49.82% November 2015 $9,252,880 $4,849,328 ($4,403,551) $166,437,120 $83,161,181 ($83,275,939) 52.40% 49.96% December 2015 $11,067,834 $5,776,016 ($5,291,818) $177,504,954 $88,937,198 ($88,567,757) 52.18% 50.10% January 2016 $8,467,745 $4,026,973 ($4,440,772) $185,972,699 $92,964,171 ($93,008,529) 47.55% 49.98% February 2016 $9,493,898 $4,346,793 ($5,147,105) $195,466,598 $97,310,964 ($98,155,634) 45.78% 49.78% March 2016 $10,224,721 $5,878,828 ($4,345,894) $205,691,319 $103,189,791 ($102,501,527) 57.49% 50.16% April 2016 $9,782,248 $4,312,369 ($5,469,879) $215,473,567 $107,502,160 ($107,971,407) 44.08% 49.89%

PHP – PHARMACY BENEFITS


19

PHP appears to have submitted approximately 100 percent of the plan processed and other vendor encounter data for this period. Monthly percentages exceeded 100 percent during most months of the reporting period and for the overall study period. Please reference potential data issues for an explanation of the possible causes.

PHP – PLAN PROCESSED ENCOUNTERS AND OTHER VENDORS

Table 5 ― PHP Plan Processed Encounters and Other Vendors

Paid Month ASD

Monthly Reported

Total

Monthly Encounter



Total


Total Cumulative

Variance % of

Monthly Claims

% of Cumulative

Total

January 2014 $11,592,813 $34,895,278 $23,302,466 $11,592,813 $34,895,278 $23,302,466 301.00% 301.00% February 2014 $35,587,348 $47,759,028 $12,171,679 $47,180,161 $82,654,306 $35,474,145 134.20% 175.18% March 2014 $42,743,032 $75,445,589 $32,702,557 $89,923,193 $158,099,895 $68,176,703 176.50% 175.81% April 2014 $46,407,629 $67,497,408 $21,089,779 $136,330,822 $225,597,304 $89,266,482 145.44% 165.47% May 2014 $49,913,465 $79,847,049 $29,933,584 $186,244,287 $305,444,353 $119,200,066 159.97% 164.00% June 2014 $48,471,668 $113,931,923 $65,460,255 $234,715,955 $419,376,275 $184,660,320 235.04% 178.67% July 2014 $53,201,425 $60,954,008 $7,752,583 $287,917,381 $480,330,284 $192,412,903 114.57% 166.82% August 2014 $55,596,044 $72,258,562 $16,662,518 $343,513,425 $552,588,846 $209,075,421 129.97% 160.86% September 2014 $60,166,685 $75,053,665 $14,886,980 $403,680,110 $627,642,510 $223,962,400 124.74% 155.48% October 2014 $62,760,006 $70,253,471 $7,493,465 $466,440,116 $697,895,981 $231,455,865 111.93% 149.62% November 2014 $63,980,871 $76,989,796 $13,008,925 $530,420,987 $774,885,777 $244,464,790 120.33% 146.08% December 2014 $61,408,508 $69,262,093 $7,853,585 $591,829,495 $844,147,870 $252,318,375 112.78% 142.63% January 2015 $62,993,797 $79,366,690 $16,372,893 $654,823,292 $923,514,560 $268,691,268 125.99% 141.03% February 2015 $69,857,505 $84,896,447 $15,038,942 $724,680,797 $1,008,411,007 $283,730,211 121.52% 139.15% March 2015 $69,765,008 $89,117,926 $19,352,917 $794,445,805 $1,097,528,933 $303,083,128 127.74% 138.15% April 2015 $80,602,121 $73,516,999 ($7,085,121) $875,047,926 $1,171,045,932 $295,998,007 91.20% 133.82% May 2015 $71,114,603 $68,247,935 ($2,866,668) $946,162,528 $1,239,293,867 $293,131,339 95.96% 130.98% June 2015 $69,284,858 $71,136,616 $1,851,757 $1,015,447,387 $1,310,430,483 $294,983,096 102.67% 129.04% July 2015 $74,193,123 $73,845,570 ($347,553) $1,089,640,510 $1,384,276,053 $294,635,543 99.53% 127.03% August 2015 $67,459,291 $77,706,464 $10,247,173 $1,157,099,801 $1,461,982,516 $304,882,715 115.19% 126.34% September 2015 $62,801,847 $70,157,792 $7,355,944 $1,219,901,648 $1,532,140,308 $312,238,660 111.71% 125.59% October 2015 $68,238,585 $76,974,565 $8,735,980 $1,288,140,233 $1,609,114,873 $320,974,639 112.80% 124.91% November 2015 $64,528,849 $75,713,509 $11,184,660 $1,352,669,082 $1,684,828,382 $332,159,300 117.33% 124.55% December 2015 $74,386,317 $79,689,898 $5,303,581 $1,427,055,399 $1,764,518,280 $337,462,881 107.12% 123.64% January 2016 $69,831,821 $71,956,990 $2,125,169 $1,496,887,220 $1,836,475,270 $339,588,050 103.04% 122.68% February 2016 $67,225,197 $72,960,177 $5,734,980 $1,564,112,417 $1,909,435,447 $345,323,030 108.53% 122.07% March 2016 $68,197,304 $80,526,281 $12,328,978 $1,632,309,721 $1,989,961,728 $357,652,008 118.07% 121.91% April 2016 $66,156,175 $75,134,394 $8,978,219 $1,698,465,896 $2,065,096,122 $366,630,226 113.57% 121.58%


20

1. HealthInsight and Myers and Stauffer recommend that PHP populate the actual date of adjudication and payment rather than repeating the date of a prior adjudication or payment on all subsequent iterations of an encounter. Populating the actual date of adjudication and payment is required by CMS in accordance with their Encounter Data Minimum Data Elements.

2. HealthInsight and Myers and Stauffer recommend that PHP work with all their vendors to ensure that reporting requirements in the Medicaid Managed Care Services Agreement are being met. In this analysis there are no data for waiver services and it seems some pharmacy data may be missing.

3. HealthInsight and Myers and Stauffer recommend that PHP review their ASD for any FOCoS claims that may be misidentified as “medical” instead of “self-directed benefit” so that their ASD accurately reflects the type of service provided.

RECOMMENDATIONS

PHP RECOMMENDATIONS


February 17, 2017

APPENDIX C-2: UPDATED ENCOUNTER RECONCILIATION REPORT - AUGUST 23, 2017

JANUARY 1, 2014 THROUGH FEBRUARY 28, 2017

COMPARISON OF MANAGED CARE ENCOUNTERS TO ACCOUNTING SYSTEM

DATA FOR PRESBYTERIAN HEALTH PLAN, INC.

AUGUST 23, 2017

2

EXECUTIVE SUMMARY ................................................................................................. 3

DEFINITIONS AND ACRONYMS ................................................................................... 5

STUDY PURPOSE .......................................................................................................... 7

DATA SOURCES ............................................................................................................ 8

ANALYSIS ...................................................................................................................... 9

POTENTIAL DATA ISSUES AND ANALYSIS ASSUMPTIONS ................................... 10

PHP – ENTIRE PLAN .................................................................................................... 12

PHP – CALCULATED VOID AND DUPLICATE SUMMARY ........................................ 14

PHP – SUMMARY REPORTING CHARTS ................................................................... 16

PHP – DENTAL BENEFITS .......................................................................................... 17

PHP – PHARMACY BENEFITS .................................................................................... 19

PHP – PLAN PROCESSED ENCOUNTERS AND OTHER VENDORS ........................ 21

RECOMMENDATIONS ................................................................................................. 23

TABLE OF CONTENTS


3

New Mexico MCO Encounter and ASD Comparison The New Mexico Human Services Department (HSD) has contracted with HealthInsight New Mexico (HealthInsight) as the external quality review organization (EQRO). Myers and Stauffer LC (Myers and Stauffer) is subcontracted and under the direction of HealthInsight for the encounter data validation (EDV) project. HSD requires that each Managed Care Organization (MCO) submit encounters to HSD’s fiscal agent (FA), which is Conduent, Inc. To ensure complete and accurate encounter data is being received, Myers and Stauffer LC (Myers and Stauffer) provides this encounter reconciliation. As part of this process, Myers and Stauffer analyzed Medicaid encounter data that had been submitted by the MCOs to Conduent, Inc. (formerly known as Xerox Health Solutions) and completed a comparison of the encounters to accounting system data (ASD) provided by each MCO. For purposes of this analysis, “encounter data” are the set of encounters which represent claims that have been paid by Presbyterian Health Plan of New Mexico, Inc. (PHP) or delegated vendors (e.g., vision and pharmacy) to healthcare providers that have provided healthcare services to members enrolled with PHP. Validated encounter data have many uses in rate setting analyses by actuaries as well as in fulfilling the federal reporting requirements related to the Medicaid Managed Care Final Rule, in providing program management and oversight and in tracking account and other ad hoc analyses. Section 4.19.2.2.11 of the contract between HSD and the MCO states, “[The Contractor shall] meet HSD Encounter timeliness requirements by submitting to HSD at least ninety percent (90%) of its Claims, both paid and denied, originals and adjustments within thirty (30) Calendar Days of the date of adjudication, and ninety-nine percent (99%) within sixty (60) Calendar Days of the date of adjudication…whether the Encounter is from a subcontractor, subcapitated arrangement, or performed by the CONTRACTOR.” Subsequently in Section 7.3.1.1, the contract states, “In the event that the CONTRACTOR or any person with an ownership interest in the CONTRACTOR, affiliate, parent or subcontractor, fails to comply with this Agreement, HSD may impose, at HSD's discretion, the remedies, sanctions and damages described in this Section [7.3].” This encounter reconciliation will also help fulfill part of the work requirements outlined in step number 3 of the Centers for Medicare & Medicaid Services (CMS) EQR Protocol 4: Validation of Encounter Data Reported by the MCO, which requires a determination of the completeness, accuracy and quality of the encounter data being submitted by each MCO. Centers for Medicare & Medicaid Services (CMS) EQR Protocol 4: Validation of Encounter Data Reported by the MCO is an excellent way to assess whether the encounter data can be used to determine program effectiveness, accurately evaluate utilization, identify service gaps, and make strong management decisions. In addition, the Protocol evaluates both departmental policies, as well as the policies, procedures and systems of the health plans to identify strengths and opportunities to enhance oversight. The full results of the EQR Protocol 4: Validation of Encounter Data Reported by the MCO work will be issued as a separate report.

EXECUTIVE SUMMARY


4

August 2017 Encounter Reconciliation Report The August 2017 New Mexico Encounter Reconciliation report is an analysis of encounters identified in the encounter data compared to the payments to service providers in the ASD. Below is a summary of the cumulative completion percentages for all encounter paid claims submitted to Conduent (FA) by PHP for the reporting period of January 1, 2014 through February 28, 2017. Included within this report, are the potential data issues and assumptions utilized during the completion of this report, as well as our recommendations to PHP, FA, and HSD to help identify and correct the root causes of the issues identified. HealthInsight and Myers and Stauffer recommend that HSD utilize this report as a management oversight tool to track the progress made by PHP over time and to monitor PHP’s contract compliance with providing complete and accurate encounter information. This report consists of PHP’s encounters and ASD.

Potential issues that may impact the completion percentages are listed below (a full list and description of all potential are included in the main report):

1) There may be encounters included without a matching ASD transaction. 2) It is possible that there were duplicate claims in the encounter data that we were

unable to identify and remove. 3) Some ASD transaction dates may not have matched the payment dates that

were reported in the encounter data resulting in potential timing issues. 4) The completion percentage could be overstated as a result of the low transaction

totals in the ASDs, specifically in January 2014.

Table A PHP ― Cumulative Completion Percentages PHP/Delegated Vendor % of Cumulative Total Entire Plan 94.46% Dental Benefits 92.20% Pharmacy Benefits 101.89% Plan Processed and Other Vendors 93.60%

EXECUTIVE SUMMARY


5

The following terms are used throughout this document:

• Accounting System Data (ASD) – A journal used to record and track cash payments by an entity.

• ASD Monthly Reported Total – The sum of all payments from PHP or delegated vendors to service providers for a given month as reported by PHP to HSD.

• ASD Cumulative Reported Total – The sum of all payments from PHP or delegated vendors to service providers for the reconciliation period as reported by PHP to HSD.

• Calculated Void Encounter (CV) – An encounter that Myers and Stauffer has identified as being a replacement encounter that does not appear to have a corresponding void of the original encounter in the FA’s data warehouse.

• Centennial Care – The name given to the Medicaid managed care program administered by the state effective January 1, 2014. It replaced the previous system, which had Salud!, State Coverage Insurance, coordination of long-term services, and behavioral health all administered as separate programs.

• Conduent, Inc. (Conduent) – The state’s fiscal agent. Conduent was formerly known as Xerox Health Solutions. The name change went into effect January 2017.

• Cumulative Encounter Total – The sum of all encounter submissions stored in the FA’s encounter data warehouse. This amount is inclusive of all amounts submitted in prior months.

• Cumulative Variance – The difference between the cumulative encounter total and the ASD cumulative reported total.

• Denied Encounter- An encounter, which has met all Health Insurance Portability and Accountability Act (HIPAA) and front end data checks and was accepted by the FA; however, once the encounter was checked against the MMIS business rules, it was denied due to an exception in a business rule. These denied encounters may be resubmitted by PHP to correct the issue, which caused the denial by the FA.

• Fiscal Agent (FA) – A contractor selected to design, develop, and maintain the claims processing system (Medicaid Management Information System); Conduent, Inc. (known as Xerox Health Solutions prior to January 2017) is the current FA.

• FOCoS Online (FOCoS) – A subcontractor of Conduent, Inc. • Health Insurance Portability and Accountability Act (HIPAA) – A federal law

that restricts access to people’s private medical information.



6

• Human Services Department (HSD) – The agency of state government

responsible for administering a portfolio of programs, including Medicaid. • Managed Care Organization (MCO) – Organizations contracted with the state

Human Services Department to provide Medicaid managed care services. As of this writing the four currently contracted Medicaid managed care organizations are Blue Cross and Blue Shield of New Mexico, Molina Healthcare of New Mexico, Presbyterian Health Plan, Inc. and United Healthcare of New Mexico, Inc. MCOs receive a capitation or per member per month (PMPM) payment from HSD for each enrolled member.

• Medicaid Management Information System (MMIS) – The claims processing system used by the FA to adjudicate New Mexico’s Medicaid claims. PHP- submitted encounters are loaded into this system and assigned a unique claim identifier.

• Monthly Encounter Total – The sum of all encounter submissions for a given month stored in the FA’s encounter data warehouse.

• Monthly Variance – The difference between the monthly encounter total and the ASD monthly reported total.

• Presbyterian Health Plan, Inc.(PHP) – One of the four managed care organizations in New Mexico.

• Potential Duplicate Encounter (PDUP) – An encounter that Myers and Stauffer has identified as being a potential duplicate of another encounter in the FA’s data warehouse.

• Rejected Encounter - An encounter that has been submitted to the FA but did not meet HIPAA or other front end data checks and was not accepted into the MMIS.

• Transaction Control Number (TCN) – A “smart number” whose characters indicate some information about the claim.

• TNT Fiscal Intermediary - A subcontractor of Conduent, Inc. • Xerox Health Solutions (Xerox) – Former name of Conduent, Inc., the state’s

fiscal agent contractor. The name change went into effect January 2017.



7

HealthInsight engaged Myers and Stauffer to analyze Medicaid encounter data that has been submitted by PHP to the FA and complete a comparison of the encounters to accounting system data provided by PHP. Such encounters are submitted by PHP to HSD via the FA for HSD’s use in rate setting, federal reporting, program management and oversight, tracking, accounting and other ad hoc analyses. HealthInsight, on behalf of HSD, requested that for this study, we estimate the percentage of PHP and delegated vendor paid encounters that appear to be included in the FA’s data warehouse. This analysis includes these percentages for all PHP paid encounters as well as separate pharmacy and dental vendor encounters paid during the period January 1, 2014 through February 28, 2017.

STUDY PURPOSE


8

Myers and Stauffer received encounter data from the FA. The data are in a standardized extract containing institutional, medical, and pharmacy encounters from all four MCOs. These encounter data extracts include encounters having plan paid dates starting with January 1, 2014. The data used for this report includes encounters received and accepted by the FA and transmitted to Myers and Stauffer through April 30, 2017. Myers and Stauffer also requested ASD from PHP ranging in dates from January 1, 2014 through February 28, 2017 in a standardized monthly format.

DATA SOURCES


9

Encounters from institutional, medical and pharmacy claim types were combined on like data fields. We analyzed the line reported information of each encounter to capture the amount paid on the entire claim. Encounter totals were calculated by summarizing the data by the PHP paid date and PHP identification number. ASD submitted by PHP were summarized by paid date. These matching tables were combined using common fields between the tables and were used to produce the results. Based on criteria provided by PHP and HSD, we identified PHP encounters as follows: General Criteria for All Populations:

Submitter ID For PHP the submitter ID is noted to be 000M1814. Encounters

with this identifier in either the submitter ID field or the provider ID field have been included in this analysis.

Filing Indicators No filing indicators were excluded from these analyses.

Criteria for Specific Populations:

Pharmacy Benefits

Pharmacy encounters were isolated by restricting the data to header type code ‘R’.

Dental Benefits Dental encounters were isolated by restricting the data to header

type code ‘D’.

Plan Processed Encounters and Other Vendors Plan Processed Encounters and Other Vendors were isolated by

excluding the data with header type code ‘D’ or ‘R’.

ANALYSIS


10

In the performance of this analysis, Myers and Stauffer makes the following assumptions and notes regarding potential data issues: 1. We assume that all data provided to Myers and Stauffer is complete and accurate.

2. This analysis only included encounter information that was submitted by PHP to the FA and loaded into the FA’s data warehouse. Encounters that were rejected by the FA for errors in submission or other reasons are excluded from this analysis.

3. We instructed PHP to exclude referral fees, management fees and other non-encounter related fees in the ASD data submitted to Myers and Stauffer.

4. We noted that there are some encounters that do not include a submitter ID, but they do include the PHP submitter ID in the Provider ID field. We have included these encounters in this analysis.

5. We identified potential duplicate encounters. We analyzed the encounter and ASD submissions to conclude that some of these potential duplicates appear to be partial payments and some are actual duplicate submissions. We have attempted to adjust our totals to reflect the actual payment made and have removed duplicate payments from our analysis, when possible.

6. The monthly completion percentages in the entire plan exceeded 100 percent for some months of the reporting period. These overstated monthly completion percentages may be due to a variety of reasons such as encounters included without a corresponding matching ASD transaction or certain voids and replacements that were absent from the encounter data, but were accounted for in the ASD. Additionally, duplicate encounters may have existed in the encounter data that we were unable to identify and remove. Also, ASD payment dates may not have matched the payment dates that were reported in the encounter data resulting in potential timing issues.

7. Myers and Stauffer historically codes void encounters contained within the encounter submissions to match the associated adjustment claim’s paid date. This allows for proper matching of ASD that occurred due to this voided transaction. We were unable to assign a paid date (to the void encounters) which was different than the date of the original submission because it appears that PHP used the date of the original submission for their paid date and the PHP received date on all subsequent adjustments, replacements, backouts and voids of an encounter.

8. During the data analyses, Myers and Stauffer noted many encounters that were categorized as voids, adjustment credits or adjustment debits that did not indicate an associated original, paid encounter. Fields that are supposed to indicate the TCN of the original encounter, the TCN of the replaced encounter and the TCN of the replacement encounter were left blank in instances where it appears they should have been completed.



11

9. Interest amounts do not appear to be included in the PHP paid amounts. We have therefore excluded the separately itemized interest expense from the ASD totals.

10. Encounters denied by the FA were included and subjected to our potential duplicate encounter logic process, which attempts to identify and remove these encounters appropriately. This methodology artificially inflates the percentages of claim counts and amounts removed as identified in Table 2 – PHP Calculated Void and Duplicate Summary, since some of these were likely already marked as denied for this very duplicate issue. This is currently the only fair and representative way to ensure that the actual PHP paid encounters remain in our analysis.

11. The ASD transaction total for January 2014 is significantly lower than the transaction totals for subsequent months. This may contribute to the completion percentage exceeding 100 percent during January 2014.

12. In the encounters, Myers and Stauffer noted that there were no waiver data for January, February, or April 2014. Missing encounters may be a contributing factor to low monthly completion percentages.

13. In the ASD, Myers and Stauffer noted missing Medicare Part A Crossover data for January 2014 and missing transportation data for September through November 2015 and January through August 2016.

14. There are instances in the PHP encounter data set where the PHP received date, paid date and dates of service are invalid dates (i.e., dates that are for the year 2105).

15. To ensure the inclusion of all encounters paid by PHP, we have not excluded any encounters that were system denied (i.e., denied by the FA). The system denied encounters were subjected to our potential duplicate encounter logic process, which attempts to identify and remove these encounters appropriately while allowing the encounters paid by PHP to remain in the analysis.

16. The pharmacy encounters for January through May 2014 show very low paid amounts. The absence of paid encounters for that time period may explain the overstated completion percentage of pharmacy encounters noted for July 2014.

17. Analysis of the encounter data and ASD, as well as interactions with PHP, HSD and the FA, have resulted in the identification of opportunities for improving the encounter reconciliation process. While we have attempted to account for these situations, other potential issues within the data may exist that have not yet been identified which may require us to restate a report or modify reconciliation processes in the future.



12

PHP appears to have submitted approximately 96 percent of their encounter data for this period, with a cumulative monthly range between 88 percent and 145 percent. Monthly percentages exceeded 100 percent during some months of the reporting period and for the overall study period. Please reference potential data issues for an explanation of the possible causes.

Table 1 ― PHP Entire Plan

Paid Month ASD Monthly

Reported Total

Monthly Encounter


ASD Cumulative

Reported Total


Total Cumulative

Variance % of Monthly Encounters


January 2014 $20,443,645 $29,736,162 $9,292,517 $20,443,645 $29,736,162 $9,292,517 145.45% 145.45% February 2014 $44,123,222 $36,249,338 ($7,873,884) $64,566,867 $65,985,500 $1,418,633 82.15% 102.19% March 2014 $53,949,502 $47,622,296 ($6,327,205) $118,516,368 $113,607,796 ($4,908,572) 88.27% 95.85% April 2014 $56,763,351 $45,674,196 ($11,089,155) $175,279,720 $159,281,992 ($15,997,727) 80.46% 90.87% May 2014 $60,236,717 $49,890,265 ($10,346,452) $235,516,437 $209,172,258 ($26,344,179) 82.82% 88.81% June 2014 $58,302,180 $61,919,360 $3,617,180 $293,818,617 $271,091,618 ($22,726,999) 106.20% 92.26% July 2014 $64,458,346 $84,316,002 $19,857,656 $358,276,964 $355,407,620 ($2,869,343) 130.80% 99.19% August 2014 $66,260,919 $58,317,219 ($7,943,700) $424,537,882 $413,724,839 ($10,813,043) 88.01% 97.45% September 2014 $70,441,938 $62,155,758 ($8,286,180) $494,979,820 $475,880,597 ($19,099,223) 88.23% 96.14% October 2014 $73,229,614 $58,113,549 ($15,116,065) $568,209,434 $533,994,146 ($34,215,288) 79.35% 93.97% November 2014 $74,484,899 $65,895,601 ($8,589,299) $642,694,334 $599,889,747 ($42,804,586) 88.46% 93.33% December 2014 $73,637,301 $65,888,954 ($7,748,346) $716,331,634 $665,778,702 ($50,552,933) 89.47% 92.94% January 2015 $73,812,919 $61,308,312 ($12,504,607) $790,144,554 $727,087,014 ($63,057,540) 83.05% 92.01% February 2015 $79,597,450 $67,351,468 ($12,245,982) $869,742,004 $794,438,481 ($75,303,522) 84.61% 91.34% March 2015 $83,192,148 $74,650,566 ($8,541,582) $952,934,152 $869,089,048 ($83,845,104) 89.73% 91.20% April 2015 $92,619,825 $66,495,940 ($26,123,885) $1,045,553,976 $935,584,987 ($109,968,989) 71.79% 89.48% May 2015 $82,692,876 $69,929,635 ($12,763,241) $1,128,246,853 $1,005,514,623 ($122,732,230) 84.56% 89.12% June 2015 $81,034,063 $67,948,765 ($13,085,298) $1,209,280,916 $1,073,463,388 ($135,817,528) 83.85% 88.76% July 2015 $87,744,741 $71,560,351 ($16,184,390) $1,297,025,657 $1,145,023,739 ($152,001,918) 81.55% 88.28% August 2015 $79,508,079 $71,600,103 ($7,907,976) $1,376,533,736 $1,216,623,841 ($159,909,894) 90.05% 88.38% September 2015 $75,526,751 $68,965,002 ($6,561,749) $1,452,060,487 $1,285,588,843 ($166,471,644) 91.31% 88.53% October 2015 $81,221,142 $71,185,031 ($10,036,110) $1,533,281,629 $1,356,773,874 ($176,507,754) 87.64% 88.48% November 2015 $77,968,284 $72,473,563 ($5,494,720) $1,611,249,912 $1,429,247,438 ($182,002,474) 92.95% 88.70% December 2015 $91,076,191 $79,608,651 ($11,467,540) $1,702,326,103 $1,508,856,088 ($193,470,014) 87.40% 88.63% January 2016 $81,927,982 $67,750,898 ($14,177,084) $1,784,254,085 $1,576,606,986 ($207,647,099) 82.69% 88.36%

PHP – ENTIRE PLAN

PHP JANUARY 2014 – FEBRUARY 2017


13

Table 1 ― PHP Entire Plan (continued)

Paid Month ASD Monthly

Reported Total

Monthly Encounter


ASD Cumulative

Reported Total


Total Cumulative


% of Cumulative

Total

February 2016 $81,137,763 $68,130,578 ($13,007,185) $1,865,391,848 $1,644,737,564 ($220,654,284) 83.96% 88.17% March 2016 $82,786,067 $80,760,672 ($2,025,395) $1,948,177,915 $1,725,498,236 ($222,679,679) 97.55% 88.56% April 2016 $80,511,668 $69,670,638 ($10,841,031) $2,028,689,583 $1,795,168,873 ($233,520,710) 86.53% 88.48% May 2016 $70,930,388 $75,778,074 $4,847,687 $2,099,619,971 $1,870,946,948 ($228,673,023) 106.83% 89.10% June 2016 $86,484,672 $78,668,545 ($7,816,126) $2,186,104,642 $1,949,615,493 ($236,489,150) 90.96% 89.18% July 2016 $77,191,975 $79,717,914 $2,525,939 $2,263,296,617 $2,029,333,407 ($233,963,210) 103.27% 89.66% August 2016 $83,889,691 $76,512,190 ($7,377,501) $2,347,186,308 $2,105,845,597 ($241,340,711) 91.20% 89.71% September 2016 $71,314,283 $79,333,230 $8,018,947 $2,418,500,591 $2,185,178,827 ($233,321,764) 111.24% 90.35% October 2016 $62,724,786 $80,209,049 $17,484,263 $2,481,225,376 $2,265,387,876 ($215,837,501) 127.87% 91.30% November 2016 $65,600,635 $73,326,489 $7,725,854 $2,546,826,012 $2,338,714,365 ($208,111,647) 111.77% 91.82% December 2016 $66,283,854 $83,766,621 $17,482,767 $2,613,109,866 $2,422,480,986 ($190,628,880) 126.37% 92.70% January 2017 $60,233,039 $82,024,673 $21,791,633 $2,673,342,905 $2,504,505,659 ($168,837,247) 136.17% 93.68% February 2017 $57,668,247 $75,412,660 $17,744,414 $2,731,011,152 $2,579,918,319 ($151,092,833) 130.76% 94.46%

*Please note that the ASD has been provided to Myers and Stauffer by PHP. Encounter data

has been provided by the FA.

PHP JANUARY 2014 –FEBRUARY 2017


14

The calculated void (CV) and potential duplicate (PDUP) encounters that have been identified through the encounter reconciliation analysis are indicated below. These encounters have been removed from the encounter reconciliation totals.

Table 2 ― PHP Calculated Void and Duplicate Summary

Paid Month Count of

Encounter Claims

Total Sum (MCO

Submitted Paid Amount)

Count of CV PDUP

Encounters

CV PDUP Amount

Removed

% of CV PDUP

Encounter Count

% of CV PDUP

Amount Removed

January 2014 244,455 $33,689,769 35,884 $3,953,607 14.68% 11.74% February 2014 238,965 $43,446,804 56,894 $7,197,466 23.81% 16.57% March 2014 323,207 $59,439,477 84,791 $11,817,181 26.23% 19.88% April 2014 299,375 $59,756,686 83,814 $14,082,490 28.00% 23.57% May 2014 327,413 $63,808,968 84,953 $13,918,703 25.95% 21.81% June 2014 484,709 $78,184,889 100,346 $16,265,529 20.70% 20.80% July 2014 1,023,488 $101,637,640 93,663 $17,321,638 9.15% 17.04% August 2014 474,941 $75,634,213 102,534 $17,316,994 21.59% 22.90% September 2014 529,249 $84,744,420 111,724 $22,588,663 21.11% 26.66% October 2014 494,088 $76,226,051 110,228 $18,112,501 22.31% 23.76% November 2014 529,585 $85,882,132 107,309 $19,986,532 20.26% 23.27% December 2014 517,172 $82,219,198 80,940 $16,330,243 15.65% 19.86% January 2015 477,169 $79,545,468 81,018 $18,237,156 16.98% 22.93% February 2015 506,307 $85,648,456 69,893 $18,296,989 13.80% 21.36% March 2015 570,375 $93,684,624 78,250 $19,034,057 13.72% 20.32% April 2015 490,688 $80,628,864 65,329 $14,132,924 13.31% 17.53% May 2015 556,950 $82,413,710 55,954 $12,484,075 10.05% 15.15% June 2015 461,749 $80,465,223 49,996 $12,516,457 10.83% 15.56% July 2015 491,161 $82,759,676 46,414 $11,199,325 9.45% 13.53% August 2015 545,254 $86,377,374 118,699 $14,777,272 21.77% 17.11% September 2015 498,181 $78,412,139 42,486 $9,447,137 8.53% 12.05% October 2015 476,175 $83,455,467 47,927 $12,270,435 10.06% 14.70% November 2015 497,237 $83,913,533 42,295 $11,439,970 8.51% 13.63% December 2015 519,311 $91,454,200 45,497 $11,845,550 8.76% 12.95% January 2016 451,625 $78,937,208 34,664 $11,186,311 7.68% 14.17% February 2016 498,520 $84,940,587 37,788 $16,810,008 7.58% 19.79% March 2016 575,616 $92,071,223 38,708 $11,310,551 6.72% 12.28% April 2016 477,806 $81,038,045 33,912 $11,367,407 7.10% 14.03% May 2016 509,127 $87,205,827 29,824 $11,427,753 5.86% 13.10% June 2016 519,568 $92,398,983 32,814 $13,730,438 6.32% 14.86% July 2016 468,618 $94,084,638 49,388 $14,366,724 10.54% 15.27% August 2016 518,819 $88,752,261 53,225 $12,240,071 10.26% 13.79% September 2016 506,292 $87,963,037 43,926 $8,629,807 8.68% 9.81% October 2016 524,972 $94,038,503 71,103 $13,829,455 13.54% 14.71% November 2016 526,552 $82,808,607 57,943 $9,482,118 11.00% 11.45% December 2016 499,112 $92,495,792 47,890 $8,729,172 9.60% 9.44% January 2017 538,985 $89,982,088 34,163 $7,957,415 6.34% 8.84% February 2017 528,219 $81,905,733 37,211 $6,493,073 7.04% 7.93% TOTALS 18,721,035 3,082,051,513 2,399,397 502,133,194 12.82% 16.29%

PHP JANUARY 2014 –FEBRUARY 2017


15

Count of Encounters – The number of encounters processed by the FA (including encounters marked as denied by the FA). Total Sum (PHP Submitted Paid Amount) – The total paid amount of encounters in a month per the encounter data provided by the FA. These amounts do not incorporate the corrections to paid amounts as explained in the Potential Data Issues and Analysis Assumptions. Count of CV PDUP Encounters – The number of encounters identified by Myers and Stauffer as potential calculated voids and duplicates. CV PDUP Amount Removed – The paid amount removed from the Monthly Encounter Total based on Myers and Stauffer’s analysis of calculated void and duplicate encounters. % of CV PDUP Encounter Count – The percentage of CV PDUP encounters out of the total number of encounters. % of CV PDUP Amount Removed – The percentage of paid amount removed from the total PHP submitted paid amount.



16

Figure 1 - PHP’s ASD totals and encounter totals as reported monthly

Figure 2 - PHP’s cumulative encounter submissions expressed as a percentage of payments submitted to the FA to reported PHP ASD payments

$0$10,000,000$20,000,000$30,000,000$40,000,000$50,000,000$60,000,000$70,000,000$80,000,000$90,000,000

$100,000,000

ASD Monthly Reported Total


80%

90%

100%

110%

120%

130%

140%

150%




17

PHP appears to have submitted approximately 92 percent of the dental encounter data for this period, with a cumulative monthly range between 91 percent and 93 percent.

PHP – DENTAL BENEFITS

Table 3 ― PHP Dental Benefits

Paid Month ASD Monthly Reported Total


Monthly Variance

ASD Cumulative

Reported Total


Total Cumulative


% of Cumulative

Total

January 2014 $4,059,774 $3,769,627 ($290,148) $4,059,774 $3,769,627 ($290,148) 92.85% 92.85% February 2014 $3,596,463 $3,329,327 ($267,136) $7,656,237 $7,098,954 ($557,284) 92.57% 92.72% March 2014 $3,572,239 $3,360,876 ($211,363) $11,228,477 $10,459,830 ($768,647) 94.08% 93.15% April 2014 $3,570,049 $3,320,016 ($250,032) $14,798,525 $13,779,846 ($1,018,679) 92.99% 93.11% May 2014 $3,764,439 $3,479,297 ($285,142) $18,562,964 $17,259,143 ($1,303,821) 92.42% 92.97% June 2014 $3,402,105 $3,168,998 ($233,108) $21,965,069 $20,428,140 ($1,536,929) 93.14% 93.00% July 2014 $5,051,745 $4,693,683 ($358,063) $27,016,814 $25,121,823 ($1,894,991) 92.91% 92.98% August 2014 $3,862,122 $3,571,246 ($290,876) $30,878,937 $28,693,069 ($2,185,868) 92.46% 92.92% September 2014 $3,507,201 $3,314,896 ($192,305) $34,386,138 $32,007,965 ($2,378,173) 94.51% 93.08% October 2014 $3,682,170 $3,399,385 ($282,785) $38,068,308 $35,407,350 ($2,660,958) 92.32% 93.01% November 2014 $3,555,065 $3,317,167 ($237,897) $41,623,372 $38,724,517 ($2,898,855) 93.30% 93.03% December 2014 $4,826,317 $4,461,401 ($364,916) $46,449,690 $43,185,918 ($3,263,771) 92.43% 92.97% January 2015 $3,339,467 $3,105,372 ($234,095) $49,789,157 $46,291,290 ($3,497,866) 92.99% 92.97% February 2015 $4,108,220 $3,810,662 ($297,559) $53,897,377 $50,101,952 ($3,795,425) 92.75% 92.95% March 2015 $4,091,504 $3,809,781 ($281,723) $57,988,881 $53,911,734 ($4,077,148) 93.11% 92.96% April 2015 $4,069,111 $3,771,087 ($298,024) $62,057,992 $57,682,821 ($4,375,171) 92.67% 92.94% May 2015 $3,891,076 $3,471,031 ($420,045) $65,949,069 $61,153,852 ($4,795,216) 89.20% 92.72% June 2015 $4,015,285 $3,537,448 ($477,838) $69,964,354 $64,691,300 ($5,273,054) 88.09% 92.46% July 2015 $5,904,803 $5,178,820 ($725,983) $75,869,157 $69,870,121 ($5,999,037) 87.70% 92.09% August 2015 $4,144,959 $3,670,493 ($474,466) $80,014,116 $73,540,613 ($6,473,503) 88.55% 91.90% September 2015 $3,876,570 $3,441,751 ($434,818) $83,890,686 $76,982,365 ($6,908,321) 88.78% 91.76% October 2015 $4,066,469 $3,723,566 ($342,903) $87,957,155 $80,705,930 ($7,251,224) 91.56% 91.75% November 2015 $4,186,555 $3,738,568 ($447,987) $92,143,710 $84,444,499 ($7,699,211) 89.29% 91.64% December 2015 $5,622,040 $5,024,689 ($597,351) $97,765,749 $89,469,188 ($8,296,562) 89.37% 91.51% January 2016 $3,628,416 $3,431,407 ($197,010) $101,394,166 $92,900,594 ($8,493,571) 94.57% 91.62% February 2016 $4,418,668 $4,093,702 ($324,966) $105,812,833 $96,994,296 ($8,818,538) 92.64% 91.66% March 2016 $4,364,042 $4,006,782 ($357,260) $110,176,875 $101,001,077 ($9,175,798) 91.81% 91.67% April 2016 $4,573,245 $4,206,647 ($366,598) $114,750,120 $105,207,724 ($9,542,396) 91.98% 91.68% May 2016 $4,452,075 $4,157,078 ($294,996) $119,202,195 $109,364,803 ($9,837,392) 93.37% 91.74%



18

Table 3 ― PHP Dental Benefits (continued)

Paid Month

ASD Monthly

Reported Total

Monthly Encounter



Total


Total Cumulative


% of Cumulative

Total

June 2016 $6,170,777 $5,719,008 ($451,768) $125,372,972 $115,083,811 ($10,289,160) 92.67% 91.79% July 2016 $3,905,721 $3,840,123 ($65,598) $129,278,692 $118,923,934 ($10,354,758) 98.32% 91.99% August 2016 $4,408,970 $4,081,142 ($327,828) $133,687,662 $123,005,076 ($10,682,587) 92.56% 92.00% September 2016 $4,240,394 $3,902,467 ($337,927) $137,928,057 $126,907,543 ($11,020,514) 92.03% 92.00% October 2016 $4,448,333 $4,147,285 ($301,048) $142,376,389 $131,054,828 ($11,321,562) 93.23% 92.04% November 2016 $6,243,281 $5,921,416 ($321,865) $148,619,671 $136,976,244 ($11,643,427) 94.84% 92.16% December 2016 $3,982,098 $3,757,054 ($225,044) $152,601,769 $140,733,298 ($11,868,471) 94.34% 92.22% January 2017 $4,063,542 $3,869,759 ($193,783) $156,665,311 $144,603,058 ($12,062,253) 95.23% 92.30% February 2017 $4,676,969 $4,156,474 ($520,496) $161,342,280 $148,759,532 ($12,582,749) 88.87% 92.20%



19

PHP appears to have submitted approximately 100 percent of the pharmacy benefit encounter data for this period, with a cumulative monthly range between -30 percent and 101 percent. Monthly percentages exceeded 100 percent during some months of the reporting period. The pharmacy encounters for January through May 2014 show very low paid amounts. The absence of paid encounters for that time period may explain the overstated completion percentage of pharmacy encounters noted for July 2014. Please reference potential data issues for an explanation of the possible causes.

Table 4 ― PHP Pharmacy Benefits


Monthly Encounter


ASD Cumulative

Reported Total


Total Cumulative


% of Cumulative

Total

January 2014 $4,791,058 ($1,484,878) ($6,275,936) $4,791,058 ($1,484,878) ($6,275,936) -30.99% -30.99% February 2014 $4,939,410 ($1,976) ($4,941,386) $9,730,469 ($1,486,853) ($11,217,322) -0.03% -15.28% March 2014 $7,634,230 $2,699 ($7,631,531) $17,364,699 ($1,484,154) ($18,848,852) 0.03% -8.54% April 2014 $6,785,674 $852 ($6,784,821) $24,150,372 ($1,483,301) ($25,633,674) 0.01% -6.14% May 2014 $6,558,813 $7,292 ($6,551,522) $30,709,186 ($1,476,010) ($32,185,195) 0.11% -4.80% June 2014 $6,428,407 $7,581,905 $1,153,497 $37,137,593 $6,105,895 ($31,031,698) 117.94% 16.44% July 2014 $6,205,176 $36,709,752 $30,504,576 $43,342,769 $42,815,647 ($527,122) 591.59% 98.78% August 2014 $6,802,752 $6,206,792 ($595,960) $50,145,521 $49,022,439 ($1,123,082) 91.23% 97.76% September 2014 $6,768,052 $7,556,418 $788,366 $56,913,573 $56,578,857 ($334,716) 111.64% 99.41% October 2014 $6,787,438 $5,463,673 ($1,323,765) $63,701,011 $62,042,530 ($1,658,481) 80.49% 97.39% November 2014 $6,948,964 $6,019,063 ($929,901) $70,649,974 $68,061,592 ($2,588,382) 86.61% 96.33% December 2014 $7,402,475 $8,296,055 $893,580 $78,052,450 $76,357,647 ($1,694,802) 112.07% 97.82% January 2015 $7,479,655 $5,445,664 ($2,033,992) $85,532,105 $81,803,311 ($3,728,794) 72.80% 95.64% February 2015 $5,631,725 $7,442,562 $1,810,837 $91,163,830 $89,245,873 ($1,917,957) 132.15% 97.89% March 2015 $9,335,636 $8,434,409 ($901,227) $100,499,465 $97,680,282 ($2,819,184) 90.34% 97.19% April 2015 $7,948,593 $6,435,538 ($1,513,055) $108,448,058 $104,115,819 ($4,332,239) 80.96% 96.00% May 2015 $7,687,197 $11,606,138 $3,918,941 $116,135,256 $115,721,957 ($413,299) 150.98% 99.64% June 2015 $7,733,919 $6,165,477 ($1,568,442) $123,869,175 $121,887,435 ($1,981,740) 79.71% 98.40% July 2015 $7,646,815 $8,920,043 $1,273,228 $131,515,990 $130,807,478 ($708,512) 116.65% 99.46% August 2015 $7,903,829 $7,750,964 ($152,865) $139,419,819 $138,558,441 ($861,377) 98.06% 99.38% September 2015 $8,848,334 $9,942,611 $1,094,277 $148,268,152 $148,501,052 $232,900 112.36% 100.15% October 2015 $8,916,088 $7,813,157 ($1,102,931) $157,184,240 $156,314,209 ($870,032) 87.62% 99.44% November 2015 $9,252,880 $9,357,064 $104,185 $166,437,120 $165,671,273 ($765,847) 101.12% 99.53% December 2015 $11,067,834 $12,567,091 $1,499,257 $177,504,954 $178,238,364 $733,410 113.54% 100.41% January 2016 $8,467,745 $7,835,724 ($632,021) $185,972,699 $186,074,088 $101,389 92.53% 100.05%

PHP – PHARMACY BENEFITS



20

Table 4 ― PHP Pharmacy Benefits (continued)


Monthly Encounter


ASD Cumulative

Reported Total


Total Cumulative


% of Cumulative

Total

February 2016 $9,493,898 $8,631,206 ($862,692) $195,466,598 $194,705,295 ($761,303) 90.91% 99.61% March 2016 $10,224,721 $12,196,567 $1,971,845 $205,691,319 $206,901,861 $1,210,543 119.28% 100.58% April 2016 $9,782,248 $8,935,750 ($846,499) $215,473,567 $215,837,611 $364,044 91.34% 100.16% May 2016 $9,660,676 $8,740,820 ($919,857) $225,134,244 $224,578,431 ($555,813) 90.47% 99.75% June 2016 $9,664,451 $11,445,028 $1,780,577 $234,798,695 $236,023,459 $1,224,764 118.42% 100.52% July 2016 $9,393,473 $8,486,413 ($907,060) $244,192,168 $244,509,872 $317,704 90.34% 100.13% August 2016 $10,564,655 $11,937,189 $1,372,534 $254,756,823 $256,447,061 $1,690,238 112.99% 100.66% September 2016 $10,468,884 $9,762,942 ($705,941) $265,225,707 $266,210,004 $984,297 93.25% 100.37% October 2016 $7,566,716 $9,606,735 $2,040,019 $272,792,423 $275,816,738 $3,024,315 126.96% 101.10% November 2016 $10,948,544 $11,232,672 $284,127 $283,740,967 $287,049,410 $3,308,443 102.59% 101.16% December 2016 $10,065,662 $9,683,474 ($382,187) $293,806,629 $296,732,884 $2,926,255 96.20% 100.99% January 2017 $9,498,653 $11,835,629 $2,336,976 $303,305,282 $308,568,513 $5,263,231 124.60% 101.73% February 2017 $9,321,842 $9,977,970 $656,128 $312,627,124 $318,546,484 $5,919,360 107.03% 101.89%



21

PHP appears to have submitted approximately 93 percent of the fee-for-service encounter data for this period, with a cumulative monthly range between 86 percent and 236 percent. Monthly percentages exceeded 100 percent during some months of the reporting period and for the overall study period. Please reference potential data issues for an explanation of the possible causes.

Table 5 ― PHP Plan Processed Encounters and Other Vendors


Monthly Encounter


ASD Cumulative Reported Total


Total Cumulative


% of Cumulative

Total

January 2014 $11,592,813 $27,451,413 $15,858,601 $11,592,813 $27,451,413 $15,858,601 236.79% 236.79% February 2014 $35,587,348 $32,921,986 ($2,665,362) $47,180,161 $60,373,399 $13,193,239 92.51% 127.96% March 2014 $42,743,032 $44,258,721 $1,515,689 $89,923,193 $104,632,120 $14,708,927 103.54% 116.35% April 2014 $46,407,629 $42,353,328 ($4,054,301) $136,330,822 $146,985,448 $10,654,626 91.26% 107.81% May 2014 $49,913,465 $46,403,677 ($3,509,789) $186,244,287 $193,389,125 $7,144,837 92.96% 103.83% June 2014 $48,471,668 $51,168,458 $2,696,790 $234,715,955 $244,557,583 $9,841,627 105.56% 104.19% July 2014 $53,201,425 $42,912,568 ($10,288,858) $287,917,381 $287,470,150 ($447,230) 80.66% 99.84% August 2014 $55,596,044 $48,539,181 ($7,056,864) $343,513,425 $336,009,331 ($7,504,094) 87.30% 97.81% September 2014 $60,166,685 $51,284,444 ($8,882,241) $403,680,110 $387,293,775 ($16,386,335) 85.23% 95.94% October 2014 $62,760,006 $49,250,492 ($13,509,514) $466,440,116 $436,544,267 ($29,895,849) 78.47% 93.59% November 2014 $63,980,871 $56,559,371 ($7,421,500) $530,420,987 $493,103,638 ($37,317,349) 88.40% 92.96% December 2014 $61,408,508 $53,131,498 ($8,277,010) $591,829,495 $546,235,136 ($45,594,359) 86.52% 92.29% January 2015 $62,993,797 $52,757,276 ($10,236,521) $654,823,292 $598,992,412 ($55,830,880) 83.74% 91.47% February 2015 $69,857,505 $56,098,244 ($13,759,261) $724,680,797 $655,090,656 ($69,590,141) 80.30% 90.39% March 2015 $69,765,008 $62,406,376 ($7,358,632) $794,445,805 $717,497,033 ($76,948,772) 89.45% 90.31% April 2015 $80,602,121 $56,289,314 ($24,312,806) $875,047,926 $773,786,347 ($101,261,579) 69.83% 88.42% May 2015 $71,114,603 $54,852,466 ($16,262,137) $946,162,528 $828,638,813 ($117,523,715) 77.13% 87.57% June 2015 $69,284,858 $58,245,840 ($11,039,018) $1,015,447,387 $886,884,653 ($128,562,734) 84.06% 87.33% July 2015 $74,193,123 $57,461,488 ($16,731,636) $1,089,640,510 $944,346,140 ($145,294,369) 77.44% 86.66% August 2015 $67,459,291 $60,178,646 ($7,280,645) $1,157,099,801 $1,004,524,786 ($152,575,014) 89.20% 86.81% September 2015 $62,801,847 $55,580,640 ($7,221,208) $1,219,901,648 $1,060,105,426 ($159,796,222) 88.50% 86.90% October 2015 $68,238,585 $59,648,309 ($8,590,276) $1,288,140,233 $1,119,753,735 ($168,386,498) 87.41% 86.92% November 2015 $64,528,849 $59,377,931 ($5,150,918) $1,352,669,082 $1,179,131,666 ($173,537,417) 92.01% 87.17% December 2015 $74,386,317 $62,016,871 ($12,369,446) $1,427,055,399 $1,241,148,537 ($185,906,863) 83.37% 86.97% January 2016 $69,831,821 $56,483,767 ($13,348,054) $1,496,887,220 $1,297,632,303 ($199,254,917) 80.88% 86.68% February 2016 $67,225,197 $55,405,670 ($11,819,527) $1,564,112,417 $1,353,037,974 ($211,074,444) 82.41% 86.50%

PHP – PLAN PROCESSED ENCOUNTERS AND OTHER VENDORS



22

Table 5 ― PHP Plan Processed Encounters and Other Vendors (continued)


Monthly Encounter


ASD Cumulative

Reported Total


Total Cumulative


% of Cumulative

Total

March 2016 $68,197,304 $64,557,323 ($3,639,980) $1,632,309,721 $1,417,595,297 ($214,714,424) 94.66% 86.84% April 2016 $66,156,175 $56,528,241 ($9,627,934) $1,698,465,896 $1,474,123,538 ($224,342,358) 85.44% 86.79% May 2016 $56,817,637 $62,880,176 $6,062,539 $1,755,283,532 $1,537,003,714 ($218,279,818) 110.67% 87.56% June 2016 $70,649,443 $61,504,509 ($9,144,935) $1,825,932,976 $1,598,508,223 ($227,424,753) 87.05% 87.54% July 2016 $63,892,781 $67,391,378 $3,498,597 $1,889,825,757 $1,665,899,601 ($223,926,156) 105.47% 88.15% August 2016 $68,916,065 $60,493,859 ($8,422,207) $1,958,741,822 $1,726,393,460 ($232,348,362) 87.77% 88.13% September 2016 $56,605,005 $65,667,821 $9,062,815 $2,015,346,827 $1,792,061,281 ($223,285,547) 116.01% 88.92% October 2016 $50,709,737 $66,455,030 $15,745,292 $2,066,056,564 $1,858,516,310 ($207,540,254) 131.04% 89.95% November 2016 $48,408,810 $56,172,401 $7,763,592 $2,114,465,374 $1,914,688,712 ($199,776,662) 116.03% 90.55% December 2016 $52,236,094 $70,326,092 $18,089,998 $2,166,701,468 $1,985,014,803 ($181,686,665) 134.63% 91.61% January 2017 $46,670,844 $66,319,284 $19,648,440 $2,213,372,312 $2,051,334,087 ($162,038,225) 142.10% 92.67% February 2017 $43,669,436 $61,278,216 $17,608,781 $2,257,041,748 $2,112,612,304 ($144,429,444) 140.32% 93.60%



23

1. HealthInsight and Myers and Stauffer recommend that PHP include their submitter ID with every encounter as required by CMS in accordance with the American National Standards Institute (ANSI), Accredited Standards Committee (ASC) X12 Version 5010. We also recommend that Conduent use an integrity constraint that prevents encounters without a submitter ID from being accepted into MMIS.

2. HealthInsight and Myers and Stauffer recommend that PHP populate the actual date of MCO adjudication and payment rather than repeating the date of MCO adjudication or payment on all subsequent iterations of an encounter. Populating the actual date of adjudication and payment is required by CMS in accordance with their Encounter Data Minimum Data Elements.

3. HealthInsight and Myers and Stauffer recommend that PHP populate valid dates of MCO receipt and payment. Populating the actual date is required by CMS in accordance with their Encounter Data Minimum Data Elements. We also recommend that Conduent use an integrity constraint that prevents encounters with invalid dates from being accepted into MMIS.

4. HealthInsight and Myers and Stauffer recommend that PHP submit all requested ASD transactions to Myers and Stauffer for inclusion in any future encounter reconciliations in accordance with the reporting requirements set out in the Medicaid Managed Care Services Agreement and in order to ensure the most accurate results are derived from the encounter reconciliation.

RECOMMENDATIONS

PHP RECOMMENDATIONS

Appendix C-3: Claims To Encounter Matching Results

Page 1

Presbyterian Health Plan: Encounter Completeness Comparison to PHP-Submitted Claims Samples

Description

Medical

Dental

Pharmacy

September 2014 December 2014 September 2014 December 2014 September 2014 December 2014

Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent

Number of Claims Submitted (Claim/Header Level)

264,523 100.0% 261,366 100.0% 19,355 100.0% 25,489 100.0% 130,175 100.0% 130,483 100.0%

Adjusted / Void 16,916 6.4% 10,012 3.8% 54 0.3% 59 0.2% 0 0.0% 0 0.0%

Denied 0 0.0% 0 0.0% 35 0.2% 74 0.3% 0 0.0% 0 0.0%

Paid 247,607 93.6% 251,354 96.2% 19,266 99.5% 25,356 99.5% 130,175 100.0% 130,483 100.0%

Number of Claims Submitted (Claim/Header Level)

264,523 100.0% 261,366 100.0% 19,355 100.0% 25,489 100.0% 130,175 100.0% 130,483 100.0%

Less Denied Claims (not required to be submitted) 0 0.0% 0 0.0% (35) -0.2% (74) -0.3% 0 0.0% 0 0.0%

Less Multiple Claim Iterations and Potential Duplicates (adjustments, voids, replacements, duplicates)

0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0% 0 0.0%

Number of Non-Denied Unique (distinct) Claims 264,523 100.0% 261,366 100.0% 19,320 99.8% 25,415 99.7% 130,175 100.0% 130,483 100.0%

Number of Non-Denied Unique (distinct) Claims 264,523 100.0% 261,366 100.0% 19,320 100.0% 25,415 100.0% 130,175 100.0% 130,483 100.0%

Number of Claims NOT Traced to MMIS Encounter Data 28,988 11.0% 26,691 10.2% 1 0.0% 0 0.0% 1,813 1.4% 1,968 1.5%

Claims Traced to MMIS Encounter Data (Completeness) 235,535 89.0% 234,675 89.8% 19,319 100.0% 25,415 100.0% 128,362 98.6% 128,515 98.5%

Number of Claims Traced to MMIS Encounter Data 235,535 100.0% 234,675 100.0% 19,319 100.0% 25,415 100.0% 128,362 100.0% 128,515 100.0%

Number of Traced Claims submitted within:

0 to 30 days 144,602 61.4% 175,008 74.6% 16,726 86.6% 22,101 87.0% 124,667 97.1% 118,186 92.0%

31 to 90 days 20,356 8.6% 3,968 1.7% 290 1.5% 462 1.8% 2,195 1.7% 290 0.2%

91 to 180 days 30,769 13.1% 23,484 10.0% 1,470 7.6% 2,213 8.7% 744 0.6% 9,236 7.2%

181 to 270 days 19,174 8.1% 3,871 1.6% 469 2.4% 142 0.6% 249 0.2% 95 0.1%

271 to 365 days 2,846 1.2% 1,844 0.8% 231 1.2% 24 0.1% 132 0.1% 308 0.2%

Over 365 days 17,788 7.6% 26,500 11.3% 133 0.7% 473 1.9% 375 0.3% 400 0.3%

Number of Claims Traced to MMIS Encounter Data 235,535 100.0% 234,675 100.0%

Inpatient 2,887 1.2% 4,293 1.8%

Outpatient 34,375 14.6% 41,410 17.6%

Professional 198,273 84.2% 188,972 80.5%

Note: Percentages that do not add to 100% are due to rounding

Appendix C-4: Key Data Element Results by Service Type

Page 1

Note: For all tables in this appendix percentages that do not add to 100% are due to rounding Presbyterian Health Plan: Dental Encounters (837D)-Header Level

Key Data Field

Matching (Sample to MMIS data)

September 2014

Missing Values (Claims Sample not

populated)

Non-Matching Values

Erroneous Matching

Values (Not Valid)

Matching Values

Blank Values (Valid Nulls)

Values Present (Valid) Matching Values


Billing Provider NPI [and/or MMIS Billing Provider Number (Medicaid ID)]

- - - - - - 19,319 100.00% 19,319 100.00%

Date of Service (Procedure Date) - - 144 0.75% - - 19,175 99.25% 19,175 99.25%

Former MMIS Claim TCN - 0.00% - - 19,277 99.78% 42 0.22% 19,319 100.00%

MMIS TCN - - - - - - 19,319 100.00% 19,319 100.00%

MMIS Member Number - - 12 0.06% - - 19,307 99.94% 19,307 99.94%

Plan Paid Date - - 167 0.86% - - 19,152 99.14% 19,152 99.14%

Plan Received Date - - - 0.00% - - 19,319 100.00% 19,319 100.00%

Total Submitted Records Traced to MMIS

19,319


Page 2

Presbyterian Health Plan: Dental Encounters (837D)-Header Level

Key Data Field


December 2014


populated)

Non-Matching Values

Erroneous Matching

Values (Not Valid)

Matching Values





- - - - - - 25,415 100.00% 25,415 100.00%

Date of Service (Procedure Date) - - 329 1.29% - - 25,086 98.71% 25,086 98.71%

Former MMIS Claim TCN 12 0.05% - - 25,330 99.67% 73 0.29% 25,403 99.95%

MMIS TCN - - - - - - 25,415 100.00% 25,415 100.00%

MMIS Member Number - - 12 0.05% - - 25,403 99.95% 25,403 99.95%

Plan Paid Date - - 147 0.58% - - 25,268 99.42% 25,268 99.42%

Plan Received Date - - - 0.00% - - 25,415 100.00% 25,415 100.00%


25,415


Page 3

- Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated) - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or a FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 4

Presbyterian Health Plan: Dental Encounters (837D)-Line Level

Key Data Field


September 2014


populated)

Non-Matching Values

Erroneous Matching

Values (Not Valid)

Matching Values




Billed Charges - - 1,789 2.60% - - 66,895 97.40% 66,895 97.40%

Place of Service - - 3,946 5.75% - - 64,738 94.25% 64,738 94.25%

Plan Paid Amount - - 1,787 2.60% - - 66,897 97.40% 66,897 97.40%

Procedure Code - - 720 1.05% - - 67,964 98.95% 67,964 98.95%

Service (Rendering) Provider NPI [and/or MMIS Service (Rendering) Provider Number (Medicaid ID)]

- - - 0.00% - - 68,684 100.00% 68,684 100.00%

Service Provider Specialty (and/or Taxonomy)

- - 1,043 1.52% - - 35 0.05% 67,606 98.43% 67,641 98.48%

Tooth Number 2,187 3.18% - - 50,647 73.74% 15,850 23.08% 66,497 96.82%


68,684


Page 5

Presbyterian Health Plan: Dental Encounters (837D)-Line Level

Key Data Field


December 2014


populated)

Non-Matching Values

Erroneous Matching

Values (Not Valid)

Matching Values




Billed Charges - - 2,294 2.49% - - 89,977 97.51% 89,977 97.51%

Place of Service - - 5,097 5.52% - - 87,174 94.48% 87,174 94.48%

Plan Paid Amount - - 2,299 2.49% - - 89,972 97.51% 89,972 97.51%

Procedure Code - - 974 1.06% - - 91,297 98.94% 91,297 98.94%

Service (Rendering) Provider NPI [and/or MMIS Service (Rendering) Provider Number (Medicaid ID)]

- - - 0.00% - - 92,271 100.00% 92,271 100.00%


- - 1,780 1.93% - - 42 0.05% 90,449 98.03% 90,491 98.07%

Tooth Number 2,563 2.78% - - 66,289 71.84% 23,419 25.38% 89,708 97.22%


92,271


Page 6

Notes: - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. -These tables were updated in the MCO rebuttal process to remove zero paid lines from consideration. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated) - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or a FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 7

Presbyterian Health Plan: Inpatient Encounters (837I)-Header Level

Key Data Field


September 2014 Missing Values

(Claims Sample not populated)

Non-Matching Values

Erroneous Matching Values

(Not Valid)

Matching Values Blank Values (Valid Nulls)


Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Admission Date 12 0.42% 17 0.59% - - 2,858 99.00% 2,858 99.00% Bill Type (Type of Bill) Facility and Class

- - 55 1.91% - - 2,832 98.09% 2,832 98.09%

Bill Type (Type of Bill) Frequency - - 373 12.92% - - 2,514 87.08% 2,514 87.08%

Billing Provider NPI (or MMIS Billing Provider Number)

- - - - - - 2,887 100.00% 2,887 100.00%

Diagnosis Code 1 - - 2 0.07% - - 2,885 99.93% 2,885 99.93%

Diagnosis Code 2 6 0.21% - - 472 16.35% 2,409 83.44% 2,881 99.79%

Diagnosis Code 3 13 0.45% - - 739 25.60% 2,135 73.95% 2,874 99.55% Diagnosis Code 4 15 0.52% - - 992 34.36% 1,880 65.12% 2,872 99.48%

Discharge Date 375 12.99% 47 1.63% - - 55 1.91% 2,410 83.48% 2,465 85.38%


Header First Date of Service - - 6 0.21% - - 2,881 99.79% 2,881 99.79%

Header Last Date of Service - - 69 2.39% - - 2,818 97.61% 2,818 97.61%

Header Paid Amount - - 98 3.39% - - 2,789 96.61% 2,789 96.61%

MMIS TCN - - - 0.00% - - 2,887 100.00% 2,887 100.00%

MMIS Member Number 3 0.10% 164 5.68% - - 2,720 94.22% 2,720 94.22%

Plan Paid Date - - 1 0.03% - - 2,886 99.97% 2,886 99.97%

Plan Received Date - - 4 0.14% - - 2,883 99.86% 2,883 99.86%


2,887


Page 8

Presbyterian Health Plan: Inpatient Encounters (837I)-Header Level

Key Data Field


December 2014 Missing Values


Non-Matching Values


(Not Valid)




Admission Date 1,710 39.83% 8 0.19% - - 2,575 59.98% 2,575 59.98%

Bill Type (Type of Bill) Facility and Class

- - 314 7.31% - - 3,979 92.69% 3,979 92.69%

Bill Type (Type of Bill) Frequency - - 704 16.40% - - 3,589 83.60% 3,589 83.60%

Billing Provider NPI (or MMIS Billing Provider Number)

- - - - - - 4,293 100.00% 4,293 100.00%

Diagnosis Code 1 - - - - - - 4,293 100.00% 4,293 100.00%

Diagnosis Code 2 8 0.19% - - 1,658 38.62% 2,627 61.19% 4,285 99.81%

Diagnosis Code 3 18 0.42% - - 2,087 48.61% 2,188 50.97% 4,275 99.58% Diagnosis Code 4 15 0.35% - - 2,372 55.25% 1,906 44.40% 4,278 99.65%

Discharge Date 1,486 34.61% 19 0.44% - - 314 7.31% 2,474 57.63% 2,788 64.94%




Header Paid Amount - - 101 2.35% - - 4,192 97.65% 4,192 97.65%

MMIS TCN - - - 0.00% - - 4,293 100.00% 4,293 100.00%


Plan Paid Date - - 1 0.02% - - 4,292 99.98% 4,292 99.98%

Plan Received Date - - 3 0.07% - - 4,290 99.93% 4,290 99.93%

Total Submitted Records Traced to MMIS Total Submitted

4,293


Page 9

Notes: - Billed charges and header last date of service are generally header level key data elements. However, the PHP-submitted claims sample values appear to reflect line level amounts. Therefore, these data elements were evaluated at the line level. - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or a FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 10

Presbyterian Health Plan: Inpatient Encounters (837I)-Line Level

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges - - 622 8.99% - - 6,296 91.01% 6,296 91.01% Line First Date of Service - - 1 0.01% - - 6,917 99.99% 6,917 99.99% Line Last Date of Service - - 170 2.46% - - 6,748 97.54% 6,748 97.54% Line Paid Amount - - 580 8.38% - - 6,338 91.62% 6,338 91.62% Procedure Code - - 2 0.03% - - 3,677 53.15% 3,239 46.82% 6,916 99.97% Procedure Modifier 1 1 0.01% - - 5,867 84.81% 1,050 15.18% 6,917 99.99% Procedure Modifier 2 - 0.00% - - 6,443 93.13% 475 6.87% 6,918 100.00% Procedure Modifier 3 - - - - 6,874 99.36% 44 0.64% 6,918 100.00% Procedure Modifier 4 - - - - 6,918 100.00% - 0.00% 6,918 100.00% Revenue Code - - 266 3.85% - - 6,652 96.15% 6,652 96.15% Surgical Procedure Code 1 2,816 40.71% - - 4,102 59.29% - 0.00% 4,102 59.29% Surgical Procedure Code 2 2,156 31.17% - - 4,762 68.83% - 0.00% 4,762 68.83% Surgical Procedure Code 3 1,706 24.66% - - 5,212 75.34% - 0.00% 5,212 75.34% Surgical Procedure Code 4 - - - - 6,918 100.00% - 0.00% 6,918 100.00%

Service/Rendering Provider NPI [and/or MMIS Service/ Rendering Provider Number (Medicaid ID)]

- - - - - - 6,918 100.00% 6,918 100.00%


- - 1 0.01% - - 6,890 99.60% 27 0.39% 6,917 99.99%


6,918


Page 11

Presbyterian Health Plan: Inpatient Encounters (837I)-Line Level

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges - - 226 1.70% - - 13,059 98.30% 13,059 98.30% Line First Date of Service - - 6 0.05% - - 13,279 99.95% 13,279 99.95% Line Last Date of Service - - 240 1.81% - - 13,045 98.19% 13,045 98.19% Line Paid Amount - - 158 1.19% - - 13,127 98.81% 13,127 98.81% Procedure Code - - 6 0.05% - - 3,739 28.14% 9,540 71.81% 13,279 99.95% Procedure Modifier 1 - 0.00% - - 11,644 87.65% 1,641 12.35% 13,285 100.00% Procedure Modifier 2 - 0.00% - - 12,322 92.75% 963 7.25% 13,285 100.00% Procedure Modifier 3 - - - - 13,204 99.39% 81 0.61% 13,285 100.00% Procedure Modifier 4 - - - - 13,285 100.00% - 0.00% 13,285 100.00% Revenue Code - - 1,398 10.52% - - 11,887 89.48% 11,887 89.48% Surgical Procedure Code 1 2,283 17.18% - - 11,002 82.82% - 0.00% 11,002 82.82% Surgical Procedure Code 2 1,539 11.58% - - 11,746 88.42% - 0.00% 11,746 88.42% Surgical Procedure Code 3 1,075 8.09% - - 12,210 91.91% - 0.00% 12,210 91.91% Surgical Procedure Code 4 - - - - 13,285 100.00% - 0.00% 13,285 100.00%

Service/Rendering Provider NPI [and/or MMIS Service/ Rendering Provider Number (Medicaid ID)]

- - - - - - 13,285 100.00% 13,285 100.00%


- - 1 - - - 13,254 191.59% 30 0.23% 13,284 99.99%


13,285


Page 12

Notes: - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. -These tables were updated in the MCO rebuttal process to remove zero paid lines from consideration. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or a FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 13

Presbyterian Health Plan: Healthcare Outpatient Encounters (837I)-Header Level

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Bill Type (Type of Bill) Facility and Class

- 0.00% 5 0.01% - 0.00% 34,370 99.99% 34,370 99.99%

Bill Type (Type of Bill) Frequency - 0.00% 4,866 14.16% - 0.00% 29,509 85.84% 29,509 85.84%


- 0.00% 6 0.02% 1 0.00% 34,368 99.98% 34,368 99.98%

Diagnosis Code 1 - 0.00% 12 0.03% - 0.00% 34,363 99.97% 34,363 99.97%

Diagnosis Code 2 - 0.00% 1,114 3.24% - 0.00% 13,236 38.50% 20,025 58.25% 33,261 96.76%

Diagnosis Code 3 - 0.00% 1,120 3.26% - 0.00% 21,641 62.96% 11,614 33.79% 33,255 96.74%

Diagnosis Code 4 - 0.00% 1,007 2.93% - 0.00% 26,509 77.12% 6,859 19.95% 33,368 97.07%

Former MMIS Claim TCN - 0.00% 3,534 10.28% - 0.00% 29,065 84.55% 1,776 5.17% 30,841 89.72%

Header First Date of Service - 0.00% 32 0.09% - 0.00% 34,343 99.91% 34,343 99.91%

Header Last Day of Service - 0.00% 192 0.56% - 0.00% 34,183 99.44% 34,183 99.44%

Header Paid Amount - 0.00% 935 2.72% - 0.00% 33,440 97.28% 33,440 97.28%

MMIS TCN - 0.00% - 0.00% - 0.00% 34,375 100.00% 34,375 100.00%

MMIS Member Number - 0.00% 2,608 7.59% - 0.00% 31,767 92.41% 31,767 92.41%

Plan Paid Date - 0.00% 5 0.01% - 0.00% 34,370 99.99% 34,370 99.99%

Plan Received Date - 0.00% 27 0.08% - 0.00% 34,348 99.92% 34,348 99.92%


34,375


Page 14

Presbyterian Health Plan: Healthcare Outpatient Encounters (837I)-Header Level

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Bill Type (Type of Bill) Facility and Class

- 0.00% 105 0.25% - 0.00% 41,305 99.75% 41,305 99.75%

Bill Type (Type of Bill) Frequency - 0.00% 10,035 24.23% - 0.00% 31,375 75.77% 31,375 75.77%


- 0.00% 19 0.05% - 0.00% 41,391 99.95% 41,391 99.95%

Diagnosis Code 1 - 0.00% - 0.00% - 0.00% 41,410 100.00% 41,410 100.00%

Diagnosis Code 2 - 0.00% 1,147 2.77% - 0.00% 15,375 37.13% 24,888 60.10% 40,263 97.23%

Diagnosis Code 3 - 0.00% 1,158 2.80% - 0.00% 25,720 62.11% 14,532 35.09% 40,252 97.20%

Diagnosis Code 4 - 0.00% 823 1.99% - 0.00% 32,042 77.38% 8,545 20.64% 40,587 98.01%

Former MMIS Claim TCN - 0.00% 4,378 10.57% - 0.00% 29,542 71.34% 7,490 18.09% 37,032 89.43%

Header First Date of Service - 0.00% 43 0.10% - 0.00% 41,367 99.90% 41,367 99.90%

Header Last Day of Service - 0.00% 366 0.88% - 0.00% 41,044 99.12% 41,044 99.12%

Header Paid Amount - 0.00% 958 2.31% - 0.00% 40,452 97.69% 40,452 97.69%

MMIS TCN - 0.00% - 0.00% - 0.00% 41,410 100.00% 41,410 100.00%

MMIS Member Number - 0.00% 2,482 5.99% - 0.00% 38,928 94.01% 38,928 94.01%

Plan Paid Date - 0.00% 2 0.00% - 0.00% 41,408 100.00% 41,408 100.00%

Plan Received Date - 0.00% 38 0.09% - 0.00% 41,372 99.91% 41,372 99.91%


41,410


Page 15

Notes: - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or a FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 16

Presbyterian Health Plan: Outpatient Encounters (837I)-Line Level

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges - 0.00% 3,790 3.71% - 0.00% 98,242 96.29% 98,242 96.29% Line First Date of Service - 0.00% 6 0.01% - 0.00% 102,026 99.99% 102,026 99.99% Line Last Date of Service - 0.00% 534 0.52% - 0.00% 101,498 99.48% 101,498 99.48% Line Paid Amount - 0.00% 3,868 3.79% - 0.00% 98,164 96.21% 98,164 96.21% Procedure Code - 0.00% 1,062 1.04% - 0.00% 3,812 3.74% 97,158 95.22% 100,970 98.96% Procedure Modifier Code1 (Compared to All 4 Procedure Modifiers in ENCs)

- 0.00% 22 0.02% - 0.00% 84,659 82.97% 17,351 17.01% 102,010 99.98%

Procedure Modifier Code2 (Compared to All 4 Procedure Modifiers in ENCs)

- 0.00% 13 0.01% - 0.00% 101,401 99.38% 618 0.61% 102,019 99.99%


- 0.00% 13 0.01% - 0.00% 102,012 99.98% 7 0.01% 102,019 99.99%


- 0.00% 13 0.01% - 0.00% 102,019 99.99% - 0.00% 102,019 99.99%

Revenue Code - 0.00% 3,185 3.12% - 0.00% 98,847 96.88% 98,847 96.88% Service/Rendering Provider NPI [and/or MMIS Service/ Rendering Provider Number (Medicaid ID)]

- 0.00% 13 0.01% - 0.00% 102,019 99.99% 102,019 99.99%


- 0.00% 4,988 4.89% 2 0.00% 97,044 95.11% 97,044 95.11%


102,032


Page 17

Presbyterian Health Plan: Outpatient Encounters (837I)-Line Level

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)

Matching Values




Billed Charges - 0.00% 4,386 3.17% - 0.00% 134,170 96.83% 134,170 96.83% Line First Date of Service - 0.00% 34 0.02% - 0.00% 138,522 99.98% 138,522 99.98% Line Last Date of Service - 0.00% 607 0.44% - 0.00% 137,949 99.56% 137,949 99.56% Line Paid Amount - 0.00% 4,570 3.30% - 0.00% 133,986 96.70% 133,986 96.70% Procedure Code - 0.00% 1,238 0.89% - 0.00% 3,833 2.77% 133,485 96.34% 137,318 99.11% Procedure Modifier Code1 (Compared to All 4 Procedure Modifiers in ENCs)

- 0.00% 19 0.01% - 0.00% 115,158 83.11% 23,379 16.87% 138,537 99.99%


- 0.00% - 0.00% - 0.00% 137,904 99.53% 652 0.47% 138,556 100.00%


- 0.00% - 0.00% - 0.00% 138,548 99.99% 8 0.01% 138,556 100.00%


- 0.00% - 0.00% - 0.00% 138,556 100.00% - 0.00% 138,556 100.00%

Revenue Code - 0.00% 5,232 3.78% - 0.00% 133,324 96.22% 133,324 96.22% Service/Rendering Provider NPI [and/or MMIS Service/ Rendering Provider Number (Medicaid ID)]

- 0.00% - 0.00% - 0.00% 138,556 100.00% 138,556 100.00%


- 0.00% 5,119 3.69% 7 0.01% 133,437 96.31% 133,437 96.31%


138,556


Page 18

Notes:

-These tables were updated in the MCO rebuttal process to remove zero paid lines from consideration. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or a FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 19

Presbyterian Health Plan: Pharmacy Encounters (NCPDP)-Header Level

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)

Matching Values



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billing Provider NPI (or MMIS Billing Provider Number)

- - - 0.00% - - 128,362 100.00% 128,362 100.00%

Date Filled (DOS) - - 214 0.17% - - 128,148 99.83% 128,148 99.83%

Former MMIS Claim TCN - 0.00% - - 128,362 100.00% 0 0.00% 128,362 100.00%

MMIS TCN - - - 0.00% - - 128,362 100.00% 128,362 100.00%


Plan Paid Date - - 4,362 3.40% - - 124,000 96.60% 124,000 96.60%

Prescription Number - - 214 0.17% - - 128,148 99.83% 128,148 99.83%

Refill Number - - 935 0.73% - - 127,427 99.27% 127,427 99.27%

Total Submitted Records Traced to MMIS 128,362


Page 20

Presbyterian Health Plan: Pharmacy Encounters (NCPDP)-Header Level

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)

Matching Values



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billing Provider NPI (or MMIS Billing Provider Number)

- - - - - - 128,515 100.00% 128,515 100.00%

Date Filled (DOS) - - 249 0.19% - - 128,266 99.81% 128,266 99.81%


MMIS TCN - - - 0.00% - - 128,515 100.00% 128,515 100.00%


Plan Paid Date - - 3,902 3.04% - - 124,613 96.96% 124,613 96.96%

Prescription Number - - 253 0.20% - - 128,262 99.80% 128,262 99.80%

Refill Number - - 1,133 0.88% - - 127,382 99.12% 127,382 99.12%

Total Submitted Records Traced to MMIS 128,515


Page 21

Notes: -The plan paid date element was updated in the MCO rebuttal process to remove zero paid lines from consideration. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or a FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 22

Presbyterian Health Plan: Pharmacy Encounters (NCPDP)-Line Level

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)




Days Supply - - 214 0.17% - - 126,315 99.83% 126,315 99.83%

NDC - - 601 0.47% - - 125,928 99.53% 125,928 99.53%

Plan Paid Amount - - - - - - 126,529 100.00% 126,529 100.00%

Prescribing Provider NPI 208 0.16% - - 6 0.00% 126,315 99.83% 126,321 99.84%

Quantity Dispensed (Dispensed Units)

- - - - - - 126,529 100.00% 126,529 100.00%


126,529


Page 23

Presbyterian Health Plan: Pharmacy Encounters (NCPDP)-Line Level

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)




Days Supply - - 246 0.19% - - 126,171 99.81% 126,171 99.81%

NDC - - 587 0.46% - - 125,830 99.54% 125,830 99.54%

Plan Paid Amount - - - - - - 126,417 100.00% 126,417 100.00%

Prescribing Provider NPI 231 0.18% - - 15 0.01% 126,171 99.81% 126,186 99.82%

Quantity Dispensed (Dispensed Units)

- - 4 0.00% - - 126,413 100.00% 126,413 100.00%


126,417


Page 24

Notes: -These tables were updated in the MCO rebuttal process to remove zero paid lines from consideration. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or a FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 25

Presbyterian Health Plan: Professional Encounters-Header Level (837P)

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent MMIS Billing Provider Number (Medicaid ID)

- - 6,602 3.33% - - 191,671 96.67% 191,671 96.67%

Diagnosis Code 1 - - 6,766 3.41% - - 191,507 96.59% 191,507 96.59%

Diagnosis Code 2 3,773 1.90% - - 116,661 58.84% 77,839 39.26% 194,500 98.10%

Diagnosis Code 3 1,530 0.77% - - 158,087 79.73% 38,656 19.50% 196,743 99.23%

Diagnosis Code 4 300 0.15% - - 178,856 90.21% 19,117 9.64% 197,973 99.85%

Former MMIS Claim TCN 13,450 6.78% - - 181,488 91.53% 3,335 1.68% 184,823 93.22%


Header Paid Amount - - 25,176 12.70% - - 173,097 87.30% 173,097 87.30%

MMIS TCN - - - - - - 198,273 181,488 198,273 100.00%

MMIS Member Number (Medicaid ID)

137 0.07% 6,358 3.21% - - 191,778 96.72% 191,778 96.72%

Plan Paid Date - - 4,472 2.26% - - 193,801 97.74% 193,801 97.74%

Plan Received Date - - 7,658 3.86% - - 190,615 96.14% 190,615 96.14%


198,273


Page 26

Presbyterian Health Plan: Professional Encounters-Header Level (837P)

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent MMIS Billing Provider Number (Medicaid ID)

- - 4,313 2.28% - - 184,659 97.72% 184,659 97.72%

Diagnosis Code 1 - - 4,354 2.30% - - 184,618 97.70% 184,618 97.70%

Diagnosis Code 2 1,141 0.60% - - 112,258 59.40% 75,573 39.99% 187,831 99.40%

Diagnosis Code 3 509 0.27% - - 150,214 79.49% 38,249 20.24% 188,463 99.73%

Diagnosis Code 4 246 0.13% - - 170,144 90.04% 18,582 9.83% 188,726 99.87%

Former MMIS Claim TCN 3,452 1.83% - - 183,633 97.17% 1,887 1.00% 185,520 98.17%


Header Paid Amount - - 14,422 7.63% - - 174,550 92.37% 174,550 92.37%

MMIS TCN - - - - - - 188,972 100.00% 188,972 100.00%

MMIS Member Number (Medicaid ID)

156 0.08% 4,821 2.55% - - 183,995 97.37% 183,995 97.37%

Plan Paid Date - - 4,541 2.40% - - 184,431 97.60% 184,431 97.60%

Plan Received Date - - 4,498 2.38% - - 184,474 97.62% 184,474 97.62%


188,972


Page 27

Notes: - Billed charges and header last date of service are generally header level key data elements. However, the PHP-submitted claims sample values appear to reflect line level amounts. Therefore, these data elements were evaluated at the line level. - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or a FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 28

Presbyterian Health Plan: Professional Encounters-Line Level (837P)

Key Data Field


September 2014 Missing Values


Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges - - 57,397 16.33% - - 294,063 83.67% 294,063 83.67%


Line First Date of Service - - 12 0.00% - - 351,448 100.00% 351,448 100.00%

Line Last Date of Service - - 11,425 3.25% - - 340,035 96.75% 340,035 96.75%

Line Paid Amount - - 3,543 1.01% - - 347,917 98.99% 347,917 98.99%

Place of Service 3 0.00% 883 0.25% 632 0.18% 350,574 99.75% 350,574 99.75%

Procedure Code 205 0.06% 6,015 1.71% 335 0.10% 345,240 98.23% 345,240 98.23% Procedure Code Modifier 1 1,380 0.39% - - 255,913 72.81% 94,167 26.79% 350,080 99.61%

Procedure Code Modifier 2 88 0.03% - - 341,562 97.18% 9,810 2.79% 351,372 99.97%

Procedure Code Modifier 3 20 0.01% - - 350,596 99.75% 844 0.24% 351,440 99.99%


Service/Rendering Provider NPI [or MMIS Service/Rendering Provider Number (Medicaid ID)]

6,965 1.98% - - - - 344,495 98.02% 344,495 98.02%


17,634 5.02% - - 59,053 16.80% 274,773 78.18% 333,826 94.98%


351,460


Page 29

Presbyterian Health Plan: Professional Encounters-Line Level (837P)

Key Data Field


December 2014 Missing Values


Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges - - 30,558 9.73% - - 283,614 90.27% 283,614 90.27%


Line First Date of Service 4,313 1.37% - 0.00% - - 309,859 98.63% 309,859 98.63%

Line Last Date of Service - - 8,948 2.85% - - 305,224 97.15% 305,224 97.15%

Line Paid Amount - - 2,541 0.81% - - 311,631 99.19% 311,631 99.19%

Place of Service - - 389 0.12% 142 0.05% 313,783 99.88% 313,783 99.88%

Procedure Code 53 0.02% 3,800 1.21% 85 0.03% 310,319 98.77% 310,319 98.77% Procedure Code Modifier 1 992 0.32% - - 221,520 70.51% 91,660 29.18% 313,180 99.68%

Procedure Code Modifier 2 178 0.06% - - 304,033 96.77% 9,961 3.17% 313,994 99.94%



Service/Rendering Provider NPI [or MMIS Service/Rendering Provider Number (Medicaid ID)]

4,736 1.51% - - - - 309,436 98.49% 309,436 98.49%


17,803 5.67% - - 16,359 5.21% 280,010 89.13% 296,369 94.33%


314,172


Page 30

Notes: - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. -These tables were updated in the MCO rebuttal process to remove zero paid lines from consideration. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or a FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.

Page 1

Appendix C-5: Member Utilization by Service Type

Presbyterian Health Plan Total Utilization

Total Number of all Services

Age Group Total

Tribal Community

Non-Tribal Community

Total Male Female Total Male Female Total Male Female

0 - 5 999,822 529,930 469,892 33,035 17,776 15,259 966,787 512,154 454,633 6 - 18 2,572,533 1,308,425 1,264,108 67,560 32,057 35,503 2,504,973 1,276,368 1,228,605

19 - 21 275,262 83,857 191,405 5,933 2,695 3,238 269,329 81,162 188,167 22 - 34 1,393,984 298,564 1,095,420 30,815 8,476 22,339 1,363,169 290,088 1,073,081 35 - 49 1,348,326 402,094 946,232 29,265 9,970 19,295 1,319,061 392,124 926,937 50 - 64 1,242,608 464,965 777,643 32,627 12,546 20,081 1,209,981 452,419 757,562 65 - 74 192,590 58,810 133,780 10,036 4,258 5,778 182,554 54,552 128,002

75 and Over 166,409 44,755 121,654 10,148 2,845 7,303 156,261 41,910 114,351 Total 8,191,534 3,191,400 5,000,134 219,419 90,623 128,796 7,972,115 3,100,777 4,871,338

Centennial Care Total Utilization


Age Group Total

Tribal Community



0 - 5 2,851,530 1,504,216 1,347,314 95,054 50,355 44,699 2,756,476 1,453,861 1,302,615 6 - 18 5,749,977 2,896,287 2,853,690 152,341 73,799 78,542 5,597,636 2,822,488 2,775,148

19 - 21 848,942 240,464 608,478 15,670 5,130 10,540 833,272 235,334 597,938 22 - 34 4,670,113 1,313,046 3,357,067 120,495 42,614 77,881 4,549,618 1,270,432 3,279,186 35 - 49 4,984,986 1,804,939 3,180,047 171,465 79,117 92,348 4,813,521 1,725,822 3,087,699 50 - 64 6,386,887 2,479,085 3,907,802 253,731 103,916 149,815 6,133,156 2,375,169 3,757,987 65 - 74 1,302,971 447,337 855,634 135,650 50,512 85,138 1,167,321 396,825 770,496

75 and Over 1,489,309 422,741 1,066,568 162,194 45,952 116,242 1,327,115 376,789 950,326 Total 28,284,715 11,108,115 17,176,600 1,106,600 451,395 655,205 27,178,115 10,656,720 16,521,395

Page 2


Presbyterian Health Plan Total Utilization Per Member

All Services on a Per Member Basis

Age Group Total

Tribal Community



0 - 5 28.7 29.9 27.6 25.7 26.9 24.5 28.9 30.0 27.7 6 - 18 29.6 29.5 29.7 23.2 22.3 24.1 29.8 29.7 29.9

19 - 21 35.9 26.6 42.3 25.3 27.3 23.9 36.2 26.6 42.9 22 - 34 48.0 36.6 52.5 37.6 32.4 40.1 48.3 36.7 52.9 35 - 49 63.6 55.3 67.9 53.7 49.2 56.4 63.8 55.5 68.2 50 - 64 96.1 85.3 104.0 86.8 79.1 92.5 96.4 85.5 104.3 65 - 74 106.1 83.9 120.1 91.8 90.1 93.1 107.0 83.4 121.6

75 and Over 123.5 102.6 133.4 110.0 81.7 127.2 124.4 104.4 133.8 Total 41.9 36.6 46.1 34.4 31.2 37.1 42.1 36.7 46.4

Centennial Care Total Utilization Per Member


Age Group Total

Tribal Community



0 - 5 30.6 31.7 29.4 26.8 28.0 25.6 30.8 31.9 29.6 6 - 18 29.1 28.8 29.4 22.7 22.0 23.5 29.3 29.0 29.7

19 - 21 34.4 23.8 41.7 25.2 20.3 28.6 34.6 23.9 42.1 22 - 34 46.6 37.1 51.8 43.4 43.6 43.3 46.7 36.9 52.1 35 - 49 69.2 61.9 74.2 82.1 89.3 76.8 68.8 61.0 74.1 50 - 64 100.1 88.4 109.2 120.9 113.6 126.6 99.4 87.5 108.6 65 - 74 108.7 93.3 118.9 119.6 112.9 124.0 107.6 91.3 118.4

75 and Over 125.7 111.1 132.6 133.5 123.7 137.8 124.8 109.7 132.0 Total 49.2 42.8 54.4 54.8 50.1 58.6 49.0 42.6 54.2

Note: Encounters per member was calculated by dividing the number of encounters by the average number of members.

Page 3


Presbyterian Health Plan Inpatient Utilization


Age Group Total

Tribal Community



0 - 5 7,729 4,147 3,582 250 142 108 7,479 4,005 3,474 6 - 18 6,811 3,875 2,936 197 93 104 6,614 3,782 2,832

19 - 21 1,913 537 1,376 64 17 47 1,849 520 1,329 22 - 34 5,791 1,034 4,757 174 42 132 5,617 992 4,625 35 - 49 3,936 1,471 2,465 161 86 75 3,775 1,385 2,390 50 - 64 4,929 2,237 2,692 311 211 100 4,618 2,026 2,592 65 - 74 2,394 875 1,519 123 46 77 2,271 829 1,442

75 and Over 5,099 1,469 3,630 374 161 213 4,725 1,308 3,417 Total 38,602 15,645 22,957 1,654 798 856 36,948 14,847 22,101

Centennial Care Inpatient Utilization


Age Group Total

Tribal Community



0 - 5 22,981 12,189 10,792 894 497 397 22,087 11,692 10,395 6 - 18 16,216 8,808 7,408 826 388 438 15,390 8,420 6,970

19 - 21 5,371 1,286 4,085 147 25 122 5,224 1,261 3,963 22 - 34 19,598 4,666 14,932 659 139 520 18,939 4,527 14,412 35 - 49 16,237 7,455 8,782 898 478 420 15,339 6,977 8,362 50 - 64 34,182 17,565 16,617 1,784 1,108 676 32,398 16,457 15,941 65 - 74 20,603 9,257 11,346 1,694 906 788 18,909 8,351 10,558

75 and Over 63,298 19,804 43,494 6,010 2,308 3,702 57,288 17,496 39,792 Total 198,486 81,030 117,456 12,912 5,849 7,063 185,574 75,181 110,393

Page 4


Presbyterian Health Plan Inpatient Utilization Per Member


Age Group Total

Tribal Community



0 - 5 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.2 6 - 18 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1

19 - 21 0.2 0.2 0.3 0.3 0.2 0.3 0.2 0.2 0.3 22 - 34 0.2 0.1 0.2 0.2 0.2 0.2 0.2 0.1 0.2 35 - 49 0.2 0.2 0.2 0.3 0.4 0.2 0.2 0.2 0.2 50 - 64 0.4 0.4 0.4 0.8 1.3 0.5 0.4 0.4 0.4 65 - 74 1.3 1.2 1.4 1.1 1.0 1.2 1.3 1.3 1.4

75 and Over 3.8 3.4 4.0 4.1 4.6 3.7 3.8 3.3 4.0 Total 0.2 0.2 0.2 0.3 0.3 0.2 0.2 0.2 0.2

Centennial Care Inpatient Utilization Per Member


Age Group Total

Tribal Community



0 - 5 0.2 0.3 0.2 0.3 0.3 0.2 0.2 0.3 0.2 6 - 18 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1

19 - 21 0.2 0.1 0.3 0.2 0.1 0.3 0.2 0.1 0.3 22 - 34 0.2 0.1 0.2 0.2 0.1 0.3 0.2 0.1 0.2 35 - 49 0.2 0.3 0.2 0.4 0.5 0.3 0.2 0.2 0.2 50 - 64 0.5 0.6 0.5 0.9 1.2 0.6 0.5 0.6 0.5 65 - 74 1.7 1.9 1.6 1.5 2.0 1.1 1.7 1.9 1.6

75 and Over 5.3 5.2 5.4 4.9 6.2 4.4 5.4 5.1 5.5 Total 0.3 0.3 0.4 0.6 0.6 0.6 0.3 0.3 0.4


Page 5


Presbyterian Health Plan Outpatient Utilization


Age Group Total

Tribal Community



0 - 5 142,470 77,597 64,873 7,075 3,974 3,101 135,395 73,623 61,772 6 - 18 307,246 142,563 164,683 12,585 5,741 6,844 294,661 136,822 157,839

19 - 21 66,681 17,103 49,578 1,549 588 961 65,132 16,515 48,617 22 - 34 315,817 61,179 254,638 9,041 2,570 6,471 306,776 58,609 248,167 35 - 49 267,729 80,537 187,192 7,996 2,426 5,570 259,733 78,111 181,622 50 - 64 225,367 88,645 136,722 7,892 2,888 5,004 217,475 85,757 131,718 65 - 74 47,192 14,507 32,685 3,701 1,681 2,020 43,491 12,826 30,665

75 and Over 28,102 8,178 19,924 1,608 490 1,118 26,494 7,688 18,806 Total 1,400,604 490,309 910,295 51,447 20,358 31,089 1,349,157 469,951 879,206

Centennial Care Outpatient Utilization


Age Group Total

Tribal Community



0 - 5 540,922 285,651 255,271 24,615 13,654 10,961 516,307 271,997 244,310 6 - 18 858,403 396,819 461,584 31,058 14,255 16,803 827,345 382,564 444,781

19 - 21 243,151 59,285 183,866 4,672 1,374 3,298 238,479 57,911 180,568 22 - 34 1,220,586 305,197 915,389 33,566 9,868 23,698 1,187,020 295,329 891,691 35 - 49 1,122,632 404,957 717,675 47,029 22,144 24,885 1,075,603 382,813 692,790 50 - 64 1,291,491 523,708 767,783 57,475 23,064 34,411 1,234,016 500,644 733,372 65 - 74 241,486 88,129 153,357 27,075 10,315 16,760 214,411 77,814 136,597

75 and Over 207,553 61,249 146,304 21,161 6,207 14,954 186,392 55,042 131,350 Total 5,726,224 2,124,995 3,601,229 246,651 100,881 145,770 5,479,573 2,024,114 3,455,459

Page 6


Presbyterian Health Plan Outpatient Utilization Per Member


Age Group Total

Tribal Community



0 - 5 4.1 4.4 3.8 5.5 6.0 5.0 4.0 4.3 3.8 6 - 18 3.5 3.2 3.9 4.3 4.0 4.7 3.5 3.2 3.8

19 - 21 8.7 5.4 11.0 6.6 6.0 7.1 8.8 5.4 11.1 22 - 34 10.9 7.5 12.2 11.0 9.8 11.6 10.9 7.4 12.2 35 - 49 12.6 11.1 13.4 14.7 12.0 16.3 12.6 11.0 13.4 50 - 64 17.4 16.3 18.3 21.0 18.2 23.0 17.3 16.2 18.1 65 - 74 26.0 20.7 29.3 33.9 35.6 32.5 25.5 19.6 29.1

75 and Over 20.8 18.8 21.9 17.4 14.1 19.5 21.1 19.2 22.0 Total 7.2 5.6 8.4 8.1 7.0 9.0 7.1 5.6 8.4

Centennial Care Outpatient Utilization Per Member


Age Group Total

Tribal Community



0 - 5 5.8 6.0 5.6 6.9 7.6 6.3 5.8 6.0 5.6 6 - 18 4.3 3.9 4.8 4.6 4.2 5.0 4.3 3.9 4.8

19 - 21 9.9 5.9 12.6 7.5 5.4 9.0 9.9 5.9 12.7 22 - 34 12.2 8.6 14.1 12.1 10.1 13.2 12.2 8.6 14.2 35 - 49 15.6 13.9 16.7 22.5 25.0 20.7 15.4 13.5 16.6 50 - 64 20.2 18.7 21.5 27.4 25.2 29.1 20.0 18.5 21.2 65 - 74 20.1 18.4 21.3 23.9 23.1 24.4 19.8 17.9 21.0

75 and Over 17.5 16.1 18.2 17.4 16.7 17.7 17.5 16.0 18.2 Total 10.0 8.2 11.4 12.2 11.2 13.0 9.9 8.1 11.3


Page 7


Presbyterian Health Plan Professional Utilization


Age Group Total

Tribal Community



0 - 5 589,445 312,283 277,162 16,172 8,600 7,572 573,273 303,683 269,590 6 - 18 1,281,639 663,692 617,947 27,793 13,387 14,406 1,253,846 650,305 603,541

19 - 21 136,286 40,046 96,240 2,695 1,264 1,431 133,591 38,782 94,809 22 - 34 711,165 149,454 561,711 14,404 4,068 10,336 696,761 145,386 551,375 35 - 49 646,337 193,370 452,967 13,199 5,100 8,099 633,138 188,270 444,868 50 - 64 600,620 224,094 376,526 16,638 6,411 10,227 583,982 217,683 366,299 65 - 74 121,605 36,756 84,849 5,445 2,204 3,241 116,160 34,552 81,608

75 and Over 127,577 33,329 94,248 7,853 2,073 5,780 119,724 31,256 88,468 Total 4,214,674 1,653,024 2,561,650 104,199 43,107 61,092 4,110,475 1,609,917 2,500,558

Centennial Care Professional Utilization


Age Group Total

Tribal Community



0 - 5 1,606,592 851,148 755,444 44,616 23,049 21,567 1,561,976 828,099 733,877 6 - 18 2,726,467 1,400,773 1,325,694 61,852 30,136 31,716 2,664,615 1,370,637 1,293,978

19 - 21 392,981 109,516 283,465 6,784 2,149 4,635 386,197 107,367 278,830 22 - 34 2,262,911 662,263 1,600,648 64,063 26,193 37,870 2,198,848 636,070 1,562,778 35 - 49 2,373,528 884,720 1,488,808 89,801 43,469 46,332 2,283,727 841,251 1,442,476 50 - 64 3,122,088 1,213,470 1,908,618 148,550 62,077 86,473 2,973,538 1,151,393 1,822,145 65 - 74 940,830 315,028 625,802 101,802 37,565 64,237 839,028 277,463 561,565

75 and Over 1,170,756 326,799 843,957 131,477 36,243 95,234 1,039,279 290,556 748,723 Total 14,596,153 5,763,717 8,832,436 648,945 260,881 388,064 13,947,208 5,502,836 8,444,372

Page 8


Presbyterian Health Plan Professional Utilization Per Member


Age Group Total

Tribal Community



0 - 5 16.9 17.6 16.3 12.6 13.0 12.1 17.1 17.8 16.4 6 - 18 14.7 15.0 14.5 9.5 9.3 9.8 14.9 15.1 14.7

19 - 21 17.8 12.7 21.3 11.5 12.8 10.6 18.0 12.7 21.6 22 - 34 24.5 18.3 26.9 17.6 15.6 18.5 24.7 18.4 27.2 35 - 49 30.5 26.6 32.5 24.2 25.2 23.7 30.6 26.6 32.7 50 - 64 46.4 41.1 50.3 44.3 40.4 47.1 46.5 41.1 50.4 65 - 74 67.0 52.4 76.1 49.8 46.6 52.2 68.1 52.8 77.6

75 and Over 94.6 76.4 103.4 85.1 59.5 100.7 95.3 77.9 103.5 Total 21.5 18.9 23.6 16.3 14.8 17.6 21.7 19.1 23.8

Centennial Care Professional Utilization Per Member


Age Group Total

Tribal Community



0 - 5 17.2 18.0 16.5 12.6 12.8 12.4 17.4 18.2 16.7 6 - 18 13.8 13.9 13.7 9.2 9.0 9.5 14.0 14.1 13.8

19 - 21 15.9 10.9 19.4 10.9 8.5 12.6 16.1 10.9 19.6 22 - 34 22.6 18.7 24.7 23.1 26.8 21.1 22.6 18.5 24.8 35 - 49 32.9 30.3 34.7 43.0 49.1 38.5 32.6 29.7 34.6 50 - 64 48.9 43.3 53.3 70.8 67.8 73.1 48.2 42.4 52.7 65 - 74 78.5 65.7 87.0 89.8 84.0 93.6 77.3 63.8 86.3

75 and Over 98.8 85.9 104.9 108.2 97.6 112.9 97.7 84.6 104.0 Total 25.4 22.2 28.0 32.1 29.0 34.7 25.1 22.0 27.7


Page 9


Presbyterian Health Plan Dental Utilization


Age Group Total

Tribal Community



0 - 5 140,110 71,264 68,846 6,072 3,115 2,957 134,038 68,149 65,889 6 - 18 585,585 291,250 294,335 17,617 8,134 9,483 567,968 283,116 284,852

19 - 21 23,111 8,979 14,132 472 183 289 22,639 8,796 13,843 22 - 34 70,070 18,725 51,345 1,202 262 940 68,868 18,463 50,405 35 - 49 54,438 17,982 36,456 888 358 530 53,550 17,624 35,926 50 - 64 32,400 13,066 19,334 515 240 275 31,885 12,826 19,059 65 - 74 2,994 1,124 1,870 96 36 60 2,898 1,088 1,810

75 and Over 1,782 587 1,195 89 62 27 1,693 525 1,168 Total 910,490 422,977 487,513 26,951 12,390 14,561 883,539 410,587 472,952

Centennial Care Dental Utilization


Age Group Total

Tribal Community



0 - 5 339,767 172,112 167,655 14,568 7,500 7,068 325,199 164,612 160,587 6 - 18 1,250,975 619,797 631,178 36,365 17,605 18,760 1,214,610 602,192 612,418

19 - 21 68,920 25,252 43,668 1,256 483 773 67,664 24,769 42,895 22 - 34 249,796 82,782 167,014 3,814 1,019 2,795 245,982 81,763 164,219 35 - 49 202,754 79,460 123,294 3,590 1,487 2,103 199,164 77,973 121,191 50 - 64 185,424 77,913 107,511 3,030 1,233 1,797 182,394 76,680 105,714 65 - 74 22,030 8,024 14,006 1,078 418 660 20,952 7,606 13,346

75 and Over 18,449 5,885 12,564 904 401 503 17,545 5,484 12,061 Total 2,338,115 1,071,225 1,266,890 64,605 30,146 34,459 2,273,510 1,041,079 1,232,431

Page 10


Presbyterian Health Plan Dental Utilization Per Member


Age Group Total

Tribal Community



0 - 5 4.0 4.0 4.0 4.7 4.7 4.7 4.0 4.0 4.0 6 - 18 6.7 6.6 6.9 6.1 5.6 6.4 6.8 6.6 6.9

19 - 21 3.0 2.8 3.1 2.0 1.9 2.1 3.0 2.9 3.2 22 - 34 2.4 2.3 2.5 1.5 1.0 1.7 2.4 2.3 2.5 35 - 49 2.6 2.5 2.6 1.6 1.8 1.5 2.6 2.5 2.6 50 - 64 2.5 2.4 2.6 1.4 1.5 1.3 2.5 2.4 2.6 65 - 74 1.6 1.6 1.7 0.9 0.8 1.0 1.7 1.7 1.7

75 and Over 1.3 1.3 1.3 1.0 1.8 0.5 1.3 1.3 1.4 Total 4.7 4.8 4.5 4.2 4.3 4.2 4.7 4.9 4.5

Centennial Care Dental Utilization Per Member


Age Group Total

Tribal Community



0 - 5 3.6 3.6 3.7 4.1 4.2 4.1 3.6 3.6 3.6 6 - 18 6.3 6.2 6.5 5.4 5.2 5.6 6.4 6.2 6.5

19 - 21 2.8 2.5 3.0 2.0 1.9 2.1 2.8 2.5 3.0 22 - 34 2.5 2.3 2.6 1.4 1.0 1.6 2.5 2.4 2.6 35 - 49 2.8 2.7 2.9 1.7 1.7 1.7 2.8 2.8 2.9 50 - 64 2.9 2.8 3.0 1.4 1.3 1.5 3.0 2.8 3.1 65 - 74 1.8 1.7 1.9 1.0 0.9 1.0 1.9 1.8 2.1

75 and Over 1.6 1.5 1.6 0.7 1.1 0.6 1.6 1.6 1.7 Total 4.1 4.1 4.0 3.2 3.3 3.1 4.1 4.2 4.0


Page 11


Presbyterian Health Plan Pharmacy Utilization


Age Group Total

Tribal Community



0 - 5 120,068 64,639 55,429 3,466 1,945 1,521 116,602 62,694 53,908 6 - 18 391,252 207,045 184,207 9,368 4,702 4,666 381,884 202,343 179,541

19 - 21 47,271 17,192 30,079 1,153 643 510 46,118 16,549 29,569 22 - 34 291,141 68,172 222,969 5,994 1,534 4,460 285,147 66,638 218,509 35 - 49 375,886 108,734 267,152 7,021 2,000 5,021 368,865 106,734 262,131 50 - 64 379,292 136,923 242,369 7,271 2,796 4,475 372,021 134,127 237,894 65 - 74 18,405 5,548 12,857 671 291 380 17,734 5,257 12,477

75 and Over 3,849 1,192 2,657 224 59 165 3,625 1,133 2,492 Total 1,627,164 609,445 1,017,719 35,168 13,970 21,198 1,591,996 595,475 996,521

Centennial Care Pharmacy Utilization


Age Group Total

Tribal Community



0 - 5 341,268 183,116 158,152 10,361 5,655 4,706 330,907 177,461 153,446 6 - 18 897,916 470,090 427,826 22,240 11,415 10,825 875,676 458,675 417,001

19 - 21 138,519 45,125 93,394 2,811 1,099 1,712 135,708 44,026 91,682 22 - 34 917,222 258,138 659,084 18,393 5,395 12,998 898,829 252,743 646,086 35 - 49 1,269,835 428,347 841,488 30,147 11,539 18,608 1,239,688 416,808 822,880 50 - 64 1,753,702 646,429 1,107,273 42,892 16,434 26,458 1,710,810 629,995 1,080,815 65 - 74 78,022 26,899 51,123 4,001 1,308 2,693 74,021 25,591 48,430

75 and Over 29,253 9,004 20,249 2,642 793 1,849 26,611 8,211 18,400 Total 5,425,737 2,067,148 3,358,589 133,487 53,638 79,849 5,292,250 2,013,510 3,278,740

Page 12


Presbyterian Health Plan Pharmacy Utilization Per Member


Age Group Total

Tribal Community



0 - 5 3.5 3.6 3.3 2.7 2.9 2.4 3.5 3.7 3.3 6 - 18 4.5 4.7 4.3 3.2 3.3 3.2 4.5 4.7 4.4

19 - 21 6.2 5.5 6.7 4.9 6.5 3.8 6.2 5.4 6.7 22 - 34 10.0 8.4 10.7 7.3 5.9 8.0 10.1 8.4 10.8 35 - 49 17.7 15.0 19.2 12.9 9.9 14.7 17.9 15.1 19.3 50 - 64 29.3 25.1 32.4 19.4 17.6 20.6 29.6 25.3 32.8 65 - 74 10.1 7.9 11.5 6.1 6.2 6.1 10.4 8.0 11.9

75 and Over 2.9 2.7 2.9 2.4 1.7 2.9 2.9 2.8 2.9 Total 8.3 7.0 9.4 5.5 4.8 6.1 8.4 7.1 9.5

Centennial Care

Pharmacy Utilization Per Member All Services on a Per Member Basis

Age Group Total

Tribal Community



0 - 5 3.7 3.9 3.5 2.9 3.1 2.7 3.7 3.9 3.5 6 - 18 4.5 4.7 4.4 3.3 3.4 3.2 4.6 4.7 4.5

19 - 21 5.6 4.5 6.4 4.5 4.3 4.7 5.6 4.5 6.4 22 - 34 9.2 7.3 10.2 6.6 5.5 7.2 9.2 7.3 10.3 35 - 49 17.6 14.7 19.6 14.4 13.0 15.5 17.7 14.7 19.7 50 - 64 27.5 23.0 30.9 20.4 18.0 22.4 27.7 23.2 31.2 65 - 74 6.5 5.6 7.1 3.5 2.9 3.9 6.8 5.9 7.4

75 and Over 2.5 2.4 2.5 2.2 2.1 2.2 2.5 2.4 2.6 Total 9.4 8.0 10.6 6.6 6.0 7.1 9.5 8.0 10.8


Appendix C-6: Demographic Analysis

Page 1

This analysis looks at whether the largest differences in population, by demographic and as a percentage to total, are correlated with the largest differences in utilization, by demographic as a percentage to total between PHP and Centennial Care. The analysis was performed on total encounters for utilization and average member months for membership. The highlighted items show the largest positive and negative differences between PHP and Centennial Care for population and utilization. A positive difference represents a demographic where PHP had a higher percentage of population or utilization than Centennial Care. A negative difference represents a demographic where PHP had less population or utilization than Centennial Care. A lower population in a demographic would be expected to lead to lower utilization in that demographic. A higher difference in population and utilization which are not correlated could be indicative of missing encounters from those segments of the population. The differences for PHP are fairly correlated and do not appear to indicate there is any missing data.

Legend

= Top 5 Negative Differences

= Top 5 Positive Differences

Note: For all tables in this appendix percentages that do not add to 100% are due to rounding


Page 2

Presbyterian Health Plan: Membership by Demographic Percent to Total

Age Group Presbyterian Health Plan

Total Tribal Community Non-Tribal Community Total Male Female Total Male Female Total Male Female

Average Number of Members Percentage to Total 0 - 5 17.78% 9.07% 8.71% 0.66% 0.34% 0.32% 17.12% 8.73% 8.39%

6 - 18 44.41% 22.68% 21.72% 1.49% 0.74% 0.75% 42.92% 21.95% 20.97% 19 - 21 3.92% 1.61% 2.31% 0.12% 0.05% 0.07% 3.80% 1.56% 2.24% 22 - 34 14.83% 4.17% 10.66% 0.42% 0.13% 0.29% 14.41% 4.04% 10.37% 35 - 49 10.84% 3.72% 7.12% 0.28% 0.10% 0.17% 10.56% 3.61% 6.95% 50 - 64 6.61% 2.79% 3.82% 0.19% 0.08% 0.11% 6.42% 2.71% 3.71% 65 - 74 0.93% 0.36% 0.57% 0.06% 0.02% 0.03% 0.87% 0.33% 0.54%

75 and Over 0.69% 0.22% 0.47% 0.05% 0.02% 0.03% 0.64% 0.21% 0.44% Total 100.00% 44.62% 55.38% 3.26% 1.49% 1.77% 96.74% 43.13% 53.61%

Centennial Care: Membership by Demographic Percent to Total

Age Group Centennial Care


Average Number of Members Percentage to Total 0 - 5 16.19% 8.24% 7.95% 0.62% 0.31% 0.30% 15.57% 7.92% 7.65%

6 - 18 34.35% 17.51% 16.84% 1.17% 0.58% 0.58% 33.19% 16.92% 16.26% 19 - 21 4.29% 1.75% 2.54% 0.11% 0.04% 0.06% 4.18% 1.71% 2.47% 22 - 34 17.41% 6.15% 11.26% 0.48% 0.17% 0.31% 16.93% 5.98% 10.95% 35 - 49 12.52% 5.07% 7.45% 0.36% 0.15% 0.21% 12.16% 4.92% 7.24% 50 - 64 11.09% 4.87% 6.22% 0.36% 0.16% 0.21% 10.73% 4.72% 6.01% 65 - 74 2.08% 0.83% 1.25% 0.20% 0.08% 0.12% 1.89% 0.76% 1.13%

75 and Over 2.06% 0.66% 1.40% 0.21% 0.06% 0.15% 1.85% 0.60% 1.25% Total 100.00% 45.09% 54.91% 3.51% 1.57% 1.94% 96.49% 43.52% 52.97%

Difference: Membership by Demographic Percent to Total

Age Group MCO to Program Difference


Difference Average Number of Members Percentage to Total 0 - 5 1.59% 0.83% 0.76% 0.04% 0.03% 0.02% 1.55% 0.81% 0.74%

6 - 18 10.05% 5.17% 4.88% 0.32% 0.15% 0.17% 9.73% 5.02% 4.71% 19 - 21 -0.37% -0.14% -0.22% 0.01% 0.01% 0.01% -0.38% -0.15% -0.23% 22 - 34 -2.58% -1.98% -0.60% -0.06% -0.04% -0.03% -2.52% -1.94% -0.57% 35 - 49 -1.69% -1.36% -0.33% -0.08% -0.05% -0.03% -1.60% -1.31% -0.30% 50 - 64 -4.49% -2.09% -2.40% -0.17% -0.08% -0.09% -4.31% -2.01% -2.30% 65 - 74 -1.16% -0.47% -0.68% -0.14% -0.05% -0.09% -1.01% -0.42% -0.59%

75 and Over -1.37% -0.44% -0.93% -0.16% -0.05% -0.12% -1.21% -0.39% -0.81% Total 0.00% -0.47% 0.47% -0.25% -0.08% -0.17% 0.25% -0.39% 0.64%


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Presbyterian Health Plan: Total Utilization by Demographic Percent to Total

Age Group Presbyterian Health Plan


Total Percentage of All Services by Demographic 0 - 5 12.21% 6.47% 5.74% 0.40% 0.22% 0.19% 11.80% 6.25% 5.55%

6 - 18 31.40% 15.97% 15.43% 0.82% 0.39% 0.43% 30.58% 15.58% 15.00% 19 - 21 3.36% 1.02% 2.34% 0.07% 0.03% 0.04% 3.29% 0.99% 2.30% 22 - 34 17.02% 3.64% 13.37% 0.38% 0.10% 0.27% 16.64% 3.54% 13.10% 35 - 49 16.46% 4.91% 11.55% 0.36% 0.12% 0.24% 16.10% 4.79% 11.32% 50 - 64 15.17% 5.68% 9.49% 0.40% 0.15% 0.25% 14.77% 5.52% 9.25% 65 - 74 2.35% 0.72% 1.63% 0.12% 0.05% 0.07% 2.23% 0.67% 1.56%

75 and Over 2.03% 0.55% 1.49% 0.12% 0.03% 0.09% 1.91% 0.51% 1.40% Total 100.00% 38.96% 61.04% 2.68% 1.11% 1.57% 97.32% 37.85% 59.47%

Centennial Care: Total Utilization by Demographic Percent to Total

Age Group Centennial Care


Total Percentage of All Services by Demographic 0 - 5 10.08% 5.32% 4.76% 0.34% 0.18% 0.16% 9.75% 5.14% 4.61%

6 - 18 20.33% 10.24% 10.09% 0.54% 0.26% 0.28% 19.79% 9.98% 9.81% 19 - 21 3.00% 0.85% 2.15% 0.06% 0.02% 0.04% 2.95% 0.83% 2.11% 22 - 34 16.51% 4.64% 11.87% 0.43% 0.15% 0.28% 16.09% 4.49% 11.59% 35 - 49 17.62% 6.38% 11.24% 0.61% 0.28% 0.33% 17.02% 6.10% 10.92% 50 - 64 22.58% 8.76% 13.82% 0.90% 0.37% 0.53% 21.68% 8.40% 13.29% 65 - 74 4.61% 1.58% 3.03% 0.48% 0.18% 0.30% 4.13% 1.40% 2.72%

75 and Over 5.27% 1.49% 3.77% 0.57% 0.16% 0.41% 4.69% 1.33% 3.36% Total 100.00% 39.27% 60.73% 3.91% 1.60% 2.32% 96.09% 37.68% 58.41%

Difference: Total Utilization by Demographic Percent to Total

Age Group MCO to Program Difference


Difference Total Percentage of All Services by Demographic 0 - 5 2.12% 1.15% 0.97% 0.07% 0.04% 0.03% 2.06% 1.11% 0.94%

6 - 18 11.08% 5.73% 5.34% 0.29% 0.13% 0.16% 10.79% 5.60% 5.19%

19 - 21 0.36% 0.17% 0.19% 0.02% 0.01% 0.00% 0.34% 0.16% 0.18%

22 - 34 0.51% -1.00% 1.50% -0.05% -0.05% 0.00% 0.56% -0.95% 1.51%

35 - 49 -1.16% -1.47% 0.31% -0.25% -0.16% -0.09% -0.92% -1.31% 0.40%

50 - 64 -7.41% -3.09% -4.32% -0.50% -0.21% -0.28% -6.91% -2.87% -4.04%

65 - 74 -2.26% -0.86% -1.39% -0.36% -0.13% -0.23% -1.90% -0.74% -1.16%

75 and Over -3.23% -0.95% -2.29% -0.45% -0.13% -0.32% -2.78% -0.82% -1.96%

Total 0.00% -0.31% 0.31% -1.23% -0.49% -0.74% 1.23% 0.18% 1.06%

Appendix C-7: Claims Processing Timeliness Results

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Presbyterian Health Plan: Percentage of Total Claims Processed

Days

Presbyterian Health Plan

Total Inpatient Outpatient Professional Dental Pharmacy

< = 15 75% 64% 60% 86% 98% 45%

< = 30 83% 80% 77% 93% 99% 53%

< = 90 89% 89% 83% 96% 100% 71%

Over 90 100% 100% 100% 100% 100% 100%

Average Days 30 37 50 15 9 61

Centennial Care: Percentage of Total Claims Processed

Days

Centennial Care


< = 15 73% 67% 70% 87% 90% 33%

< = 30 82% 84% 83% 94% 92% 46%

< = 90 89% 91% 89% 97% 95% 66%

Over 90 100% 100% 100% 100% 100% 100%

Average Days 38 33 35 14 17 109

Appendix C-8: Encounter Submission Rate Results

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Presbyterian Health Plan: Percentage of Total Encounters Submitted

Days



< = 30 60% 43% 62% 45% 53% 100%

< = 90 70% 53% 72% 58% 68% 100%

< = 180 84% 64% 86% 78% 85% 100%

< = 270 90% 68% 90% 86% 95% 100%

< = 365 93% 70% 92% 90% 98% 100%

Over 365 100% 100% 100% 100% 100% 100%

Average Days 90 248 87 127 73 0

Centennial Care: Percentage of Total Encounters Submitted

Days

Centennial Care


< = 30 53% 37% 45% 40% 48% 100%

< = 90 64% 49% 56% 55% 63% 100%

< = 180 77% 65% 69% 73% 77% 100%

< = 270 84% 71% 74% 81% 86% 100%

< = 365 87% 74% 80% 86% 90% 100%

Over 365 100% 100% 100% 100% 100% 100%

Average Days 133 239 185 161 124 0

Appendix C-9: Place of Service Detail

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Presbyterian Health Plan: Utilization for Top Four Place of Services

Place of Service



Office (Place of Service 11)

3,155,583 - - 2,245,093 910,490 -

Hospital (Type of Bill 11X and 12X)

1,674,267 21,383 1,129,854 523,030 - -

Pharmacy (Place of Service 01)

1,627,249 - - 85 - 1,627,164

Home (Place of Service 12)

570,001 - - 570,001 - -

All Other 1,164,434 17,219 270,750 876,465 - -

Centennial Care: Utilization for Top Four Place of Services

Place of Service

Centennial Care


Office (Place of Service 11) 8,825,516 - - 6,528,275 2,297,241 -

Hospital (Type of Bill 11X and 12X) 6,736,352 80,748 4,616,095 2,039,016 493 -

Pharmacy (Place of Service 01) 5,426,453 - - 716 - 5,425,737

Home (Place of Service 12) 3,397,188 - - 3,397,150 38 -

All Other 3,899,206 117,738 1,110,129 2,630,996 40,343 -

Appendix C-10: Provider Type Detail

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Presbyterian Health Plan: Utilization for Top Five Provider Types

Provider Type



Pharmacy 1,598,086 0 1 2,322 - 1,595,763

Physician, MD 1,674,597 510 4,394 1,669,322 4 367

Hospital, General Acute 1,149,580 19,110 1,097,278 33,192 - -

Dentist 885,094 - - 914 884,180 -

Personal Care Services 322,270 796 888 320,586 - -

All Other 2,561,907 18,186 298,043 2,188,338 26,306 31,034

Centennial Care: Utilization for Top Five Provider Types

Provider Type

Centennial Care


Pharmacy 5,251,260 5 26 12,983 - 5,238,246

Physician, MD 5,131,509 709 24,787 5,099,744 1,814 4,455

Hospital, General Acute 4,491,520 70,756 4,380,446 40,318 - -

Dentist 2,298,968 - - 2,317 2,296,651 -

Personal Care Services 2,297,953 907 1,812 2,295,234 - -

All Other 8,813,505 126,109 1,319,153 7,145,557 39,650 183,036

Appendix C-10: Provider Type Detail

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Note: The following percentages are the percentage of the top five services in Centennial Care and not representative of the entire population; therefore, they do not add up to 100% for any of the encounter types.

Presbyterian Health Plan: Percentage of Total Service Type for Top Five Provider Types

Provider Type



Pharmacy 19.51% 0.00% 0.00% 0.06% - 98.07%

Physician, MD 20.44% 1.32% 0.31% 39.61% 0.00% 0.02%

Hospital, General Acute 14.03% 49.51% 78.34% 0.79% - -

Dentist 10.80% - - 0.02% 97.11% -

Personal Care Services 3.93% 2.06% 0.06% 7.61% - -

Centennial Care: Percentage of Total Service Type for Top Five Provider Types

Provider Type

Centennial Care


Pharmacy 18.57% 0.00% 0.00% 0.09% - 96.54%

Physician, MD 18.14% 0.36% 0.43% 34.94% 0.08% 0.08%

Hospital, General Acute 15.88% 35.65% 76.50% 0.28% - -

Dentist 8.13% - - 0.02% 98.23% -

Personal Care Services 8.12% 0.46% 0.03% 15.72% - -

Appendix C-11: Dental Utilization Detail

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Dental Utilization by Category of Service

Category of Service Centennial

Care Presbyterian Health plan

Centennial Care

Presbyterian Health plan

Diagnostic 1,057,969 407,138 45.25% 44.72% Preventive 630,168 273,698 26.95% 30.06% Restorative 331,867 121,439 14.19% 13.34% Oral and Maxillofacial Surgery 152,745 46,423 6.53% 5.10% Adjunctive General Services 96,729 40,862 4.14% 4.49%

Note: Percentages that do not add to 100% are due to rounding

Appendix C-12: Dental Utilization Statistics

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Note: The percentages in this appendix are the percentage of total membership using dental services. They will not add to 100% Presbyterian Health Plan: Dental Statistics

Description Dental Procedure Codes Category


Total Children

(under age 21) Adults

(ages 21 and over)

Count Percentage Count Percentage Count Percentage

Member Months 2,348,236 1,532,332 815,904 Average Number of Members 195,686 127,694 67,992 Number of Members Utilizing Dental

108,455 84,672 23,783

Percentage of Member Utilization 55.4% 66.3% 35.0% Adult Oral Prophylaxis D1110 Preventive 11,433 10.5% 0 0.0% 11,433 48.1% Child Oral Prophylaxis D1120 Preventive 75,568 69.7% 75,566 89.2% 2 0.0% Dental Sealants D1351 Preventive 11,978 11.0% 11,978 14.1% 0 0.0% Fluoride Treatments D1201 - D1208 Preventive 80,538 74.3% 74,138 87.6% 6,400 26.9% Composite Fillings D2330 - D2394 Restorative 25,450 23.5% 18,306 21.6% 7,144 30.0% Extractions D7111 - D7250, D7280 Oral Maxillofacial Surgery 17,379 16.0% 10,967 13.0% 6,412 27.0%

Centennial Care: Dental Statistics

Description Dental Procedure Codes Category

Centennial Care

Total Children

(under age 21) Adults

(ages 21 and over)

Count Percentage Count Percentage Count Percentage

Member Months 6,903,881 3,698,486 3,205,395 Average Number of Members 575,323 308,207 267,116 Number of Members Utilizing Dental

273,843 186,552 87,291

Percentage of Member Utilization 47.6% 60.5% 32.7% Adult Oral Prophylaxis D1110 Preventive 42,106 15.4% 22 0.0% 42,084 48.2% Child Oral Prophylaxis D1120 Preventive 167,067 61.0% 167,039 89.5% 28 0.0% Dental Sealants D1351 Preventive 27,407 10.0% 27,348 14.7% 59 0.1% Fluoride Treatments D1201 - D1208 Preventive 187,209 68.4% 163,318 87.5% 23,891 27.4% Composite Fillings D2330 - D2394 Restorative 68,665 25.1% 41,344 22.2% 27,321 31.3% Extractions D7111 - D7250, D7280 Oral Maxillofacial Surgery 49,911 18.2% 23,427 12.6% 26,484 30.3%

Appendix C-13: Drug Category Detail

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Presbyterian Health Plan: Utilization for Top Five Drug Categories

Drug Group


Total Original

Prescriptions Refills Legend

Over the Counter

PSYCHOTHERAPEUTIC 227,172 140,780 86,392 227,169 3

ANTIBIOTICS 195,105 185,150 9,955 194,993 112

ANALGESICS 153,883 137,459 16,424 144,734 9,149

CARDIOVASCULAR 114,840 49,472 65,368 114,840 0

GASTROINTESTINAL 102,997 61,535 41,462 95,523 7,474

All Other 833,167 505,668 327,499 729,620 103,547

Centennial Care: Utilization for Top Five Drug Categories

Drug Group

Centennial Care

Total Original

Prescriptions Refills Legend

Over the Counter

PSYCHOTHERAPEUTIC 715,135 406,605 308,530 715,117 18

ANTIBIOTICS 550,591 505,957 44,634 549,561 1,030

ANALGESICS 488,164 420,574 67,590 457,320 30,844

CARDIOVASCULAR 487,677 178,255 309,422 487,674 3

GASTROINTESTINAL 341,871 188,511 153,360 312,034 29,837

All Other 2,842,299 1,572,802 1,269,497 2,449,610 392,689

Appendix C-14: Service Type Relationships

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Presbyterian Health Plan: Analysis by Service Type

Services


Average Number of Members

Visits Number of Services

Count Average

Per Member

Count Average

Per Visit

Average Per

Member

Ancillary

195,686

558,609 2.9 1,249,701 2.2 6.4

Outpatient 430,298 2.2 1,438,143 3.3 7.3

Primary Care 545,919 2.8 1,011,575 1.9 5.2

Specialty Care 1,062,028 5.4 1,806,524 1.7 9.2

Inpatient 144,206 0.7 438,676 3.0 2.2

Rx - New Prescriptions 1,075,571 5.5 1,080,064 1.0 5.5

Rx - Refills 544,511 2.8 547,100 1.0 2.8

Total 4,361,142 22.3 7,571,783 1.7 38.7

Centennial Care: Analysis by Service Type

Services

Centennial Care

Average Number of Members

Visits Number of Services

Count Average

Per Member

Count Average

Per Visit

Average Per

Member

Ancillary

575,323

2,562,951 4.5 5,922,320 2.3 10.3

Outpatient 1,938,362 3.4 6,102,233 3.1 10.6

Primary Care 1,379,576 2.4 2,705,433 2.0 4.7

Specialty Care 3,109,877 5.4 5,023,120 1.6 8.7

Inpatient 668,784 1.2 2,013,471 3.0 3.5

Rx - New Prescriptions 3,259,524 5.7 3,272,704 1.0 5.7

Rx - Refills 2,140,971 3.7 2,153,033 1.0 3.7

Total 15,060,045 26.2 27,192,314 1.8 47.3

Appendix C-15: Response to PHP Rebuttal

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The managed care organizations (MCOs) were given the opportunity to rebut the findings and recommendations noted in this report. The MCO provided their rebuttal, which is included within this appendix. Following the MCO rebuttal is HealthInsight/Myers and Stauffer’s response to the MCO’s disagreements and requests for reconsideration. Findings and recommendations for which the MCO acknowledged, agreed or did not comment are not addressed. When reiterating the MCO’s rebuttal in our response, we included the rebuttal verbatim as stated by the MCO. There may be some variation in the response format based on the MCO’s rebuttal submission.

It should be noted that the findings and recommendations are based on the on-site visits, conference calls, documents and data provided for validation purposes. The MCO provided accounting system data, and a sample of data from their claims processing system for validation and the fiscal agent (FA) provided encounter data extracts from the Medicaid management information system (MMIS) system. The 837 files, which are an electronic data transaction set for communicating claim information in a Health Insurance Portability and Accountability Act (HIPAA)-compliant format, were not provided for validation. Findings and recommendations are specific to the validation period, calendar year 2014, are based on correct coding standards, HIPAA rules and regulations and industry best practices, and may not reflect the current status of the MCO’s claims and encounter systems data or the FA’s MMIS encounter systems data if subsequent modifications have been made.

P.O. Box 27489, Albuquerque, NM 87125-7489 www.phs.org

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09/21/2017 Andy Romero, RHIT, CCS, CPC Program Manager, EQRO Health Insights of New Mexico 5801 Osuna Road NE, Suite 200 Albuquerque, NM 87109 Heather Ingram Director of Government Programs Presbyterian Health Plan 9521 San Mateo Blvd NE Albuquerque, NM 87113 Dear Ms. Romero, Please find included in this letter the Presbyterian Health Plan rebuttal response to the State of New Mexico, Human Services Department, External Quality Review (EQR) Protocol 4 audit. We have answered the Findings and Recommendations to the best of our ability with the time we have been given and the details provided. Sincerely,

Heather Ingram Director of Government Programs Presbyterian Health Plan


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Rebuttal Response to the document titled:

STATE OF NEW MEXICO HUMAN SERVICES DEPARTMENT

EXTERNAL QUALITY REVIEW (EQR) PROTOCOL 4 FOR CALENDAR YEAR 2014 SUBMISSION OF FINDINGS

Page Finding Recommendations PHP Rebuttal Response

5 None 1. HSD should review the provider registration process with Conduent to ensure that it is working efficiently and not causing delays and the inability of the MCOs to submit certain encounters to Conduent. During the on‐site visits, the MCOs stated that certain providers’ encounters would be rejected by Conduent because the providers had multiple taxonomy codes and the services they submitted on the encounters were not allowed with the submitted taxonomy code. HSD should explore aligning provider taxonomy codes used in the State’s registration process with the provider‐registered taxonomy codes in the National Provider Identifier (NPI) registry.

Acknowledged. While the process has not been perfected, HSD and PHP have been working to identify and fix areas of improvement. We have open channels of communication as well as monthly meetings to discuss and resolve provider related issues that arise.

5 None 2. HSD should assess the effectiveness of the affiliation process. Not only must the providers submitting claims to the MCOs for payment be registered with the State with the taxonomy code

Acknowledged. While the process has not been perfected, HSD and PHP have been working to identify and fix areas of improvement. We have open channels of communication as well as monthly meetings to discuss


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indicated on the claim, the MCO must also be affiliated with the provider in order for the MCO to submit the encounter to Conduent. Based on the experience of M & S LC in other states, the affiliation process and the provider registration is unique and appears to be causing some delays with the submitting of encounters.

and resolve provider related issues that arise.


6 None 3. HSD should enhance oversight of the encounter data submission decision‐making process by Conduent and the MCOs to ensure the decisions made are aligned with the State's Plan and fiduciary responsibilities.

Acknowledged. PHP and HSD work constantly to identify and resolve issues with encounters processing. We have open channels of communication and monthly meetings to identify and resolve system related issues.

6 None 4. HSD should consider increasing the 30‐day encounter submission requirement in the MCO contract (Section 4.19.2.2.11) to 95 percent, based on best practice.

PHP does not support this recommendation until the provider registration, MCO affiliation, and system issues are resolved. While PHP and HSD are working diligently to improve these processes, we cannot support this recommendation without these issues resolved. PHP believes this should be re‐evaluated with the implementation of the MMIS‐R.


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6 None 5. HSD should direct Conduent to accept MCO denied encounter data. As of the time of the on‐site visits, the MCO denied encounters were not being accepted by Conduent. By not accepting MCO denied encounter data, some encounters with both MCO denied and MCO paid detail lines were not being submitted and this would reduce the completeness of the encounter data. The MCO denied claims are necessary in order to have a complete picture of the services being provided to the members and non‐submission contradicts the MCO contract (Section 4.19.2.2.5).

No comment.

6 None 6. HSD should consider an on‐going measurement of the completeness and accuracy of encounters to comply with the Medicaid Managed Care Final Rule (Mega Rule, 42 CFR 438.602(E)), as directed by CMS, such as the encounter reconciliation, which is part of this analysis.

No comment.


6 None 7. HSD and Conduent should require the MCOs to attest to all encounter data submissions. It is best practice to require an attestation by the MCOs related to the accuracy and completeness of each of the encounter data submissions.

No comment.


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6 None 8. Conduent and HSD should review the operations of the Self‐Directed Community Benefit (SDCB) program to ensure the MCOs have the ability to adequately oversight their members.

No comment.

6 None 9. Conduent should update their data dictionary to include a list of the code set(s) and a description of each allowable code as required for specific fields (e.g., three digit provider type codes, three digit provider specialty codes, two digit place of service codes, etc.).

No comment.

6 None 10. Conduent should send control totals for the enrollment files to the MCOs so that the MCOs can ensure that they have the complete file before processing it into their enrollment and claims system and their subcontractor vendor’s claims systems.

No comment.

6 None 11. Conduent should increase the amount and frequency of updates to system companion guides and provide advanced communication about system changes to ensure the MCOs have adequate time to account for the changes. Keeping these documents up to date and giving advanced notification to the MCOs would allow for upfront adjustments to their

No comment.


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claims processing systems and help protect the MCOs against spikes in rejected encounters after the implementation of new exception codes and edits.


6 None 12. Conduent should ensure they are providing adequate notice whenever possible to the MCOs about system changes to ensure the MCOs have adequate time to adjust the claims processing system to account for the changes.

No comment.

6 None 13. Conduent should capture and retain all encounter data submitted.

No comment.

6 None 14. Conduent should make necessary changes to ensure the claims data is reflective of the encounter data submitted by the MCO, remains as submitted by the provider of service and values are in the appropriate field(s).

No comment.

Self‐Directed Community Benefit Findings

17 1. The MCOs have limited ability to oversee the claims function of the Self‐Directed Community Benefit. They are involved with setting up

None PHP received encounter data for self‐directed benefits and we have improved our monitoring process. In addition, we have established weekly communication with Conduent to inquire about identified concerns and discuss potential process improvements.


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the beneficiary’s annual budget and care plan, but have minimal ability to confirm the validity of individual self‐directed claims. This results in a risk that the MCOs may be paying for unsubstantiated services.


17 2. Due to the lack of a contractual relationship between the MCOs and TNT, the MCO’s ability to oversight this vendor is limited. However, the MCOs are still required to pay for services provided through this benefit.

None PHP works closely with Conduent to identify trends and service issues that may occur with the payroll subcontractor TNT of Conduent. There are no current issues or concerns at this point. Weekly teleconferences occur between Conduent and PHP Clinical Operations in addition to quarterly calls with all MCOs and Conduent to discuss processes or opportunities with the FMA process. Conduent has an internal audit process with their employees to monitor key entry for payroll and provider information in the system. TNT then will


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not release any payments without all paperwork properly entered into the FOCoS system.

Conduent Findings

18 1. Per interviews conducted, an attestation is not required to be submitted by the MCOs with each encounter data submission.

None No comment.

18 2. Control totals are not sent to the MCOs by Conduent for enrollment files.

None No comment.

3. There were numerous issues noted by the MCOs with the provider registration process. These issues included backlogs in registering and affiliating with providers, which has resulted in encounters that could not be accepted as part of HSD’s encounter data set. There was an issue noted where the provider’s taxonomy code used in the registration process is not aligning with the provider‐registered taxonomy codes in the NPI registry. The taxonomy code issue has led to situations where the provider submits a taxonomy code that is different than the taxonomy in the State’s provider registration. This has resulted in encounters that are not accepted by Conduent. Additionally, based on the experience of M & S in other states, the

None Acknowledged. While the process has not been perfected, HSD and PHP have been working to identify and fix areas of improvement. We have open channels of communication as well as monthly meetings to discuss and resolve provider related issues that arise.


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affiliation process is unique and it appears to be causing some additional issues in the submitting of encounters, which could be potentially avoided with refinements to the process.


18 4. The MCOs are not submitting their denied claims, and in some cases, encounters with both denied and paid detail lines were not being submitted, which would reduce the completeness of the encounter data. The MCO indicated that they were instructed by Conduent not to submit denied claims, and non‐submission contradicts the MCO contracts (4.19.2.2.5).

None PHP will continue to follow process as required by HSD. At this moment in time denied claims are not to be submitted.


18 5. The MCOs indicated a desire that the system companion guides be updated more frequently. Several MCOs stated that changes to exception codes and edits are not always communicated to the MCOs by Conduent in advance of implementation.

None Acknowledged. PHP and HSD work constantly to identify and resolve issues with encounters processing. We have open channels of communication and monthly meetings to identify and resolve system related issues.

Activity 2: Review MCO’s System Capabilities for Presbyterian Health Plan, Inc.

29 1. PHP indicated that they pay the self‐directed benefit based on the invoice received from

1. PHP should reconcile the amount paid to FOCoS/TNT from the monthly invoice to the 837 containing

PHP is developing processes to require all encounters submitted by third parties to be tied to


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FOCoS/TNT. They also receive the related encounters in a Health Insurance Portability and Accountability Act (HIPAA)‐compliant electronic data interchange (EDI) format or 837 for submission to Conduent. However, they do not reconcile the invoice to the encounter data contained in the 837.

the encounter data they receive from FOCoS/TNT to ensure the encounters support the amount remitted.

invoices and vice versa to improve our current reconciliation processes.

29 2. Based on the interviews conducted with PHP, it appears that the correction and resubmission of denied and rejected encounters is not internally oversighted by one single individual. The various departments worked the corrections that were within their purview.

2. PHP should look at implementing a team that has general oversight over the encounter correction process.

PHP has created a dedicated Encounters Department to oversee and manage the encounters process.


29 3. PHP indicated that each claims examiner has two percent of their processed claims audited each week. Best practice would be to audit at least three percent of the claims processed by each processor each week.

3. Best practice would indicate that PHP should be auditing at least three percent of the claims processed by each processor each week.

The Internal Claims audit has been in place for over a decade. Since 2007, the audit results have shown overall claims payment accuracy rates within 1.05% of the Procedural Accuracy target and within <0.07%> of the Financial Accuracy target. The Claims Payment Procedural Accuracy target is 95%. The Claims Payment Financial Accuracy target


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is 99.25%. In 2014, internal audit proactively worked with a statistician and benchmarked industry standard to determine the adequacy of our approach. The internal business process analysis of PHP claims audit data in 2014 showed that the average audit sample of 2.5% resulted in a sample of 2,553 claims, 1,933 system‐adjudicated (System) and 670 manually‐adjudicated (Touched). The overall accuracy rate was 98.41% with an accuracy rate of 99.52% for System claims and 94.95% for Touched claims. We explored the analysis further and the results showed that if the claims audit sample size was reduced to 1% or a minimum of 1,300 claims per week, the sample would include 1,040 System claims and 260 Touched claims. The calculated overall accuracy rate would be 98.32% to 98.50%; the calculated accuracy rate for System claims would be 99.47% to 99.57% and the calculated accuracy


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rate for Touched claims would be 94.58% to 95.32%. Based on the extensive analysis of claims payment accuracy audit data, the sample size was reduced to 1% in June 2014. This was to create capacity to complete other focused audit work. We are open to consider any additional data and information that Myers & Stauffer might provide as to industry best practices, but as the claims payment and audit processes have not significantly changed and our initial analysis of the audit process was extensive, we will keep our sample methodology at 1%.


29 4. During the interview process, PHP indicated that there was no formal reconciliation process between their ODS (data warehouse) and FACETS, PHP’s claim adjudication system.

4. PHP should implement a formal internal reconciliation process between the ODS (Data Warehouse) and FACETS (Claims System) to ensure data is not lost in the transfer process.

Presbyterian Health Plan has a formal process in place currently. The process is run twice a month and it reconciles all of the ODS database to the source Facets data. This process is administered by the EDW team and involves a very comprehensive validation of the ODS Contents.

The validation is performed doing large ‘Minus’ queries between the 2


Page 14

environments, such that

Every row in

each table is

reviewed,

from Source

to Target and

from Target

to Source.

Every

character in

every row is

compared

from Source

to Target and

from Target

to Source

This practice has been in place since PHP began using the Facets Claim Processing System in 2005. Attached is a tracking spreadsheet for the last several years of comparisons resulting from this process. Also attached are the comparison logs from a recent compare.


29 5. PHP indicated that they perform a duplicate claim check on the vendor encounter files entered into their vendor claims database. The duplication logic looks only at the

5. PHP should consider expanding duplication logic performed on inbound vendor encounter data files beyond the current claims number check to include additional key data elements, which will

PHP is constantly updating their Encounter Management System and surrounding processes, to include duplicate identification and reconciliation.


Page 15

claim number of the inbound encounter claim. If the vendor submits the same encounter claim with different claim numbers, the encounter claim could be allowed to enter into PHP’s vendor database multiple times and be submitted to Conduent multiple times as well.

allow for a more robust detection of

Activity 3: Analyze Electronic Encounter Data Detailed Findings and Recommendations for Presbyterian Health Plan, Inc.

32 1. Encounter Reconciliation Reports This reconciliation process uses ASD from PHP and their subcontractors to compare to Conduent encounter data extracts paid amounts to determine completeness from a paid amount perspective. Results are displayed monthly and cumulatively. The initial encounter reconciliation report (Appendix C‐1) completed in April 2017, included encounters paid by PHP and its subcontractors during the period, January 1, 2014 through April 30, 2016 and accepted by Conduent through May 31, 2016. The updated report (Appendix C‐2) reflects encounters paid during the period January 1, 2014 through February

None No comment.


Page 16

28, 2017 and accepted by Conduent through April 30, 2017. The full reports included in the appendices contain a complete description of the methodology, assumptions and potential data issues identified for all months in the reporting period.


33 2) Duplicate claims that exist in the encounter data that could not be identified and removed; 3) ASD payment dates not matching the payment dates that were recorded in the encounter data and/or; 4) MCO‐submitted ASD transaction files missing significant activity. The increase in pharmacy encounters could be linked to the HSD/MCO encounter data initiative between the MCOs and Conduent in the fall of 2016 to help submit previously rejected encounters as the second report includes all 2016 submissions. The decrease in the completion percentages of the encounters between the first and second reconciliation

None Acknowledged.


Page 17

reports appears to be due to unmatched adjustment credits, adjustment debits and voids that did not include the TCNs of the encounter that was being adjusted or voided. These missing TCNs contributed to the overstated percentages in the first report. More replacement TCNs were included in the updated encounter data extract, which allowed for more adjustment credits, adjustment debits and voids to be linked to the original encounter. This led to more accurate dollar values being reflected in the completion analysis for the second encounter reconciliation report.

Activity 4: Review of Medical Records Detailed Findings and Recommendations for Presbyterian Health Plan, Inc.

61 1. Inpatient Institutional Encounters: The key data elements reviewed were servicing provider, bill type, admission and discharge dates, date(s) of service, revenue codes, procedure codes, procedure modifier codes, diagnosis codes, and surgical procedure codes. As Table C‐8 shows, PHP submitted 108 medical records for

None PHP will include updates in future contracts with providers and subcontractors to include additional requirements for medical record retention and availability, as well as encounter completeness and accuracy.


Page 18

review and 38.89 percent (42 records) were found to be acceptable (all key elements were reflected in the medical record).


61 2. Outpatient Institutional Encounters: Key data elements reviewed were servicing provider, bill type, and dates of service, revenue codes, procedure codes, procedure modifier codes, and diagnosis codes. In the Table C‐8 summary, PHP submitted 107 medical records for review and 62.62 percent (67 records) were found to be acceptable.


61 3. Professional Encounters: Key data elements reviewed were dates of service, place of service, procedure codes, procedure modifier codes, and diagnosis codes. As noted in Table C‐8, PHP submitted 99 medical records for review and 65.66 percent (65 records) were found to be acceptable.


61 4. Pharmacy Encounters: A medical record review of the pharmacy encounter data was not performed. PHP’s pharmacy subcontractor (OptumRx), cumulatively,

None The initial finding on pharmacy encounters not meeting the 95% completeness threshold appeared on the original M&S report. The updated M&S report, which


Page 19

did not meet the 95 percent completeness threshold. As a result, the pharmacy encounters were determined to be substantially incomplete.

included additional encounter activity from May 2016 through February 2017, showed threshold rates above the 95% threshold. We are currently at 0.05% error rate with a 99.95% accuracy rate for the 3rd quarter. Information regarding what was missing is essential in understanding corrective action planning.


61 5. Dental Encounters: A review of the dental encounter medical records was not performed. PHP’s dental subcontractor (DentaQuest), cumulatively, did not meet the 95 percent completeness threshold. Subsequently, the dental encounters were determined to be substantially incomplete.

None The initial finding on dental encounters did not meet the 95% completeness threshold appeared on the original M&S report. The updated M&S report, which included additional encounter activity from May 2016 through February 2017, showed threshold rates above the 95% threshold. Information regarding what was missing is essential in understanding corrective action planning.

1. PHP should ensure the provider contracts contain language regarding medical record retention and availability for audit requests and establish firm guidelines on how quickly the records should be provided. Based on the experience of Myers and Stauffer LC in other states, the timeframe for remitting medical records is typically 30

PHP believes the appropriate language currently exists in our contracts. Executed Contract Language below from DentaQuest contract.(as well as this in in every executed contract) 3.2.7. Provider shall maintain all of its records


Page 20

days.

relating to services provided to Members for a ten (10) year period and shall make all Member medical records or other service records in Provider’s possession available for the purpose of quality review conducted by HSD, or their designated agents both during and after the term of this Agreement; 3.2.33. Provider acknowledges and shall, at PRESBYTERIAN’S option, assist PRESBYTERIAN when applicable, and cooperate with PRESBYTERIAN in complying with the following requirements: 3.2.33.1.Maintenance of Medical Records Provider shall maintain and/or shall contractually require its subcontractors and/or Contract Providers to maintain appropriate records in accordance with federal and State statutes and regulations relating to Contract Provider’s performance under this Agreement, including but not limited to records relating to services provided to


Page 21

Members, including a separate medical record for each Member. Each medical record shall be maintained on paper and/or in electronic format in a manner that is timely, legible, current and organized, and that permits effective and confidential patient care and quality review. 3.2.34. Provider acknowledges and shall, at PRESBYTERIAN’S option, assist PRESBYTERIAN when applicable, and cooperate with PRESBYTERIAN in complying with the following requirements, to the extent they are applicable to Provider: 3.2.34.1.Program Integrity ‐ General 3.2.34.1.1. Comply with PRESBYTERIAN’s comprehensive internal Fraud, waste and Abuse program. 3.2.34.1.2. Cooperate with the MFEAD and other investigatory agencies in accordance with the provisions of NMSA 1978, 27‐11‐1 et seq. 3.2.34.1.3. Comply with all federal and State requirements regarding Fraud, waste and Abuse,


Page 22

including but not limited to, sections 1128, 1156 and 1902(a) (68) of the Social Security Act, section 6402(h) of PPACA, the CMS Medicaid integrity program and the Deficit Reduction Act of 2005. 3.2.34.1.4. Cooperate fully in any activity performed by the HSD, MFEAD, Medicaid Recovery Audit Contractor (RAC), CMS, and/or Payment Error Rate Management and CMS Audit Medicaid Integrity Contractors (MIC). Provider shall, upon request, make available to the RAC any and all administrative, financial and medical records relating to the delivery of items or services for which State monies are expended, unless otherwise provided by law. In addition, Provider shall provide the RAC with access during normal business hours to its respective place of business and records.


2. PHP should ensure their subcontractor vendors have strategies in place for medical record retention and

PHP believes the appropriate language currently exists in our contracts. Executed


Page 23

accessibility.

Contract Language below from DentaQuest contract (as well as this in in every executed contract) 3.2.33.1.Maintenance of Medical Records Provider shall maintain and/or shall contractually require its subcontractors and/or Contract Providers to maintain appropriate records in accordance with federal and State statutes and regulations relating to Contract Provider’s performance under this Agreement, including but not limited to records relating to services provided to Members, including a separate medical record for each Member. Each medical record shall be maintained on paper and/or in electronic format in a manner that is timely, legible, current and organized, and that permits effective and confidential patient care and quality review.

Activity 5: Submission of Findings‐ System Capabilities


63 1. PHP indicated that they pay the self‐directed benefit based on the invoice received from FOCoS/TNT. They also receive the related

None PHP is developing processes to require all encounters submitted by third parties to be tied to invoices and vice versa to improve our current


Page 24

encounters in a Health Insurance Portability and Accountability Act (HIPAA)‐compliant electronic data interchange (EDI) format or 837 for submission to Conduent. However, they do not reconcile the invoice to the encounter data contained in the 837.

reconciliation processes.

2. Based on the interviews conducted with PHP, it appears that the correction and resubmission of denied and rejected encounters is not internally oversighted by one single individual. The various departments worked the corrections that were within their purview.

None PHP has created a dedicated Encounters Department to oversee and manage the encounters process.

3. PHP indicated that each claims examiner has two percent of their processed claims audited each week. Best practice would be to audit at least three percent of the claims processed by each processor each week.

None See page 29 Finding and Recommendation # 3


4. During the interview process, PHP indicated that there was no formal reconciliation process between their ODS (data warehouse) and FACETS, PHP’s claim adjudication system.

None Please see Presbyterian Health Plans response provided on Finding #4, page 29 of the audit document.


Page 25

5. PHP indicated that they perform a duplicate claim check on the vendor encounter files entered into their vendor claims database. The duplication logic looks only at the claim number of the inbound encounter claim. If the vendor submits the same encounter claim with different claim numbers, the encounter claim could be allowed to enter into PHP’s vendor database multiple times and be submitted to Conduent multiple times as well.

None PHP is constantly updating their Encounter Management System and surrounding processes, to include duplicate identification and reconciliation.

Activity 5: Submission of Findings‐ Analysis of Encounter Data

63 1. Initially, PHP’s non‐pharmacy and non‐dental encounters were above the 95 percent threshold for completeness compared to their submitted accounting system data. Pharmacy and dental encounters; however, were below the 95 percent completion threshold. A second encounter reconciliation was completed in order to see the difference in completion percentages, which included additional encounter activity from May 2016 through February 2017. Once the second encounter

None Since the audit, PHP has created an Encounters Department dedicated to encounters oversight and management. We have implemented additional oversight processes as well as enhancements to our Encounter Management System and reconciliation process.


Page 26

reconciliation was completed, the cumulative percentage of completion for all non‐pharmacy and non‐dental encounters was below the 95 percent completion threshold. Dental encounters remained below the 95 percent completion threshold and pharmacy encounters increased above the 95 percent completion threshold. The decrease in the completion percentages between the first and second reconciliation reports for the non‐pharmacy and non‐dental encounters appears to be due to unmatched adjustment credits, adjustment debits and voids that did not include the transaction control number (TCN) of the encounter that was being adjusted or voided.

64 2. The completeness percentage for the medical claim type in the PHP‐submitted sample claims data did not meet the 95 percent completion threshold for the two months tested, September 2014 and December 2014. The pharmacy and dental claims sample data

None Encounters accuracy has significantly improved since the implementation of Centennial Care in 2014. These numbers do not reflect current performance.


Page 27

exceeded the 95 percent completeness threshold for both September 2014 and December 2014.


64 3. PHP’s submittedencounters included a number of key data elements that were at or above the 95 percent accuracy threshold. However, there were certain key data elements that were below the 95 percent accuracy threshold. Aggregate accuracy percentages for inpatient, outpatient and pharmacy encounter types (i.e., all key data elements within the encounter type), were below the 95 percent accuracy rate. Aggregate dental and professional encounters exceeded the 95 percent accuracy rate for the key data elements tested.

None Encounters accuracy has significantly improved since the implementation of Centennial Care in 2014. These numbers do not reflect current performance.

Activity 5: Submission of Findings‐ Medical Record Review

64 1. The medicalrecord review for pharmacy and dental encounters was not pursued. Based on the initial encounter reconciliation, all months in the measurement year, CY 2014, were below the 95 percent completion

None The initial finding on pharmacy encounters not meeting the 95% completeness threshold appeared on the original M&S report. The updated M&S report, which included additional encounter activity from May 2016 through


Page 28

threshold.

February 2017, showed threshold rates above the 95% threshold. We are currently at 0.05% error rate with a 99.95% accuracy rate for the 3rd quarter. Dental encounters initially fell below the 95% threshold however the final review had dental encounters above this threshold. PHP believes we could have obtained dental and pharmacy records if asked.


64 2. PHP did not reach the 95 percent acceptance rate on any of the encounter types tested.

None Since the audit, PHP has created an Encounters Department dedicated to encounters oversight and management. We have implemented additional oversight processes as well as enhancements to our Encounter Management System and reconciliation process. Additionally, encounters accuracy has significantly improved since the implementation of Centennial Care in 2014. These numbers do not reflect current performance.

64 3. PHP provided 314 (95.15 percent) of the 330 medical records requested. PHP indicated that the records not submitted could not be obtained due to

None Response to medical record requests is part of all provider contracts. PHP Compliance has and is taking appropriate correct action with those providers that did not


Page 29

unresponsive network providers.

meet their contractual obligations to provide medical records within the timeframes specified.


Page 30

EDV Audit, Table C6 of PHP Rebuttal Response

Key Data

Element

Encounter

Type

Finding Recommendation PHP Response

Admission

Date

Inpatient The admission

date in the claims

sample is after the

corresponding

admission date in

the encounter

data. On average,

for the September

2014 data is 23

days after and the

December 2014

data is 12 days

after.

We recommend PHP

and Conduent work

together to ensure

encounter data

accurately reflects

encounters as submitted

by PHP.

PHP and HSD work

constantly to

identify and resolve

issues with

encounters

processing. We

have open channels

of communication

and monthly

meetings to identify

and resolve system

related issues.

Bill Type

(Type of

Bill) Facility

and Class

Inpatient For the non‐

matching records,

the encounter

data is not

populated.

Conduent encounter

data is expected to

reflect the encounter

data elements

submitted by the

provider to PHP. We

recommend Conduent

research this issue to

determine if the bill type

is not being captured

and, if so, make any

necessary changes to

accept the bill type as

submitted by PHP in the

encounter data

submissions.

Acknowledged.


Page 31

Bill Type

(Type of

Bill)

Frequency

Inpatient

Outpatient

For the majority of

the non‐matching

records the

encounter data

reflects a value of

"1", Admit

through discharge

or a "7"

replacement or

corrected claim,

whereas, the

corresponding

claims sample

data reflects

values 1 through

9. It is unclear if

this is an

encounter

submission issue

or an issue with

Conduent.

PHP should ensure that

valid Bill Type Frequency

codes are included on all

encounters submitted to

Conduent.

PHP needs

additional examples

for proper research

and response,

however frequency

can differ from

what PHP has

received from the

provider vs what is

submitted to

Conduent due to

the fact that if PHP

had received an

original submission

(frequency = 1) and

then a adjustment

(frequency = 7)

before a the

original submission

was submitted to

Conduent. PHP

would send the

latest iteration of

the encounter with

a frequency of '1'

since this would be

the original

submission to

Conduent.

Key Data

Element

Encounter

Type


Discharge

Date

Inpatient It is unclear as to

why the claims

sample does not

agree with the

encounter data. A


discharge date

information is being

captured and

maintained on all

PHP includes the

discharge date on

encounters when it

is available on the

claim. PHP will


Page 32

portion of the

claims sample did

not have discharge

dates populated.

inpatient claims.

Additionally, they

should review the

encounter submission

requirements to ensure

this information is

submitted on the

encounters sent to

Conduent.

perform additional

research to resolve

the issue where

present.

Former

MMIS

Claim TCN

Inpatient

&

Outpatient

Professional

For the non‐

matching values,

the claims sample

data is not

populated,

whereas, the

corresponding

encounter data

reflects a valid

value.

Additionally, the

non‐matching

claims sample

values that were

populated, could

be identified in

the encounter

data (c_tcn_num).

PHP should review the

requirements for

submitting void,

replacement and

adjusted claims to

ensure the TCN(s) of the

original claim are

included on the

encounter

resubmissions.

PHP follows

Conduent's

requirements for

submitted voids,

replacements and

adjusted claims by

including the

original MCO TCN in

the REF*F8 segment

and the appropriate

frequency type (7 or

8).


Page 33

Key Data

Element

Encounter

Type


MMIS

Member

Number

Inpatient

&

Outpatient

For the non‐

matching values,

the claims sample

data reflects a 10‐

digit value that

begins with a "3".

For the non‐

matching values,

the corresponding

encounter data

value reflects a 9‐

digit value that

begins with a "5".


a valid member

Medicaid ID is included

on all encounters

submitted to Conduent.

Conduent should review

requirement for

receiving and accepting

encounters to ensure

the member’s Medicaid

ID is on all encounters

submitted. Encounters

without a valid member

Medicaid ID should not

be accepted into the

encounter data system

and should be rejected

during the inbound


process.

PHP stores the

Medicaid ID that is

10 digits and begins

with the number

"3". PHP submits all

encounters based

off of an active

record in Facets,

which is updated

based on HSD's

enrollment files.

PHP would need to

see examples of any

deviations from this

sent as encounters

to research further.

Plan Paid

Date

Pharmacy It is unclear as to

why the encounter

data values and

the claims sample

values do not

agree.



Conduent reflect the

date the claim was

adjudicated (paid or

denied) to the provider

and not the date the

encounter was

Currently, paid date

is not a field on

NCPDP encounters

sent to Conduent.

The available date

field for NCPDP is

fill date, which PHP

sends to Conduent


Page 34

submitted to Conduent,

or the date the check

was issued to the

provider, or the date

PHP paid the

subcontractor vendor.

as it is received.


the requirements for



they are capturing the

dates as submitted by

PHP and/or


Key Data

Element

Encounter

Type


Billed

Charges

Inpatient,

Outpatient

,

Profession

al &

Dental

For some of the

non‐matching

values, it appears

that some of the

claims sample

values reflect

header level billed

charges and

others reflect line

level charges. For

some of the non‐

matching records,

a positive amount

is reflected in the

claims sample

data, whereas, a

negative amount

is reflected in the

PHP should review the

requirements for

submitting voids,

replacements and

adjusted claims to

ensure that all

replacement, void and

adjusted claims

processed through

PHP’s or subcontractor

vendor’s adjudication

systems are submitted

to Conduent.

Additionally, PHP should

ensure that billed

charges are consistently

reported at the

claim/header and/or

PHP follows

Conduent's

requirements for

submitted voids,

replacements and

adjusted claims by

including the

original MCO TCN in

the REF*F8 segment

and the appropriate

frequency type (7 or

8). Additionally,

amounts may differ

due to the fact that

sample data from

PHP's claim system

would have

included denied


Page 35

encounter data. line/service level as

appropriate.

services and the

Conduent data

would not. This

would lead to

discrepancies

between the claim

billed amount and

supporting lines in

the claim.

It is unclear as to

why the encounter

data billed charges

do not agree with

the claims sample

data for the

remaining non‐

matches.

Line Paid

Amount

Outpatient It is unclear as to

why the encounter

data values and

the claims sample

values do not

agree.




amount PHP or

subcontractor vendor

paid for each

service/procedure/line

reflected on the claim.





the amounts PHP paid

for each


on the claim are

captured.

Amounts may differ


sample data from

PHP's claim system

would have

included denied

services and the

Conduent data

would not. This

would lead to

discrepancies

between the claim

billed amount and

supporting lines in

the claim. PHP does

not change paid or

billed amounts on

encounters.


Page 36

Key Data

Element

Encounter

Type


Place of

Service

Dental Professional

The claims sample

data reflects a

variety of values

from 01 through

99.

For the non‐

matching values,

the encounter

data reflects only

one place of

service code,

Office Visit (11).

The location in which

the treatment/service

was performed is

required on all dental

(ADA 2012) and

professional (CMS 1500)

claims. Conduent should

ensure that all dental

encounters reflect the

place of services code

submitted by PHP or

subcontracted vendor.

Acknowledged.

Plan Paid

Amount

Dental It is unclear as to

why the encounter

data values and

the claims sample

values do not

agree.




amount PHP or


paid on the claim.






amounts PHP paid on

the claim.

Amounts may differ


sample data from

PHP's claim system

would have

included denied

services and the

Conduent data

would not. This

would lead to

discrepancies

between the claim

billed amount and

supporting lines in

the claim. PHP does

not change paid or

billed amounts on

encounters.

Procedure

Code

Outpatient

&

It is unclear as to

why the encounter



PHP would need

specific examples


Page 37

Dental

data values and

the claims sample

values do not

agree.


procedure codes paid

for by PHP or


on each








procedure codes on

each


as submitted by PHP or


for proper research

and response;

however no

procedure codes

are changed during

the encounter

process.

Additionally, the

absence of denied

lines in submitted

encounters leads to

mismatched lines

on the submitted

claim vs the

encounter received

by Conduent.

Key Data

Element

Encounter

Type


Revenue

Code

Inpatient

&

Outpatient

For the non‐

matching values, it

is unclear as to

why the claims

sample data and

the encounter

data do not agree.




revenue codes paid for

by PHP or subcontractor

vendor on each







PHP would need

specific examples

for proper research

and response;

however no

revenue codes are

changed during the

encounter process.

Additionally, the

absence of denied

lines in submitted

encounters leads to

mismatched lines

on the submitted


Page 38


revenue codes on each


as submitted by PHP or


claim vs the

encounter received

by Conduent.

Key Data

Element

Encounter

Type


Service

Provider

Specialty

(and/or

Taxonomy)

Professional The claims sample

provider specialty

taxonomy was not

populated;

however,

taxonomy values

were reflected for

provider type

taxonomy. The

claims sample

data was

compared to the

encounter data

using the provider

type taxonomy

and/or the

provider specialty

code.

It is unclear as to

why the claims

sample taxonomy

and the encounter

data taxonomy

does not agree.


the encounter data

submitted to Conduent

reflects the taxonomy as

submitted by the

provider on the claim.

Additionally, PHP should

ensure that claims deny

when a taxonomy is

submitted that is not

associated with the

provider, as reflected on

the State’s provider

registry.


requirements for




taxonomy as submitted

by PHP. Additionally,

Conduent should ensure

that the State’s provider

registry and affiliation

information is

frequently and routinely

In order to comply

with the provider

registration

requirements and

provider matching

process with

taxonomies used by

Conduent, PHP

must change

taxonomy values in

order for

encounters to be

accepted.


Page 39

updated, loaded into

the MMIS system, and

distributed to the MCOs.

Key Data

Element

Encounter

Type


Surgical

Procedure

Codes

Inpatient Encounter data

was not populated

for this element;

however, the

claims sample

contained valid

values.



Conduent reflect all

surgical procedure

codes for which services

were rendered and paid

by PHP or subcontractor

vendor to the provider

on each

service/procedure/claim

line.

Conduent should

review the requirements

for receiving and

accepting encounters to

ensure the surgical

procedure codes PHP

submits on the

encounter are captured

and stored.

Currently, this is not

identified as a

requirement for

PHP to submit this

information to HSD

with encounters.

Tooth

Number

Dental For the non‐

matching values, it

appears that the

corresponding

encounter data

value is not

populated.





the tooth numbers PHP

submits on the

encounter are captured

and stored.

Acknowledged.


Page 40

Admission

Date

Inpatient The admission

date in the claims

sample is after the

corresponding

admission date in

the encounter

data. On average,

for the September

2014 data is 23

days after and the

December 2014

data is 12 days

after.

It is unclear as to

why the claims

sample does not

agree with the

encounter data.

We recommend PHP

and Conduent work

together to ensure

encounter data

accurately reflects

encounters as submitted

by PHP.

PHP and HSD work

constantly to

identify and resolve

issues with

encounters

processing. We

have open channels

of communication

and monthly

meetings to identify

and resolve system

related issues.

Key Data

Element

Encounter

Type


Bill Type

(Type of

Bill) Facility

and Class

Inpatient For the non‐

matching records,

the encounter

data is not

populated.

Conduent encounter

data is expected to


data elements

submitted by the

provider to PHP. We

recommend Conduent



is not being captured

and, if so, make any

necessary changes to

accept the bill type as

submitted by PHP in the

encounter data

Acknowledged.


Page 41

submissions.

Bill Type

(Type of

Bill)

Frequency

Inpatient

&

Outpatient

For the majority of

the non‐matching

records the

encounter data

reflects a value of

"1", Admit

through discharge

or a "7"

replacement or

corrected claim,

whereas, the

corresponding

claims sample

data reflects

values 1 through

9. It is unclear if

this is an

encounter

submission issue

or an issue with

Conduent.


valid Bill Type Frequency

codes are included on all


Conduent.

Conduent encounter

data is expected to


data elements

submitted by the

provider to PHP. We

recommend Conduent



is being updated and, if

so, make any necessary

changes to accept the

bill type as submitted by

PHP in the encounter

data submissions.

PHP needs

additional examples

for proper research

and response,

however frequency

can differ from

what PHP has

received from the

provider vs what is

submitted to

Conduent due to

the fact that if PHP

had received an

original submission

(frequency = 1) and

then an adjustment

(frequency = 7)

before a the

original submission

was submitted to

Conduent. PHP

would send the

latest iteration of

the encounter with

a frequency of '1'

since this would be

the original

submission to

Conduent.


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Key Data

Element

Encounter

Type


Discharge

Date

Inpatient It is unclear as to

why the claims

sample does not

agree with the

encounter data. A

portion of the

claims sample did

not have discharge

dates populated.


discharge date

information is being

captured and

maintained on all

inpatient claims.

Additionally, they

should review the


requirements to ensure

this information is

submitted on the

encounters sent to

Conduent.

PHP includes the

discharge date on

encounters when it

is available on the

claim. PHP will

perform additional

research to resolve

the issue where

present.


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Response to Presbyterian Health Plan’s Rebuttal Activity 1: Review State Requirements

HealthInsight/Myers and Stauffer’s Recommendation: HSD should consider increasing the 30-day encounter submission requirement in the MCO contract (Section 4.19.2.2.11) to 95 percent, based on best practice.

PHP’s Rebuttal: “PHP does not support this recommendation until the provider registration, MCO affiliation, and system issues are resolved. While PHP and HSD are working diligently to improve these processes, we cannot support this recommendation without these issues resolved. PHP believes this should be re-evaluated with the implementation of the MMIS-R.”

HealthInsight/Myers and Stauffer’s Response: PHP’s comments regarding the provider registration and affiliation process are valid; however, increasing the submission requirement from 90 percent to 95 percent would ensure the encounter data is complete for federal reporting, program management and oversight, tracking, accounting, and other ad hoc analyses with minimal margin of error. We recommend that HSD take into consideration PHP’s concerns regarding the provider registration and affiliation process should they choose to increase the encounter submission rate requirement. Activity 2: Review MCO’s Capability

1. Self-Directed Community Benefits A. HealthInsight/Myers and Stauffer’s Finding 1:

The MCOs have limited ability to oversee the claims function of the Self-Directed Community Benefit. They are involved with setting up the beneficiary’s annual budget and care plan, but have minimal ability to confirm the validity of individual self-directed claims. This results in a risk that the MCOs may be paying for unsubstantiated services.

PHP’s Rebuttal: “PHP received encounter data for self-directed benefits and we have improved our monitoring process. In addition, we have established weekly communication with Conduent to inquire about identified concerns and discuss potential process improvements.”

B. HealthInsight/Myers and Stauffer’s Finding 2: Due to the lack of a contractual relationship between the MCOs and TNT, the MCO’s ability to oversee this vendor is limited. However, the MCOs are still required to pay for services provided through this benefit.


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PHP’s Rebuttal: “PHP works closely with Conduent to identify trends and service issues that may occur with the payroll subcontractor TNT of Conduent. There are no current issues or concerns at this point. Weekly teleconferences occur between Conduent and PHP Clinical Operations in addition to quarterly calls with all MCOs and Conduent to discuss processes or opportunities with the FMA process. Conduent has an internal audit process with their employees to monitor key entry for payroll and provider information in the system. TNT then will not release any payments without all paperwork properly entered into the FOCoS system.”

C. HealthInsight/Myers and Stauffer’s Recommendation 1, Activity 2: PHP should reconcile the amount paid to FOCoS/TNT from the monthly invoice to the 837 containing the encounter data they receive from FOCoS/TNT to ensure the encounters support the amount remitted.

PHP’s Rebuttal: “PHP is developing processes to require all encounters submitted by third parties to be tied to invoices and vice versa to improve our current reconciliation processes.”

HealthInsight/Myers and Stauffer’s Response: We encourage PHP and Conduent to continue working together to improve the SDCB processes. The findings and recommendations, however, are specific to the validation period, CY2014, and are based on the data, documents and information collected applicable to CY2014.

2. Conduent

HealthInsight/Myers and Stauffer’s Finding 2: The MCOs are not submitting their denied claims, and in some cases, encounters with both denied and paid detail lines were not being submitted, which would reduce the completeness of the encounter data. The MCO indicated that they were instructed by Conduent not to submit denied claims, and non-submission contradicts the MCO contracts (4.19.2.2.5).

PHP’s Rebuttal: “PHP will continue to follow process as required by HSD. At this moment in time denied claims are not to be submitted.”

HealthInsight/Myers and Stauffer’s Response: We encourage HSD to require the MCOs to submit denied claims, as denied claims are necessary in order to have a complete picture of the services being provided to the members and non-submission contradicts the MCO contract (Section 4.19.2.2.5).

3. PHP A. HealthInsight/Myers and Stauffer’s Recommendation 2, Activity 2:


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PHP should look at implementing a team that has general oversight over the encounter correction process.

PHP’s Rebuttal: “PHP has created a dedicated Encounters Department to oversee and manage the encounters process.”

HealthInsight/Myers and Stauffer’s Response: We encourage PHP to continue to work on improving their oversight and management of the encounter correction process. The findings and recommendations, however, are specific to the validation period, CY2014, and are based on the data, documents and information collected applicable to CY2014.

B. HealthInsight/Myers and Stauffer’s Recommendation 3, Activity 2:

Best practice would indicate that PHP should be auditing at least three percent of the claims processed by each processor each week.

PHP’s Rebuttal: “The Internal Claims audit has been in place for over a decade. Since 2007, the audit results have shown overall claims payment accuracy rates within 1.05% of the Procedural Accuracy target and within <0.07%> of the Financial Accuracy target. The Claims Payment Procedural Accuracy target is 95%. The Claims Payment Financial Accuracy target is 99.25%.

In 2014, internal audit proactively worked with a statistician and benchmarked industry standard to determine the adequacy of our approach. The internal business process analysis of PHP claims audit data in 2014 showed that the average audit sample of 2.5% resulted in a sample of 2,553 claims, 1,933 system-adjudicated (System) and 670 manually-adjudicated (Touched). The overall accuracy rate was 98.41% with an accuracy rate of 99.52% for System claims and 94.95% for Touched claims.

We explored the analysis further and the results showed that if the claims audit sample size was reduced to 1% or a minimum of 1,300 claims per week, the sample would include 1,040 System claims and 260 Touched claims. The calculated overall accuracy rate would be 98.32% to 98.50%; the calculated accuracy rate for System claims would be 99.47% to 99.57% and the calculated accuracy rate for Touched claims would be 94.58% to 95.32%. Based on the extensive analysis of claims payment accuracy audit data, the sample size was reduced to 1% in June 2014. This was to create capacity to complete other focused audit work.

We are open to consider any additional data and information that Myers & Stauffer might provide as to industry best practices, but as the claims payment and audit processes have not significantly changed and our initial analysis of the audit process was extensive, we will keep our sample methodology at 1%.”


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HealthInsight/Myers and Stauffer’s Response: Best practice within the healthcare industry is to internally audit 3 percent of the claims processed by each processor. Myers and Stauffer would further recommend that PHP introduce a greater level of automation and data analysis to their auditing process so that the percentage of processed claims being audited can be increased from 1 percent to 3 percent.

C. HealthInsight/Myers and Stauffer’s Recommendation 4, Activity 2:

PHP should implement a formal internal reconciliation process between the ODS (Data Warehouse) and FACETS (Claims System) to ensure data is not lost in the transfer process.

PHP’s Rebuttal: “Presbyterian Health Plan has a formal process in place currently. The process is run twice a month and it reconciles all of the ODS database to the source Facets data. This process is administered by the EDW team and involves a very comprehensive validation of the ODS Contents. The validation is performed doing large ‘Minus’ queries between the 2 environments, such that − Every row in each table is reviewed, from Source to Target and from Target to

Source. − Every character in every row is compared from Source to Target and from Target to

Source

This practice has been in place since PHP began using the Facets Claim Processing System in 2005”

Attached is a tracking spreadsheet for the last several years of comparisons resulting from this process. Also attached are the comparison logs from a recent compare.”

HealthInsight/Myers and Stauffer’s Response: The additional information provided in PHP’s rebuttal describes the formal reconciliation process that is in place. However, the reconciliation process was not disclosed during the on-site interviews, and supporting documentation was not provided during the validation process.

D. HealthInsight/Myers and Stauffer’s Recommendation 5, Activity 2: PHP should consider expanding duplication logic performed on inbound vendor encounter data files beyond the current claims number check to include additional key data elements, which will allow for a more robust detection of duplicate records.

PHP’s Rebuttal: “PHP is constantly updating their Encounter Management System and surrounding processes, to include duplicate identification and reconciliation.”

HealthInsight/Myers and Stauffer’s Response:


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During the onsite visit, PHP indicated that their duplication logic was based solely on claim number. Duplication logic that relies on multiple fields is recommended to improve the detection of duplicate records. We encourage PHP to continue to work on improving their encounter management and surrounding processes. The findings and recommendations, however, are specific to the validation period, CY2014, and are based on the data, documents and information collected applicable to CY2014.

Activity 3: Analyze Electronic Encounter Data

1. HealthInsight/Myers and Stauffer’s Recommendation, Key Data Elements – Admission Dates for Inpatient Encounters: We recommend PHP and Conduent work together to ensure encounter data accurately reflects encounters as submitted by PHP.

PHP’s Rebuttal: “PHP and HSD work constantly to identify and resolve issues with encounters processing. We have open channels of communication and monthly meetings to identify and resolve system related issues.”

HealthInsight/Myers and Stauffer’s Response: We encourage PHP and Conduent to continue communications to correct and resolve encounter processing issues.

2. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements – Bill Type for Inpatient and Outpatient Encounters: PHP should ensure that valid Bill Type Frequency codes are included on all encounters submitted to Conduent.

PHP’s Rebuttal: “PHP needs additional examples for proper research and response, however frequency can differ from what PHP has received from the provider vs what is submitted to Conduent due to the fact that if PHP had received an original submission (frequency = 1) and then a adjustment (frequency = 7) before a the original submission was submitted to Conduent. PHP would send the latest iteration of the encounter with a frequency of '1' since this would be the original submission to Conduent.”

HealthInsight/Myers and Stauffer’s Response: We provided PHP with examples of the issue identified.

3. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements – Discharge Date for Inpatient Encounters: PHP should ensure that discharge date information is being captured and maintained on all inpatient claims. Additionally, they should review the encounter submission requirements to ensure this information is submitted on the encounters sent to Conduent.

PHP’s Rebuttal: “PHP includes the discharge date on encounters when it is available on the claim. PHP will perform additional research to resolve the issue where present.”


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HealthInsight/Myers and Stauffer’s Response: The discharge date should be present, as appropriate, for all inpatient claims and encounters.

4. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements –Former MMIS Claim TCN for Inpatient, Outpatient and Professional Encounters: PHPshould review the requirements for submitting void, replacement and adjusted claims toensure the ICN/TCN(s) of the original claim are included on the encounter resubmissions.

PHP’s Rebuttal:“PHP follows Conduent's requirements for submitted voids, replacements and adjustedclaims by including the original MCO TCN in the REF*F8 segment and the appropriatefrequency type (7 or 8).”

HealthInsight/Myers and Stauffer’s Response:All of Myers and Stauffer’s recommendations are based on the data submitted to us by theMCOs and Conduent. In the data provided for this validation, instances were identifiedwhere the ICN/TCN of the original claim was not populated.

5. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements –MMIS Member Number for Inpatient and Outpatient Claims: PHP should ensure that avalid member Medicaid ID is included on all encounters submitted to Conduent.

Conduent should review the requirement for receiving and accepting encounters to ensurethe member’s Medicaid ID is on all encounters submitted. Encounters without a validmember Medicaid ID should not be accepted into the encounter data system and should berejected during the inbound encounter submission process.

PHP’s Rebuttal:“PHP stores the Medicaid ID that is 10 digits and begins with the number "3". PHP submitsall encounters based off of an active record in Facets, which is updated based on HSD'senrollment files. PHP would need to see examples of any deviations from this sent asencounters to research further.”

HealthInsight and Myers and Stauffer’s Response:Based on the MCO SYSTEM REQUIREMENTS OCTOBER, 2013, PAGE 4, I. MCO SYSTEM REQUIREMENTS, it is required that an MCO’s Management Information System (MIS) be capable of accepting, processing, maintaining, and reporting specific information necessary to the administration of the managed care program. The MCO’s MIS must meet the following requirements…3. Client Information Requirements The MCO is required to accept, maintain, and transmit Client information to include, but not be limited to...d. Assign as the key Medicaid client ID number, the RECIP-MCD-CARD-ID-NO that is sent on the Enrollment Roster file…The primary client id number within Omnicaid is the System ID number. The Medicaid ID number printed on the client’s Medicaid card is the System ID number preceded by a ‘3’ (page 6 of most current systems manual).


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As the Medicaid client ID is a minimum requirement for accepting and processing claims, it would be expected that encounter data submitted to the FA by the MCOs where the Medicaid ID is missing, would reject upon submission and not be accepted into the MMIS. We have provided examples of encounters, during the rebuttal process, from the encounter data extracts provided by the FA where the Medicaid ID is missing.

6. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements – Plan Paid Date for Pharmacy Claims: PHP should ensure that encounters submitted to Conduent reflect the date the claim was adjudicated (paid or denied) to the provider and not the date the encounter was submitted to Conduent, or the date the check was issued to the provider, or the date PHP paid the subcontractor vendor.

Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the dates as submitted by PHP and/or subcontractor vendor.

PHP’s Rebuttal: “Currently, paid date is not a field on NCPDP encounters sent to Conduent. The available date field for NCPDP is fill date, which PHP sends to Conduent as it is received.”

HealthInsight and Myers and Stauffer’s Response: We reevaluated our matching analysis of the plan paid date for pharmacy claims, comparing the plan paid date in the PHP-submitted sample claims data to the date found in the encounter data. We recalculated the matching percentages and updated the report accordingly.

7. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements Key Data Elements A. Billed Charges for Inpatient, Outpatient, Professional and Dental Claims: PHP should

review the requirements for submitting voids, replacements and adjusted claims to ensure that all replacement, void and adjusted claims processed through PHP’s or subcontractor vendor’s adjudication systems are submitted to Conduent. Additionally, PHP should ensure that billed charges are consistently reported at the claim/header and/or line/service level as appropriate.

PHP’s Rebuttal: “PHP follows Conduent's requirements for submitted voids, replacements and adjusted claims by including the original MCO TCN in the REF*F8 segment and the appropriate frequency type (7 or 8). Additionally, amounts may differ due to the fact that sample data from PHP's claim system would have included denied services and the Conduent data would not. This would lead to discrepancies between the claim billed amount and supporting lines in the claim.”

B. Line Paid Amount for Outpatient Claims: PHP should ensure that encounters submitted to Conduent reflect the amount PHP or subcontractor vendor paid for each service/procedure/line reflected on the claim.


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Conduent should review the requirements for receiving and accepting encounters to ensure the amounts PHP paid for each service/procedure/line on the claim are captured.

PHP’s Rebuttal: “Amounts may differ due to the fact that sample data from PHP's claim system would have included denied services and the Conduent data would not. This would lead to discrepancies between the claim billed amount and supporting lines in the claim. PHP does not change paid or billed amounts on encounters.”

C. Plan Paid Amount for Dental Claims: PHP should ensure that encounters submitted to Conduent reflect the amount PHP or subcontractor vendor paid on the claim.

Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the amounts PHP paid on the claim.

PHP’s Rebuttal: “Amounts may differ due to the fact that sample data from PHP's claim system would have included denied services and the Conduent data would not. This would lead to discrepancies between the claim billed amount and supporting lines in the claim. PHP does not change paid or billed amounts on encounters.”

D. Procedure Code for Outpatient and Dental Claims: PHP should ensure that encounters submitted to Conduent reflect the procedure codes paid for by PHP or subcontractor vendor on each service/procedure/line reflected on the claim.

Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the procedure codes on each service/procedure/line as submitted by PHP or subcontractor vendor.

PHP’s Rebuttal: “PHP would need specific examples for proper research and response; however no procedure codes are changed during the encounter process. Additionally, the absence of denied lines in submitted encounters leads to mismatched lines on the submitted claim vs the encounter received by Conduent.”

HealthInsight/Myers and Stauffer’s Response: We reevaluated our line level key data element analysis. The majority of the unmatched values appeared to be for paid claims where certain line paid amounts reflected zero paid dollars ($0.00). We removed the lines with zero paid dollars from the PHP-submitted claims sample data and recalculated the matching percentages for all line level key data elements and updated the report accordingly.

8. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements – Service Provider Specialty for Professional Claims: PHP should ensure that the encounter data submitted to Conduent reflects the taxonomy as submitted by the provider on the


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claim. Additionally, PHP should ensure that claims deny when a taxonomy is submitted that is not associated with the provider, as reflected on the State’s provider registry.

Conduent should review requirements for receiving and accepting encounters to ensure they are capturing the taxonomy as submitted by PHP. Additionally, Conduent should ensure that the State’s provider registry and affiliation information is frequently and routinely updated, loaded into the MMIS system, and distributed to the MCOs.

PHP’s Rebuttal: “In order to comply with the provider registration requirements and provider matching process with taxonomies used by Conduent, PHP must change taxonomy values in order for encounters to be accepted.”

HealthInsight/Myers and Stauffer’s Response: PHP should ensure that the encounter data submissions are reflective of the claims submitted by the providers and remain as submitted by the provider of service on the claim. Additionally, we encourage PHP to work with the provider to ensure the provider is registered with the State under the taxonomy submitted on the claim.

9. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements – Surgical Procedure Codes for Inpatient Claims: PHP should ensure that encounters submitted to Conduent reflect all surgical procedure codes for which services were rendered and paid by PHP or subcontractor vendor to the provider on each service/procedure/claim line.

Conduent should review the requirements for receiving and accepting encounters to ensure the surgical procedure codes PHP submits on the encounter are captured and stored.

PHP’s Rebuttal: “Currently, this is not identified as a requirement for PHP to submit this information to HSD with encounters.”

HealthInsight/Myers and Stauffer’s Response: According to the Centennial Care MCO Systems Manual (page 246, v1.21), if revenue codes 0360 - 0379, 0490 - 0499 or 0710 - 0719 are used then an ICD-9-CM surgical procedure code is required unless one of the claim diagnosis codes is equal to “V641” (surgical procedure not performed due to complications).

Additionally, we encourage PHP to work with Conduent to ensure that all required data elements are included in PHP’s encounter data submissions and that Conduent is capturing all data elements as submitted.

10. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements – Admission Date for Inpatient Claims: We recommend PHP and Conduent work together to ensure encounter data accurately reflects encounters as submitted by PHP.


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PHP’s Rebuttal: “PHP and HSD work constantly to identify and resolve issues with encounters processing. We have open channels of communication and monthly meetings to identify and resolve system related issues.”

HealthInsight/Myers and Stauffer’s Response: The admission date is a required data element per CMS’s Encounter Data Minimum Data Elements (DTP01*, 435 = admission). The admission date in the PHP-submitted sample claims data should agree with the admission date in the encounter data.

11. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements – Bill Type for Inpatient and Outpatient Claims: PHP should ensure that valid Bill Type Frequency codes are included on all encounters submitted to Conduent.

Conduent encounter data is expected to reflect the encounter data elements submitted by the provider to PHP. We recommend Conduent research this issue to determine if the bill type is being updated and, if so, make any necessary changes to accept the bill type as submitted by PHP in the encounter data submissions.

PHP’s Rebuttal: “PHP needs additional examples for proper research and response, however frequency can differ from what PHP has received from the provider vs what is submitted to Conduent due to the fact that if PHP had received an original submission (frequency = 1) and then an adjustment (frequency = 7) before a the original submission was submitted to Conduent. PHP would send the latest iteration of the encounter with a frequency of '1' since this would be the original submission to Conduent.”

HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity 3: Analyze Electronic Encounter Data, Item 2, above.

12. HealthInsight/Myers and Stauffer’s Recommendation, Table C6, Key Data Elements – Discharge Date for Inpatient Claims: PHP should ensure that discharge date information is being captured and maintained on all inpatient claims. Additionally, they should review the encounter submission requirements to ensure this information is submitted on the encounters sent to Conduent.

PHP’s Rebuttal: “PHP includes the discharge date on encounters when it is available on the claim. PHP will perform additional research to resolve the issue where present.”

HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity 3: Analyze Electronic Encounter Data, Item 3, above.

Activity 4: Medical Record Review

1. HealthInsight/Myers and Stauffer’s Findings 1 - 3, Activity 4: A. Inpatient Institutional Encounters: The key data elements reviewed were servicing

provider, bill type, admission and discharge dates, date(s) of service, revenue codes,


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procedure codes, procedure modifier codes, diagnosis codes, and surgical procedure codes. As Table C-8 shows, PHP submitted 108 medical records for review and 38.89 percent (42 records) were found to be acceptable (all key elements were reflected in the medical record).

B. Outpatient Institutional Encounters: Key data elements reviewed were servicing provider, bill type, and dates of service, revenue codes, procedure codes, procedure modifier codes, and diagnosis codes. In the Table C-8 summary, PHP submitted 107 medical records for review and 62.62 percent (67 records) were found to be acceptable.

C. Professional Encounters: Key data elements reviewed were dates of service, place of service, procedure codes, procedure modifier codes, and diagnosis codes. As noted in Table C-8, PHP submitted 99 medical records for review and 65.66 percent (65 records) were found to be acceptable.

PHP’s Rebuttal: “PHP will include updates in future contracts with providers and subcontractors to include additional requirements for medical record retention and availability, as well as encounter completeness and accuracy.”

HealthInsight/Myers and Stauffer’s Response: We encourage PHP to continue to work with their providers and subcontractors to improve medical record retention and availability, and encounter completeness and accuracy. The findings and recommendations, however, are specific to the validation period, CY2014, and are based on the data, documents and information collected applicable to CY2014.

2. HealthInsight/Myers and Stauffer’s Finding 4, Activity 4: Pharmacy Encounters: A MRR of the pharmacy encounter data was not performed. PHP’s pharmacy subcontractor (OptumRx), cumulatively, did not meet the 95 percent completeness threshold. As a result, the pharmacy encounters were determined to be substantially incomplete.

PHP’s Rebuttal: “The initial finding on pharmacy encounters not meeting the 95% completeness threshold appeared on the original M&S report. The updated M&S report, which included additional encounter activity from May 2016 through February 2017, showed threshold rates above the 95% threshold. We are currently at 0.05% error rate with a 99.95% accuracy rate for the 3rd quarter. Information regarding what was missing is essential in understanding corrective action planning.”

HealthInsight/Myers and Stauffer’s Response: PHP’s completion percentage improved considerably between the initial and updated Encounter Reconciliation Reports. The low completion percentages shown in early 2014 may have been a result of a delay in the submission of pharmacy encounters, which was not disclosed as part of or during the validation activities.

3. HealthInsight/Myers and Stauffer’s Finding 5, Activity 4:


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Dental Encounters: A review of the dental encounter medical records was not performed. PHP’s dental subcontractor (DentaQuest), cumulatively, did not meet the 95 percent completeness threshold. Subsequently, the dental encounters were determined to be substantially incomplete.

PHP’s Rebuttal: “The initial finding on dental encounters did not meet the 95% completeness threshold appeared on the original M&S report. The updated M&S report, which included additional encounter activity from May 2016 through February 2017, showed threshold rates above the 95% threshold. Information regarding what was missing is essential in understanding corrective action planning.”

HealthInsight/Myers and Stauffer’s Response: PHP’s completion percentage improved considerably between the initial and updated Encounter Reconciliation Reports. The low completion percentage shown in early 2014 may have been a result of issues experienced with implementation of the Centennial Care program.

4. HealthInsight/Myers and Stauffer’s Recommendation 1 and 2, Activity 4: A. PHP should ensure the provider contracts contain language regarding medical record

retention and availability for audit requests and establish firm guidelines on how quickly the records should be provided. Based on the experience of Myers and Stauffer LC in other states, the timeframe for remitting medical records is typically 30 days.

B. PHP should ensure their subcontractor vendors have strategies in place for medical record retention and accessibility.

PHP’s Rebuttal: “PHP believes the appropriate language currently exists in our contracts. Executed Contract Language below from DentaQuest contract (as well as this in in every executed contract)

3.2.7. Provider shall maintain all of its records relating to services provided to Members for a ten (10) year period and shall make all Member medical records or other service records in Provider’s possession available for the purpose of quality review conducted by HSD, or their designated agents both during and after the term of this Agreement;

3.2.33. Provider acknowledges and shall, at PRESBYTERIAN’S option, assist PRESBYTERIAN when applicable, and cooperate with PRESBYTERIAN in complying with the following requirements:

3.2.33.1. Maintenance of Medical Records

Provider shall maintain and/or shall contractually require its subcontractors and/or Contract Providers to maintain appropriate records in accordance with federal and State statutes and regulations relating to Contract Provider’s performance under this Agreement, including but not limited to records relating to services provided to Members, including a separate medical record for each Member. Each medical record shall be maintained on paper and/or


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in electronic format in a manner that is timely, legible, current and organized, and that permits effective and confidential patient care and quality review.

3.2.34. Provider acknowledges and shall, at PRESBYTERIAN’S option, assist PRESBYTERIAN when applicable, and cooperate with PRESBYTERIAN in complying with the following requirements, to the extent they are applicable to Provider:

3.2.34.1. Program Integrity - General

3.2.34.1.1. Comply with PRESBYTERIAN’s comprehensive internal Fraud, waste and Abuse program.

3.2.34.1.2. Cooperate with the MFEAD and other investigatory agencies in accordance with the provisions of NMSA 1978, 27-11-1 et seq.

3.2.34.1.3. Comply with all federal and State requirements regarding Fraud, waste and Abuse, including but not limited to, sections 1128, 1156 and 1902(a) (68) of the Social Security Act, section 6402(h) of PPACA, the CMS Medicaid integrity program and the Deficit Reduction Act of 2005.

3.2.34.1.4. Cooperate fully in any activity performed by the HSD, MFEAD, Medicaid Recovery Audit Contractor (RAC), CMS, and/or Payment Error Rate Management and CMS Audit Medicaid Integrity Contractors (MIC). Provider shall, upon request, make available to the RAC any and all administrative, financial and medical records relating to the delivery of items or services for which State monies are expended, unless otherwise provided by law. In addition, Provider shall provide the RAC with access during normal business hours to its respective place of business and records.”

HealthInsight/Myers and Stauffer’s Response: It appears the DentaQuest contract includes language regarding medical records retention and availability; however, PHP cited provider issues related to the ability to obtain certain medical records requested for review.

Activity 5: Submission of Findings

1. HealthInsight/Myers and Stauffer’s Finding 1, Activity 5 - Submission of Findings- System Capabilities: PHP indicated that they pay the self-directed benefit based on the invoice received from FOCoS/TNT. They also receive the related encounters in a Health Insurance Portability and Accountability Act (HIPAA)-compliant electronic data interchange (EDI) format or 837 for submission to Conduent. However, they do not reconcile the invoice to the encounter data contained in the 837.

PHP’s Rebuttal: “PHP is developing processes to require all encounters submitted by third parties to be tied to invoices and vice versa to improve our current reconciliation processes.”


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HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity 2: Review of MCO’s Capability, Item 1C, above.

2. HealthInsight/Myers and Stauffer’s Finding 2, Activity 5 - Submission of Findings- System Capabilities: Based on the interviews conducted with PHP, it appears that the correction and resubmission of denied and rejected encounters is not internally oversighted by one single individual. The various departments worked the corrections that were within their purview.

PHP’s Rebuttal: “PHP has created a dedicated Encounters Department to oversee and manage the encounters process.”

HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity2: Review of MCO’s Capability, Item 3A, above.

3. HealthInsight/Myers and Stauffer’s Finding 3, Activity 5 - Submission of Findings- System Capabilities: PHP indicated that each claims examiner has two percent of their processed claims audited each week. Best practice would be to audit at least three percent of the claims processed by each processor each week.

PHP’s Rebuttal: “See page 29 Finding and Recommendation # 3.”

HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity 2: Review of MCO’s Capability, Item 3B, above.

4. HealthInsight/Myers and Stauffer’s Finding 4, Activity 5 - Submission of Findings- System Capabilities: During the interview process, PHP indicated that there was no formal reconciliation process between their ODS (data warehouse) and FACETS, PHP’s claim adjudication system.

PHP’s Rebuttal: “Please see Presbyterian Health Plans response provided on Finding #4, page 29 of the audit document.”

HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity 2: Review of MCO’s Capability, Item 3C, above.

5. HealthInsight/Myers and Stauffer’s Finding 5, Activity 5 - Submission of Findings- System Capabilities: PHP indicated that they perform a duplicate claim check on the vendor encounter files entered into their vendor claims database. The duplication logic looks only at the claim number of the inbound encounter claim. If the vendor submits the same encounter claim with different claim numbers, the encounter claim could be allowed to enter into PHP’s vendor database multiple times and be submitted to Conduent multiple times as well.


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PHP’s Rebuttal: “PHP is constantly updating their Encounter Management System and surrounding processes, to include duplicate identification and reconciliation.”

HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity 2: Review of MCO’s Capability, Item 3D, above.

6. Myers and Stauffer’s Finding 1, Activity 5 - Submission of Findings- Medical RecordReview: The MRR for pharmacy and dental encounters was not pursued. Based on theinitial encounter reconciliation, all months in the measurement year, CY2014, were belowthe 95 percent completion threshold.

PHP’s Rebuttal:“The initial finding on pharmacy encounters not meeting the 95% completeness thresholdappeared on the original M&S report. The updated M&S report, which included additionalencounter activity from May 2016 through February 2017, showed threshold rates abovethe 95% threshold. We are currently at 0.05% error rate with a 99.95% accuracy rate forthe 3rd quarter. Dental encounters initially fell below the 95% threshold however the finalreview had dental encounters above this threshold. PHP believes we could have obtaineddental and pharmacy records if asked.”

HealthInsight/Myers and Stauffer’s Response:In order to perform an accurate review of the medical records in accordance with theProtocol, while still meet the HSD prescribe timelines, HSD directed Myers and Stauffer tomove forward with the MRR based on the data available at the time. While the pharmacydata did rise above the 95 percent threshold in the updated Encounter ReconciliationReport, the dental strata did not. We encourage PHP to monitor, oversight and work withtheir subcontractor vendors to ensure compliance.

7. HealthInsight/Myers and Stauffer’s Finding 2, Activity 5 - Submission of Findings- MedicalRecord Review: PHP did not reach the 95 percent acceptance rate on any of the encountertypes tested.

PHP’s Rebuttal:“Since the audit, PHP has created an Encounters Department dedicated to encountersoversight and management. We have implemented additional oversight processes as wellas enhancements to our Encounter Management System and reconciliation process.Additionally, encounters accuracy has significantly improved since the implementation ofCentennial Care in 2014. These numbers do not reflect current performance.”

HealthInsight/Myers and Stauffer’s Response:Please see our response to Activity 4: Medical Record Review, Item 1, above.

8. Myers and Stauffer’s Finding 3, Activity 5 - Submission of Findings- Medical RecordReview: PHP provided 314 (95.15 percent) of the 330 medical records requested. PHPindicated that the records not submitted could not be obtained due to unresponsivenetwork providers.


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PHP’s Rebuttal: “Response to medical record requests is part of all provider contracts. PHP Compliance has and is taking appropriate correct action with those providers that did not meet their contractual obligations to provide medical records within the timeframes specified.”

HealthInsight/Myers and Stauffer’s Response: We encourage PHP to continue working with their providers and subcontractor vendors to improve record retention, availability and responsiveness to requests for medical records.

Appendix C-16: Response to HSD and Conduent Recommendations

Page 1

*Language was updated as a result of HSD review and discussion. Please see main report, pages 10-11, forupdated language.

HSD and Conduent Recommendations (Multiple Pages)

Section Recommendation

Number Recommendation* HSD Response HealthInsight and Myers and Stauffer LC Response

Executive Summary 1

HSD review the provider registration process with Conduent to ensure that it is working efficiently and not causing delays or the inability of the MCOs to submit certain encounters to Conduent.

The provider registration process is constantly being evaluated and streamlined and we believe many of the MCO’s issues have been their failure to deny or suspend payment to providers not enrolled with New Mexico Medicaid even after explicit instruction from HSD to do so. This was, of course, most prevalent in the CY2014 that was reviewed. Another factor has been their slowness in mapping the state’s assigned provider type to the matching taxonomy codes and enforcing submission of the correct taxonomy based on the services being rendered for those providers who carry multiple lines of business under one NPI. Much of this is getting corrected at this time by the MCOs, but it created a huge backlog of provider applications for providers the MCOs had paid without requiring their enrollment. Some MCOs have reported to continue to pay claims to non-enrolled providers more than 2 years after HSD’s guidance to deny or suspend until enrollment occurs.

It was represented during the on-site visits that the MCOs were instructed by HSD, to not deny claims from providers who were not registered with the State. The MCOs indicated this directive was changed July 1, 2015 and the MCOs were then allowed to deny the claims from non-registered providers and work with those providers to register with the State. Also, in the fall of 2016, there was a work effort with HSD and the MCOs to resubmit the encounters which were initially rejected by Conduent due to provider registration issues.


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Executive Summary

Incorporated Into Recommendation

One

HSD should consider exploring aligning provider taxonomy codes used in the State’s registration process with the provider-registered taxonomy codes in the National Provider Identifier (NPI) registry.

HSD does not believe the NPI registry is the source of truth when it comes to correct designation of the provider in New Mexico’s system. The NPI registry conducts no validation of the taxonomy a provider selects when registering and there can be a large discrepancy between what the provider selects and what the provider is actually certified/licensed to perform for New Mexico Medicaid. This is complicated by providers who have multiple lines of business but do not always update the NPI Registry with the different taxonomies they are doing business under. In addition, there are State requirements for certain provider services that drive the assignment of a provider type in Omnicaid that is not consistent with the provider’s self-registered taxonomy.

It is recognized that the NPI registry may not solve the taxonomy registration issues that have been experienced in New Mexico. The NPI registry may be leveraged in the future as the provider registration process is reviewed for efficiencies as it is a national list that could provide guidance on current taxonomy codes being used by the provider community.


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Executive Summary 2

HSD evaluate the effectiveness of the affiliation process. Not only must the providers submit claims to the MCOs for payment be registered with the State with the taxonomy code indicated on the claim, the MCO must also be affiliated with the provider in order for the MCO to submit the encounter to Conduent. Based on the experience of Myers and Stauffer LC in other states, the affiliation process and the provider registration is unique and appears to be causing some delays with the submitting of encounters.

We agree; however, this would represent a major change to the structure of our provider and claims process at this time. This suggestion has already been made in relation to the State’s new MMIS-R and the plan is to discontinue the MC affiliation in the new system.

Agreement noted.


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Executive Summary 3

HSD consider increasing the 30-day encounter submission requirement in the MCO contract (Section 4.19.2.2.11) to 95 percent, based on best practice.

HSD will consider this, but is reluctant to tighten this requirement (the current standard is 90% within 30 days) further until we have better means of evaluating compliance

We encourage the State to consider all factors when determining the timing of the increase.

Executive Summary 4

HSD consider accepting MCO denied encounter data submissions. As of the time of the on-site visits, the MCOs were not required to submit denied encounters. The MCO denied claims would provide a more complete picture of the services being provided to the members. Additionally, we recommend that special consideration be given to encounters with both paid and denied lines.

HSD made the decision not to require Conduent to make the changes required to be able to take in denied encounters as originally intended because the system changes required to collect the data in any meaningful way would be too great. It is part of the plan for the MMIS-R that all claims will be captured in the MMIS-R with the MCOs reporting back paid and denied status on all claims. The MCO’s contract and Systems Manual are being revised to remove the Denied Encounter requirement.

We acknowledge HSD’s position; however, by not accepting denied claim lines on a claim with a paid header status, the encounter data does not reflect the entire paid claim as submitted by the provider.


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Executive Summary 5

HSD consider an on-going measurement of the completeness and accuracy of encounters to comply with the Medicaid Managed Care Final Rule (Mega Rule, 42 CFR 438.602(E)), as directed by CMS, such as the encounter reconciliation, which is part of this analysis.

HSD does have on-going measurement of encounter completeness and accuracy that is conducted quarterly and has been for some time. Starting with the quarter ending September, 2017, HSD will be applying monetary penalties to MCOs not meeting the 97% accuracy required in the contract. Completeness of encounters is evaluated by comparing the financial reports and claims lag data submitted by the MCOs to encounter data. No penalties have yet been applied based on encounter completeness measures.

This recommendation was included to ensure processes are in place to review encounter completeness and accuracy and based on HSD’s response, the department has begun to use a process. We encourage HSD to consider a more frequent measurement period.

Executive Summary 6

HSD and Conduent consider requiring the MCOs to attest to all encounter data submissions. It is best practice to require an attestation by the MCOs related to the accuracy and completeness of each of the encounter data submissions.

HSD is evaluating the possibility of adding an attestation to the EDI site where the MCOs upload their encounter files.

Agreement noted.


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Executive Summary 7

Conduent and HSD review the operations of the Self-Directed Community Benefit (SDCB) program to ensure the MCOs have the ability to adequately oversee its members.

Each MCO is required to have a contract with the SDCB vendor and the MCO has the ability through that contract to provide adequate oversight. HSD will work with the MCOs to ensure they are aware of and performing their responsibilities for oversight of this program for their members.

Based on the documentation and information received during the validation process, it appeared that the MCOs were not empowered to oversight this part of the program.

Executive Summary 8

Conduent consider updating its data dictionary to include a list of the code set(s) and the descriptions of each code. A code set is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, medical procedure codes, three-digit provider type codes, three-digit provider specialty codes, or two digit place of service codes.

The data dictionary is already complete and includes all code sets. The auditor seems to have confused a data warehouse file layout with data dictionary.

A copy of the Systems Manual was provided to Myers and Stauffer LC on 10/13/17. A list of valid values did not appear to be included in the version of the Systems Manual provided. A data dictionary should include any code sets and the description of each code used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes; as well as information describing the contents, format, and structure of a database and the relationship between its elements.


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Executive Summary 9

Conduent consider adding MCO training regarding the resources available for accessing control totals for the enrollment files. Control totals are used to verify the accuracy of transmitted data files, so that the MCOs can ensure that it has the complete file beforeprocessing it into its enrollment and claims system and its subcontractor vendor’s claims systems.

The MCO receives a number of files and reports as files are accepted through EDI and passed to Omnicaid for processing. The confirmation report which the MCO receives within 15 minutes of their transmission of a file gives control totals for all the records in the file submitted. Further, once the file is processed in Omnicaid, the RC072 summary also gives totals of all the encounter records processed in Omnicaid. The MCOs uses these totals to question when a report has indicated it was not fully processed.

Per the Systems Manual, there is a trailer record in the enrollment file that provides control totals. We encourage HSD and Conduent to add this information to the next MCO encounter data meeting agenda to ensure the MCOs are aware that control totals are available for the enrollment data files.


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Executive Summary 10

Conduent consider increasing the amount and frequency of updates to system companion guides and provide advance communication about system changes to ensure the MCOs have adequate time to account for the changes. Keeping these documents up to date and giving advance notification to the MCOs would allow for upfront adjustments to its claims processing systems and help protect the MCOs against spikes in rejected encounters after the implementation of new exception codes and edits.

The purpose of Companion guides is to give instruction for fields that the State requires specific values on the standard format. They only get updated when there is something the State has changed about some field’s usage. We have not had such a change in years so there is no reason for an update to the companion guide. The CC Systems Manual is used for advising the MCOs about any changes to how the system is editing encounters (as well as requirements related to Enrollment, long term care spans, health homes, etc.). In addition, HSD places 13 different files on the DMZ monthly for the MCOs so that the MCOs have a complete update every month of any changes made to the Omnicaid reference files. MCOs are always advised in advance of any changes to how HSD is going to edit their encounters.

Based on the documentation and information received during the validation process, it appeared that the MCOs did not have timely, updated documentation related to changes in submission or data requirements. We encourage HSD and Conduent to educate the MCOs related to the resources available to ensure the MCOs have the most current information.


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Conduent ensure it provides advance notice, whenever possible, to the MCOs about system changes to ensure the MCOs have ample time to adjust the claims processing system to account for the changes.

It is HSD’s responsibility to communicate changes to the MCOs, not Conduent’s. HSD meets with the MCOs at least monthly, and for the past 6 months has been meeting biweekly to discuss issues and the MCOs are told ahead of time when changes are going to be made, receiving any changes in file layouts or requirements well in advance of the implementation date. The MCOs are routinely consulted with re: the amount of time required for them to make the necessary changes. Communication about changes is in the form of emails and/or Letters of Direction if the change will impact how the MCO is to do business. Once the change is implemented, the change is noted in the CC Systems Manual.

We acknowledge that HSD has the responsibility to communicate with the MCOs. We encourage Conduent and HSD to work together to ensure timely and accurate information is communicated to the MCOs.


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Conduent consider implementing additional reviews or edits to ensure the MMIS is capturing and retaining all encounter data submitted, is reflective of the encounter data submitted by the MCO, remains as submitted by the provider of service and values are in the appropriate field(s).

Conduent does with the exception of encounters that don’t make it through the very basic Level 1 and II HIPAA EDI validation edits (such claims would be unintelligible to our system). Encounter data is stored online for 7 years with archived data available beyond that. All encounter data is captured as submitted with no changes made by Conduent. Based on the examples submitted, the claims reviewed from the MCO were not the encounters that were reviewed. MCOs frequently resubmit encounters that have denied and when these encounters represent a reprocessing by the MCO, the date received and date paid have changed and thus the paid encounter will not agree with the original claim received by the MCO. If the original denied encounter had been viewed, the dates would have matched.

This recommendation was included to ensure processes are in place to review the system and its edits on an ongoing basis.

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