External Quality Review of Centennial Care Program Compliance · Scoring for this review subject...

External Quality Review of Centennial Care Program

Compliance

Review Period: January 1 – December 31, 2016 Report: February 9, 2018

Section D: UHC

External Quality Review of Centennial Care Program Compliance Section D: UHC

CY2016 Centennial Care Compliance Report Section D: UHC February 9, 2018 of 48

Table of Contents

Section D: United Healthcare of New Mexico, Inc. ............................................................................... 3



Section D: United Healthcare of New Mexico, Inc.

Findings and Conclusions

This portion of the report provides details on the scores, findings, recommendations and conclusions from the CY2016 EQRO Compliance review.

Tables D-1 and D-2 provide the scoring breakdown for UHC. Table D-1 shows those review areas that received a policy review but for which there are no member files to review. Table D-2 addresses review areas that received both a policy and a file review. There were no review areas receiving a file review without a corresponding policy review. Each review subject is listed along with the available points for that subject and the actual points received by the MCO.

The values reported in both tables use a weighted scoring system. Weighted scoring is a system that allows decisions to be made about the focus of an audit by managing the relative value of each review area to the overall score. The system allows flexible design of a review.

In this audit, each review question was assigned one point and was scored zero, 0.5 or one. All review areas contribute equally to the overall score.

Table D-1: Policy Review Scores for UHC

Review Subject Available

Points Actual Points Total Score

Enrollment/Disenrollment 5.00 5.00 100.00%

Maintenance of Medical Records See footnote1

Member Materials 5.00 5.00 100.00%

Member Services 5.00 4.50 90.00%

Program Integrity 5.00 3.64 72.00%

Provider Network 5.00 5.00 100.00%

Provider Services 5.00 5.00 100.00%

Reporting Requirements 5.00 5.00 100.00%

Self-Directed Community Benefit 5.00 4.50 100.00%

The overall score subtotal and overall score for this compliance review are reported at the bottom of Table D-2.

To interpret Table D-2, first understand that it shows review subjects for which both a policy and a file review were performed; there are points available and points received for both. Using Care Coordination as an example, there are five points available for the policy review and six for the file review, for 11 available points. Weighted scoring has been used to balance each review area with all the other review areas, so that areas having many questions do not have a disproportionate impact on the Composite Score. Again, using Care Coordination to illustrate, the MCO received 4.45 of five points for policy review and 5.46 of six for the file review. Therefore, the organization received 9.91 (4.45 + 5.46) out of 11 points, which equals 90.09 percent. (This review uses rounding to two decimal points.)

1 For CY2016, the review questions for this subject were redesigned; as a result, this review was not scored. The EQRO reviewed and assessed MCO policies and procedures; then, recommended strategies for improvement.



Table D-2: Policy and File Review Subject Scores for UHC

Review Subject

Policy Review

File Review

Composite Totals

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Care Coordination 5.00 4.45 88.00% 6.00 5.46 90.91% 11.00 9.91 90.09%

Transitions of Care 5.00 5.00 100.00% 6.00 2.58 43.00% 11.00 7.58 68.91%

Grievance and Appeal Systems

5.00 5.00 100.00% 6.00 5.52 92.00% 11.00 10.52 95.64%

PCP and Pharmacy Lock-ins 5.00 5.00 100.00% 6.00 6.00 100.00% 11.00 11.00 100.00%

UM: Adverse Benefit Determinations

5.00 5.00 100.00% 6.00 4.98 83.00% 11.00 9.98 90.73%

Overall Score Subtotal 91.73%

Penalty Point Assessment2 -1

Composite Score 90.73%

As shown in Table D-1, the review areas of Enrollment/Disenrollment through Maintenance Medical Records are areas for which the review is purely a policy review. Member files were not reviewed for these subjects; whereas in D-2, the remaining areas, Care Coordination through UM: Adverse Benefit Determinations, have both a policy review and a file review component. The scores shown at the beginning of each review area below are composite scores, meaning that they include both policy and file review scores, where both components are applicable.

A penalty point was deducted from the overall score for this MCO because the MCO did not name the files properly according to the EQRO directions.

2 See the Summary Report for an explanation of the potential point deductions from the overall score.



Enrollment/Disenrollment

Table D-3 shows the composite score and compliance level for the Enrollment/Disenrollment policy review.

Table D-3: Enrollment/Disenrollment

Total Score 100.00% Compliance Level Full Compliance

Table D-4 lists the focus question, which provides guidance on the review area, the citations of authority that were used to generate each review question, the questions that were asked for the policy review and if the MCO met the requirement. Additional detail is provided after the table for any questions that did not receive full credit.

Table D-4: Enrollment/Disenrollment

Question

Number

Citation of

Authority Question Score

Focus Question: Does the MCO have the processes in place to handle members transferring into or out of the MCO?

HSD/MCO Contract Amendment 5; Section 4.2.10 Transfers from Other MCOs

1 4.2.10.1 Does the MCO accept all members transferring from any MCO?

1

2 4.2.10.2 Does the MCO have policies and procedures to handle a mass transfer of members to another MCO?

1

3 4.2.10.2 Does the MCO have policies and procedures to handle a mass transfer of members into the contractor's MCO?

1

HSD/MCO Contract Amendment 5; Section 4.3 Disenrollment

4 4.3.1 Does the MCO explicitly state that it will not, under any circumstances, request the disenrollment of a member?

1

5 4.3.1 Is it clear how the MCO determines if a member's continued enrollment in the MCO seriously impairs the MCO's ability to furnish services to either that particular member or other members?

1

Enrollment/Disenrollment Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

Enrollment/Disenrollment Recommendations

The MCO met all requirements and there were no recommendations.

Enrollment/Disenrollment Previous Year’s Recommendations Follow-up

The EQRO previously recommended that the MCO:

Update the related policies to include the contract-required language specifying:

o The [MCO] shall not request disenrollment because of a change in the member's health status, or because of the member's utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs except when his or her continued enrollment in the MCO seriously impairs the MCO's ability to furnish services to either this particular member or other members.



Follow-up: This recommendation is no longer necessary because, by new contractual direction and HSD regulation, the MCOs ability to dis-enroll a member unilaterally is eliminated. The current process for discussion of potentially threatening or unstable members occurs during a monthly High Utilization call between UHC and HSD. Once HSD receives the information, it is responsible for determining further action and direction. The MCO proceeds based on the outcome of the decision.

Enrollment/Disenrollment Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Maintenance of Medical Records

Table D-5 shows that no score was provided for the Maintenance of Medical Records review section. This section was restructured for the CY2016 review. CY2016 was an exploratory year in terms of assessing processes used by each MCO to provide oversight and guidance to its contracted providers regarding the maintenance of medical and behavioral health records. Therefore, the EQRO has conducted a non-scored audit for the present review. Scoring for this review subject will resume with the next EQRO review.

Table D-5: Maintenance of Medical Records

At present, there are no new scores to report, because this subject area was restructured for the CY2016 review.

Table D-6 lists the focus question, which provides guidance on the review area, the citations of authority that were used to generate each review question and the questions that were asked for the policy review.

Table D-6: Maintenance of Medical Records

Question Number

Citation of Authority

Question

Focus Question: Is the MCO providing oversight of its network providers in accordance with the contractual requirement?

HSD/MCO Contract Amendment 5, Section 7.16 Terms and Conditions; 7.16.1 Maintenance of Medical Records

1 7.16.1 Did the MCO use a standardized tool for all provider audits completed during the review period?

2 7.16.1 How did the MCO choose which providers would have a medical records audit during the review period?

3 7.16.1 How did the MCO identify the providers that were audited during this review period?

4 7.16.1 Did the MCO document training and implement standardized auditing processes?

5 7.16.1 Did the MCO provide a comprehensive analysis of the findings and results from the audits?

6 7.16.1 Did the MCO provide follow-up activities that support quality improvement when an individual provider or group practice scores below the threshold identified by the MCO?

7 7.16.1 Did the MCO provide follow-up activities that support quality improvement among all providers in the MCO network regarding trends or patterns identified among the MCO network providers?

8 7.16.1 Was the MCO able to demonstrate improvement in medical record maintenance for contracted network providers?



Maintenance of Medical Records Deficient Score Additional Detail CY2016 was an exploratory year in terms of assessing processes used by each MCO to provide oversight and guidance to its contracted providers regarding the maintenance of medical and behavioral health records. In reviewing this MCO’s evidence, the EQRO reviewers determined that this MCO identified opportunities for improvement, reported back to the providers, recommended improvement strategies and followed up on the outcome of its recommendations.

Maintenance of Medical Records Recommendations The MCO met all requirements and there were no recommendations.

Maintenance of Medical Records Previous Year’s Recommendations Follow-up This section has been restructured since the CY2015 review. In CY2015, this review area was comprised of both a policy and a file review. In CY2016, the EQRO and HSD made the decision to change the focus from reviewing providers’ maintenance of medical records (member files) to reviewing MCO oversight of providers. Because of the change in focus and the fact that the audit did not include any member files, the EQRO did not have data to compare to the previous year for the file review.

Maintenance of Medical Records Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Member Materials

Table D-7 shows the composite score and compliance level for the Member Materials policy review.

Table D-7: Member Materials


Table D-8 lists the focus question, which provides guidance on the review area, the citations of authority that were used to generate each review question, the questions that were asked for the policy review and whether or not the MCO met the requirement. Additional detail is provided after the table for any questions that did not receive full credit.


Question

Number

Citation of


Focus Question: Does the MCO adequately communicate required information to its members?

Code of Federal Regulations; Title 42 Public Health; Part 438 Managed Care, Subpart A General Provisions

1 42 CFR 438.10.(f)(6)

Does the member handbook clearly state the procedures for authorization requirements?

1

2 42 CFR 438.10.(f)(6)

Does the member handbook clearly state how enrollees may obtain benefits from out of network providers?

1

3 42 CFR 438.10.(f)(6)

Does the member handbook clearly state how after-hours and emergency coverage are provided?

1

4 42 CFR 438.10.(f)(6)

Does the member handbook clearly state what constitutes an emergency medical condition?

1

HSD/MCO Contract Amendment 5; Section 4 Scope of Work; 4.14 Member Materials; 4.14.2 Written Member Material Guidelines

5 4.14.2.2 Did the MCO submit a policy that says that all member materials will be worded at or below a sixth grade reading level? If so, did the MCO submit at least one example of such analysis being conducted?

1

6 4.14.2.8 Did the MCO submit a policy that says that they document in the member's file any preferences for alternative formats? If so, did the MCO submit a redacted screen shot example of where this information is documented?

1

HSD/MCO Contract Amendment 5; Section 4.14.4.2 Member Rights and Responsibilities

7 4.14.4.2.1 Did the MCO submit documentation stating that they treat members with respect and due consideration for his or her dignity and privacy?

1

8 4.14.4.2.2 Did the MCO submit documentation stating that they provide members with information on available treatment options and alternatives, presented in a manner appropriate to his or her condition and ability to understand?

1




Question

Number

Citation of


HSD/MCO Contract Amendment 5; Section 4.14.10 Member Health Education

9 4.14.10.3 Did the MCO submit a health education plan that supports member’s efforts to achieve and maintain good health?

1

HSD/MCO Contract Amendment 5; Section 4.14.5 Provider Directory

10 4.14.5.1 Did the MCO submit a provider directory? 1

HSD/MCO Contract Amendment 5; Section 4.14.6 Member Handbook and Provider Directory Distribution

11 4.14.6.2 Did the MCO submit a policy that says that they sent member handbooks to members within 30 days of enrollment and provider directories as requested? If so, did the MCO submit evidence such as a list of members who have been mailed these materials in a given month?

1

Member Materials Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

Member Materials Recommendations The MCO met all requirements and there were no recommendations.

Member Materials Previous Year’s Recommendations Follow-up The EQRO made no recommendations in the previous EQRO report.

Member Materials Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Member Services

Table D-9 shows the composite score and compliance level for the Member Services policy review.

Table D-9: Member Services



Table D-10: Member Services

Question

Number

Citation of


Focus Question: Does the MCO operate a local call center that meets the needs of its members?

HSD/MCO Contract Amendment 5; Section 4 Scope of Work; Section 4.15 Member Services; Section 4.15.1 Member Services Call Center

1 4.15.1.1 Does the MCO operate a call center in New Mexico to respond to member needs?

1

2 4.15.1.2 Does the MCO have policies and procedures to maintain a member services information line?

1

3 4.15.1.3 Does the MCO's call center have the ability to monitor calls remotely?

1

4 4.15.1.13 Does the MCO measure the accuracy of responses to member questions and phone etiquette?

1

5 4.15.1.15 Does the call center have the ability to access electronic documentation from previous member contact?

1

HSD/MCO Contract Amendment 5; Section 4.15.2 Performance Standards for Member Services Line/Queue

6 4.15.2.2 Does the call center have the ability to track call center metrics?

1

HSD/MCO Contract Amendment 5; Section 4.15.3 Interpreter and Translation Services

7 4.15.3.1-2 Are interpreter services available for Limited English Proficiency (LEP), telecommunication device for the deaf or hearing impaired sign language and in-person interpreters or telephonic assistance such as the Language Line?

1

8 4.15.3.4 Did the MCO document that it offered the member an interpreter and whether or not the individual accepted or declined the offer?

1

9 4.15.3.5 Did the MCO document that it does not require or suggest that members with LEP provide their own interpreters?

0

HSD/MCO Contract Amendment 5; Section 4.15.4 Personal Health Records

10 4.15.4.1 How does the MCO provide members access to their health records?

1



Member Services Deficient Score Additional Detail

Regarding Question 9

The question had to do with interpreter services for members with LEP. In Section 4.15.3.5, the contract between UHC and HSD states, “[UHC] is prohibited from requiring or suggesting that Members with LEP or Members using sign language provide their own interpreters or utilize friends or family members.” It is unclear from the documentation how UHC leadership communicates this requirement to its staff.

Member Services Recommendations

The EQRO recommends that the MCO will:

Clarify its policy to direct staff members that they are prohibited from requiring or suggesting that members with LEP provide their own interpreters or utilize friends or family members.

Member Services Previous Year’s Recommendations Follow-up The EQRO made no recommendations in the previous EQRO report.

Member Services Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Program Integrity

Table D-11 shows the composite score and compliance level for the Program Integrity policy review.

Table D-11: Program Integrity

Total Score 72.00% Compliance Level Minimal Compliance



Question

Number

Citation of


Focus Question: Does the MCO have the policies and procedures in place to discover and take action to address fraud, waste and abuse when they occur in the Medicaid program?

HSD/MCO Contract Amendment 5; Section 4.17 Program Integrity

1 4.17.1.1 Does the MCO have a comprehensive internal Fraud, Waste and Abuse (FWA) program?

1

2 4.17.1.4 Request that the MCO provide an example of corrective action plans that are used to assist the MCO in preventing and detecting potential fraud, waste and abuse.

0

3 4.17.3.1 Does the MCO have a written fraud and abuse compliance plan? 1

4 4.17.3.2.8 Request that the MCO provide an example of a work plan that is for announced and unannounced site visits and field audits to high-risk contract providers.

1

5 4.17.4.2.1 Request that the MCO provide one example of an overpayment report from a contracted provider for the review period.

1

HSD Managed Care Policy Manual, Effective March 1, 2016

6 Section 17, Managed Care Reporting and Appendix Q,

page 257

Request that the MCO provide each quarterly report for Program Integrity, Report #56, which was submitted and accepted by HSD for the review period.

1

7 Section 17, Managed Care Reporting and Appendix Q,

page 257

Request that the MCO provide each semiannual report for Provider Suspensions and Terminations, Report #51, which was submitted and accepted by HSD for the review period.

1




Question

Number

Citation of


42 CFR, Subchapter C Medical Assistance Programs, Part 455 Program Integrity: Medicaid, Subpart E, Provider Screening and Enrollment

42 CFR 455.436 Federal Database Checks

8 42 CFR 455.436(a)(b)(c)

(1)(2), Subpart E - Federal Database

Checks

Request that the MCO provide documentation for one newly enrolled provider that shows evidence that federal database3 checks were completed. The MCO may need to submit the completed provider enrollment form and the results from the various databases4 for the provider who is enrolling.

0

9 42 CFR 455.436(a)(b)(c)

(1)(2), Subpart E - Federal Database

Checks

Request that the MCO provide documentation for one reenrolled provider that shows evidence that federal database5 checks were completed. The MCO may need to submit the completed provider enrollment form and the results from the various databases6 for the provider who is enrolling.

0

HSD/MCO Contract Amendment 5; Section 4.17.2 Program Integrity: Reporting and Investigating Suspected Fraud and Abuse

10 MCO Contract 4.17.2.4

Does the MCO have a documented process to perform preliminary investigations of all suspected/confirmed incidents of fraud and abuse?

1

11 MCO Contract 4.17.2.6

Does the MCO have a process in place to notify HSD within 30 calendar days of an adverse action taken against a provider?

1

Program Integrity Deficient Score Additional Detail


The MCO provided an example of a letter sent to a provider regarding the results of an onsite medical record audit but not a written action plan from the provider. During the clarification process for this review, the MCO responded on the clarification request document that the provider failed to respond to the Corrective Action Plan (CAP) and has now been placed on a Directed Corrective Action Plan, yet no follow up documentation on this directed CAP was submitted by the MCO. The MCO had an opportunity to send a different example but did not.

Regarding Questions 8 and 9

During the clarification process, UHC indicated that it is not required to check the Social Security Administration’s Death Master File, stating that it is not a contractual requirement. The EQRO staff reviewed Amendment 5 of the contract between UHC and HSD and found language on page 154 of the

3 The Code of Federal Regulations at: 42 CFR, Subchapter C Medical Assistance Programs, Part 455 Program Integrity: Medicaid, Subpart E, Provider Screening and Enrollment, 42 CFR 455.436 Federal Database Checks requires the MCOs to check four federally maintained databases to confirm identity upon enrollment and reenrollment. These four databases are:

1. Centers for Medicare and Medicaid Services’ (CMS) National Plan and Provider Enumeration System (NPPES) 2. Office of the Inspector General’s Excluded Parties List System (EPLS) 3. Office of the Inspector General’s List of Excluded Individuals and Entities (LEIE) 4. Social Security Administration’s Death Master File

4 Ibid 5 Ibid 6 Ibid



contract that indicates that UHC must comply with all Program Integrity provisions of the PPACA, specifically Section 6401. Section 6401 of PPACA was codified in 42 CFR 455 – the citation used in this section of the review – per a letter issued by the Center for Medicare and CHIP Services on Dec 23, 2011.

Program Integrity Recommendations


Review its Centennial Care contract requirements for Program Integrity database checking, the MCO's National Disclosure Program policy and procedure, PPACA Section 6401 and 42 CFR 455 to make sure all policies and procedures are in alignment with the federal requirements and the work being done by staff.

Go back in its files where the Social Security Administration Death Master File has not been checked, complete this check and take any necessary action pending the outcome of the check, in order to be in compliance.

Provide a completed example of a corrective action plan in response to Question 2.

Program Integrity Previous Year’s Recommendations Follow-up


Update its policies and procedures for identifying and investigating suspected fraud cases to state that the policy does not infringe on the legal rights of persons involved and affords due process of law.

o Follow-up: Based on the documentation submitted for this review, UHC has addressed this recommendation and resolved this issue.

Program Integrity Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Provider Network

Table D-13 shows the composite score and compliance level for the Provider Network policy review.

Table D-13: Provider Network




Question

Number

Citation of


Focus Question: Does the MCO have the policies and procedures in place to manage a network that meets the needs of its membership?

HSD/MCO Contract Amendment 5; Section 4.8.1 General Requirements

1 4.8.1.1.2 Does the MCO state outright that it does not discriminate against providers that serve high-risk populations or specialize in conditions that require costly treatment?

1

2 4.8.1.1.3 Does the MCO state outright that it does not discriminate with respect to participation, reimbursement, or indemnification of any provider acting within the scope of that provider's license or certification?

1

3 4.8.1.1.4 Does the MCO state outright that it gives affected providers written notice of the reason the MCO declined to include the individual or group practice in its network?

1

4 4.8.1.1.5 Does the MCO state outright that it is allowed to negotiate different reimbursement amounts for different specialties or for different practitioners in the same specialty?

1

5 4.8.1.1.6 Does the MCO state outright that it is allowed to establish measures that are designed to maintain quality of services and control of costs and are consistent with its responsibility to members?

1

6 4.8.1.1.7 Does the MCO state outright that it does not make payments to any provider who has been barred from participation based on existing Medicare, Medicaid or SCHIP sanctions, except for emergency services?

1

7 4.8.1.1.8 Does the MCO state outright that it provides members with special health care needs direct access to a specialist, as appropriate for the member's health care condition?

1

8 4.8.1.2 Did the MCO submit a Provider Network Development and Management Plan to the EQRO?

1

9 4.8.1.3 Did the MCO submit a provider suspension/termination report to the EQRO?

1




Question

Number

Citation of


HSD/MCO Contract Amendment 5; Attachment 1: Deliverable Requirements

10 4.21.5.1.5 Did the submitted Provider Network Development and Management Plan include demonstration of monitoring activities to ensure that access standards are met and that members have timely access to services?

1

Provider Network Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

Provider Network Recommendations The MCO met all requirements and there were no recommendations.

Provider Network Previous Year’s Recommendations Follow-up The EQRO made no recommendations in the previous EQRO report.

Provider Network Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Provider Services

Table D-15 shows the composite score and compliance level for the Provider Services policy review.

Table D-15: Provider Services




Question Number


Question Score

Focus Question: Is the MCO communicating with its providers appropriately and in a way that conforms to the requirements outlined in the contract?

HSD/MCO Contract Amendment 5; Section 4.11.1 Provider Handbook

1 4.11.1.1 Does the MCO issue a provider handbook to all contract providers either electronically or hard copy?

1

HSD/MCO Contract Amendment 5; Section 4.11.2 Provider Services Call Center

2 4.11.2.1 Does the MCO operate a provider services call center with a separate toll free line to respond to provider questions, comments, inquiries and requests for prior authorizations?

1

3 4.11.2.1 Unless approved by HSD, is the MCO's provider services call center and its staff located and operated in the State of New Mexico?

1

HSD/MCO Contract Amendment 5; Section 4.11.5 Provider Education, Training and Technical Assistance

4 4.11.5.1 Does the MCO have a Provider Training and Outreach Plan? 1

5 4.11.5.1 Is the Provider Training and Outreach Plan reviewed/updated annually to educate contract providers on Centennial Care requirements and the contractor's processes and procedures?

1

6 4.11.5.1 Did the MCO submit a Provider Training and Outreach Evaluation Report?

1

7 4.11.5.3.1 Did the MCO communicate to the provider the conditions of participation with the MCO?

1

8 4.11.5.3.5 Did the MCO provide a definition of "high volume provider" and a list of whom they consider “high volume providers?”

1




Question Number


Question Score

9 4.11.5.3.12 Did the MCO educate the providers on their responsibility to report Critical Incident information and the mechanisms to accomplish this task?

1

10 4.11.5.4 Did the MCO submit a record of its training and technical assistance activities?

1

11 4.11.5.5 Did the MCO provide documentation to HSD that provider education and training was done?

1

Provider Services Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

Provider Services Recommendations The MCO met all requirements and there were no recommendations.

Provider Services Previous Year’s Recommendations Follow-up The EQRO made no recommendations in the previous EQRO report.

Provider Services Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Reporting Requirements

Table D-17 shows the composite score and compliance level for the Reporting Requirements policy review. Although the specific requirements have changed since the initial development and implementation of the question list used for this review, the MCO continues to meet all requirements outlined below.

Table D-17: Reporting Requirements



Table D-18: Reporting Requirements

Question

Number

Citation of


HSD/MCO Contract Section 4.21.1 General Requirements

1 4.21.1.5 Does the MCO have a policy that states that it will include a summary table in all quantitative reports?

1

2 4.21.1.8 Does the MCO have a policy that states that it will include appropriate analysis in each report?

1

3 4.21.1.16 Does the MCO have a policy that states that it will resubmit any rejected reports within 10 business days from the notification?

1

HSD/MCO Contract Section 4.21.2 Member Reports

4 4.21.2.1.1 Did the MCO submit its Health Education Plan Report to the EQRO?

1

5 4.21.2.3 Did the MCO submit its Member Satisfaction Survey Report to the EQRO?

1

HSD/MCO Contract Section 4.21.5 Provider Reports

6 4.21.5.2.1 Did the MCO submit its Provider Training and Outreach Evaluation Report to the EQRO?

1

HSD/MCO Contract Section 4.21.8 Utilization Management

7 4.21.8.2 Did the MCO submit its quarterly Over and Under Utilization Management Report for the four quarters of calendar year 2016?

1



Reporting Requirements Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

Reporting Requirements Recommendations The MCO met all requirements and there were no recommendations.

Reporting Requirements Previous Year’s Recommendations Follow-up The EQRO made no recommendations in the previous EQRO report.

Reporting Requirements Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Self-Directed Community Benefit

Table D-19 shows the composite score and compliance level for the Self-Directed Community Benefit policy review.

Table D-19: Self-Directed Community Benefit



Table D-20: Self-Directed Community Benefit

Question

Number

Citation of


Focus Question: Are members who are enrolled in the Self-Directed Community Benefit program receiving adequate support from the MCO?

HSD/MCO Contract Amendment 5; Section 4.6.1 General

1 4.6.1.2 Did the MCO document having entered into a contract with the Fiscal Management Agency specified by HSD to assist members who choose the Self-Directed Community Benefit?

1

2 4.6.1.9.1 Did the MCO document a process for determining annual cost limitations for members who did not have an approved self-directed budget?

1

HSD/MCO Contract Amendment 5; Section 4.6.2 Contractor Responsibilities

3 4.6.2.1.2 Did the MCO document a process for identifying resources outside the Centennial Care program, including natural and informal supports that may assist in meeting the member's needs?

1

4 4.6.2.1.4 Did the MCO document a process for determining the annual budget for the Self-Directed Community Benefit, based on the CNA to address the needs of the member?

1

5 4.6.2.1.9 Did the MCO document a process for recognizing and reporting critical incidents including abuse, neglect, exploitation, emergency services, law enforcement involvement and environmental hazards?

1

6 4.6.2.2 Did the MCO document a process for the care coordinator to follow while working with the member to determine the appropriate level of assistance necessary to recruit, interview and hire providers and provide the necessary assistance for successful program implementation?

1

HSD/MCO Contract Amendment 5; Section 4.6.3 Support Broker Functions

7 4.6.3.2 Did the MCO document a process for collaboration between support brokers and care coordinators?

1



Self-Directed Community Benefit Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

Self-Directed Community Benefit Recommendations The MCO met all requirements and there were no recommendations.

Self-Directed Community Benefit Previous Year’s Recommendations Follow-up The EQRO made no recommendations in the previous EQRO report.

Self-Directed Community Benefit Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Care Coordination

Table D-21 shows the composite score and compliance level for the Care Coordination policy and file review. The following sections have both a policy and a file review component.

Table D-21: Care Coordination



Table D-22: Care Coordination Policy Review

Question

Number

Citation of


Focus Question: Does the MCO have the processes in place to monitor the effectiveness of its care coordination processes?

HSD/MCO Contract Amendment 5; Section 4.4.2 Health Risk Assessment

1 4.4.2.2 and 4.4.2.3

Does the MCO have a procedure that explicitly states how it will complete an HRA within 30 calendar days of each member's enrollment?

1

HSD/MCO Contract Amendment 5; Section 4.4.3 Assignment to Care Coordination Levels

2 4.4.3.2 Does the MCO have a procedure that explicitly states how it will inform members of the need for a CNA within seven calendar days of the HRA?

1

3 4.4.3.3.1 Does the MCO have a procedure that explicitly states how it will communicate Care Coordination Unit contact information to members who require a CNA?

1

4 4.4.3.3.2 Does the MCO have a policy that defines when to provide the name of a specific care coordinator to a member who requires a CNA?

1

5 4.4.3.3.3 Does the MCO have a procedure that explicitly states how it will communicate to the member the timeframe in which to expect to be contacted regarding conducting a CNA for members who require a CNA?

0

HSD/MCO Contract Amendment 5; Section 4.4.5 Comprehensive Needs Assessment for Care Coordination Level 2 and Level 3

6 4.4.5.1 Does the MCO have a procedure that outlines the process for performing in-person CNAs?

1

7 4.4.5.2.1 Does the MCO have a policy that explicitly states that it will schedule a CNA within 14 calendar days?

1

8 4.4.5.2.2 Does the MCO have a policy that explicitly states that it will complete a CNA within 30 calendar days of the completion of the HRA, if required, unless the member is in a health home and/or using the Treat First model of care?

1



Table D-22: Care Coordination Policy Review

Question

Number

Citation of


HSD/MCO Contract Amendment 5; Section 4.4.9 Care Plan Requirements

9 4.4.9.3 Does the MCO have a policy that explicitly states that the care coordinator shall ensure that at least the member and/or representative participate in the CCP development?

1

Care Coordination Policy Review Deficient Score Additional Detail While not a scoring issue, it was noted that UHC’s policy states that the care coordinator’s name will be provided if applicable; however, it does not define the circumstances when that would be applicable versus when it would not.


UHC provides information on the timeline for scheduling the CNA directly to each member during the HRA call and it is included in the HRA call script. This information is documented in the clinical system. However, the practice is not reflected in the policy. The policy needs to indicate how it will communicate to the member the timeframe in which to expect contact to schedule the CNA. It was indicated to the EQRO on the last review that the policy would be updated. The policy submitted has not been updated.

Care Coordination Policy Review Recommendations


Update the policy to include definitions of when it would or would not be applicable to provide the care coordinator’s name.

Update the policy to state explicitly how it will communicate to the member the timeframe in which to expect contact regarding conducting a CNA for those members who require a CNA.

Care Coordination Policy Review Previous Year’s Recommendations Follow-up


Update its policies and procedures for Care Coordination to reflect how the member will be informed of the timeframe expectations for the CNA.

o Follow-up: Based on the documentation submitted for the CY2016 review, this issue has not been addressed, as evidenced by the score of zero for Question 5 above.

Care Coordination Policy Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Care Coordination File Review for New Members

In the CY2016 review, two types of member files were scored for Care Coordination: (1) members who were new to the MCO during CY2016 and (2) those who had previously been enrolled. This is because the requirements for timeliness and documentation vary for the two types of member files. The two member types are included in the same six weighted points for the overall score, three points for each type.

The EQRO calculated the ratio of one type to the other and stratified the sample accordingly so that 30 files were reviewed for this section. For example, the universe submitted by the MCO had 6.00 percent of its members as new and 94.00 percent continuously enrolled. Therefore, the sample consists of two (6.00 percent of 30) new members with the remainder pulled from the continuously enrolled members.

In Amendment 6 of the MCO contract, some of the requirements for this review subject were altered; other requirements remained the same as stated in Amendment 5. In the table below, the parenthetical reference to A5 or A6 references MCO contract Amendment 5 or 6 respectively. These parenthetical citations are included so the reader can locate the correct language in the contracts.

Table D-23 lists the focus question, which provides guidance on the review area, the citations of authority that were used to generate each review question, the questions that were asked for the file review, how many files were deficient and how many files were reviewed. Additional detail is provided after the table for any questions that did not receive full credit.

Table D-23: Care Coordination File Review for New Members

Question

Number

Citation of

Authority Question

Number of

Deficient Files

Number of

Files Reviewed

Focus Question: Does the MCO have the evidence that shows they are effectively administering their care coordination program (e.g., timeliness of assessments and care plan development, provision of appropriate information to the member, member involvement)?

HSD/MCO Contract Amendments 5 and 6, Section 4 Scope of Work; 4.4 Care Coordination

1 4.4.2.3 (A6) Was the HRA completed within 30 calendar days of the member's enrollment?

0 2

2 4.4.3.2 (A6) Was member notified of the need to perform a CNA within seven calendar days of the completion of the HRA?

0 2

3 4.4.3.3.1 (A5) Was the member given the Care Coordination Unit contact information within 10 calendar days of the completion of the HRA?

1 2

4 4.4.5.2.1 (A6) Was a CNA scheduled within 14 calendar days of the completion of the HRA when it was required by the outcome of the HRA?

0 2

5 4.4.5.2.2 (A6) Was a CNA completed within 30 days of the completion of the HRA when it was required by the outcome of the HRA?

0 2

6 4.4.9.3 and 4.4.9.7 (A5)

Did the member or the member's representative participate in the CCP development?

0 2



Table D-23: Care Coordination File Review for New Members

Question

Number

Citation of

Authority Question

Number of

Deficient Files

Number of

Files Reviewed

7 4.4.1.5 (A5) If no CCP is developed in coordination with the member or the member's representative, is there documentation that the member or member's representative was offered but refused to participate in the development process?

0 2

8 4.4.9.2 (A6) Was the CCP developed and authorized within 14 business days of completion of the CNA?

0 2

Care Coordination File Review for New Members Deficient Score Additional Detail


In one of two files, UHC provided no evidence that it communicated the Care Coordination Unit’s contact information to the member.

Care Coordination File Review for New Members Recommendations The MCO met all requirements and there were no recommendations.

Care Coordination File Review for New Members Previous Year’s Recommendations Follow-up

The EQRO made no recommendations in the previous EQRO report.

Care Coordination File Review for New Members Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Care Coordination File Review for Continuously Enrolled Members

In Amendment 6 of the MCO contract, some of the requirements for this review subject were altered; other requirements remained the same as stated in Amendment 5. In Table D-24, the parenthetical reference to A5 or A6 refers to the MCO contract Amendment 5 or 6, respectively. The table shows the number of deficiencies found for each element in the files for the Care Coordination File Review for Continuously Enrolled Members.


Table D-24: Care Coordination File Review for Continuously Enrolled Members

Question

Number

Citation of

Authority Question

Number of

Deficient

Files

Number of

Files

Reviewed

Focus Question: Does the MCO have the evidence that shows they are effectively administering their care coordination program (e.g., timeliness of assessments and care plan development, provision of appropriate information to the member, member involvement)?

HSD/MCO Contract Amendments 5 and 6, Section 4 Scope of Work; 4.4 Care Coordination

1 4.4.5.6 (A5) Was annual CNA completed within one year of previous CNA?

3 28

2 4.4.9.3 and 4.4.9.7 (A5)

Did the member or the member's representative participate in the CCP development?

1 28

3 4.4.1.5 (A5) If no CCP is developed in coordination with the member or the member's representative, is there documentation that the member or member's representative was offered but refused to participate in the development process?

0 28

4 4.4.9.2 (A6) Was the CCP developed and authorized within 14 business days of completion of the CNA?

4 28

Care Coordination File Review for Continuously Enrolled Members Deficient Score Additional Detail


In three of 28 files, the documentation did not indicate an annual CNA being completed within one year of the previous CNA. There was no documentation of the member being difficult to reach prior to the due date of the CNA.


The member’s, or the member representative’s, participation in the development of the CCP can be indicated by a dated signature at the time of the CCP development. For UHC, the electronic system used to obtain the signature typically captures the date. However, in one of 28 cases, the signature was there but it was not dated. Once the signature is captured, the system does not allow revisions; therefore, UHC staff were unable to fix the issue.




In three of 28 files, the documentation did not indicate that the CCP was completed within 14 business days of the CNA. In a fourth case, as with Question 4, the electronic system did not capture the date; therefore, the timeliness could not be established.

Care Coordination File Review for Continuously Enrolled Members Recommendations


Create a field on the CNA that indicates the date the CNA was actually completed.

Develop a consistent process to complete the CCPs within the required 14-business day timeframe.

Care Coordination File Review for Continuously Enrolled Members Previous Year’s Recommendations Follow-up


Care Coordination File Review for Continuously Enrolled Members Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Transitions of Care

Table D-25 shows the composite score and compliance level for the Transitions of Care (ToC) policy and file review. The following sections have both a policy and a file review component.

Table D-25: Transitions of Care

Total Score 68.91% Compliance Level Minimal Compliance


Table D-26: Transitions of Care Policy Review

Question Number


Question Score

Focus Question: Does the MCO have the policies and procedures in place to facilitate smooth transitions for its members going from a NF setting to a CB setting?

HSD/MCO Contract Amendment 5, Section 4 Scope of Work; 4.4 Care Coordination; 4.4.15 Transition from Institutional Facility to Community

1 4.4.15.1 Does the MCO have processes in place to identify members who were assessed and transitioned from a NF to the community?

1

2 4.4.15.2 Does the MCO have the processes in place to develop a formal transition plan for members who are transitioning from a NF to the community?

1

3 4.4.15.2 Does the MCO's policy on transition plan development clearly state that the transition plan is to remain in force for a minimum of 60 days from the date the decision to transition is made?

1

4 4.4.15.2 Does the MCO's policy on transition plan development clearly state that the transition plan is to remain in force until a CCP is developed for the member's post NF life?

1

5 4.4.15.3 Does the MCO have processes in place to assess members within 75 days of a transition to determine if the transition was successful?

1

Transitions of Care Policy Review Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

Transitions of Care Policy Review Recommendations The MCO met all requirements and there were no recommendations.

Transitions of Care Policy Review Previous Year’s Recommendations Follow-up The EQRO made no recommendations in the previous EQRO report.

Transitions of Care Policy Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Transitions of Care File Review

Table D-27 lists the focus question, which provides guidance on the review area, the citations of authority that were used to generate each review question, the questions that were asked for the file review and whether or not the MCO met the requirement. Additional detail is provided after the table for any questions that did not receive full credit.

Table D-27: Transitions of Care File Review

Question

Number

Citation of

Authority Question

Number of

Deficient

Files

Number of

Files

Reviewed

Focus Question: Did the MCO implement adequate transition plans to facilitate smooth transitions for its members going from an institutional care setting to a CB setting?

HSD/MCO Contract Amendment 5, Section 4 Scope of Work; 4.4 Care Coordination; 4.4.15 Transition from Institutional Facility to Community

1 4.4.15.2 Was a transition plan developed for the member?

3 18

2 4.4.15.2.1 Did the transition plan address the member’s physical health needs?

13 18

3 4.4.15.2.1 Did the transition plan address the member’s behavioral health needs?

13 18

4 4.4.15.2.2 Did the transition plan address the member’s selection of providers in the community?

10 18

5 4.4.15.2.3 Did the transition plan address the member’s housing needs?

4 18

6 4.4.15.2.4 Did the transition plan address the member’s financial needs?

11 18

7 4.4.15.2.5 Did the transition plan address the member’s interpersonal skills?

14 18

8 4.4.15.2.6 Did the transition plan address the member’s safety?

14 18

Transitions of Care File Review Deficient Score Additional Detail


In three of 18 files, there was insufficient evidence of a complete, discrete transition plan being created in advance of the member’s discharge from a NF. UHC appeared to identify and address the transition elements within a document titled, “LTC NF Repatriation Assessment.” In this assessment, if a need was identified, then interventions were listed immediately below within the document; however, the assessment is not the transition plan.


Since insufficient evidence of a complete, discrete transition plan was not present in three files, then this question was also scored zero for those three files. In the remaining 15 files for which a transition plan was present, ten files had transition plans where the assessments identified physical health needs that were not addressed in the transition plan interventions or the interventions listed conflicted with the needs identified in the assessments.




Since insufficient evidence of a complete, discrete transition plan was not present in three files, then this question was scored zero for those three files. In the remaining 15 files for which a transition plan was present, ten files had transition plans in which the assessments identified behavioral health needs that were not addressed in the transition plan interventions or the interventions listed conflicted with the needs identified in the assessments.


Since insufficient evidence of a complete, discrete transition plan was not present in three files, then this question was scored zero for those three files. In the remaining 15 files for which a transition plan was present, seven files had the transition plan elements addressed but were scored zero for this question because community providers were identified on the assessments as being needed but those providers were not identified as part of the intervention.


Since insufficient evidence of a complete, discrete transition plan was not present in three files, then this question was scored zero for those three files. In the remaining 15 files for which a transition plan was present, one did not address the member’s housing needs.


Since insufficient evidence of a complete, discrete transition plan was not present in three files, then this question was scored zero for those three files. In the remaining 15 files for which a transition plan was present, eight files had a transition plan where the assessments identified financial needs that were not addressed in the transition plan interventions or the interventions listed conflicted with what was identified in the assessments.


Since insufficient evidence of a complete, discrete transition plan was not present in three files, then this question was scored zero for those three files. In the remaining 15 files for which a transition plan was present, 11 files had a transition plan where the assessments revealed the member had diminished interpersonal skills that were not addressed in the transition plan interventions or the interventions listed conflicted with what was identified in the assessments.


Since insufficient evidence of a complete, discrete transition plan was not present in three files, then this question was scored zero for those three files. In the remaining 15 files for which a transition plan was present, eleven files had a transition plan where the assessments identified safety concerns that were not addressed in the transition plan interventions or the interventions listed conflicted with what was identified in the assessments.

Transitions of Care File Review Recommendations


Train staff in the consistent use of a transition plan that identifies the transitioning member’s needs and consistent documentation of the interventions used to address the identified needs.



Transitions of Care File Review Previous Year’s Recommendations Follow-up


Develop and implement a consistent way of documenting transition plans for members that puts the data in one place to facilitate care coordinator management of the transition process and follow-up.

o Follow-up: Based on the documentation submitted for the CY2016 review, UHC implemented a new data system; however, the documentation for Transitions of Care remained unorganized and difficult to follow.

HSD will be expanding an IAP to address the identified compliance issue.

Transitions of Care File Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Grievance and Appeal System

Table D-28 below shows the composite score and compliance level for the Grievance and Appeal System policy and file review. The following sections have both a policy and a file review component.

Table D-28: Grievance and Appeal System



Table D-29: Grievance and Appeal System Policy Review

Question

Number

Citation of


Focus Question: Does the MCO dispose of each grievance and resolve each appeal and provide notice, as expeditiously as the enrollee's health condition requires, within the timeframes established by the State?

HSD/MCO Contract Amendment 5; Section 4.16 Grievance and Appeal System

1 4.16.1.2.3 Does the MCO advise its members that assistance is available to help them file grievances and appeals?

1

2 4.16.2.2 Does the MCO have a policy, procedure, or program description that states the MCO's intention to provide a written acknowledgement of the receipt of the grievance and the expected date of its resolution?

1

3 4.16.2.3 Does the MCO have a policy, procedure, or process that states the MCO's intention to resolve grievances within 30 calendar days of the receipt of the grievance?

1

4 4.16.3.7 Does the MCO have a policy, procedure, or program description that states the MCO's intention to provide a written acknowledgement of the receipt of the appeal and the expected date of its resolution?

1

5 4.16.3.5 Does the MCO have a policy, procedure, or process that states the MCO's intention to resolve oral and written appeals within 30 calendar days of receipt?

1

6 4.16.4.3 Does the MCO have a policy, procedure, or process that states the MCO's intention to resolve expedited appeals in three working days or less?

1

7 4.16.4.3 Does the MCO have a policy, procedure, or process that states the MCO's intention to provide information to members whose appeal outcome is less than wholly favorable for the member? The information to be provided includes the following:

The right to request a State fair hearing

How to do so

1



Table D-29: Grievance and Appeal System Policy Review

Question

Number

Citation of


The right to request to receive benefits while the hearing is pending

How to make the request

That the member may be held liable for the cost of those benefits if the hearing decision upholds the MCO's action (decision to deny)

Grievance and Appeal System Policy Review Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

Grievance and Appeal System Policy Review Recommendations The MCO met all requirements and there were no recommendations.

Grievance and Appeal System Policy Review Previous Year’s Recommendations Follow-up


Grievance and Appeal System Policy Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Member Grievances File Review


Table D-30: Member Grievances File Review

Question

Number

Citation of

Authority Question

Number of

Deficient

Files

Number of

Files

Reviewed Focus Question: Did the MCO adhere to timeliness and communication requirements for processing member grievances?

HSD/MCO Contract Amendment 5; Section 4.16 Grievance and Appeal System; 4.16.2 Grievances

1 4.16.2.2 Did the MCO send a written notification of its receipt of the grievance (acknowledgement letter) to the member within five business days after receiving the oral or written grievance?

0 30

2 4.16.2.2 Did the acknowledgement letter convey the expected date of the resolution to the member?

0 30

3 4.16.2.3 and

4.16.2.4

Did the MCO resolve the grievance and send a written notification of its resolution (resolution letter) to the member within 30 calendar days after receiving the oral or written grievance?

0 30

4 4.16.2.5 Did the MCO include the information considered during the investigation in the resolution letter?

0 30

5 4.16.2.5 Did the resolution letter advise the member of its findings and conclusions?

0 30

Member Grievances File Review Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

Member Grievances File Review Recommendations The MCO met all requirements and there were no recommendations.

Member Grievances File Review Previous Year’s Recommendations Follow-up The EQRO made no recommendations in the previous EQRO report.

Member Grievances File Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Member Appeals File Review


Table D-31: Member Appeals File Review

Question

Number

Citation of

Authority Question

Number of

Deficient

Files

Number of

Files

Reviewed

Focus Question: Did the MCO adhere to timeliness and communication requirements for processing member appeals?

HSD/MCO Contract Amendment 5; Section 4.16 Grievance and Appeal System; 4.16.3 Appeals

1 4.16.3.7 Did the MCO send a written notification of its receipt of the appeal (acknowledgement letter) to the petitioner within five business days after receiving the oral or written appeal?

2 30

2 4.16.3.7 Did the acknowledgement letter convey the expected date of the resolution to the petitioner?

2 30

3 4.16.3.9 Did the acknowledgement letter advise the petitioner of the opportunity to present evidence and allegations of fact or law, in person as well as in writing?

30 30

4 4.16.3 Did the MCO resolve the appeal and send a written notification of its resolution (resolution letter) to the petitioner within 30 (or 44) calendar days after receiving the oral or written appeal?

2 30

5 4.16.3.10 Did the MCO include the results of the appeal in the resolution letter?

0 30

6 4.16.3.10 If the appeal was not completely in the member's favor, did the resolution letter advise the petitioner of his or her right to request a State fair hearing?

0 30

Member Appeals File Review Deficient Score Additional Detail


In two of 30 files, the acknowledgement letter was not sent within the 5-day turnaround time required for appeals.


In two of 30 files, there were two acknowledgement letters sent, each with a different date given as possibilities and clarification could not be provided by the MCO.


The form letter used as the MCO’s acknowledgement letter does not provide a physical location for members to bring evidence. The requirement is that members must be provided the opportunity to present evidence and allegations of fact or law, in person as well as in writing. A post office box in Salt



Lake City, Utah was provided which does not meet the ‘in person’ aspect of the requirement. For this question, the MCO received no points for any of the 30 files.


In two of 30 files, the resolution was not with in the 30-day turnaround timeframe for standard appeals. Both case files documented a process in which UHC first requested an authorization of representation (AOR) and upon receipt of the AOR, requested a written appeal. This practice resulted in prolonged turnaround times for resolution of these appeals. In one of the case files, the guardians indicated that they had submitted this same information at least three time in the past.

Member Appeals File Review Recommendations


Review and revise its existing grievance and appeals procedures to support the identification of all necessary information from the member and to request all necessary information from the member at one time. This is especially important when a verbal appeal is received from someone other than the member.

o This recommendation stems from two case files. In both case files, the case was pended twice while the MCO requested different types of information that could have been handled at one time, specifically the signed authority from the member in one case and the guardianship papers from the guardian in another case.

o In the case where the MCO requested the guardianship papers, the member’s guardian stated that the same information had been requested by the MCO on multiple occasions.

Identify a way to indicate in each member’s file when authorizations for representation have been previously received by the MCO in order to prevent the repetitive requisition of the same information from the same member.

o This recommendation also stems from two case files. In both case files, the case was pended twice while the MCO requested different types of information that could have been handled at one time, specifically the signed authority from the member in one case and the guardianship papers from the guardian in another case.

o In the case where the MCO requested the guardianship papers, the member’s guardian stated that the same information had been requested by the MCO on multiple occasions.

Identify a consistent way to resolve standard appeals and provide written resolution to the member within 30 calendar days of the receipt of the appeal.

Revise the template for the written acknowledgment letter to add language that also reminds the member of the right to present evidence, including in person and provide the physical address at which the information may be delivered. The physical address can be located in any part of the letter, including the letterhead and/or the footer.

o Alternatively, consistently include the letter originally denying authorization of benefits

in appeals files that are being prepared for EQRO review.

Compare the UM policies and SOPs to 42 CFR 438.404 and 42 CFR 438.210(c) and make any adjustments necessary in order to be fully compliant with government regulations.



Member Appeals File Review Previous Year’s Recommendations Follow-up


Provide a process whereby members can present evidence in support of their appeals in person. o Follow-up: Based on the documentation provided for the CY2016 review, UHC has not

addressed this recommendation.

HSD will implement an IAP to address the identified compliance deficiency.

Member Appeals File Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



Member Expedited Appeals File Review


Table D-32: Member Expedited Appeals

Question

Number

Citation of

Authority Question

Number of

Deficient

Files

Number of

Files

Reviewed

Focus Question: Did the MCO adhere to timeliness and communication requirements for processing member appeals?

HSD/MCO Contract Amendment 5; Section 4.16 Grievance and Appeal System; 4.16.4 Expedited Resolution of Appeals

1 4.16.4.3 Did the MCO resolve the appeal and send a written notification of its resolution (resolution letter) to the petitioner within three calendar days after receiving the oral or written appeal?

0 30

2 4.16.4.3 Did the MCO include the results of the appeal in the resolution letter?

0 30

3 4.16.4.3 If the appeal was not completely in the member's favor, did the resolution letter advise the petitioner of the right to request a State fair hearing?

0 30

4 4.16.4.3 If the appeal was not completely in the member's favor, did the resolution letter advise the petitioner of the right to request continuation of current benefits while a hearing with the State fair hearing officer is pending?

0 30

5 4.16.4.3 If the appeal was not completely in the member's favor, did the resolution letter advise the petitioner that the member may be held liable for the costs of any services continued if the State fair hearing officer finds in favor of the MCO?

0 30

Member Expedited Appeals File Review Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

Member Expedited Appeals File Review Recommendations The MCO met all requirements and there were no recommendations.

Member Expedited Appeals File Review Previous Year’s Recommendations Follow-up


Member Expedited Appeals File Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



PCP and Pharmacy Lock-ins

Table D-33 shows the composite score and compliance level for the PCP and Pharmacy Lock-ins policy and file review. The following sections have both a policy and a file review component.

Table D-33: PCP and Pharmacy Lock-ins



Table D-34: PCP and Pharmacy Lock-ins Policy Review

Question

Number

Citation of


Focus Question: Does the MCO have policies and procedures in place to identify and communicate with members who require lock-in services?

HSD/MCO Contract Amendment 5; Section 4.22.2 PCP Lock-ins

1 4.22.2 Does the MCO have a policy or procedure in place to inform the member of the intent to begin a PCP lock-in?

1

2 4.22.2 Does the MCO have a policy or procedure in place to review a PCP lock-in quarterly?

1

3 4.22.2 Does the MCO have a policy or procedure in place to report PCP lock-ins quarterly to HSD?

1

4 4.22.2 Does the MCO have a process in place to determine when a member should be removed from a PCP lock-in?

1

5 4.22.2 Does the MCO have a process in place to notify HSD when it removes someone from a PCP lock-in?

1

HSD/MCO Contract Amendment 5; Section 4.22.3 Pharmacy Lock-ins

6 4.22.3 Does the MCO have a policy or procedure in place to inform the member of the intent to begin a Pharmacy lock-in?

1

7 4.22.3 Does the MCO have a policy or procedure in place to review a Pharmacy lock-in quarterly?

1

8 4.22.3 Does the MCO have a policy or procedure in place to report Pharmacy lock-ins quarterly to HSD?

1

9 4.22.3 Does the MCO have a process in place to determine when a member should be removed from a Pharmacy lock-in?

1

10 4.22.3 Does the MCO have a process in place to notify HSD when it removes someone from a Pharmacy lock-in?

1



PCP and Pharmacy Lock-ins Policy Review Deficient Score Additional Detail

Regarding Questions 4 and 9

The submitted policy from the MCO labeled states, “Plan will use multiple sources to identify members for whom the listed behaviors are suspected. Possible sources would include referrals from the Care Coordinators, High Risk Case Management, Pharmacy reviews, community providers, HSD and the Quality Department. The decision to place a member on a Provider Lock-in will be made by a Medical Director in consultation with Health Services, Care Coordinators, Pharmacy Director and the Primary Care Provider (PCP).”

The supplied documentation was sufficient for positive scoring; however, the policy did not include or reference specific criteria for identifying cases that may benefit from restricted access to one PCP or when a member should be released from such a lock-in status. The MCO must establish a process for

the reviewing the member’s lock-in status to determine when the behavior has been resolved and the recurrence of the problems is judged to be improbable. When a MCO does not have such a process, the member’s access to providers remains restricted indefinitely.

PCP and Pharmacy Lock-ins Policy Review Recommendations


Update its policy and/or procedures to include what criteria will be used to determine when to implement and release a member from a PCP or pharmacy lock-in.

PCP and Pharmacy Lock-ins Policy Review Previous Year’s Recommendations Follow-up


PCP and Pharmacy Lock-ins Policy Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



PCP and Pharmacy Lock-ins File Review


Table D-35: PCP and Pharmacy Lock-ins File Review

Question

Number

Citation of

Authority Question

Number of

Deficient

Files

Number of

Files

Reviewed

Focus Question: Is the MCO communicating with members who require lock-in services?

HSD/MCO Contract Amendment 5; Section 4.22.2-3 PCP and Pharmacy Lock-ins

1 4.22.2 Is it a PCP or a Pharmacy Lock-in? 0 11

2 4.22.2 Did the MCO notify the member of the PCP or Pharmacy Lock-in?

0 11

3 4.22.2 Did the MCO provide a rationale for the PCP or Pharmacy Lock-in?

0 11

PCP and Pharmacy Lock-ins File Review Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

PCP and Pharmacy Lock-ins File Review Recommendations The MCO met all requirements and there were no recommendations.

PCP and Pharmacy Lock-ins File Review Previous Year’s Recommendations Follow-up The EQRO made no recommendations in the previous EQRO report.

PCP and Pharmacy Lock-ins File Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



UM: Adverse Benefit Determinations

Table D-36 shows the composite score and compliance level for the UM: Adverse Benefit Determinations file review. The following sections have both a policy and a file review component.

Table D-36: UM: Adverse Benefit Determinations



Table D-37: UM: Adverse Benefit Determinations Policy Review

Question

Number

Citation of


Focus Question: Does the MCO establish and implement a UM system that promotes quality of care, adherence to standards of care, the efficient use of resources, member choice and the identification of service gaps within the service system?

HSD/MCO Contract Amendment 5; Section 4.12.10 Standards for Utilization Management

1 4.12.10 Does the MCO have a UM program that follows NCQA UM standards?

1

2 4.12.10 Does the MCO have a UM program that promotes quality of care?

1

3 4.12.10 Does the MCO have a UM program that promotes adherence to standards of care?

1

4 4.12.10 Does the MCO have a UM program that promotes the efficient use of resources?

1

5 4.12.10 Does the MCO have a UM program that promotes member choice?

1

6 4.12.10 Does the MCO have a UM program that promotes the identification of service gaps within the service system?

1

HSD/MCO Contract Amendment 5; Section 4.12.10.5

7 4.12.10.5.1 Does the MCO's UM program description contain structure and accountability mechanisms?

1

8 4.12.10.5.2 Does the MCO have a description of the UM work plan that includes the goals and specific indicators that are used for performance tracking and trending?

1

9 4.12.10.5.2 Does the MCO have a description of the UM work plan that includes the processes or mechanisms used for the assessment and intervention?

1

10 4.12.10.5.3 Does the MCO have a comprehensive UM program evaluation?

1



UM: Adverse Benefit Determinations Policy Review Deficient Score Additional Detail The MCO met all requirements and no deficiencies were identified.

UM: Adverse Benefit Determinations Policy Review Recommendations The MCO met all requirements and there were no recommendations.

UM: Adverse Benefit Determinations Policy Review Previous Year’s Recommendations Follow-up


UM: Adverse Benefit Determinations Policy Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



UM: Adverse Benefit Determinations File Review


UM: Adverse Benefit Determinations File Review Deficient Score Additional Detail


In eight of 29 files, no clinical information was included as part of the denial. All eight cases involved dental providers. Case notes were provided in some files. While case notes add to the evidence, they are not a substitute for source clinical evidence.


The written notifications of denial provided to UHC’s member by its dental vendor use medical terminology and internal coding without a plain language explanation. The EQRO understands that the technical language is required; however, a plain language summary for the member is necessary to meet

Table D-38: UM: Adverse Benefit Determinations File Review

Question

Number

Citation of

Authority Question

Number of

Deficient Files

Number of

Files Reviewed

Focus Question: Does the MCO provide evidence that shows the MCO established and implemented a UM system that promotes quality of care, adherence to standards of care, the efficient use of resources, member choice and the identification of service gaps within the service system?

HSD/MCO Contract Amendment 5; Section 4.12.10 Standards for Utilization Management

1 Initial/Continuation: 4.12.12.5 42

Non-Urgent: 42 CFR

431.211

Emergent/Urgent: 42 CFR 456.126 (a)

and (b)

Was the MCO's response timely based on one of the four categories listed in the cell to the left?

0 29

2 4.12.10.11 Is there documentation of the use of qualified professionals in making the determination?

0 29

3 4.12.10.1.1 Is there documentation of the clinical information to make the determination?

8 29

4 §438.404(a) and

§438.10(d)

Is the denial rationale provided to the member in the denial letter easy to understand?

11 29

5 4.12.10.8 Did the denial letter indicate that a copy of the UM decision criteria is available upon request?

0 29



the contractual requirement that the letter be easy to understand. The dental written notifications of denial caused this issue in 11 of 29 files.

UM: Adverse Benefit Determinations File Review Recommendations


Include source documentation of the clinical information used to determine the member's eligibility for services for all case files submitted to the EQRO for compliance review.

Work with the dental vendor to write the denial rationale in plain language to increase the ease of understanding to the member.

Compare the UM policies and SOPs to 42 CFR 438.404 and 42 CFR 438.10(d) and make any adjustments necessary in order to be fully compliant with government regulations.

UM: Adverse Benefit Determinations File Review Previous Year’s Recommendations Follow-up


Work with its dental vendors to update the dental service written notifications of denial to mirror more closely those issued by UHC.

o Follow-up: Based on the documentation supplied for the CY2016 review, these issues have not been completely resolved, as reflected in the outcome of Questions 3 and 4 above. UHC did revise its internal letters to conform to the requirement that the letters be “understandable to a layperson;” however, the letters from dental providers remain problematic. Because additional improvement is needed, these recommendations stand for the CY2016 review.


Adopt the practice of having medical directors write a plain language summary of the denial rationale for the member that is clear and understandable to a layperson. This documentation is to be included with the technical description that is required.

o Follow-up: Based on the documentation supplied for the CY2016 review, these issues have not been completely resolved, as reflected in the outcome of Questions 3 and 4 above. UHC did revise its internal letters to conform to the requirement that the letters be “understandable to a layperson;” however, the letters from dental providers remain problematic. Because additional improvement is needed, these recommendations stand for the CY2016 review.


UM: Adverse Benefit Determinations File Review Rebuttal Upon preliminary approval from HSD, MCO rebuttals will be solicited. Upon receipt of the rebuttal material from the MCO, this section may be revised.



For additional information concerning this report, contact:

External Quality Review Department

5801 Osuna NE, Suite 200 Albuquerque, NM 87109-2587

www.healthinsight.org

http://www.healthinsight.org/

http://www.healthinsight.org/

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