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External Quality Review of Centennial Care Program

Compliance

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

Section A: BCBS

External Quality Review of Centennial Care Program Compliance Section A: BCBS

CY2016 Centennial Care Compliance Report Section A: BCBS

February 9, 2018 of 51

Table of Contents

Section A: Blue Cross and Blue Shield of New Mexico ............................................................ 3

Findings and Conclusions ................................................................................................. 3

Enrollment/Disenrollment ................................................................................................ 5

Maintenance of Medical Records ..................................................................................... 6

Member Materials ............................................................................................................ 8

Member Services ............................................................................................................ 10

Program Integrity ........................................................................................................... 12

Provider Network ........................................................................................................... 16

Provider Services ............................................................................................................ 18

Reporting Requirements ................................................................................................ 20

Self-Directed Community Benefit ................................................................................... 22

Care Coordination........................................................................................................... 24

Care Coordination File Review for New Members ......................................................... 26

Care Coordination File Review for Continuously Enrolled Members............................. 29

Transitions of Care .......................................................................................................... 31

Transitions of Care File Review ...................................................................................... 33

Grievance and Appeal System ........................................................................................ 36

Member Grievances File Review .................................................................................... 38

Member Appeals File Review ......................................................................................... 40

Member Expedited Appeals File Review ........................................................................ 42

PCP and Pharmacy Lock-ins ............................................................................................ 44

PCP and Pharmacy Lock-ins File Review ......................................................................... 46

UM: Adverse Benefit Determinations ............................................................................ 47

UM: Adverse Benefit Determinations File Review ......................................................... 49




Section A: Blue Cross and Blue Shield of New Mexico

Findings and Conclusions

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

Tables A-1 and A-2 provide the scoring breakdown for BCBS. Table A-1 shows those review areas that received a policy review but for which there are no member files to review. Table A-2 shows those 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 contribution of each review area to the overall score.

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 A-1: Policy Review Scores for BCBS

Review Subject Available Points Points Received Total Score

Enrollment/Disenrollment 5.00 5.00 100.00%

Maintenance of Medical Records See footnote1

Member Materials 5.00 4.75 95.00%

Member Services 5.00 4.50 90.00%

Program Integrity 5.00 4.10 82.00%

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 5.00 100.00%

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

To interpret Table A-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 all five points for policy review and 4.98 of six for the file review. Therefore, the organization received 9.98 (5.00 + 4.98) out of 11 possible points, which equals 90.727 percent. (This review uses rounding to two decimal points, which is why the total score is 90.73 rather than 90.72.)

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 A-2: Policy and File Review Scores for BCBS

Review Subject

Policy Review File Review Composite Totals

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Po

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Re

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File

Sco

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Tota

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Tota

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Sub

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

Transitions of Care 5.00 5.00 100.00% 6.00 2.94 49.00% 11.00 7.94 72.18%

Grievance and Appeal Systems

5.00 5.00 100.00% 6.00 5.40 90.00% 11.00 10.40 94.55%

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 5.46 91.00% 11.00 10.46 95.09%

Composite Score Subtotal 92.77%

Penalty Point Assessment2 -1

Composite Score 91.77%

As shown in Table A-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 A-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 A-3 shows the composite score and compliance level for the Enrollment/Disenrollment policy review.

Table A-3: Enrollment/Disenrollment

Total Score 100.00% Compliance Level Full Compliance

Table A-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 whether or not the MCO met the requirement. Additional detail is provided after the table for any questions that did not meet the requirement to receive full credit.

Table A-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 made no recommendations in the previous EQRO report.

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 A-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 A-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 A-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 A-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 results 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 for the CY2016 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 A-7 shows the composite score and compliance level for the Member Materials policy review.

Table A-7: Member Materials




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





Question

Number

Citation of


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

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?

0.5

Member Materials Deficient Score Additional Detail

Regarding Question 11

While the MCO provided appropriate policy and procedure documentation, no evidence was provided by the MCO documenting mailings of the member handbook within 30 days of enrollment or mailings that have gone out to those members who requested a physical copy of the handbook or directory.

Member Materials Recommendations

The EQRO recommends that the MCO will:

Provide evidence of mailings to members of both the handbook and the directory.

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

Table A-9: Member Services



Table A-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?

1

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?

0




Member Services Deficient Score Additional Detail


In section 4.15.4.1 of the contract between HSD and BCBS, the following requirement is stated: “The contractor shall provide members with access to electronic versions of their personal health records.” The MCO did not provide evidence that it informed members that their personal health records are available electronically. The MCO did not provide evidence it informed members on how to access these records. In answer to Question 10, the MCO submitted a member appeals policy, which did not meet the requirements for evidence for the Member Services review. In response to a request for clarification, they provided the member handbook as evidence of meeting the requirement. The handbook does state that the member has the right to access his or her medical records but does not address electronic access or methods of accessing records. Furthermore, the handbook does not provide guidance to members on how to access their medical records either on paper or electronically. Therefore, the MCO received a zero score for this question.

Member Services Recommendations


Advise its members that access to electronic versions of personal health records is available and how to access their records.

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

Table A-11: Program Integrity

Total Score 81.00% Compliance Level Moderate Compliance



Question

Number Citation of Authority Question Score

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.

1

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

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),

Request that the MCO provide documentation for one newly enrolled provider that shows evidence that federal

0





Question

Number Citation of Authority Question Score

Subpart E - Federal Database Checks

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.

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


BCBS provided a policy stating that the Office of the Inspector General’s Excluded Parties List System (EPLS) would be searched but not the other exclusion databases the MCO is required to check. The MCO also provided a PDF of provider documents, which showed only a search of the CMS National Plan and Provider Enumeration System (NPPES) but not the other exclusion databases. In addition, the MCO policy referenced checking exclusion lists from other states but does not mention whether or not New Mexico has an exclusion list and if it is checked for excluded providers.


The MCO provided several documents for a specific provider for reenrollment. The documents only showed that the NPPES and EPLS were checked and not the Office of the Inspector General’s List of Excluded Individuals and Entities (LEIE) or the Social Security Administration’s Death Master File. In addition, in one of the documents provided by the MCO, the contracted provider documents indicated

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




there were two people with an ownership and a control interest and a managing employee of the contracted provider. However, the MCO did not provide evidence that these persons were also checked within the exclusion databases. This is required by the CFR and the MCO contract.

General: Program Integrity Documents

The MCO submitted several documents that did not follow the file assembly directions. These documents were not pertinent to the file assembly tool provided to BCBS, did not pertain to the period under review, were missing or the title in the file assembly tool was not identical to the title on the PDF submitted.

Program Integrity Recommendations


Upon enrollment and reenrollment of any provider, confirm the identity and determine the exclusion status of that provider and any person with an ownership or control interest or who is an agent or managing employee of the provider through routine checks of all the Federal exclusion databases as cited within 42 CFR 455.436(a)(b)(c)(1)(2). The MCO should be able to show clear evidence that these exclusion databases were checked, when they were checked and the results of the search. See the footnote following Table A-12 for a comprehensive list of required exclusion databases.

Implement a quality control (QC) process for checking documents submitted for external audit. This QC process would include a checklist, using the file assembly tool provided to the MCO, for the documents that are to be submitted for the review. The checklist could include that each document is present, that the file name listed in the roadmap is identical to the file name on the PDF, that the document is pertinent to the period under review and that all documents listed in the file assembly tool are uploaded to the secure portal at the same time.

Program Integrity Previous Year’s Recommendations Follow-up

The EQRO previously recommended that the MCO:

Amend its New Mexico-specific policies and procedures to include checking all the listed exclusion databases upon enrollment and reenrollment for contracted providers and those with an ownership or control interest or who are an agent or managing employee. Enrollment for atypical providers (transportation, home/community-based workers, etc.) appeared to be addressed but not enrollment or reenrollment for the other provider types. Additionally, the MCO should amend their policies and procedures to indicate that the LEIE and EPLS are checked monthly for all applicable persons, not just for atypical providers.

o Follow-up: This recommendation does not appear to have been addressed for the CY2016 review.

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




Conduct a review to identify contracted providers and any person with an ownership and control interest or who is an agent or managing employee, as identified by the provider enrollment documents, to ensure that all applicable persons have been checked.

o Follow-up: This recommendation does not appear to have been addressed for the CY2016 review.


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

Table A-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 State Children’s Health Insurance Program (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





Question

Number

Citation of


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

1

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

Table A-15: Provider Services



Table A-16: Provider Services

Question

Number

Citation of


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

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 A-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 A-17: Reporting Requirements



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

Table A-19: Self-Directed Community Benefit



Table A-20: Self-Directed Community Benefit

Question Number

Citation of Authority

Question Score

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 comprehensive needs assessment 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 While it did not constitute a scoring issue, some of the documents identified on the MCO submission list were not present in the original submission. BCBS identified a technical issue that resulted in the files not being transmitted to the EQRO. The issue was corrected. However, some of the documents that were present did not contain any bookmarking.

Self-Directed Community Benefit Recommendations


Submit and bookmark all documents provided on the submission list. Perform a quality check on documents prior to submission for EQR to make sure that all appropriate documents are included in the submission and that each document is accurately bookmarked.

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 A-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 A-21: Care Coordination



Table A-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 HRA

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?

1

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 A-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 Several documents in the original submission were either:

Not pertinent to the element on the file assembly tool

Not pertinent to the period under review

Missing

The stated title in the file assembly tool was not identical to the title on the PDF submitted

While these issues did not create a scoring issue, there is a potential risk to future scores if the appropriate documentation cannot be found during initial scoring or clarification.

If the documents submitted for an element do not pertain to that element and/or if the documents submitted do not fully cover the period under review, the EQRO reserves the right to assess penalty points for accuracy. Documents submitted should be pertinent and should be accurately listed in the file assembly tool.

Care Coordination Policy Review Recommendations


Implement a Quality Check process for checking documents submitted for external audit.

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

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 differ 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 in total were reviewed for this section. For example, the universe submitted by the MCO had 13 percent of its members as new and 87 percent continuously enrolled. Therefore, the sample consists of four (13 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 A-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 meet the requirement to receive full credit.

Table A-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?

2 4

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

1 4

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?

0 4

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?

1 4




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

Question

Number

Citation of

Authority Question

Number of

Deficient Files

Number of

Files

Reviewed

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

1 4

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 4

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 4

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

1 4

Care Coordination File Review for New Members Deficient Score Additional Detail


In two of four files, the HRA was not completed in a timely manner. In neither case was documentation submitted indicating BCBS made unsuccessful attempts to reach the member.


In one of four files, the letter to the member notifying them of the need to perform a CNA was not sent in a timely manner.


In one of four files, the CNA was not scheduled in a timely manner.


In one of four files, the CNA was not completed in a timely manner.


In one of four files, the CCP was not developed and authorized in a timely manner.




Care Coordination File Review for New Members Recommendations


Implement a process to improve the timeliness of completion of the HRA.

Capture the actual date of HRA completion in its system.

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


Complete all HRAs and CNAs within required timeframes and document their completion.

o Follow-up: Based on the documentation submitted for the CY2016 review, BCBS continues to have difficulty completing HRAs and CNAs in a timely manner.

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

Provide member notifications within required timeframes and document that activity.

o Follow-up: Based on the documentation submitted for the CY2016 review, BCBS appears to have addressed timely member notification and documentation of the notification.

Conduct a root cause analysis to determine why such a high percentage (46.67 percent) of sampled members refused care coordination.

o Follow-up: Based on the documentation submitted for the CY2016 review, BCBS has addressed this recommendation. In the sample for the CY2015 review, nearly 50 percent of the files involved members who had declined care coordination. In the current review, only one member (3 percent) was in this category. This is a significant achievement for BCBS. After performing a root cause analysis, BCBS implemented an outreach to members in CY2016 that utilized community health workers. Of members reached, 60 percent have reportedly accepted care. BCBS indicated that this new process was developed in direct response to the recommendation made in CY2015.

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 A-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 A-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 26

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 26

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?

1 26

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

7 26

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


In three of 26 files, the CNA was not completed within one year of the previous CNA.


In one of 26 files, there was no documentation of the member’s or the member representative’s participation in the CCP development.





In one of 26 files, there was no documentation indicating that the member or the member representative was offered but refused to participate in the CCP development.


A total of seven of 26 files were found to be deficient. In four files, the CCP was developed within 14 business days but the NF Level of Care (NFLOC) services were not authorized within the 14 business days. In three files, the CCP was developed within 14 business days but the care coordinator signature that indicates authorization of services was not present.

Care Coordination File Review for Continuously Enrolled Members Recommendations


Implement a quality check process for checking documents for the audit. During the clarification phase of the project, BCBS stated it had additional documentation that had not been provided with the files submitted to the EQRO.

The quality check process would include checking to be sure that supporting evidence for all questions in the file assembly tool has been provided and is bookmarked in each file.

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

In the CY2015 review, the Care Coordination File Review did not have two constituent parts. For the current review, the EQRO subdivided the Care Coordination File Reviews into two sets: one being those members who were new to the MCO in CY2016 and one being those who were enrolled in the MCO prior to CY2016. The audit was designed this way because the contract requirements vary between these two cohorts of members. The recommendations made in CY2015 are included above under the section Care Coordination File Review for New 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 A-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 A-25: Transitions of Care

Total Score 72.18% Compliance Level Minimal Compliance


Table A-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

Regarding Questions 3 and 4

Questions 3 and 4 specifically ask for the MCO policy but the MCO provided their Standard Operating Procedure (SOP) and Job Aid as evidence. The SOP and Job Aid support the process of creating the transition plan. Ideally, the EQR would review the policies that support the processes. However, the contract language does not specify what documentation is required; therefore, the EQRO will accept these as suitable documentation.




Transitions of Care Policy Review Recommendations


Align policy with its SOP documentation and Job Aid as supporting documentation for specifics related to ToC.

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


Update its policies to reflect the need to develop and implement specific, individual transition plans.

o Follow-up: Based on the documentation submitted for the CY2016 review, it appears that BCBS has addressed this issue.

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


BCBS submitted a full universe of 40 files; however, during subsequent discussion, it was discovered that BCBS had included member files in its initial universe that should not have been included. This information came after the files had been prepared, submitted and reviewed. There was insufficient time before the reporting deadline for BCBS to prepare a new sample. The EQRO removed the files from the sample, leaving 14 files in the current review.

The member files inappropriately included in the universe were:

Automated System Program and Eligibility Network members (ASPEN): These are Medicaid-eligible individuals with an enrollment record in the HSD system but whose enrollment with the MCO is not yet in effect.

Failed transitions: members for whom transition planning began but ultimately did not proceed.

Early transitions: usually, these are unexpected discharges.

Short-terms stays of less than 90 days in a NF.

Table A-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? 6 14

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

8 14

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

7 14

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

8 14

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

6 14

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

6 14

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

8 14

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

8 14




Transitions of Care File Review Deficient Score Additional Detail


In six of 14 files, there was insufficient evidence of a complete, discrete transition plan being created in advance of the member’s discharge from a NF. In these six files, all of the subsequent questions were then scored zero. In one file, the documentation indicated that the transition plan was created after the transition. At the site visit, BCBS stated that in cases of an unexpected discharge or against medical advice (AMA) departure, a transition plan is created retroactively to ensure member safety but that does not appear to be the case in this instance.


Since insufficient evidence of a complete, discrete transition plan was not present in six files, then this question was scored zero for those six files. In the remaining eight files for which a transition plan was present, two files had transition plans in which the assessments identified physical health needs that were not addressed in transition plan interventions.


Since insufficient evidence of a complete, discrete transition plan was not present in six files, then this question was scored zero for those six files. In the remaining eight files for which a transition plan was present, one file had a transition plan in which the assessments identified behavioral health needs that were not addressed in transition plan interventions.


Since insufficient evidence of a complete, discrete transition plan was not present in six files, then this question was scored zero for those six files. In the remaining eight files for which a transition plan was present, two files had transition plans in which the providers were not identified.


Since insufficient evidence of a complete, discrete transition plan was not present in six files, then this question was scored zero for those six files. In the remaining eight files for which a transition plan was present, all files sufficiently addressed the member’s housing needs.


Since insufficient evidence of a complete, discrete transition plan was not present in six files, then this question was scored zero for those six files. In the remaining eight files for which a transition plan was present, all files sufficiently addressed the member’s financial needs.


Since insufficient evidence of a complete, discrete transition plan was not present in six files, then this question was scored zero for those six files. In the remaining eight files for which a transition plan was present, two files had transition plans but were scored zero for this question. In one case, the member’s cognitive needs were not addressed in the transition plan. In the second case, there were identified memory issues with the member that were not addressed in transition plan interventions.





Since insufficient evidence of a complete, discrete transition plan was not present in six files, then this question was scored zero for those six files. In the remaining eight files for which a transition plan was present, two files had transition plans in which there was unclear documentation regarding the member’s safety needs.

Transitions of Care File Review Recommendations


Create, document and implement specific, individual transition plans that are informed by assessments and other data gathering activities and interactions to facilitate smooth, successful member transitions from NF to CB settings.

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


Create, document and implement specific, individual transition plans that are informed by assessments and other data gathering activities and interactions to facilitate smooth, successful member transitions from a NF to CB setting.

o Follow-up: BCBS has made strides toward improving documentation including soliciting and implementing EQRO input on the subject. Because additional improvement is needed, Recommendation #1 stands for the CY2016 review.

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

Update policies to reflect the need to develop and implemented specific, individual transition plans. o Follow-up: BCBS has updated their policies per Recommendation #2.

HSD instituted an IAP in October 2017 to address the continuing deficiencies.

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 A-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 A-28: Grievance and Appeal System



Table A-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 A-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

The EQRO made no recommendations in the previous EQRO report.

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 A-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 Systems; 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?

4 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?

3 30

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

1 30

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

1 30

Member Grievances File Review Deficient Score Additional Detail


In four of 30 files, BCBS did not meet the requirement to provide a written acknowledgment of its receipt of grievance to the member within the five-day timeframe.


In three of 30 files, BCBS did not meet the requirement to provide a written resolution of the grievance to the member within the 30-day timeframe.

Regarding Questions 4 and 5

In one of 30 files, BCBS included a letter addressed to someone other than the member in question. As a result, no resolution letter was provided for review. Therefore, the MCO did not receive points for these two questions.




Member Grievances File Review Recommendations


Identify a consistent process to provide written acknowledgment of its receipt of a grievance to

the member within five business days of the receipt of the grievance.

Identify a consistent process to resolve grievances and provide written resolution to the

member within 30 calendar days of the receipt of the grievance.

Compare UM policies and SOPs to 42 CFR 438.404 and make any adjustments necessary to be

fully compliant with government regulations.

Institute a quality management intervention to assist MCO personnel to ensure that each letter

is addressed to the appropriate member. Institute a quality management intervention to assist MCO personnel to ensure that files

prepared for EQRO compliance review are complete and accurate prior to submission.

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 A-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 Systems; 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?

8 30

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

0 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?

17 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 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 her right to request a State fair hearing?

0 30

Member Appeals File Review Deficient Score Additional Detail


In eight of 30 files, there were issues of timeliness. In six cases, the acknowledgement letter was late by one to two business days and in the remaining two cases, by 12 business days.


When the MCO communicates with a member to acknowledge the receipt of an appeal, there is language that must be included in the letter. Among other things, the MCO must advise the petitioner of the opportunity to present evidence and allegations of fact or law, in person as well as in writing. Three BCBS acknowledgment letters contained the following information for the member:

For more information about the appeal process, such as expediting your appeal, continuing benefits for services and fair hearings, please refer to the initial denial dated March 25, 2016




and/or your Blue Cross Community Centennial Member Handbook. Please let us know if you need another copy of that letter by calling the Appeal Unit at the number below with any other questions you may have. There is no charge for the call.

The EQRO observed that the MCO is reminding the members of some of their rights in the acknowledgment letter and offering to provide a copy of the original benefit denial letter to the member at no cost. However, the contract between HSD and the MCOs requires the language regarding presenting evidence in person also be included. Therefore, the MCO lost points for this question on 17 of 30 files.


In two cases, the written resolution of the appeals was provided after 30 calendar days had passed. In one case, it took the MCO 42 calendar days from the date of receipt of the verbal appeal to resolve the appeal and provide written notification to the member; in the other case, it took 50 calendar days to resolve the appeal.

Member Appeals File Review Recommendations


Identify a consistent way to provide written acknowledgment of the MCO’s receipt of an appeal within five business days of the receipt of the grievance.

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. Then follow through to ensure to provide the physical address at which the information may be delivered. The physical address can be in any part of the letter, including the letterhead and/or the footer. Alternately, consistently include the letter originally denying authorization of services or payment in appeals files that are being prepared for EQRO review as this letter contains the requisite language.

Identify a consistent way to resolve grievances and provide written resolution to the member within 30 calendar days of the receipt of the grievance.

Compare UM policies and SOPs to 42 CFR 438.404 and make any adjustments necessary to be fully compliant with government regulations.

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

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

Tables A-32 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 meet the requirement to receive full credit.

Table A-32: Member Expedited 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 Systems; 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?

4 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


In four of 30 files, the appeal was not resolved and/or the member was not notified of the appeal within the required timeframes. The federal language in 42 CFR 438.408(2) and (3) requires that the MCO notify members in writing for all appeals. Expedited appeals have the additional requirement of oral notice, usually done by telephone and this must be completed within 72 hours. Otherwise, no scoring issues were identified based on the questions used to conduct this quality review.




Member Expedited Appeals File Review Recommendations


Identify a consistent way to resolve expedited appeals and provide written resolution to the member within 72 hours of the receipt of the appeal.

Compare UM policies and SOPs to 42 CFR 438.404 and make any adjustments necessary to be fully compliant with government regulations.

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 A-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 A-33: PCP and Pharmacy Lock-ins



Table A-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 The MCO met all requirements and no deficiencies were identified.

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

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

0 30

2 4.22.2 Did the MCO provide a rationale for the PCP or Pharmacy Lock-in?

0 30

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


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 A-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 A-36: UM: Adverse Benefit Determinations



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

Question Number


Question Score

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 National Committee for Quality Assurance (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


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

Question Number


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 timeliness categories?

2 30

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

0 30

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

0 30

4 §438.404(a) and

§438.10(d)

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

9 30

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

2 30

UM: Adverse Benefit Determinations File Review Deficient Score Additional Detail


In two of 30 files, written documentation of the resolution was not provided to the member, so timeliness could not be calculated. Therefore, the files were marked as deficient for this question. These same two files were also marked off for Question 5 because of the absence of the denial letter.


The contract between HSD and the MCO requires that communications to the member be easy to understand. In nine letters reviewed, BCBS used medical terminology and internal coding to




communicate, without a plain language explanation included. The EQRO understands that the technical language is required; however, a plain language summary for the member is necessary to meet the contractual requirement that the letter be easy to understand.


In two of 30 files, the denial letter was not included; therefore, these files were found deficient. These same two files were also marked off for Question 4 because of the absence of the denial letter.

UM: Adverse Benefit Determinations File Review Recommendations


Consistently provide written denial of a service benefit to members.

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 along with the technical description that is required.

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

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


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, this issue has not been resolved.


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/