state of california—health and human services agency ...€¦ · -a document titled “mmum-012...

JENNIFER KENT DIRECTOR

EDMUND G. BROWN JR.

GOVERNOR

State of CaliforniaHealth and Human Services Agency Department of Health Care Services

December 13, 2016

John Baackes, CEO L.A. Care Health Plan 1055 W 7th Street, 10th floor Los Angeles, CA 90017

RE: Department of Managed Health Care Cal MediConnect Survey

Dear Mr. Baackes:

The Department of Managed Health Care conducted an on-site Cal MediConnect Survey of L.A. Care Health Plan, a Managed Care Plan (MCP), from July 20, 2015 through July 24, 2015. The survey covered the period of July 1, 2014 through June 30, 2015.

On December 13, 2016, the MCP provided DHCS with additional information regarding its Corrective Action Plan (CAP) in response to the report originally issued on May 10, 2016.

All items have been reviewed and found to be in compliance. The CAP is hereby closed. The enclosed report will serve as DHCS final response to the MCPs CAP.

Please be advised that in accordance with Health & Safety Code Section 1380(h) and the Public Records Act, the final report will become a public document and will be made available on the DHCS website and to the public upon request.

If you have any questions, feel free to contact me at (916) 552-8946 or Farzaneh

Aflatooni at (916) 319-8298.

Sincerely,

Jeanette Fong, Chief Compliance Unit

Managed Care Quality and Monitoring Division 1501 Capitol Avenue, P.O. Box 997413, MS 4400

Sacramento, CA 95899-7413 Phone (916) 449-5000 Fax (916) 449-5005

www.dhcs.ca.gov

http:www.dhcs.ca.gov

Enclosures: Attachment A CAP Response Form

cc: Stephanie Issertell, Contract Manager Department of Health Care Services Medi-Cal Managed Care Division P.O. Box 997413, MS 4408 Sacramento, CA 95899-7413

ATTACHMENT A Corrective Action Plan Response Form

Plan Name: L.A. Care Health Plan

Survey Type: DMHC CMC Medical Survey Report Review Period: 07/01/2014- 06/30/2015

MMPs are required to provide a CAP and respond to all documented deficiencies within 30 calendar days, unless an alternative timeframe is indicated in the letter. MMPs are required to submit the CAP via email in word format which will reduce turnaround time for DHCS to complete its review.

The CAP submission must include a written statement identifying the deficiency and describing the plan of action taken to correct the deficiency, and the operational results of that action. For deficiencies that require long term corrective action or a period of time longer than 30 days to remedy or operationalize, the MMP must demonstrate it has taken remedial action and is making progress toward achieving an acceptable level of compliance. The MMP will be required to include the date when full compliance is expected to be achieved.

DHCS will maintain close communication with the MMP throughout the CAP process and provide technical assistance to ensure the MMP provides sufficient documentation to correct deficiencies. Depending on the volume and complexity of deficiencies identified, DHCS may require the MMP to provide weekly updates, as applicable.

Deficiency Number and Finding

Action Taken Implementation Documentation

Completion/ Expected

Completion Date

DHCS Comments

1. Utilization Management #1

The Plan does not consistently issue routine preauthorization decisions within required timeframes.

To ensure that decisions for routine prior authorizations are issued within the required timeframes, L.A. Care will:

1. Reviewed and revised existing UM policies related to authorization of MLTSS services to ensure compliance with UM

1a. MMUM.PP047A Initial Organization Determination. 1b. MMUM.DP047A Initial Organization Determination. 1b MMUM.PP-012

1a. 1/8/16 1b. 1/21/16

10/14/15 1c. 1/6/16

5/21/15

2a. 1/5/16 2b. August

6/10/16 The following documentation supports the MMPs efforts to correct this finding:

-A document titled MMUM-012 Attachment B- Utilization Management Timeliness Standard for CMC Centers for Medicare and Medicaid Services (CMS) (5/21/15) to show timeframes to make Prior-authorization




Completion Date

DHCS Comments

decision making timeframes. The policies include the process for requesting extensions for UM

Timeliness of UM Decision Making 1c. MMUM-012

2015 decisions for CMC meet the requirements.

-Power Point training, Utilization decision making. Attachment A UM 3a. 7/31/15 Management (UM) (August of 2016) which

Timeliness 3b. 7/31/15 educates staff on processing UM prior2. Reviewed and revised MLTSS Standards 3c. 8/6/15 authorizations within the required training materials to ensure the appropriate regulatory timeframes are included.

1c. MMUM-012 Attachment B UM Timeliness Standards

3d. 12/1/15 timeframes. MMP sent a revised slide via email (10/12/16) which is part of this P&P training to elaborate the 5 working day timeframe necessary to make the decision.

3. Provide targeted training to 4a. 6/20/16 CBAS/LTC Staff on processing 2a. Turn Around 4b August -A document titled CBAS Authorization UM authorizations within the regulatory timeframes.

4. Authorization monitoring and oversight program which includes electronic alert notifications for all authorizations using the due date for resolution based on the request type (urgent/standard) now include MLTSS

Compliance Grid 2b. Utilization Management (UM) Training

3a CBAS Auth Process 073115 3b CBAS Auth Workflow_ Nurse Specialist 07312015 3c CBAS Cross-functional Workflow 20150806 3d. CBAS Auth Workflow_ Coordinator 1201151i

2015 Workflow (12/01/15) as evidence that the authorization coordinator receives guidance on how to process prior-authorizations timely including the 14-calendar extension if necessary.

-A documents titled CBAS Authorization for Nurse Specialist (07/31/15) as evidence that the nurse specialist receives guidance to process prior-authorizations timely according to the requirements.

-A tool template for internal audit which MMP has developed to monitor UM process. The tool includes monitoring for timely decision making.

-An example of daily notification of a past due case as an evidence that shows MMPs oversight of timely prior-authorization

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Completion Date

DHCS Comments

4a. Clinical Reviewer Audit Tool 4b. Example of daily notification of past due auths

process.

10/14/16 The following additional documentation submitted supports the MMPs efforts to correct this finding:

-Updated Policy MMUM-012 attachment B Timeliness standard for Call Mediconnect (CMC) (10/11/16) which has been amended to include required the 5 working day timeframe to receive information to render a decision.

This finding is closed.

#2 To ensure that written notifications 1.1a MMUM.PP 1a. 10/14/15 6/10/16 The following documentation to the provider and enrollee are 012 Timeliness of 1b. 5/21/15 supports the MMPs efforts to correct this

The Plan does not consistently made within the UM Decision 1c. 1/8/16 finding: consistently notify the required timeframes, L.A. Care Making 1/21/16 provider and enrollee will: 1.1b. MMUM-012 1d. August -A policy titled UM-108: Delaying A Prein writing when itcannot make a decision within the required timeframe.

1. Reviewed and revised existing UM policies related to authorization of MLTSS services to ensure compliance with notification to the member and provider to advise them of the need for an extension to acquire the information in order to make the determination. This includes any face to face evaluations for MLTSS services.

Attachment B UM Timeliness Standards c. MMUM.PP047A Initial Organization Determination. 1c. MMUM.DP047A Initial Organization Determination. 1d. UM-108

2015 Service Authorization Request which outlines processes for delaying a UM preservice decision.

10/14/16 The following additional documentation submitted supports the MMPs efforts to correct this finding:

-Updated Policy UM-108 Delaying a Pre-Service Request (10/11/16) which has been amended to add the contract language that plan will notify provider and member of the

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Completion Date

DHCS Comments

2. Reviewed and revised MLTSS training materials to ensure the appropriate regulatory timeframes are included, and the process for notification to members and

Delaying a Pre-Service Authorization Request

anticipated date on which a decision is made when there is a delay in the process.

-Template of MMPs CMC approved deferral letter sent to the members to inform them that an extension is needed to request

provides when an extension is 2a. Turn Around 2a. 1/5/16 further information. necessary. Compliance Grid 2b. August

3. Provide targeted training to CBAS/LTC Staff on processing UM authorizations within the

2b. Utilization Management (UM) Training

2015 This finding is closed.

regulatory timeframes and written 3a CBAS Auth 3a. 7/31/15 notification process. Process 073115 3b. 7/31/15

3b CBAS Auth 3c. 8/6/15 4. Review and revise, as needed, the monitoring and oversight program includes assessing cases for the presence of written notification of the extension when additional information is necessary to complete a prior authorization decision

Workflow_ Nurse Specialist 07312015 3c CBAS Cross-functional Workflow 20150806 3d. CBAS Auth Workflow_ Coordinator 1201151i

3d. 12/1/15

4a. Clinical Reviewer Audit Tool

4. 6/20/16

2. Case Management and Coordination of Care

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Completion Date

DHCS Comments

#3 To ensure the plan will notify 1a. HRA UTC 1a. 7/1/16 6/10/16 The following documentation

The Plan does not PCPs of new enrollees who have not completed a Health Risk

Letter CMC EN CMC

1b. 7/1/16 supports the MMPs efforts to correct this finding:

notify PCPs ofenrollment of new enrollees who have not completed aHealth Risk Assessment.

Assessment (HRA), LA Care will:

1. The In-House HRA process will automatically generate two items:

a. An Unable to Contact enrollee letter with the enrollee PCP ccd.

b. A blank LA Care Health Risk Assessment (HRA) form.

2. Update LA Care P&P, MMCM008 to reflect the new policy of PCP notification for new enrollees who have not completed a Health Risk Assessment.

11-04-16 Updated MMP Response:

2014_LAC_0039_ HRA UnabletoCtct_Eng

1b. LA1285 CMC HRA 021015 LACare_Eng

2. MMCM-008 HRA for CMC 2016-0531_HoArev (2) _ae edit_6.1.16

2. 6/2/16 -Updated P&P, MMCM-008, Health Risk Stratification and Assessment for Cal MediConnect Members (5/31/16) which was amended to include L.A. Care will notify PPGs/PCPs of enrollment of any new member who has not completed a HRA within the time period of 45 or 90 days from their enrollment date, according to their initial stratification. The PPG/PCP notification will include language to encourage PCPs to conduct outreach to these members and schedule visits. (page 6, 2.11)

-A template letter that is sent to members informing them that the MMP has been unable to contact them for completion of the HRA. The letter includes a blank HRA form for easy access and the PCPs are ccd on the letter.

10/20/16 The following additional documentation submitted supports the MMPs efforts to correct this deficiency:

With regards to the attachment 3, the letter template, Provider Relations of L.A. Care will

-Written response indicating that the plan has drafted the PCP notification letter which informs providers to access the portal to

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Completion Date

DHCS Comments

complete sending out this onetime communication to the PCPs this November. Starting in December and monthly thereafter, Case Management department of LA Care will start sending out the list of unable to contact members manually to the PCPs until the original plan of an automated process is in place. All Participating Physician Groups with CalMediConnect line of business were trained on how to access the provider portal during the beginning of the year and midyear using the attachment 3, power point slides, and similar slides. This November, along with the letter template, our Provider Relations will provide all PCPs guide on how to access the HRA summary list in the Provider Portal. The HRA summary list includes members who completed HRAs and unable to contact members.

retrieve the monthly list of members who have not completed the HRA.

-Accessing the Provider Portal for Accessing HRAs PowerPoint (08/01/16) as evidence that providers were trained on the process of accessing the provider portal to retrieve the list of members who have not yet received the HRA.


-Written response from MMP clarifying that MMP will send the providers the proposed Unable to Contact New Enrollees to Complete an HRA letter beginning November 2016. MMP will manually send providers a list of members who have not completed the HRA in December 2016 and each month thereafter until the provider portal is in use. All providers have received training on the portal.


#4 To ensure that Health Risk 1. Business 1. 7/1/16 6/10/16 The following documentation Assessments (HRAs) are Requirement 2. 7/1/16 supports the MMPs efforts to correct this

The Plan does not consistently completed within the Document (BRD) 3. 7/1/16 finding: consistently complete required timeframes, LA Care will: CCA Case Mgmt 4. 1/1/17 Health Risk In-House HRA -A document titled Business Requirements

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Completion Date

DHCS Comments

Assessments within required timeframes.

1. Transition from a vendor based HRA (APS) to an LA Care In-House HRA.

2. The In-House HRA at a minimum will allow Member Services to see, at a GLANCE, those that NEED to complete the attempts within the stated time frames so we can ensure proper handling from an ATTEMPT perspective.

3. Face to Face HRA encounters by MSSP providers.

4. Strategic vision of having on-site Care Teams at the Family Resource Center (FRC) Palmdale location starting January 2017.

10/20/16 Update:

There are 3 types of monitoring, starting with monthly monitoring of outreach attempts. Followed by monthly audits of staff performance related to HRA, and lastly, LA Care completes data validation of reports prior to submission to Regulatory bodies.

Addendum_V1.5

2. CM In-House HRA forCSP+ Workflow_V0.0

3. (MSSP provider agreement-pending)

4. LAC1052 StrategicVision LetterSize_102915

Document for CSPPlus CCA Case Management Implementation Addendum: Member Services Activities I CM Module as evidence that the MMP has processes in place to ensure that repeated attempts are made to ensure timely completion of HRA.

-LA Care CSPPlus Health Risk Assessment (HRA) Administration in CCA Work Flow which shows that the MMP has processes in place to ensure that repeated attempts are made to ensure timely completion of HRA.


-Three sample screenshots as evidence of timely completion of HRAs for the high risk and the low risk members.

-In-Person HRA Completed by MSSP Providers report which shows the total number of HRAs requested and completed for all four contracted MSSP providers on a monthly basis (July, August and September 2016). The corresponding LA Care Cal MediConnect Face-to Face Health Risk Assessment (HRA) Communication Log/Tracking Sheet provides documented evidence of outreach attempts and tracking

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Completion Date

DHCS Comments

All HRA monitoring findings are discussed during LA Cares weekly meetings.

11/10/16 Update: In the current operational process, all members are treated high risk. This gives LA Care a have a higher chance of reaching the members and a higher HRA completion rate.

FYI -During the HRA in-house transition phase, the initial stratification based on claims are not fully set up in our core system (CCA), so all members are treated high risk. We followed the same concept in the DPL that if data is not available, members must be stratified as high.

The 90 days pertains to the Medicare-Medicaid Capitated Financial Alignment Model Reporting Requirements under CORE 2.1 Members with an assessment completed within 90 days of enrollment.

for MSSP members.

-Various flow charts (HRA Outreach Monthly Monitoring Process; MORE Teams CMC Welcome Call/HRA Audit Process Workflow; Initial HRA Outreach Requirements for CMC Business Process Workflow; Workflow Process for Monitoring CMC HRA Data that demonstrate processes are in place to ensure monitoring of timely HRA completion including outreach attempts.

-CSC Workgroup Meeting Agenda/Minutes (10/19/16) as evidence that the MMP is discussing member outreach regarding HRA completion for CMC members.


-Additional CSC Workgroup Meeting Agenda/Minutes (10/25/16) as evidence that the MMP continues to review and discuss HRA completion. Minutes show review of monthly audit results regarding HRA completion (September and October 2016). Documentation includes raw data.

-Clinical Assurance HRA Data Validation audit results (Q2 and Q3 2016) as evidence that MMP is conducting quarterly audits to

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Completion Date

DHCS Comments

monitor HRA completion, outreach attempts, etc. 30 files are sampled on a quarterly basis.


#5 To ensure that Individualized Care 1a. MOC and CA 1a. 4/28/16 6/10/16 The following documentation Plans (ICPs) integrate HRA Reporting 1b. 4/20/16 supports the MMPs efforts to correct this

Individualized Care information, enrollee Requirements 1c. 4/20/16 finding: Plans (ICPs) are not developed in a timely

goals/preferences, measureable objectives and timetables for

Training Calendar. 1b. MOC Training

1d. 4/5/15 -A training calendar and sign-in sheets as

manner and do medical needs, including Attestation 2a. 4/12/16 evidence that multiple trainings were not consistently Behavioral Health and MLTSS InHouse 2b. 4/12/16 provided to educate the staff on ICPs. integrate information needs; all developed in a timely 1c. MOC Training 2c. 4/12/16 from the HRA and fail manner, LA Care will: Attestation 2d. 4/26/16 -Power Point training titled CMC Model of to include enrollee Synermed 2e. 4/26/16 Care & CMC Reporting Requirements goals and 1. Develop and educate 1d. CMC MOC 2f. 5/13/16 Updates & Feedback (3/24/16) as evidence preferences, PPGs on best practices for Updates and 2g. 5/13/16 that providers were trained on timely ICP measurable objectives ICP completion. Feedback 2h. 6/17/16 completion with incorporation of member and timetables to meet 2. Develop and educate LA 2i. 6/17/16 input and problems identified in the HRA. medical needs, Care clinical staff on best 2a. 4.12.16 CM 2j. 7/15/16 Behavioral Health and LTSS needs.

practices for ICP completion.

Workflow Process 2b. 4.12.16 CCM

2k. 7/15/16 -Power Point training titled QI 5 Complex Case Management (3/14/16) as evidence

3. Develop and Audit Tool for inclusion of Behavioral

Training - 041216 Attendance Sheet

3. 5/31/16 that providers are trained on using HRA information to develop ICPs with

Health and MLTSS needs. 4. Monitor and oversight for

proper documentation of ICPs.

2c. 4.12.16 QI 5 Complex Case Management PowerPoint 2d. 4.26.16 CCM Scenario 1_advce dementia

4. 5/31/16 measureable goals.

-Case scenario samples of members with various conditions as evidence that providers were trained on incorporating the members medical, functional, behavioral, and social needs into the ICP.

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Completion Date

DHCS Comments

caregiver support 2e. 4.26.16 CP Training Sign-In 2f. 5.13.16 CCM Scenario 2_brain injury multiple comorbidities 2g. 5.13.16 CP Training Sign-In 2h. 6.17.16 CCM Scenario 3 COPD_Lung Cancer 2i. 6.17.16 CCM Training Attendance (Pending) 2j. 7.15.16 CCM Scenario 4_No PCP Mental Health Issues 2k. 7.15.16 CCM Training Attendance (Pending)

3. 2016 CM NCQA MOC Audit Tool 5.31.16

4. 2016 CM NCQA MOC Audit Tool


-Updated P&P MMCM-005 Individualized Care Plan (01/21/16) which has been amended to include language regarding IPC requirements, including but not limited to, goals and objectives including measurable outcomes, required timeframes, and development of the IPC by qualified and licensed staff.


-Desktop procedure, MMCM.DP-001A: 10.2 Case Review Audit (11/03/16) as evidence that Care Management clinical supervisory staff conduct case review of 10 cases on a monthly basis.

-Corresponding CM File Review Worksheet blank audit tool as evidence MMP has created a monitoring tool to ensure ICP integrates results of the HRA including behavioral health and LTSS needs when conducting audits.

-Two sample HRAs and corresponding ICTs

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Completion Date

DHCS Comments

5.31.16 which document evidence of timely completion of ICP and integration of HRA identified needs.

-CM Case Type Report (9/1/16-9/30/16) which tracks timely completion of ICPs.


4. Members Rights #6 To ensure that the Plan 1a. Revised Call 1a. 7/1/16 6/10/16 The following documentation

consistently considers enrollee Center Procedure 1b. 7/1/16 supports the MMPs efforts to correct this The Plan consistentlyfails to consider

expressions of dissatisfaction as grievances, L.A. Care will:

Member.Provider Grievances

1c. 7/1/16 finding:

enrollee expressions of dissatisfaction as 1. Review and revise, as

Addendum 1 1b. Revised Call

2. 9/1/16 -Revised desktop procedure, Addendum #1 Appeals & Grievances FAQs as evidence

grievances. necessary, Member Services desktop procedures.

Center Procedure Member. Provider

3. 9/1/16 that member services staff receive guidance on how to assess and process any

2. Review and revise, as Grievances Addendum 2

4. 8/1/16 expression of dissatisfaction correctly according to the requirements.

necessary, Member Services P&Ps for grievance identification.

3. Train Member Services staff on the identification of grievances.

4. Revise monitoring process to include validation that staff are correctly identifying grievances.

5. Monitor/report staff performance.

1c. Member Rights #6 Call Center Procedure Member.Provider Grievances

2. Revised MS P&Ps (pending)

3. MS training calendar (pending)

5. 8/1/16 -A document titled Addendum #2 CC 17 Member and Provider Quick Documentation Reference (7/1/16) which provides guidance, examples, and different scenarios for the member service staff on how to document and resolved grievances received accurately according to the requirements.


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Completion Date

DHCS Comments

4. MS quality audit tool -Desk Level Procedure, DLP-17, Member (pending) Grievance Process (10/24/2016) as

evidence that member service staff received 5. MS quality guidance on how to distinguish inquiries audit tool from grievances/complains and different (pending) ways of documenting and handling inquiries,

grievances and exempt grievances.

-Desk Level Procedure, DLP-017B, Data Reporting & Analysis of Inquiries, Grievances, Exempt Grievances, and Appeals to demonstrate that MMP has separate call type codes for inquiries, exempt grievances, standard grievances, and appeals. In addition, MMP has separate exempt grievance codes for tracking and trending purposes.

- Inquiry and Grievance Process audit results (10/24/16-10/27/16) as evidence that MMP reviewed a sample of standard grievances, exempt grievances, and inquiries for accurate coding and documentation.

-PowerPoint training, Complaints/Grievances and Potential Quality Issues (10/14/16) as evidence that training was provided for member services staff. The training materials address correct ways to identify inquiries,

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Completion Date

DHCS Comments

complaints/grievances.


#7 To ensure that the Plan 1a. AG. DP-008A 1a. 9/1/16 11/7/16 The following documentation

The Plan does not consistently includes the required Department contact information in

(pending) 1b. AG. DP-007A

1b. 9/1/16 submitted supports the MMPs efforts to correct this deficiency:

consistently include the required

grievance acknowledgment and resolution letters, L.A. Care will:

(pending) 2. 9/1/16 -A template A&G Acknowledgment and

Department contactinformation in 1. Revise DTP to address the

2. 2016 Training Schedule (Jan

3. 9/1/16 Resolution Letter Pre-Mail Checklist (9/16/16) as evidence that MMP has a

grievance requirement that the Department's Dec) (pending) 4a. 9/1/16 process in place to ensure that the required acknowledgment and resolution letters.

contact information is included in written grievance response. 3. Pre-mail

4b. 9/1/16 DMHC language is included.

checklist 5a. 9/1/16 11/23/16 The following additional 2. Conduct staff training on the requirement.

3. Develop Pre-Mail Checklist process to ensure information is included.

4. Monitor and provide oversight for compliance.

5. Revise QA Audit process to include assessment that Department contact information is included.

developed and implemented (pending)

4a. A&G Audit Tool_Revised (pending) 4b. A&G Monthly Audit Scope_Revised (pending)

5a. A&G Audit Tool_Revised

5b. 9/1/16 documentation submitted supports the MMPs efforts to correct this deficiency:

-Draft templates of grievance acknowledgement letter and resolution letters (11/23/16) which was amended to add the required language. MMP has stated that these templates will be submitted to CMS for approval and will be utilized as soon as they are approved.


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Completion Date

DHCS Comments

(pending) 5b. A&G Monthly Audit Scope_Revised (pending)

#8 To ensure that members with 1a.AG 008A 1a. 7/1/16 6/10/16 The following documentation limited English proficiency have Desktop 1b. 7/1/16 supports the MMPs efforts to correct this

The Plan does not adequately ensure

access to, and can fully participate in, the grievance system, L.A.

Procedure 1b. AG 007A

1c. 9/1/16 finding:

that members with limited English

Care will: Desktop Procedure

2. 7/1/16 -A draft of the revised resolution letter (9/1/16) which was edited to address

proficiency have 1. Modify A&G policies and letter 1c. Revised 3. 9/1/16 linguistic needs of members with limited access to, and can fully participate in, the

workflows to ensure language insert is present.

Resolution Letter 1d. Revised

4. 9/1/16 English proficiency.

grievance system. Acknowledgement 4a. 9/1/16 -Revised P&P, Desktop Procedure AG. DP2. Review process to validate member's preferred language for written communication and revise as needed.

3. Train A&G staff on the identification and utilization of appropriate templates in various threshold languages.

4. Revise monitoring process to include validation that resolution letters are sent in the member's threshold language and contain specific language that provides

Letter (pending)

2. AG. DP-008A

3. Training for Threshold Templates-Pending

4a. A&G Monthly Audit (pending) Scope_Revised 4b. A&G Audit Tool-Revised (pending)

4b. 9/1/16 008A: Grievance Processes for Members (9/1/16) which was edited to add required information about availability of linguistic services in the acknowledgment and resolution letters.


-Results of a focus audit of grievance resolution letters (May - July 2016) as evidence that MMP reviewed letters on a weekly basis to ensure they were sent in the members threshold language.

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Completion Date

DHCS Comments

the member the option to request a fully translated letter within 5 business days.

5. Develop acknowledgement and resolution letter checklist to ensure the language insert is attached prior to mailing.

-Acknowledgment and Resolution letter checklist which ensures that the language block is attached and the letter is translated in the members threshold language if applicable.

- CalMediConnect_Languageblock that is included on all grievance acknowledgment and resolution letters, informing members of the availability of free translation services.

-Sample acknowledgment and resolution letters sent to the members as evidence that the letters include the CMC language block.

-A&G Team meeting agenda (8/16/16) agenda as evidence that MMP provided a refresher training on using the correct letter template.


#9 To ensure that the Plan 1a. AG. DP-008A 1a. 9/1/16 11/7/16 The following documentation

The Plan did not acknowledges receipt of each grievance in a timely manner and

(pending) 1b. AG. DP-007A

1b. 9/1/16 supports the MMPs efforts to correct this finding:

acknowledge receiptof each grievance in a

includes the date of receipt and the name, telephone number, and

(pending) 2. 9/1/16 -Acknowledgment and Resolution letter

timely manner anddid not include the

address of the Plan representative, L.A. Care will:

2. 2016 Training Schedule (Jan

3. 9/1/16 checklist which ensures that the acknowledgement letter includes the receipt

date of the receipt and Dec) (pending) 4a. 9/1/16 date of the grievance and information the name, telephone 1. Revise DTP to address the 4b. 9/1/16 regarding the MMPs representative.

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Completion Date

DHCS Comments

number, and address of the Plan representative who may be contacted about the grievance.

requirement that the required information is to be included in acknowledgment and resolution letters.

2. Conduct staff training on the requirement.

3. Develop Pre-mail Checklist process to ensure information is included.

4. Monitor and provide oversight for compliance.

5. Revise QA Audit process to include assessment that required information is included.

3. Pre-mail checklist developed and implemented (pending)



5a. 9/1/16 5b. 9/1/16

-Samples of acknowledgment letters and resolution letters sent to the members as evidence that the letters have provided required information (date of the receipt of the grievance and the name, phone number, and address of Plan representative)

-A&G Team meeting agenda (8/16/16) agenda as evidence that MMP provided a refresher training on using the correct letter template.

-Updated P&P, AG-007, Appeal Processes for Members (8/19/16) which was amended to include required information (date of the receipt of the grievance and name, phone number, and address of Plan representative) in letters sent to members (page 5; Section 2.3.2.9)


-Revised grievance letters audit tool which was edited to add a column to ensure that the acknowledgment letters are sent within five working days.


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Completion Date

DHCS Comments

#10 To ensure that the Plan consistently provides a clear and

1. Revised Training module

1. 5/27/16 6/10/16 The following documentation supports the MMPs efforts to correct this

The Plan does not consistently provide a

concise explanation and addresses all issues included in 2. Revised

2. 7/1/16 finding:

clear and concise explanation or

member grievances., L.A. Care will:

Grievance Resolution Letter

3. 5/31/16 -A draft of revised grievance resolution letters (7/1/16) to ensure concern of the

address all issues Template 4a. 9/1/16 compliant is reflected in the letter properly. included in member grievances.

1. Revise A&G training materials to include identification of all 3. Cultural

4b. 9/1/16 -PowerPoint training, How to Identify and

aspects of grievance. Competency PowerPoint

5. 7/1/16 address all complaints/concern(s) in the resolution letter (4/27/16) as evidence that

2. Revise the grievance letter 6a. 9/1/16 staff has received training. The training resolution template to ensure all elements of the complaint are

4a. Plain Language Training

6b.9/1/16 materials address how to identify concerns, steps to take when reviewing the evidence

numbered to match the resolution. & Readability 7a. 9/1/16 and steps to take to compose a final letter

3. Use of Health Literacy Advisor w/Health Literacy Advisor (pending)

7b. 9/1/16 according to the requirements.

software to assess reading level of 4b. writing in 8a. 9/1/16 11/7/16 The following documentation written documents. Plain Language &

Readability 8b. 9/1/16 supports the MMPs efforts to correct this

finding: 4. The Health Education Unit will provide training sessions for staff on use of software as well as how to write in plain language.

5. Make the training available as an e-learning module on L.A. Cares Learning Management System for anytime learning.

6. Revise the quality review process to include review of

Testing with Health Literacy Advisor Training Flyer (pending)

5. Learning Source Snapshot

6a. A&G Monthly Audit Scope_Revised (pending)

9. 9/1/16 -Results of a focus audit of grievance resolution letters (May - July 2016) as evidence that MMP reviewed letters on a weekly basis to ensure letters addressed all of the members concerns and that the resolution language was clear and concise.

-Acknowledgment and Resolution letter checklist which ensures that the letter includes a clear and concise explanation of the MMPs decision.

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Completion Date

DHCS Comments

resolution letters to identify opportunities for improvement.

7. Review and revise Audit Scope to include 30% per specialist

8. Conduct one-on-one trainings with each staff member, focusing on areas of opportunity.

9. Monitor/report staff performance.

6b. A&G QA Audit Workflow-Revised (pending)

7a. A&G Monthly Audit Scope_Revised (pending) 7b. A&G QA Audit Workflow-Revised (pending)

8a. 2016 Training Schedule (Jan Dec) (pending) 8b. A&G Staff Training (pending)

9. Enhance monitoring and reporting staff performance scope (pending)


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Completion Date

DHCS Comments

5. Quality Management #11

The Plan does not include monitoringand improvement of Long-Term SupportServices (LTSS) in its

L.A. Care will include monitoring and improvement of Managed Long Term Services and Supports (MLTSS) in its Quality Improvement Program by:

Review the 2016 MLTSS


- MLTSS Program Description (2016) which includes a description of the various LTSS provided by the MMP including goals

Quality ImprovementProgram.

program performance goals and measures, including monitoring use of non-emergency and non-medical transportation by L.A. Care members enrolled in MLTSS

Ensure that that the MLTSS performance goals and measures are included in L.A. Cares 2016 Quality Improvement Program

Develop a performance

2016 MLTSS Program Description

7/17/16 and structure of the program.


-An email response explaining that the MLTSS Program Description is an extension of the 2016 QI Program Description.

-Quality Oversight Committee meeting minutes (8/22/16) which provide evidence of MLTSS and QI Departments collaboration

measure matrix, which includes a reporting calendar and quality improvement structure for MLTSS

11/02/16 Update: The 2016 QI Program Description mentions MLTSS in several areas, but does not have a complete description of their program from a

9/30/16 on a State-required PIP. Minutes document approval of the revised 2016 MLTSS Program Description.

-MLTSS Program Description Matrix (8/17/16).


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Completion Date

DHCS Comments

QI perspective. The 2016 QI Program Description was approved earlier this year and the 2016 MLTSS Program Description was approved as a separate document by the QOC, but it is essentially an extension of the QI Program Description. For 2017, it will be more fully integrated into the QI Program Description.

Submitted by: John Baackes Date: June 10, 2016 Title: Chief Executive Officer

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Utilization ManagementCase Management and Coordination of CareMembers RightsQuality Management

state of california—health and human services agency ...€¦ · -a document titled “mmum-012...

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