MAC Binder Section 10 –Operational Status & UM...

MAC Binder Section 10 –Operational Status & UM Reports

Table of Contents with Document Summary

Located online at http://chfs.ky.gov/dms/mac.htm

1 – KY MMIS Operational Status Report November 2017

This report is contractual deliverable produced by the Department’s Fiscal Agent on a monthly basis, which summarizes operational duties performed by the Fiscal Agent. It provides statistics related to claims, encounters loads and change orders. In addition, it provides a status update as to the inventory for FFS financial adjustments and the provider relations team activates.

2 – UM Status Report Nov 2017 This report is produced on a monthly basis and provides statistics related to the operational duties of utilization management.

http://chfs.ky.gov/dms/mac.htm

Operational Status Report Kentucky MMIS Project

Cabinet for Health and Family Services

Department for Medicaid Services November 2017

Cabinet for Health and Family Services Department for Medicaid Services

Role: Name:

Author Janet Penn

Reviewer Donna Sims

HP Enterprise Services Management Richard DeGise, Account Executive

Client Commissioner Stephen P. Miller Medicaid Systems Director Stacy Fish

DELIVERABLE TITLE: Operational Status Report

DATE SUBMITTED: November 15, 2017

FILE NAME: 2017_11_KY_MMIS_Operational_Status_Report.docx

AUTHORING TOOL: Microsoft Word 2007

Commonwealth of Kentucky New KY MMIS Operational Status Report

Status Month Ending October 2017 Page 2

Table of Contents

1 Executive Summary ............................................................................................................................ 3 1.1 Change Order and Defect Statistics ............................................................................................. 5 1.2 Change Order and Defect Statistics (continued) .......................................................................... 6

2 Unplanned System Outages .............................................................................................................. 7 2.1 Billable Hours Usage Summary (Contract Year 2017) ................................................................. 8 2.2 Running Total (Contract Year 2017) ............................................................................................. 8

3 Monthly Ad hoc Requests ................................................................................................................ 10 3.1 Inventory Summary ..................................................................................................................... 10

4 FFS Paper Claim Receipt Statistics ................................................................................................ 16

5 Electronic Claims Processed ........................................................................................................... 17

6 Monthly FFS Claim Totals by Media ................................................................................................ 18

7 Monthly Claims Operations .............................................................................................................. 19 7.1 FFS Monthly Financial Cycle Summary...................................................................................... 19 7.2 Monthly MCO & NEMT Capitations ............................................................................................ 20 7.2 Monthly MCO & NEMT Capitations (continued) ........................................................................ 21 7.3 FFS Adjudicated Original Claims (By Claim) .............................................................................. 22 7.4 Monthly FFS Top Ten Procedure Codes .................................................................................... 23 7.5 Monthly FFS Top Ten Diagnosis Codes ..................................................................................... 23 7.6 Monthly MCO Top Ten Procedure Codes .................................................................................. 24 7.7 Monthly MCO Top Ten Diagnosis Codes ................................................................................... 24 7.8 Monthly FFS Top Ten Denial Reasons (By Detail Line) ............................................................. 25 7.9 Monthly FFS Top Ten Suspense Reasons (By Detail Line) ....................................................... 25 7.9 FFS Suspended Original Claims by Age (By Claim) .................................................................. 26 7.10 FFS Claims Suspense Over 30 Days by Responsible Unit (By Claim) ...................................... 26

8 Monthly Third-Party Liability ............................................................................................................ 27 8.1 FFS Third-Party Liability Monthly Activity ................................................................................... 27

9 Monthly Finance/Adjustments ......................................................................................................... 28 9.1 Monthly FFS Financial – Accounts Receivable .......................................................................... 28 9.2 Monthly FFS Financial - Checks ................................................................................................. 28 9.3 Monthly FFS Financial – Adjustments ........................................................................................ 28 9.4 Monthly FFS Financial - Mass Adjustments ............................................................................... 29

10 Provider Relations ............................................................................................................................ 30 10.1 Provider Field Representatives ................................................................................................... 30

10.1.1 Provider Visits ................................................................................................................ 30 10.2 Conference Calls (Calls Greater Than 30 Minutes) ................................................................... 30 10.3 Association Meetings .................................................................................................................. 31 10.4 Provider Contacts ....................................................................................................................... 31 10.5 Provider Workshops.................................................................................................................... 31 10.6 Provider Services ........................................................................................................................ 32

10.6.1 Provider Services ........................................................................................................... 32 10.6.2 Top 5 Provider Calls ...................................................................................................... 33 10.6.3 Notable Topics ............................................................................................................... 33

10.7 Commonwealth Training ............................................................................................................. 34 10.7.1 Current Activities ............................................................................................................ 34

11 EDI Customer/Provider Interaction ................................................................................................. 35 11.1 Electronic Data Interchange Calls Received .............................................................................. 35 11.2 EDI E-mails and Faxes Received ............................................................................................... 37



1 Executive Summary

November Page Number

Claims Processed 920,880 Page 16

Total Dollars Paid $205,803,218.30 Page 19

Claims Paid 691,818 Page 19

Claims Denied 229,062 Page 19

% Denied Claims 24.87% Page 19

Average Claims Held in Cash Management

85,635 N/A

Average Dollars Held in Cash Management

$14,450,366.58 N/A

Capitation Financial Transactions 2,789,637 Page 20

Capitation Financial Payments $626,459,284.99 Page 20

Suspended Claims 10,961 Page 26

Total Suspended Claims > 90 Days 892 Page 26

Provider Services Calls Received 9,1 Page 32

Provider Services Current Service Level %

98% Page 32



Encounter Load Statistics

Managed Care Organizations (MCOs)

June 2017

July 2017

August 2017

September 2017

October 2017

November 2017

Coventry 860,207 788,964 862,541 1,103,453 877,481 843,506

Humana 529,968 470,700 709,086 726,126 621,437 514,843

Kentucky Spirit 0 0 0 0 0 0

Passport (R03) 77 19 13 48 40 3

Passport R31 1,154,588 1,090,816 1,162,861 1,379,855 1,289,248 1,270,295

WellCare 1,825,279 1,640,246 1,641,554 2,224,485 1,780,502 1,763,158

Anthem 671,184 492,733 417,128 602,440 481,676 539,400

Other

Transportation Encounters 316,204 111,508 476,560 593,128 314,979 280,341

Magellan Pharmacy Claims 237,208 247,693 652,258 238,680 245,512 237,512

Totals 5,594,715 4,842,679 5,622,001 6,868,215 5,610,875 5,449,058



1.1 Change Order and Defect Statistics

Change Orders / Defects Inventory

Jun Jul Aug Sept Oct Nov

Beginning 500 497 499 437 446 489

Added 35 58 55 102 81 48

Implemented 28 37 98 89 30 21

Cancelled 10 19 19 4 8 9

Ending 497 499 437 446 489 507

0

100

200

300

400

500

600

June July August September October November

Beginning Added Implemented Cancelled Ending



1.2 Change Order and Defect Statistics (continued)

November 2017 Change Orders Defects

Total Comments Open On

Hold Open On Hold

DMS Priority 33 76 0 0 109

Federally Mandated 43 1 1 0 45

Non-Priority 265 38 49 1 353

Totals 341 115 50 1 507

*The priority list consists of 76 Change Orders & Defects.

Change Orders Defects

November 2017 Added Implemented Cancelled Added Implemented Cancelled

DMS Priority 8 0 0 0 0 0

Federally Mandated 4 0 0 0 0 0

Non-Priority 31 19 9 5 2 0

Totals 43 19 9 5 2 0



2 Unplanned System Outages

A Breakdown Of The Downtime

Date Time Reason For Downtime ******** There were no unplanned outages in November 2017.



2.1 Billable Hours Usage Summary (Contract Year 2017) Month BILLABLE UNDECIDED CCB Approved Need CCB Review

Dec 2016 1,650.25 241.25 1,643.25 248.25

Jan 2017 1,146.50 577.75 1,145.75 578.50

Feb 2017 1,116.50 508.00 1,115.75 508.75

Mar 2017 905.75 1,196.00 867.75 1,234.00

Apr 2017 1,512.25 1,875.50 1,503.25 1,884.50

May 2017 1,634.25 1,837.00 1,601.00 1,870.25

Jun 2017 1,630.75 1,823.00 1,602.50 1,851.25

Jul 2017 1,335.50 2,085.00 1,323.75 2,096.75

Aug 2017 1,711.75 4,410.00 1,665.50 4,456.25

Sep 2017 1,312.50 4,079.00 1,307.75 4,083.75

Oct 2017 689.50 1,754.50 654.50 1,789.50

Nov 2017 561.00 1,576.25 544.00 1,593.25 * Time entry is finalized on the 5th day of the following month.

**These totals EXCLUDE hours logged against HBE - Realtime project, ORP, and T-MSIS 2.0.

2.2 Running Total (Contract Year 2017)

Month Contractual limit Billable + Undecided CCB

Approved

Forecast (based on last

3 months)

Need CCB

Review Dec 2016 24,000.00 1,891.50 1,643.25 1,643.25 248.25 Jan 2017 24,000.00 1,724.25 1,145.75 3,286.50 578.50 Feb 2017 24,000.00 1,624.50 1,115.75 4,929.75 508.75 Mar 2017 24,000.00 2,101.75 867.75 6,573.00 1,234.00 Apr 2017 24,000.00 3,387.75 1,503.25 8,216.25 1,884.50 May 2017 24,000.00 3,471.25 1,601.00 9,859.50 1,870.25 Jun 2017 24,000.00 3,453.75 1,602.50 11,502.75 1,851.25 Jul 2017 24,000.00 3,420.50 1,323.75 13,146.00 2,096.75 Aug 2017 24,000.00 6,121.75 1,665.50 14,789.25 4,456.25 Sep 2017 24,000.00 5,391.50 1,307.75 16,432.50 4,083.75 Oct 2017 24,000.00 2,444.00 654.50 18,075.75 1,789.50 Nov 2017 24,000.00 2,137.25 544.00 19,719.00 1,593.25

* Time entry is finalized on the 5th day of the following month.

**These totals EXCLUDE hours logged against SOW



5,000

10,000

15,000

20,000

25,000

30,000

Dec2016

Jan2017

Feb2017

Mar2017

Apr2017

May2017

Jun2017

Jul2017

Aug2017

Sep2017

Oct2017

Nov2017

Ho

urs

Months

Running Total

Contractual limit Billable + Undecided CCB Approved FORECAST (based on last 3 mo.)



3 Monthly Ad hoc Requests

3.1 Inventory Summary

Beginning of

Month Received

This Month Closed

This Month

DMS Hold Ending Inventory

Type A 0 6 6 1 0 Type B 0 7 7 0 0 Type C 0 36 35 1 0 Type D 0 0 0 0 0 Type E 0 0 0 0 0

Not Specified 0 3 3 1 0 Total 0 52 51 3 0

Type A – completed correctly within twenty-four (24) hours of receipt Type B – completed correctly and delivered within forty-eight (48) hours of request Type C – completed correctly and delivered within seven (7) business days of request Type D – completed correctly and delivered within time frame established by DMS (greater than seven (7) business days) Type E – Emergency reports completed correctly within two (2) hours of submitted request.



CO # Type Requested By Status Date Requested

Date Completed Description

26989 Givens, Cassie On Hold 20160829 Group 8 Adhoc reports

27205 A Patel, Parul On Hold 20161114 Pharmacy claims with reject codes

28318 C Shields, Teresa Completed 20171103 20171107 KHIPP Employers

28322 C Barrett, Hope Completed 20171103 20171108 DBH #7 11-3-2017

28324 A Godshall, Kurt Completed 20171106 20171106 Claims not Finalized

28325 C Barrett, Hope Completed 20171106 20171109 DMS Professionals 5-1-2016 to 4-30-2017

28330 C Wells, Phyllis Completed 20171107 20171108 Kims Hometown Pharmacy

28331 C Wells, Phyllis Completed 20171107 20171109 Anita Cornett

28332 C Wells, Phyllis Completed 20171107 20171109 Steven Spady

28333 A Patel, Parul Completed 20171107 20171107 Re-run Missing county from Sept 2017-current

28334 C Patel, Parul On Hold 20171107 APA - Member Eligibility





28348 A Godshall, Kurt Completed 20171113 20171113 Claims not finalized

28351 C Keeling, Michelle Completed 20171113 20171113 Stephen Brown

28352 C Keeling, Michelle Completed 20171113 20171113 Muad Maya

28353 C Keeling, Michelle Completed 20171113 20171113 Sean Dillon

28354 C Keeling, Michelle Completed 20171113 20171113 Paul Pearson

28355 C Keeling, Michelle Completed 20171113 20171113 David Swan

28356 C Keeling, Michelle Completed 20171113 20171113 David Sincavage

28357 C Keeling, Michelle Completed 20171113 20171113 Michael Cummings

28358 C Keeling, Michelle Completed 20171113 20171113 Twin Lakes MRI LLC

28359 C Keeling, Michelle Completed 20171113 20171113 Michael Cummings PSC

28360 C Keeling, Michelle Completed 20171113 20171113 Pineville Comm Hosp SNF





28361 C Keeling, Michelle Completed 20171113 20171113 Alfred ADkins

28362 C Keeling, Michelle Completed 20171113 20171113 Christopher Steward

28363 C Keeling, Michelle Completed 20171113 20171113 William Short

28364 C Keeling, Michelle Completed 20171113 20171113 Chris Ethridge

28365 C Keeling, Michelle Completed 20171113 20171114 Saul Blecher

28366 C Keeling, Michelle Completed 20171113 20171113 Brandon Conrad

28367 C Keeling, Michelle Completed 20171113 20171113 Mark Jordan

28370 B Mays, Jada Completed 20171115 20171115 Novixus

28371 B Mays, Jada Completed 20171115 20171115 DCI

28372 C Keeling, Michelle Completed 20171115 20171115 Eluojo Okonji

28373 C Keeling, Michelle Completed 20171115 20171115 William Hutton





28374 C Keeling, Michelle Completed 20171115 20171115 Gregory Shy

28375 C Keeling, Michelle Completed 20171115 20171115 Dorthy Thompson

28376 C Keeling, Michelle Completed 20171115 20171115 John Oesterle

28377 C Keeling, Michelle Completed 20171115 20171115 Ron Tilford

28378 C Keeling, Michelle Completed 20171115 20171115 James Pickett

28379 C Keeling, Michelle Completed 20171115 20171115 Ronald Clements

28380 C Keeling, Michelle Completed 20171115 20171115 Rebecca Tabony

28381 C Keeling, Michelle Completed 20171115 20171115 John Franklin

28387 C Guice, Lee Completed 20171117 20171121 DOC Payments

28392 Patel, Parul Completed 20171120 20171120 ORR 17-396

28394 A Godshall, Kurt Completed 20171120 20171120 claims not Finalized





28399 B Wells, Phyllis Completed 20171127 20171127 Professional Home Health

28406 A Godshall, Kurt Completed 20171127 20171127 Claims not Finalized

28410 Douglass, Charles Completed 20171128 20171128 FFA

28412 B Shannon, Kimberly Completed 20171129 20171129 Ahamon

28413 B Shannon, Kimberly Completed 20171129 20171129 Ghiggason

28414 B Shannon, Kimberly Completed 20171129 20171129 Dwrede

28415 B Shannon, Kimberly Completed 20171129 20171129 Oali

28416 A Shannon, Kimberly Completed 20171129 20171129 Eeze

28420 Patel, Parul Completed 20171129 20171130 HCB individuals and their LOC dates

28421 C Guice, Lee Completed 20171130 20171130 479 Details - 2016



4 FFS Paper Claim Receipt Statistics

Mailroom Beginning Inventory Received RTP Scanned Ending

Inventory Oldest Claim

June 843 26,061 1,330 24,576 998 0 days July 998 25,605 1,831 22,823 1,949 0 days August 1,949 27,130 2,833 24,997 1,249 0 days September 1,249 25,938 2,391 23,980 816 0 days October 816 26,633 1,512 25,662 275 0 days November 275 21,031 1,500 19,119 687 0 days

02,0004,0006,0008,000

10,00012,00014,00016,00018,00020,00022,00024,00026,00028,00030,00032,00034,00036,00038,00040,00042,00044,00046,000

Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17

Cla

ims

FFS Paper Claim Receipts

Beginning Inventory Received Return to Provider Scanned Ending Inventory



5 Electronic Claims Processed

Jun 2017 Jul 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017 Bulletin Board System Claims

Processed 712,328 601,642 659,494 613,373 676,153 681,448

Kentucky HealthNet Claims Processed 104,424 96,629 114,273 102,644 105,620 102,612

50,000

250,000

450,000

650,000

Jun 2017 Jul 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017

Month

Electronic Claims Processed

BBS Claims

KyHealth Net



6 Monthly FFS Claim Totals by Media

Begin Date End Date

11/01/2017 11/30/2017

TOTAL Denied Claims Paid Claims Suspense Claims

Billed Amount Billed Amount Paid Amount Billed Amount Electronic $321,148,517.85 $710,240,222.01 $186,734,795.42 $6,527,896.09

Paper $39,703,506.75 $26,560,200.40 $19,068,422.88 $7,758,583.69 TOTAL: $360,852,024.60 $730,800,422.41 $205,803,218.30 $14,286,479.78



7 Monthly Claims Operations

7.1 FFS Monthly Financial Cycle Summary Category

June 2017 July 2017 August 2017 September 2017 October 2017 November 2017

Paid Claims 854,073 629,919 629,067 802,563 651,415 691,818 Denied Claims 270,848 208,739 216,265 264,946 236,378 229,062 Total Adjudicated Claims 1,124,921 838,658 845,332 1,067,509 887,793 920,880 Adjustments 27,375 20,645 23,257 72,938 27,867 24,964 Total Claims 1,152,296 859,303 868,589 1,140,447 915,660 945,844 Suspended/Re-suspended Claims 13,983 16,099 14,347 18,989 15,695 10,961 % of Denied Claims 24.08% 24.89% 25.58% 24.82% 26.63% 24.87% Avg $ per Claim $277.49 $333.69 $320.17 $301.11 $329.86 $297.48 Claim Payment Amount $236,995,434.44 $210,199,273.10 $201,406,544.33 $241,662,722.93 $214,874,184.62 $205,803,218.30 (+) Payouts $324,638.59 $1,069,083.21 $7,578,079.93 $2,700,384.40 $2,263,453.35 $77,575.61 (-) Recoupments $4,352,998.72 $3,274,534.06 $3,880,456.19 -$4,072,024.94 -$5,859,457.78 -$2,744,306.28 Check Issue $232,967,074.31 $207,993,822.25 $205,104,168.07 $240,291,082.39 $211,278,180.19 $203,136,487.63 Capitation Payment $633,511,867.55 $622,184,096.78 $628,037,763.24 $631,991,040.86 $627,004,640.10 $626,459,284.99 Total Paid $866,478,941.86 $830,177,919.03 $833,141,931.31 $872,282,123.25 $838,282,820.29 $829,595,772.62

Note: Claim Payment Amount divided by Paid Claims = Avg $ per Claim Total Denied Claims divided by Total Adjudicated Claims = % of Denied Claims

Category June 2016 July 2016 August 2016 September 2016 October 2016 November 2016

Paid Claims 672,745 1,020,909 616,006 792,978 702,781 696,114 Denied Claims 225,191 271,005 222,286 271,596 234,352 207,139 Total Adjudicated Claims 897,936 1,291,914 838,292 1,064,574 937,133 903,253 Adjustments/Claim Credits 16,568 32,851 16,174 44,415 19,498 26,521 Total Claims 914,504 1,324,765 859,466 1,108,989 956,631 929,774 Suspended/Resuspended Claims 11,401 10,534 9,617 10,289 12,165 9,925 % of Denied Claims 25.08% 21.00% 27.00% 25.51% 25.00% 23.00% Avg $ per Claim $279.89 $279.53 $335.16 $296.25 $303.37 $302.77 Claim Payment Amount $188,295,835.02 $285,378,473.15 $206,457,911.79 $234,921,546.56 $213,199,703.37 $210,762,630.40 (+) Payouts $5,079,983.93 $1,851,779.05 $2,463,244.42 $25,441,580.10 $10,082,135.87 $232,640,.53 (-) Recoupments -$3,080,594.50 -$7,150,658.11 -$4,049,582.34 -$6,373,142.10 -$5,040,959.14 -$7,345,305.45 Check Issue $190,295,224.45 $280,079,594.09 $204,871,573.87 $253,989,984.56 $218,240,880.10 $203,649,965.48 Capitation Payment $562,841,805.68 $560,196,032.51 $597,636,042.10 $560,546,748.04 $568,873,747.68 $559,088,941.89 Total Paid $753,137,030.13 $840,275,626.60 $802,507,615.97 $814,536,732.60 $787,114,627.78 $762,738,907.37

Note: Claim Payment Amount divided by Paid Claims = Avg $ per Claim Total Denied Claims divided by Total Adjudicated Claims = % of Denied Claims



7.2 Monthly MCO & NEMT Capitations

Begin Date End Date 11/01/2017 11/30/2017

Regular Capitations Reconciliation (Recoup & Payout) Capitations Totals

MCO Count Amount Count Amount Count Amount AETNA 239,087 $94,994,884.33 44,712 $2,183,680.12 283,799 $97,178,564.45

ANTHEM 122,742 $55,439,100.05 23,250 $3,384,661.74 145,992 $58,823,761.79

HUMANA 142,667 $75,032,462.13 26,754 $3,581,585.19 169,421 $78,614,047.32

KENTUCKY SPIRIT

124 -$16,788.64 124

NEMT 1,281,402 $9,273,661.88 38,888 $107,968.88 1,320,290 $9,381,630.76

PASSPORT 305,845 $153,597,021.05 48,379 $5,511,265.05 354,224 $159,108,286.10

WELLCARE 437,820 $216,659,995.06 77,967 $6,692,999.51 515,787 $223,352,994.57

Sum: 2,529,563 $604,997,124.50 260,074 $21,462,160.49 2,789,637 $626,459,284.99



7.2 Monthly MCO & NEMT Capitations (continued)

NEMT Cap Transactions

Amount Paid

AUDUBON AREA COMMUNITY SERVICES INC/GRITS 54,871 $439,532.58 PENNYRILE ALLIED COMSERVICES, INC 61,602 $409,727.20 GREEN RIVER INTRA TRANSIT SYSTEM 63,115 $347,194.40 AUDUBON AREA COMMUNITY SERVICES INC 72,046 $512,738.56 LKLP CAC INC REGION 5 105,617 $1,013,795.25 FEDERATED TRANSPORTATION SERVICES 251,674 $1,964,936.54 BLUE GRASS COMMUNITY ACTION AGENCY INC 88,716 $443,909.16 FEDERATED TRANSPORTATION SERVICES OF THE BLUEGRASS INC

99,272 $538,373.00

LKLP CAC INC REGION 9 1 -$5.40 FEDERATED TRANSPORTATION SERVICES 68,774 $368,101.06 FEDERATED TRANSPORTATION SERVICES OF THE BLUEGRASS 71,745 $477,919.24 RURAL TRANSIT ENTERPRISES 138,404 $1,211,138.79 LKLP COMMUNITY ACTION 90,471 $716,618.30 SANDY VALLEY TRANSPORTATION 65,178 $449,568.00 LKLP CAC INC REGION 15 68,682 $339,856.98 LICKING VALLEY COMMUNITY ACTION PROGRAM INC 20,122 $148,227.10 TOTAL 1,320,290 $9,381,630.76



7.3 FFS Adjudicated Original Claims (By Claim)

Paper Claims June 2017

July 2017

August 2017

September 2017

October 2017

November 2017

Paid 8,031 6,926 6,686 8,227 7,049 6,286 Denied 11,754 9,380 9,972 12,360 13,720 9,995 Total 19,785 16,306 16,658 20,587 20,769 16,281 % of Total Adjudicated Claims 1.76% 1.94% 1.97% 1.93% 2.34% 1.77% % of Paper Denied Claims 59.41% 57.52% 59.86% 60.04 66.06% 61.39%

Note: Total Adjudicated Paper Claims divided by Total Adjudicated Claims = % of Total Adjudicated Claims. Total Denied Paper Claims divided by Total Adjudicated Claims = % of Denied Claims.

Electronic Claims

June 2017

July 2017

August 2017

September 2017

October 2017

November 2017

Paid 846,042 622,993 622,381 794,336 644,366 685,532 Denied 259,094 199,359 206,293 252,586 222,658 219,067 Total 1,105,136 822,352 828,674 1,046,922 867,024 904,599 % of Total Adjudicated Claims 98.24% 98.05% 98.03% 98.07% 97.66% 98.23% % of Electronic Denied Claims 23.44% 24.24% 24.89% 24.13% 25.68% 24.22%

Note: Total Adjudicated Electronic Claims divided by Total Adjudicated Claims = % of Total Adjudicated Claims. Total Denied electronic Claims divided by Total Adjudicated Claims = % of Denied Claims.

Begin Date End Date

11/01/2017 11/30/2017



7.4 Monthly FFS Top Ten Procedure Codes Begin Date End Date 11/01/2017 11/30/2017

Procedure Description Member Count Claim Count Amount Paid

S5108 HOMECARE TRAIN PT 15 MIN 10,412 61,334 $19,358,403.90

T2016 HABIL RES WAIVER PER DIEM 3,855 30,602 $18,252,419.52

99213 OFFICE/OUTPATIENT VISIT EST 84,907 115,177 $10,247,838.98

99199 SPECIAL SERVICE/PROC/REPORT 4,260 4,427 $7,591,685.22

T2021 DAY HABIL WAIVER PER 15 MIN 4,716 29,984 $4,837,653.56

T2022 CASE MANAGEMENT, PER MONTH 12,376 14,005 $3,864,617.25

H0004 ALCOHOL AND/OR DRUG SERVICES 4,024 10,553 $3,837,260.99

S5100 ADULT DAYCARE SERVICES 15MIN 2,679 19,947 $3,186,972.46

T1019 PERSONAL CARE SER PER 15 MIN 609 4,695 $2,504,732.47

97535 SELF CARE MNGT TRAINING 2,249 8,155 $2,401,469.08

7.5 Monthly FFS Top Ten Diagnosis Codes

Diagnosis Description Member Count Claim Count Amount Paid

F70 MILD INTELLECTUAL DISABILITIES 6,093 43,218 $17,408,109.53

F71 MODERATE INTELLECTUAL DISABILITIES 4,596 29,389 $12,076,719.97

F840 AUTISTIC DISORDER 4,322 28,142 $8,330,487.47

F911 CONDUCT DISOR, CHILDHOOD-ONSET 4,258 4,441 $7,578,446.98

F72 SEVERE INTELLECTUAL DISABILITIES 1,077 6,922 $5,820,663.30

F73 PROFOUND INTELLECTUAL DISABILITIES 579 2,950 $5,528,185.59

F0390 UNSPC DEMENTIA W/O BEHAVIORAL DIST

1,747 3,196 $5,203,937.70

G309 ALZHEIMER'S DISEASE, UNSPECIFIED 1,271 2,435 $5,183,038.85

J449 COPD UNSPECIED 5,416 11,022 $4,028,848.15

F79 UNSPEC INTELLECTUAL DISABILITIES 1,862 10,926 $3,416,044.64



7.6 Monthly MCO Top Ten Procedure Codes Begin Date End Date 11/01/2017 11/3/2017

Procedure Description Member Count Claim Count Amount Paid

99213 OFF/OUTPATIENT VISIT 218,468 299,650 $11,496,218.53

99284 EMERGENCY DEPT VISIT 45,327 56,464 $10,259,350.66



99214 OFFICE/OUTPATIENT VISIT EST 89,526 107,233 $5,758,818.66

90837 PSYTX PT&/FAMILY 60 MINUTES 31,859 56,015 $5,489,608.39

74177 CT ABD & PELVIS W/CONTRAST 7,111 8,914 $3,634,983.54

T2023 TARGETED CASE MGMT PER MN 8,734 9,892 $3,517,479.34

G0483 DRUG TEST DEF 22+ CLASSES 10,500 16,632 $3,363,698.21

80307 DRUG TEST PRSMV CHEM ANLYZR 27,020 45,109 $3,133,565.26

Note: Data taken from encounters received from the Managed Care Organizations

7.7 Monthly MCO Top Ten Diagnosis Codes

Diagnosis Description Member Count Claim Count Amount Paid

Z3800 SNGL LIVEBORN INFANT, DEL VAGINALLY

3,507 4,741 $9,482,794.82

F1120 OPIOID DEPENDENCE, UNCOMPLICATED 20,127 79,121 $8,803,963.19

A419 SEPSIS, UNSPECIFIED ORGANISM 1,366 2,359 $8,186,765.87

Z3801 SNGL LIVEBORN INFANT, DEL Cesarean 1,879 2,649 $8,139,682.63

Z5111 ENCOUNTER ANTINEOPLASTIC CHEMO 939 1,893 $5,625,345.75

Z00129 ENCNTR ROUTINE CHILD HLTH EXAM W/O ABNORMAL FINDINGS

32,334 36,821 $3,847,898.66

R079 CHEST PAIN, UNSPECIFIED 10,761 16,192 $3,385,433.98

R0789 OTHER CHEST PAIN 6,530 9,109 $2,613,024.60

F329 MJR DEPRESS DISORDER SNGL EPISODE

7,039 11,728 $2,315,169.30

M545 LOW BACK PAIN 16,177 23,472 $2,313,054.29



Note: Data taken from encounters received from the Managed Care Organizations

7.8 Monthly FFS Top Ten Denial Reasons (By Detail Line)

Error Description Number of

Denials

% of Top Ten

1010 Rendering Prov not a Member of Billing Grp 9,743 14.5% 4021 No Coverage for Billed Procedure 9,683 14.4% 2003 Member Ineligible on Detail Date of Service 8,370 12.4% 3317 This Service was not Approved by Medicare 7,301 10.8% 2017 Services Covered Under Member’s MCO Plan 7,057 10.5% 268 Billed Amount Missing 6,632 9.8% 5001 Exact Duplicate 5,565 8.3% 4804 No Contract for Billed Rev Code 4,894 7.3% 1955 Cannot Determine Medicaid NBR for Billing Prov 4,645 6.9% 4393 Contract Invalid Revenue/Procedure Combo 3,476 45.2

Totals 67,366 55.7%

Total Denied Details – 120,873

NOTE: Total # of top ten denials (67,366) divided by total denied details (120,873) = % of top ten denials (55.7%)

7.9 Monthly FFS Top Ten Suspense Reasons (By Detail Line)

Error Description Number

of Failures

% of Top Ten

4405 Unable to assign provider contract 3,407 27.8% 3305 Member requires valid pt liability for dos recycle 2,322 18.9% 2001 Member ID Number not on File Recycle 1,875 15.3% 2503 Member Covered by Medicare B (with attachment 816 6.7% 3001 PA Not Found on Database 798 6.5% 3597 MFP assignment plan and program code conflict 657 5.4% 4314 Claim Type Restriction Covered Diagnosis 624 5.1% 3395 Hospice Eligibility - Recycle 621 5.0% 4371 Claim type restriction for covered procedure 609 4.9% 3003 Procedure Code Requires PA 520 4.2%

Totals 12,249 72.9%

Total Suspended Details – 16,814

NOTE: Total # of top ten failures (12,249) divided by total suspended details (16,814) = % of top ten suspense (72.9%)



7.9 FFS Suspended Original Claims by Age (By Claim)

Category June 2017 July 2017 August 2017 September 2017 October 2017 November 2017

Details Pct. Details Pct. Details Pct. Details Pct. Details Pct. Details Pct. 0-30 days 12,707 90.88 14,553 90.40 12,913 90.00 17,444 91.86 14,613 93.11 9,836 89.74 31-60 days 196 1.40 384 2.38 251 1.75 140 .74 158 1.00 124 1.13 61-90 days 182 1.30 172 1.07 213 1.49 242 1.28 80 .51 109 .99 91+ days 898 6.42 990 6.15 970 6.76 1,163 6.12 844 5.38 892 8.14 Total 13,983 16,099 14,347 18,989 15,695 10,961

7.10 FFS Claims Suspense Over 30 Days by Responsible Unit (By Claim)

Category June 2017

July 2017

August 2017

September 2017

October 2017

November 2017

Oldest Julian Date

Resolutions 57 46 18 88 77 30 17-314 Med.Review 302 371 85 87 113 176 17-104 TPL 4 14 4 8 7 3 17-304 Adjustments 0 0 0 0 0 0 0 Recycle 0 0 0 0 0 0 0 DMS 913 1,115 1,327 1,362 885 916 16-243 Total 1,276 1,546 1,434 1,545 1,082 1,125



8 Monthly Third-Party Liability

8.1 FFS Third-Party Liability Monthly Activity

Third Party Liability

Begin Inv Received Worked To DMS Ending

Inventory Oldest Date

PA40-Kames/Eligible with Other Ins.

1,461 2,110 2,042 0 1,529 13 days

CS40-Child Support 0 476 476 0 0

0 days

SSI-Local Offices 0 0 0 0 0

0 days

TPL Edits 244 1,537 1,582 0 199 15 days Accident/Trauma Leads 0 0 0 0 0 0 days

DMS Attorney 0 0 0 0 0 0 days RUSH Attorney 0 0 0 0 0 0 days HP Attorney 158 160 113 0 205 6 days TPL Checks 18 138 156 0 0 5 days TPL Mail 444 3,799 3,818 0 425 13 days KHIPP 0 358 358 0 0 0 days Total 2,325 8,578 8,545 0 2,358



9 Monthly Finance/Adjustments

9.1 Monthly FFS Financial – Accounts Receivable

Category Beginning Inventory Received Keyed Return to

Provider To

DMS On

Hold Ending

Inventory Age

Oldest AR

Accounts Receivable Set-up 0 89 72 0 0 0 17 1 day

Payouts 0 141 140 0 0 0 1 1 day Accounts Receivable Updates 0 12 12 0 0 0 0 0 days

Accounts Receivable Transfers 0 0 0 0 0 0 0 0 days

Total 0 242 224 0 0 0 18

9.2 Monthly FFS Financial - Checks

Category Beginning Received Completed Ending Age

Oldest Check

Provider Warrant 9 10 7 12 4 days HP Financial 147 631 540 238 5 days DMS Financial 44 117 116 45 2 days Total 200 758 663 295

9.3 Monthly FFS Financial – Adjustments

Category Beginning Inventory Received Completed Returns Ending

Inventory Age

Oldest Adj

Professional 0 494 451 7 36 1 day Institutional 0 27 19 1 7 1 day Voids 14 199 163 12 38 1 day Total 14 720 633 20 81



9.4 Monthly FFS Financial - Mass Adjustments

Category Beginning Inventory

Received (plus)

Released (minus)

Deleted (minus)

Zero

Claims Pulled

(minus)

Ending Inventory

On Hold

DMS

Review

Mass Adjustment (region 52)

136 49 10 7 9 159 159 159

SE Processed Adjustment (region 58)

0 0 0 0 0 0 0 0

Suppl Pymt Mass Adjustment (region 88)

0 35 33 0 2 0 0 0

Total 136 84 43 7 11 159 159 159



10 Provider Relations

10.1 Provider Field Representatives

10.1.1 Provider Visits

There were no provider visits in November 2017.

10.2 Conference Calls (Calls Greater Than 30 Minutes)

November 1, 2017

Vicky Hicks, DXC Provider Representative, conducted a conference call with Kids Dentistree on November 1, 2017. The provider requested a conference call to review the use of KYHealth Net for claim resubmission, and discuss claim denials. Those who attended were: Lisa and Tamara

November 3, 2017

Vicky Hicks, DXC Provider Representative, conducted a conference call with Kids Dentistree on November 3, 2017. The provider requested a conference call to discuss additional claim denials. Those who attended were: Lisa and Tamara

November 6, 2017

Vicky Hicks, DXC Provider Representative, conducted a conference call with Little Ears Hearing Center on November 6, 2017. The provider requested a conference call to discuss claim denials. Those who attended were: Clarke

November 13, 2017

Kelly Gregory, DXC Provider Representative, conducted a conference call with Mark D. Miller, Dentist on November 13, 2017. The provider requested a conference call to review claim denials. Those who attended were: Heather

November 15, 2017

Kelly Gregory, DXC Provider Representative, conducted a conference call with Thera Kids, LLC on November 15, 2017. The provider requested a conference call to review claim denials and learn how to adjust a claim on KYHealth Net. Those who attended were: Carol Cain

November 16, 2017

Vicky Hicks, DXC Provider Representative, conducted a conference call with Neurorestorative on November 16, 2017. The provider requested a conference call to discuss claim denials. Those who attended were: Somer Bowden



November 20, 2017

Kelly Gregory, DXC Provider Representative, conducted a conference call with Ephraim McDowell Health Resources on November 20, 2017. The provider requested a conference call to review claim denials. Those who attended were: Tammy

November 30, 2017

Vicky Hicks, DXC Provider Representative, conducted a conference call with Wellstone Regional Hospital on November 30, 2017. The provider requested a conference call to discuss claim denials. Those who attended were: Vickie Sommers

10.3 Association Meetings

There were no Association Meetings in November 2017.

10.4 Provider Contacts

Provider Calls 60

Provider E-mails 501

Total 561

Total number of calls and e-mails between Provider Field Representatives and Providers during the month.

10.5 Provider Workshops

November 2, 2017

Kelly Gregory and Vicky Hicks, DXC Provider Field Representatives, conducted Provider Workshop Webinars on November 2, 2017 at 10:00 and 3:00. During the provider webinars the following subjects were reviewed: How Medicaid works, Kentucky Medicaid websites, accessing KYHealth Net, KYHealth Net panels, ORP, and contacts.

There were 23 providers in attendance for the 10:00 A.M webinar. There were 9 providers in attendance for the 3:00 P.M. webinar.



November 8, 2017


There were 17 providers in attendance for the 10:00 A.M webinar. There were 3 providers in attendance for the 3:00 P.M. webinar.

November 14, 2017


There were 21 providers in attendance for the 10:00 A.M webinar. There were 7 providers in attendance for the 3:00 P.M. webinar

10.6 Provider Services

10.6.1 Provider Services

Category June 2017

July 2017

Aug 2017

Sept 2017

Oct 2017

Nov 2017

% Service Level 99% 98% 98% 98% 98% 98%

Abandoned Calls 145 140 167 155 199 181

Avg Speed Ans .07 .06 .06 .09 .08 .12

Incoming Calls 9,695 8,735 9,847 8,387 9,273 9,136

Paper Correspondence 674 377 509 410 408 459

E-Mail Correspondence 159 113 281 214 236 195

Fax 5 9 9 0 6 2

Total* 10,533 9,234 10,646 9,011 9,923 9,792

HPE Callbacks 51 68 77 89 86 80 *Total of Calls, Paper Correspondence, E-Mail Correspondence, and Faxes

Formula for % Service Level: Number of incoming calls minus abandoned calls divided by total number of incoming calls = % Service Level.



10.6.2 Top 5 Provider Calls 1. Claim Status

2. Member Services/Member Calls

3. Billing Help

4. Prior Authorizations

5. Check Amounts

10.6.3 Notable Topics 1. Reason for claim denial or suspended. How to get the MCO to void

the claim in order for Medicaid to process the claim?

2. Which MCO the member has & MAP 552 questions? Calls from

providers wanting to know how to get the member’s file corrected to

show whether the member is traditional Medicaid or managed care.

Calls from members wanting to know if they are eligible for Medicaid

and which MCO are they enrolled and how to change the MCO.

3. Timely filing – CMS 1500 Crossover EOMB Form (is this form

completed if Medicare pays or if Medicare denies).

4. What is the PA number and how do I correct the overlapping dates?

5. Questions about ARs and the ACA primary care recoupments.

01,0002,0003,0004,0005,0006,0007,0008,0009,000

10,00011,00012,00013,000

Provider Services Call Volumes

Calls



10.7 Commonwealth Training

10.7.1 Current Activities

DXC was approved by DMS to hold trainings every-other month in 2017 and approved for no training for November, December, and January.

Member/TPL Subsystem (November, 2017) 0 attended

Provider Subsystem (November, 2017) 0 attended

Prior Authorization Subsystem (November, 2017) 0 attended

Reference Subsystem (November, 2017) 0 attended

Claims Subsystem (November, 2017) 0 attended

Financial Subsystem (November, 2017) 0 attended

OnBase Application (November, 2017) 0 attended

Encounters (November, 2017) 0 attended

Staff members' supervisors are sent a confirmation via email of attendance.



11 EDI Customer/Provider Interaction

11.1 Electronic Data Interchange Calls Received

Category June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017

EDI Calls 755 630 725 552 621 632

MEUPS Calls 865 725 686 577 717 588

Voice Response Calls

7,813 7,204 7,882 7,154 7,919 7,484

Expanded Call Data

Month EDI Calls Abandoned

Calls Avg. Speed of Answer

Avg. Talk Time

June 755 21 :15 2:32 97%

July 630 11 :06 2:32 99%

August 725 20 :07 2:24 97%

September 552 06 :05 2:31 99% October 621 14 :08 2:25 98%

November 632 11 :06 2:20 98%

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

11000

12000

13000

14000

15000

June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017

EDI CallsMEUPS CallsVoice Response Calls



Expanded Call Data (continued)

Month MEUPS

Calls Abandoned


Avg. Talk Time

June 865 5 :04 2:01 99%

July 725 4 :05 2:04 99%

August 686 5 :04 2:07 99%

September 577 2 :03 1:59 99% October 717 10 :06 2:04 99%

November 588 4 :06 2:11 99%

Month

Voice Response

Calls Abandoned


Avg. Talk Time

June 7,813 106 :01 1:57 99%

July 7,204 78 :01 2:01 99%

August 7,882 128 :01 1:59 98%

September 7,154 106 :01 1:56 99% October 7,919 112 :01 1:56 99%

November 7,484 100 :01 1:51 99% *Formula for % Service Level: Number of incoming calls minus abandoned calls divided by total number of incoming calls = % Service Level.

EDI Top 5 calls:

1. Request to repost 835s 2. Verify electronic file transmission 3. Request to repost 999s 4. Confirm setup of MAP 380s/246s 5. Questions about 837 file structure

MEUPS Top 5 calls:

1. Password resets (see table below) 2. Request to change Administrator of account 3. PIN release request to set up new account 4. Medicaid contract has end-dated, resulting in no access to KyHealth Net 5. How to navigate member eligibility

Category June 2017

July 2017

Aug 2017

Sept 2017

Oct 2017

Nov 2017

Password Resets Received via phone 642 579 580 483 616 530



11.2 EDI E-mails and Faxes Received

Category June 2017

July 2017

Aug 2017

Sept 2017

Oct 2017

Nov 2017

E-mails Received 1,376 1,620 1,334 1,201 1,391 1,252

E-mails Answered 1,376 1,620 1,334 1,201 1,391 1,252

Faxes Received 231 198 180 194 143 159

Faxes Answered 231 198 180 194 143 159

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

June 2017 July 2017 Aug 2017 Sept 2017 Oct 2017 Nov 2017

Month

EDI E-mails and Faxes Received

Faxes

Email



EDI Top 5 E-mail Requests:

1. Password resets (see table below)

2. Status of MAP 380 3. Status of 835 4. Research 5. Verify electronic file transmission

Category June 2017

July 2017

Aug 2017

Sept 2017

Oct 2017

Nov 2017

Password Resets Received via email 315 435 380 329 449 342

EDI Top 5 Fax Requests:

1. PIN release forms* (see table below) 2. Change of Administrator forms* (see table below) 3. MAP 380s and 246s 4. 835s 5. Trading Partner Agreements

Category June 2017

July 2017

Aug 2017

Sept 2017

Oct 2017

Nov 2017

PINs Received via fax 61 133 49 72 49 77

Admins Received via fax 59 141 172 270 86 239

*All PIN release and Change of Administrator responses are outbound via e-mail only.

Cabinet for Health and Family ServicesDepartment for Medicaid Services

Utilization Management Operational Status Report

Status Month: November 2017

Report Date: December 7, 2017Author: Carewise Health Staff

Confidential 2 of 17

Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17

Pended

20 10 16 14 24 8 Escalated 0 0 0 0 0 000:24 00:19 00:16 00:20 00:31 00:12 Lack of Information 0 0 0 0 0 004:39 04:15 04:07 04:03 04:25 04:30 MD Review 0 0 0 0 0 099.5% 99.5% 99.1% 94% 99% 99% RN Review 30 48 21 51 57 351269 1218 1273 1214 1252 1211

Total 30 48 21 51 57 351 2 1 11 21 14

00:40 00:28 00:59 01:34 05:40 06:08 Current Month Top 5 LOI Pended Reasons08:35 08:04 08:33 10:53 14:26 14:28 1.84% 94% 98% 97% 88% 93% 2.

Total Clinical Calls 247 246 232 249 218 184 3.1516 1464 1505 1463 1470 1395 4.

5.

Requests Processed Current Month Top 10 Diagnosis Codes266 253 288 264 211 202 1. J18.9 Pneumonia, unspecified o 96

1,513 1,353 1,569 1,400 1,542 1,579 2. A41.9 Sepsis, unspecified orga 850 0 0 0 0 0 3. N17.9 ACUTE KIDNEY FAILURE, UN 440 0 1 0 0 0 4. J44.1 Chron obstr pulm dz w/ex 370 0 0 0 0 0 5. N39.0 Urinary tract infectn,si 3612 17 12 21 19 14 6. K92.2 Gastrointestinal hemorrh 3230 48 21 51 57 35 7. I50.9 Heart failure, unspecifi 29

1,821 1,671 1,891 1,736 1,829 1,830 8. O80 Encountr,full-term uncom 269. J96.20 Acut&chrnc resp fail,uns 2610. J96.90 Resp fail,unsp,w/hypoxia 25

9 12 8 12 13 9N/A N/A N/A N/A N/A N/AN/A N/A N/A N/A N/A N/A Current Month Top 5 Reasons for MD Denial

9 12 8 12 13 91. 4

2. 1

3.15 22 19 17 15 14 4.3 5 4 9 6 5 5.

0.99% 1.62% 1.22% 1.50% 1.15% 1.04%17% 19% 17% 35% 29% 26%18 27 23 26 21 19 Current Month Top 5 Reasons for Lack of Information Denial

1.2.

0 1 2 1 2 2 3.0 0 0 0 0 0 4.0 1 2 1 2 2 5.

*Reconsiderations are not incuded in Request Processed Total

Lack of Information

N/A

Referred to MD RateNot Medically Necessary Denial Rate

ReconsiderationsOverturned

Total Reconsiderations

Admission was not clinically appropriate using the criteria and guidelines established in 907 KAR 3:130. 907 KAR 10:012(2)

Total Denied

MD ReviewMedical Necessity

Upheld

Total MD Review

Total

Administrative DenialsTechnical (Out of Time Frame)

Average Talk TimeFirst Call Resolution

Total Admin Calls

Clinical

Recipient should have been cared for at a lower level of care. 907 KAR 10:012(2) and 907 KAR 3:130

N/AAverage Speed of Answer


Total Calls

Pended

ApprovalsAdministrative Approval

Client Approved/Negotiation

Acute Inpatient ServicesCall MetricsAdministrative

Abandoned CallsAverage Speed of Answer

Not Medically Necessary

Medicare Primary

Abandoned Calls

Split DecisionState Mandate

Denials



0 4 1 1 6 0 Escalated N/A N/A N/A N/A N/A N/A00:18 00:24 00:12 00:20 00:29 00:16 Lack of Information 265 287 443 347 442 42204:06 03:50 03:57 03:47 03:50 04:01 MD Review 2 20 12 7 25 3100% 99.7% 99.4% 98.9% 99.8% 100% RN Review 1 18 2 1 1 3473 373 487 431 513 398 HP Review 0 0 0 0 0 0

Total 268 325 457 355 468 428

11 16 23 34 51 8 Current Month Top 5 LOI Pended Reasons00:12 00:23 00:21 00:54 01:58 01:24 1. 42205:31 04:53 05:50 06:44 08:09 07:31 2.90% 94% 97.8% 96.7% 97.4% 96.1% 3.


Current Month Top 10 Diagnosis CodesRequests Processed 1. G80.9 Cerebral palsy, unspecif 380

1,249 1,057 1,259 1,081 1,043 1,277 2. G80.8 Other cerebral palsy 78Agreed Reduction 0 0 0 0 0 0 3. G80.0 Spastic quadriplegic cer 65

0 0 0 0 0 0 4. J44.9 Chro obstruc pulm dz uns 600 0 0 0 1 0 5. G82.20 Paraplegia, unspecified 410 0 0 0 0 0 6. Q05.9 Spina bifida, unspecifie 34

159 117 123 126 121 108 7. G12.9 Spinal muscular atrophy, 32268 325 457 355 468 428 8. R13.10 Dysphagia, unspecified 31

1,676 1,499 1,839 1,562 1,633 1,813 9. G71.0 Muscular dystrophy 3010. Z74.09 Other reduced mobility 24

N/A N/A N/A N/A N/A N/A Current Month Top 5 Reasons for MD Denial

Medicare Primary N/A N/A N/A N/A N/A N/A1. 20

116 95 93 98 86 732. 6

116 95 93 98 86 73 3.3

4.1

5.1

68 58 116 87 80 9343 22 30 28 35 35 Current Month Top 5 Reasons for Lack of Information Denial

6.62% 5.34% 7.94% 7.36% 7.04% 7.06% 1. LOI response not received or incomplete 7339% 28% 21% 24% 30% 27% 2.111 80 146 115 115 128 3.

4.5.

2 17 3 0 10 41 1 2 2 0 83 18 5 2 10 12

Lack of Information

Clinical

State Mandate

Abandoned Calls

Referred to MD Rate

Total

Administrative Denials

DenialsPended

Average Speed of AnswerAverage Talk Time

First Call Resolution


First Call ResolutionTotal Admin Calls


Total Denied


Lack of Information

Upheld

Not Medically Necessary Denial Rate

Reconsiderations



Overturned

Total MD Review

Durable Medical EquipmentCall MetricsAdministrative Pended

Abandoned Calls

Total Calls

Approvals

Client Approved/NegotiationSplit Decision

Technical (Out of Time Frame)

Item is not primarily and customarily used for a medical purpose. 907 KAR 1:479(6) and 907 KAR 3:130Equipment is used primarily for the convenience of the recipient or caregiver. 907 KAR 1:479(6) and 907 KAR 3:130

Item is commercially available. Customization is not covered. 907 KAR 1:479(4) and 907 KAR 3:130

Oxygen therapy is not medically necessary or appropriate for the recipient's diagnosis or condition. 907 KAR 1:023 and 907 KAR 3:130

Request exceeds the quantity maximum. 907 KAR 1:479(7) and 907 KAR 3:130


May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17

250 250 250 250 250 25035 29 35 25 33 44215 221 215 225 217 206

Outcomes220 216 237 149 197 235

Outcomes30 34 13 101 53 15

2 1 1 5 0 127 32 12 96 53 141 1 0 0 0 0

Billing 0 0 0 0 0 030 34 13 101 53 15

0 0 0 0 1 00 0 0 0 0 00 0 0 0 1 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

0 0 0 0 0 0

* DRG report will be one month behind the other review types included in this report.

DeniedTotal Reviewed

DRG

Total Approved

In-House

Target File

Total Denied

Severity 2 - Quality problem with the potential for significant adverse effect (s) on the patient

Target FileOn-Site Requested

Denial ReasonsNot Medically Necessary

Total Denied

TechnicalReassignments

Total Denial Reasons

Severity 3 - Quality problem with significant adverse affect (s) on the patient

ReconsiderationsApproved

Quality of Concern

Severity 1 - Quality concern with minimumpotential for significant effect (s) on the patient



2 0 1 0 6 1 Escalated N/A N/A N/A N/A N/A N/A00:19 00:16 00:16 00:21 00:27 00:17 Lack of Information 38 61 31 63 17 29 04:18 04:22 04:00 03:53 04:16 03:48 MD Review 0 0 1 10 0 198% 100% 100% 99% 99% 100% RN Review 1 1 0 0 6 097 89 91 84 110 79

Total 224 208 257 73 23 302 1 1 3 3 0

00:35 00:35 01:34 02:20 02:35 04:01 Current Month Top 5 LOI Pended Reasons05:18 06:47 05:45 05:53 07:36 06:42 1. 2996% 93.8% 87.0% 98.1% 94.4% 94.0% 2.


5.

Requests Processed Current Month Top 10 Diagnosis Codes1,346 1,090 792 1,143 1,125 641 1. F84.0 Autistic disorder 187

0 0 0 0 0 0 2. Q90.9 Down syndrome, unspecifi 840 0 0 0 0 0 3. G80.9 Cerebral palsy, unspecif 740 0 0 0 0 0 4. R62.50 Uns lack nrml physiolgcl 276 0 0 0 0 0 5. Q90.0 Trisomy 21 nonmosaicism 1217 6 30 36 19 13 6. F81.9 Develop disord of schola 1139 62 32 73 23 30 7. F80.2 Mixed recep-expressiv la 10

1,408 1,158 854 1,252 1,167 684 8. F80.89 Oth develop disord speec 89. G80.1 Spastic diplegic cerebra 810. Q93.5 Othr deletions part of c 8

N/A N/A N/A N/A N/A N/AMedicare Primary N/A N/A N/A N/A N/A N/A Current Month Top 5 Reasons for MD Denial

8 6 16 4 9 4 1.Meets for Level 3 PPEC and not Level 4 3

8 6 16 4 9 4 2. Not medically necessary 3

3. Member does not meet criteria for Level 3 PPEC 2

4.1

12 8 11 31 23 19 5.9 0 14 32 10 9

1.49% 0.69% 2.93% 5.03% 2.83% 4.09%43% 0% 56% 51% 30% 32% Current Month Top 5 Reasons for Lack of Information Denial21 8 25 63 33 28 1. LOI response not received or incomplete 4

2.3.

1 0 0 5 2 2 4.0 0 7 4 23 0 5.1 0 7 9 25 2


Lack of InformationTotal Denied

Reconsiderations

OverturnedUpheld



Not Medically NecessaryReferred to MD Rate


Total MD Review



EPSDT Special ServicesCall MetricsAdministrative Pended

Abandoned Calls

Clinical

ApprovalsAgreed Reduction



Total Calls


Denials

Abandoned Calls



Total


Pended

Lack of Information

There is no reasonable expectation for improvement as the therapy appears to be for maintainence. 907 KAR 1:030(4) and 907 KAR 3:130



10 7 16 5 14 14 Escalated N/A N/A N/A N/A N/A N/A00:26 00:18 00:20 00:22 00:38 00:22 Unreviewed 15 40 48 38 44 7705:31 05:23 04:53 05:21 05:20 04:55 MD Review 1 1 4 2 0 099.8% 99.7% 99.6% 99.6% 99.5% 99.2% RN Review 11 10 56 5 10 19816 701 831 694 748 759

Total 27 51 108 45 54 9618 15 34 13 5 1

02:37 02:53 03:00 02:04 00:51 01:00 Current Month Top 5 LOI Pended Reasons08:56 08:29 09:16 09:42 09:04 08:38 1.90% 88% 78% 93% 95% 95% 2.


5.

Requests Processed Current Month Top 10 Diagnosis Codes3,934 3,686 3,781 3,715 3,818 3,378 1. G80.9 Cerebral palsy, unspecif 311

65 39 66 80 58 55 2. F79 Unspec intellectual disa 2320 0 0 0 0 0 3. R32 Unspecified urinary inco 1980 0 0 1 0 0 4. F84.0 Autistic disorder 1410 17 0 0 17 0 5. E11.9 Type 2 DM w/o complicati 1214 4 20 15 20 11 6. J44.9 Chro obstruc pulm dz uns 11428 51 108 45 54 96 7. L89.154 Pressre ulcr sacral regn 77

4,031 3,797 3,975 3,856 3,967 3,540 8. F72 Severe intellectual disa 729. I10 Essential (primary) hype 7010. R15.9 Full incontinence of fec 67

Lack of Information N/A N/A N/A N/A N/A N/A0 0 10 0 5 02 3 9 9 10 9 Current Month Top 5 Reasons for MD Denial

2 3 19 9 15 91. 1

2. 13.

18 21 34 44 25 324.

2 1 1 6 5 2 5.

0.50% 0.58% 0.88% 1.30% 0.76% 0.96%10% 5% 3% 12% 17% 6% Current Month Top 5 Reasons for Lack of Information Denial20 22 35 50 30 34 1.

2.3.

0 0 1 0 0 0 4.0 0 0 0 0 0 5.0 0 1 0 0 0

Abandoned Calls

Home HealthCall MetricsAdministrative Pended



Total Admin Calls

Clinical

PendedDenials


State Mandate

Total Reconsiderations*Reconsiderations are not incuded in Request Processed Total



Total Calls


Not Medically Necessary Denial RateTotal MD Review


Upheld


Split Decision

Referred to MD Rate

Total


Medicare PrimaryTechnical (Out of Time Frame)

Total Denied

MD Review

Medical Necessity

N/A

N/A

Services can be safely and effectively provided on an outpatient basis. 907 KAR 1:030(4) and 907 KAR 3:130Not medically necessary



N/A N/A N/A N/A N/A N/A Escalated N/A N/A N/A N/A N/A N/AN/A N/A N/A N/A N/A N/A Lack of Information 0 0 0 0 6 0N/A N/A N/A N/A N/A N/A MD Review 0 0 0 0 0 0N/A N/A N/A N/A N/A N/A RN Review 0 2 0 0 0 0N/A N/A N/A N/A N/A N/A

Total 0 2 0 0 6 0N/A N/A N/A N/A N/A N/AN/A N/A N/A N/A N/A N/A Current Month Top 5 LOI Pended ReasonsN/A N/A N/A N/A N/A N/A 1.N/A N/A N/A N/A N/A N/A 2.N/A N/A N/A N/A N/A N/A 3.N/A N/A N/A N/A N/A N/A 4.

5.

Requests Processed Current Month Top 10 Diagnosis Codes76 47 197 88 17 5 1. I60.32 NTSAH fr lt posterior co 4N/A N/A N/A N/A N/A N/A 2. G31.1 Senile degeneration of b 1N/A N/A N/A N/A N/A N/A 3.0 0 0 0 0 0 4.0 0 0 0 0 0 5.0 0 0 0 0 0 6.0 2 0 0 6 0 7.

76 49 197 88 23 5 8.9.10.

Lack of Information 0 0 0 0 0 0N/A N/A N/A N/A N/A N/AN/A N/A N/A N/A N/A N/A Current Month Top 5 Reasons for MD Denial0 N/A N/A N/A N/A N/A 1. N/A

2.3.

0 0 0 0 0 0 4.0 0 0 0 0 0 5.

0.00% 0.00% 0.00% 0.00% 0.00% 0.00%0% 0% 0% 0% 0% 0%0 0 0 0 0 0 Current Month Top 5 Reasons for Lack of Information Denial

1.2.

0 0 0 0 0 0 3.0 0 0 0 0 0 4.0 0 0 0 0 0 5.


N/A

Upheld


Total Denied



Referred to MD Rate

Medical NecessityNot Medically Necessary

MD Review



State MandateDenialsPended

Total



Total CallsTotal Clinical Calls

Agreed Reduction


ClinicalAbandoned Calls

Average Speed of Answer

Approvals

HospiceCall MetricsAdministrative Pended


N/A

Average Talk Time



18 13 16 15 17 9 Lack of Information 173 317 594 444 460 33700:19 00:16 00:18 00:24 00:30 00:14 MD Review 0 0 0 0 0 004:24 04:16 04:17 04:39 04:34 04:09 RN Review 57 58 93 44 43 1999.5% 99.5% 99.6% 99.0% 99.3% 99.3%654 631 812 607 618 480

Total 230 375 687 488 503 356

5 8 6 3 16 15 Current Month Top 5 LOI Pended Reasons00:19 00:50 00:39 01:12 02:50 02:28 1. 33705:44 05:08 06:30 06:41 07:01 06:55 2.97.4% 98.5% 97.1% 95.0% 84.9% 82.9% 3.


Current Month Top 10 Diagnosis CodesRequests Processed 1. F03.90 Unsp dementia w/o behavi 1002

7,673 5,475 9,958 6,205 2,742 7,601 2. I10 Essential (primary) hype 5922,844 2,833 3,870 2,879 2,747 2,848 3. J44.9 Chro obstruc pulm dz uns 545

0 0 0 0 0 0 4. G30.9 Alzheimer's disease, uns 4530 0 0 0 0 0 5. M62.81 Muscle weakness (general 3507 7 9 7 3 9 6. E11.9 Type 2 DM w/o complicati 31528 25 20 50 42 38 7. I50.9 Heart failure, unspecifi 279230 375 687 490 503 356 8. F02.80 Dem oth dzs CE w/o behav 172

10,782 8,715 14,544 9,631 6,037 10,852 9. F03.91 Unsp dementia w behavior 160

10. I48.91 Unspec atrial fibrillati 156

17 15 11 28 24 17 Current Month Top 5 Reasons for MD Denial

0 0 0 0 0 0

1. 18

17 15 11 28 24 17 2. 3*Reconsiderations are not incuded in Request Processed Total 3.

4.25 25 65 24 24 18 5.11 10 9 22 18 21

15.65% 9.33% 10.77% 9.39% 8.35% 10.96% Current Month Top 5 Reasons for Lack of Information Denial31% 29% 12% 48% 43% 54% 1. LOI response not received or incomplete 1736 35 74 46 42 39 2.

3.4.

7 5 5 7 8 12 5.0 0 0 1 4 27 5 5 8 12 14


Abandoned Calls

Nursing FacilityCall Metrics

Administrative Pended



Total Admin Calls

Clinical

Pended


State Mandate


Total Calls

Split Decision

Approvals

Client Approved/NegotiationInitial LOC Approval

Denials

Total


Non-Certified BedTotal Denied

Lack of Information

UpheldTotal Reconsiderations




Total MD Review


Not medically necessary

Recipient does not have a stable medical condition requiring intermittent high-intensity nursing care, continuous personal care or supervision in an institutional setting. 907 KAR 1:022(4) and 907 KAR 3:130

Lack of Information



19 11 15 15 29 12 MD Review 0 3 4 0 6 300:30 00:19 00:19 00:23 00:44 00:25 RN Review 280 179 207 252 118 19604:39 04:39 04:28 04:20 04:31 04:1899% 99% 100% 99% 99% 99%993 864 960 909 971 889

Total 280 182 211 252 124 199

N/A N/A N/A N/A N/A N/A Current Month Top 5 LOI Pended ReasonsN/A N/A N/A N/A N/A N/A 1.N/A N/A N/A N/A N/A N/A 2.N/A N/A N/A N/A N/A N/A 3.

Total Clinical Calls N/A N/A N/A N/A N/A N/A 4.993 864 960 909 971 889 5.

Current Month Top 10 Diagnosis CodesRequests Processed 1. J44.9 Chro obstruc pulm dz uns 603

2,587 2,877 3,000 2,492 2,844 2,566 2. M62.81 Muscle weakness (general 3030 0 6 0 0 0 3. R06.02 Shortness of breath 2280 0 2 0 0 0 4. I50.9 Heart failure, unspecifi 930 0 3 0 0 0 5. R09.02 Hypoxemia 791 1 2 1 0 1 6. J18.9 Pneumonia, unspecified o 78

222 235 271 321 329 229 7. R26.2 Difficulty in walking, N 68280 182 211 252 124 199 8. J44.1 Chron obstr pulm dz w/ex 65

3,090 3,295 3,495 3,066 3,297 2,995 9. J96.01 Acute respiratory failur 4310. I10 Essential (primary) hype 41

189 188 215 269 271 173 Current Month Top 5 Reasons for MD Denial2 9 12 9 3 10 1. 468 7 8 8 11 8 2.

199 204 235 286 285 191 3.4.5.


1.55% 2.46% 2.83% 1.47% 1.58% 1.74% 1.52% 49% 48% 98% 90% 88% 2.48 81 99 45 52 52 3.

4.5.

3 2 4 2 3 20 2 1 0 1 03 4 5 2 4 2



Not Medically NecessaryReferred to MD Rate N/A


OverturnedUpheld


Total MD Review

Reconsiderations

Total Denied




Total Calls


FRN Reconsideration Upheld


Total

RN Denials/OverturnsFRN Criteria

FRN Reconsideration Overturned

Nursing Facility AncillaryCall MetricsAdministrative Pended

Abandoned Calls



Pended

N/A


Total Admin Calls


Denials



2 3 5 5 8 2 Lack of Information 0 0 0 0 0 000:17 00:17 00:07 00:19 00:33 00:12 MD Review 10 0 21 0 2 805:26 04:04 03:33 03:47 03:13 03:23 RN Review 0 0 0 0 0 0100% 100% 100% 100% 100% 100%

41 49 47 34 42 34Total 10 0 21 0 2 8

N/A N/A N/A N/A N/A N/A Current Month Top 5 LOI Pended ReasonsN/A N/A N/A N/A N/A N/A 1.N/A N/A N/A N/A N/A N/A 2.N/A N/A N/A N/A N/A N/A 3.

Total Clinical Calls N/A N/A N/A N/A N/A N/A 4.41 49 47 34 42 34 5.

Current Month Top 10 Diagnosis CodesRequests Processed 1. Z46.4 Encntr fitting&adjust or 29

16 17 8 31 9 17 2.0 0 0 0 0 0 3.0 0 0 0 0 0 4.0 0 0 0 0 0 5.0 2 1 4 0 4 6.10 0 21 0 2 8 7.26 19 30 35 11 29 8.

9.10.

Lack of Information N/A N/A N/A N/A N/A N/AN/A N/A N/A N/A N/A N/A Current Month Top 5 Reasons for MD DenialN/A N/A N/A N/A N/A N/A 1. 3N/A N/A N/A N/A N/A N/A 2.

3.4.

16 17 7 31 9 17 5.0 2 1 4 0 3

62% 100% 27% 100% 82% 69% Current Month Top 5 Reasons for Lack of Information Denial0% 11% 13% 11% 0% 15% 1.16 19 8 35 9 20 2.

3.4.

0 0 0 2 0 0 5.

0 0 0 1 0 10 0 0 3 0 1




Total Calls



DenialsPended

Total



OrthodontiaCall Metrics


Abandoned Calls

Approvals


Total Admin Calls


State Mandate

N/A



Total Denied

Overturned



Reconsiderations


N/A



5 9 3 2 4 5 Lack of Information 15 21 19 14 24 4700:20 00:15 00:14 00:17 00:25 00:20 MD Review 0 6 6 0 19 1003:57 03:45 03:39 03:43 03:44 03:44 RN Review 1 0 1 0 0 499.8% 99.8% 99.8% 99.8% 99.6% 99.3%345 347 356 316 344 320

Total 16 27 26 14 43 61

3 3 0 2 5 6 Independent Therapy00:51 00:34 00:31 02:41 03:48 02:50 Total 0 0 0 0 1 005:41 04:46 06:03 07:13 09:14 08:3894% 96% 73% 98.6% 97.5% 93.5% Current Month Top 5 LOI Pended Reasons

Total Clinical Calls 71 63 59 64 60 65 1. 47416 410 415 380 404 385 2.

3.

4.Requests Processed 5.

830 707 870 737 1,015 8720 0 0 0 0 0 Current Month Top 10 Diagnosis Codes0 0 0 0 0 0 1. F84.0 Autistic disorder 1830 0 0 0 0 0 2. G80.9 Cerebral palsy, unspecif 490 0 0 0 0 0 3. Q90.9 Down syndrome, unspecifi 4724 14 14 36 20 17 4. M25.561 Pain in right knee 3816 27 26 14 43 61 5. M54.5 Low back pain 35

870 748 910 787 1,078 950 6. M62.81 Muscle weakness (general 247. M54.2 Cervicalgia 238. F82 Specific develop disord 20

24 8 10 26 20 13 9. S06.2X9D Dif trau bra inj LOC uns 20N/A N/A N/A N/A N/A N/A 10. F88 Oth disorders of psych d 18N/A N/A N/A N/A N/A N/A24 8 10 26 20 13

Current Month Top 5 Reasons for MD Denial

1.4

24 25 157 86 109 135 2.0 6 4 10 0 4 3.

2.76% 4.14% 17.69% 12.20% 10.11% 14.63% 4.0% 19% 2% 10% 0% 3% 5.24 31 161 96 109 139

Current Month Top 5 Reasons for Lack of Information Denial1. LOI response not received or incomplete 13

6 0 0 5 2 0 2.0 0 0 0 0 0 3.6 0 0 5 2 0 4.

5.

Lack of Information


*Reconsiderations are not incuded in Request Processed TotalTotal Reconsiderations



Upheld

Total MD Review

Reconsiderations

Abandoned Calls

Outpatient TherapiesCall Metrics




Total Admin Calls

Clinical


Medicare Primary




Total Calls

Average Talk Time

Recipient has reached maximum improvement. 907 KAR 1:014(4) and 907 KAR 3:130.

Overturned

MD Review

Denials


Total


Pended

Lack of Information

Total Denied



6 1 3 4 6 4 Lack of Information N/A N/A N/A N/A N/A N/A

00:19 00:17 00:11 00:14 00:21 00:16Incomplete Data(Consent Forms) 3 3 2 5 2 5

03:24 03:09 03:18 03:12 03:05 03:02 MD Review 4 1 0 1 2 0100% 100% 100% 100% 100% 100% RN Review 9 5 4 3 6 2275 273 299 281 257 273

Total 16 9 6 9 10 7

6 4 1 2 7 3 Current Month Top 5 LOI Pended Reasons00:54 01:03 00:38 02:53 04:19 05:30 1.05:28 06:19 08:23 08:04 10:50 11:52 2.70% 100% 100% 100% 100% 100% 3.


Current Month Top 10 Diagnosis CodesRequests Processed 1. G47.33 Obstructive sleep apnea( 11

40 48 59 47 50 45 2. Z30.2 Encounter for sterilizat 69 4 19 8 11 8 3. E66.01 Morbid (sevr)obesity d/t 40 0 0 0 0 0 4. N93.9 Abnorml uterine&vaginal 20 0 0 0 0 0 5. N92.1 Excessv&freq menstru w/i 20 0 0 0 0 0 6. I87.321 Chrnc venous HTN w/inflm 20 2 0 0 2 0 7. R07.9 Chest pain, unspecified 216 9 6 9 10 7 8. R13.10 Dysphagia, unspecified 265 63 84 64 73 60 9. N62 Hypertrophy of breast 2

10. K95.09 Oth complic of gastric b 2

0 0 0 0 0 0 Current Month Top 5 Reasons for MD DenialN/A N/A N/A N/A N/A N/A 1.0 0 0 0 0 0 2.0 0 0 0 0 0 3.

4.5.


27.69% 26.98% 36.90% 25.00% 27.40% 33.33% 1. N/A0% 12% 0% 0% 10% 0% 2.18 17 31 16 20 20 3.

4.5.

0 0 0 0 0 00 0 0 0 0 00 0 0 0 0 0

N/A

N/A


Total Admin Calls

Administrative Approval




Physician ServicesCall Metrics

Administrative PendedAbandoned Calls


Total Denied

Upheld

Total MD Review

Reconsiderations

Overturned







Total Calls

Administrative DenialsLack of Information

TotalPended

Approvals


State MandateDenials

Medicare Primary



N/A N/A N/A N/A N/A N/A Escalated N/A N/A N/A N/A N/A N/AN/A N/A N/A N/A N/A N/A Lack of Information 54 3 13 18 12 35N/A N/A N/A N/A N/A N/A MD Review 0 0 0 4 4 0N/A N/A N/A N/A N/A N/A RN Review 4 0 2 0 0 0N/A N/A N/A N/A N/A N/A

Total 58 3 15 22 16 35N/A N/A N/A N/A N/A N/AN/A N/A N/A N/A N/A N/A Current Month Top 5 LOI Pended ReasonsN/A N/A N/A N/A N/A N/A 1. 35N/A N/A N/A N/A N/A N/A 2.N/A N/A N/A N/A N/A N/A 3.N/A N/A N/A N/A N/A N/A 4.

5.

Requests Processed Current Month Top 10 Diagnosis Codes81 208 75 60 50 64 1. P91.2 Neonatal cerebral leukom 120 0 0 0 0 0 2. E88.49 Oth mitochondrial metabo 100 0 0 0 0 0 3. P91.60 Hypox ischemic encephlpt 80 0 0 0 0 0 4. Q31.1 Congenital subglottic st 61 0 0 0 0 0 5. G80.9 Cerebral palsy, unspecif 66 6 0 6 4 2 6. R56.9 Unspecified convulsions 658 3 15 22 16 35 7. I27.0 Primary pulmonary hypert 6

146 217 90 88 70 101 8. Q23.4 Hypoplastic left heart s 69. P27.1 Bronchopul dysplas orig 610. Q99.8 Othr spec chromosome abn 6

Lack of Information 0 0 0 0 0 0N/A N/A N/A N/A N/A N/AN/A N/A N/A N/A N/A N/A Current Month Top 5 Reasons for MD DenialN/A N/A N/A N/A N/A N/A 1. Requested services are in excess of what is medically necessary 2

2.3.

2 2 2 0 6 10 4.6 6 0 6 4 2 5.

5.48% 3.69% 2.22% 6.82% 14.29% 11.88%75% 75% 0% 0% 0% 0%

8 8 2 6 10 12 Current Month Top 5 Reasons for Lack of Information Denial1.2.

0 0 6 0 0 0 3.0 0 0 0 0 4 4.0 0 6 0 0 4 5.

Abandoned Calls

Private Duty Nursing Call MetricsAdministrative Pended





Average Speed of AnswerAverage Talk Time Lack of Information

Denials

Total Clinical CallsTotal Calls



State Mandate

Total MD Review

PendedTotal


Medicare Primary

Total Reconsiderations*Reconsiderations are not incuded in Request Processed Total


OverturnedUpheld

Reconsiderations

Total Denied




N/A



4 2 1 0 9 4 Lack of Information 0 0 0 0 0 000:28 00:22 00:15 00:21 00:29 00:15 RN Review 12 11 8 2 2 903:48 03:18 03:17 03:27 03:12 03:25 MD Review 0 0 0 0 0 0100% 100% 100% 100% 100% 100%261 222 287 231 283 261

Total 12 11 8 2 2 9

8 16 19 4 12 6 By Place of Service03:06 06:00 05:30 02:15 04:32 03:33 Distinct Part Units - Psychiatric 74 60 103 72 92 75

09:21 12:04 11:43 08:55 11:33 12:16 EPSDT 5 6 8 4 4 5

100% 100% 100% 100% 100% 100% Freestanding Psychiatric Facility 34 28 37 41 38 39

Total Clinical Calls 222 198 254 210 228 228 Inpatient Hospital 4 7 0 0 3 2

483 420 541 441 511 489Non-Freestanding Psychiatric Facility 119 119 137 108 101 146

Onsite EPSDT Psych 0 0 0 0 0 0Psychiatric Residential Treatment Center 1 1 0 3 2 1

Requests Processed Total 237 221 285 228 240 268221 209 274 221 236 2560 0 0 0 0 0 Current Month Top 5 LOI Pended Reasons0 0 0 0 0 0 1.0 0 0 0 0 1 2.0 0 0 0 0 0 3.4 1 3 5 2 2 4.12 11 8 2 2 9 5.

237 221 285 228 240 268Current Month Top 10 Diagnosis Codes

1. F32.9 MDD, single episode, uns 38N/A N/A N/A N/A N/A N/A 2. F29 Unsp psych not d/t sub/k 20N/A N/A N/A N/A N/A N/A 3. F34.81 Disruptive mood dysregul 184 1 3 4 2 2 4. F31.9 Bipolar disorder, unspec 184 1 3 4 5. F20.9 Schizophrenia, unspecifi 16

6. F03.91 Unsp dementia w behavior 167. F25.9 Schizoaffective disorder 12

1 4 5 1 5 4 8. F91.9 Conduct disorder, unspec 120 0 0 1 0 0 9. F25.0 Schizoaffective disord, 9

0.42% 1.81% 1.75% 0.88% 2.08% 1.49% 10. F33.2 MDD, recurrent, severe w 90% 0% 0% 0% 0% 0%1 4 5 2 5 4 Current Month Top 5 Reasons for MD Denial

1. N/A2.

0 0 0 0 0 0 3.0 0 0 0 0 0 4.0 0 0 0 0 0 5.

Current Month Top 5 Reasons for Lack of Information Denial1.2.3.4.5.


Abandoned Calls

N/A

Lack of InformationMedicare Primary

N/A





Psychiatric ProgramsCall MetricsAdministrative Pended

Abandoned Calls

Clinical

Total


Pended

Average Talk Time


Total Calls



State MandateDenials



Overturned

Total Denied



Reconsiderations

Total MD Review



8 6 13 9 5 6 Lack of Information 1 1 0 2 6 100:20 00:18 00:18 00:18 00:29 00:17 MD Review 1 4 0 7 4 303:42 03:37 03:26 03:32 03:29 03:36 RN Review 8 13 5 13 12 599.8% 99.8% 100% 99.8% 99.6% 99.3%714 647 765 680 749 653

Total 10 18 5 22 22 9

9 2 6 11 14 2 Current Month Top 5 LOI Pended Reasons00:12 00:19 00:38 02:01 04:08 02:10 1. 106:44 05:59 06:00 07:54 09:33 08:38 2.94% 96% 100% 99% 98% 94% 3.

Total Clinical Calls 439 406 474 441 477 387 4.1,153 1,053 1,239 1,121 1,226 1,040 5.

Current Month Top 10 Diagnosis CodesRequests Processed 1. R07.9 Chest pain, unspecified 46

508 459 514 464 480 422 2. M54.5 Low back pain 240 0 0 0 0 0 3. M54.2 Cervicalgia 180 0 0 0 0 0 4. M54.16 Radiculopathy, lumbar re 170 0 0 0 0 0 5. R07.89 Other chest pain 120 0 0 0 0 0 6. I25.10 Athr hrt dz ntv cornry a 110 5 8 4 15 11 7. G35 Multiple sclerosis 1110 18 5 22 22 9 8. R51 Headache 9

518 482 527 490 517 442 9. R56.9 Unspecified convulsions 910. R07.2 Precordial pain 8

0 1 0 0 0 4N/A N/A N/A N/A N/A N/A Current Month Top 5 Reasons for MD Denial

N/A N/A N/A N/A N/A N/A 1.6

0 1 0 0 0 4 2.1

3.4.

91 58 72 68 84 60 5.0 3 8 4 15 7

17.57% 12.66% 15.18% 14.69% 19.15% 15.16% Current Month Top 5 Reasons for Lack of Information Denial0% 5% 10% 6% 15% 10% 1. LOI response not received or incomplete 491 61 80 72 99 67 2.

4.0 2 0 1 4 5 5.0 1 0 1 0 00 3 0 2 4 5

Other approved imaging meets care needs. 907 KAR 3:005(5) and 907 KAR 3:130



Medicare Primary

State Mandate

Lack of Information

Denials

TotalPended


Total Calls

Lack of Information


Lower level imaging required first. 907 KAR 3:005(5) and 907 KAR 3:130


Reconsiderations



Overturned

Total Denied

Total MD Review

MD Review



RadiologyCall Metrics




Total Admin Calls

Split Decision



*Report runs off Status of In Progress for open cases.

Case Type Primary Category Appeal Type Status Appeal Start Date Decision Required Date Attending Physician

Waiver HCB - LOC Administrative Hearings In Progress Sep 14, 2017 Dec 7, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Nov 28, 2016 Mar 30, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Feb 13, 2017 Mar 21, 2017 ALI, MARLYCE RENEE

Waiver Michelle P - LOC Administrative Hearings In Progress Apr 9, 2015 Jun 26, 2015 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Jun 21, 2017 Jul 10, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Nov 28, 2017 Feb 20, 2018 PELLEGRINI, ADRIAN

Waiver Michelle P - LOC Administrative Hearings In Progress Jul 8, 2015 Aug 18, 2015 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Jul 6, 2017 Sep 28, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Jan 5, 2017 Feb 10, 2017 PELLEGRINI, ADRIAN

Waiver HCB CDO - LOC Administrative Hearings In Progress Feb 24, 2017 Jul 11, 2017 PELLEGRINI, ADRIAN


Home Health Home Health Administrative Hearings In Progress Jun 18, 2014 Jul 30, 2014 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Dec 21, 2016 Mar 30, 2017 PELLEGRINI, ADRIAN

Waiver HCB CDO - LOC Administrative Hearings In Progress Jul 20, 2016 Oct 4, 2016 PELLEGRINI, ADRIAN

Waiver Michelle P - LOC Administrative Hearings In Progress Jul 20, 2017 Oct 12, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Dec 9, 2016 Feb 21, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress May 8, 2017 Jun 22, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Jun 22, 2017 Sep 14, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Nov 17, 2016 Jan 31, 2017 PELLEGRINI, ADRIAN

Waiver HCB CDO - LOC Administrative Hearings In Progress Aug 31, 2016 Jan 13, 2017 PELLEGRINI, ADRIAN

Nursing Facility Nursing Facility Administrative Hearings In Progress Nov 28, 2017 Feb 20, 2018 PELLEGRINI, ADRIAN


Waiver HCB - LOC Administrative Hearings In Progress Apr 19, 2017 Jun 13, 2017 PELLEGRINI, ADRIAN

Waiver HCB CDO - LOC Administrative Hearings In Progress Jul 20, 2016 Oct 4, 2016 PELLEGRINI, ADRIAN


Waiver HCB CDO - LOC Administrative Hearings In Progress Sep 23, 2016 Nov 3, 2016 PELLEGRINI, ADRIAN

KY Department for Medicaid Services Administrative Hearings Report

New/In Progress/Closed/All In ProgressReport Run Date: Dec 1, 2017

Case Type Primary Category Appeal Type Status Appeal Start Date Decision Required Date Attending Physician

Waiver HCB CDO - LOC Administrative Hearings In Progress Dec 19, 2016 Jun 9, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Jul 20, 2017 Oct 12, 2017 PELLEGRINI, ADRIAN


Waiver HCB - LOC Administrative Hearings In Progress Dec 8, 2016 May 26, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Jun 27, 2017 Aug 29, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Apr 14, 2017 May 30, 2017 PELLEGRINI, ADRIAN

Waiver HCB - LOC Administrative Hearings In Progress Apr 14, 2017 May 25, 2017 PELLEGRINI, ADRIAN

MAC Binder Section 10 –Operational Status & UM...

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Transcript of MAC Binder Section 10 –Operational Status & UM...