Medicaid Care Management Grievance and Appeals Prepared by the - - PowerPoint PPT Presentation
Medicaid Care Management Grievance and Appeals Prepared by the Office of Quality Assurance and Improvement NH Department of Health and Human Services 1 4/9/2018 Member Grievances per 10,000 Member Months 5 4 Rate per 10,000 member months 3
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Prepared by the Office of Quality Assurance and Improvement NH Department of Health and Human Services 4/9/2018
Member Grievances per 10,000 Member Months
Source Data: Medicaid Quality Information System Retrieved on 3/26/2018 2
0.8 0.6 0.8 1.9 1.2 1.5 1.3 1.1 1 2 3 4 5 Q1-2016 Q2-2016 Q3-2016 Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017 Rate per 10,000 member months
Grievances by Grievance Category*
3 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018
* Categories are determined by the National Committee for Quality Assurance of Health Plans
78.1 61.5 57.6 65.9 60.4 68.3 67.3 80.0 9.4 23.1 15.2 15.4 22.9 16.7 13.5 8.9 3.8 12.1 5.5 2.1 5.0 9.6 4.4 9.4 11.5 9.1 9.9 6.3 6.7 5.8 6.7 3.1 11.1 3.3 8.3 3.3 1.9 1.9
10 20 30 40 50 60 70 80 90 100 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3 2017-Q4
Percent
Customer Service Billing & Financial Coverage Benefits Quality of Care Access Website System or Material Attitude and Services
Grievance Count by Provider Type*
4 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018
*Provider type indicates who the grievance is filed against.
4 4 8 10 3 8 3 8 10 18 21 20 22 15 19 20 15 11 49 18 35 29 23
10 20 30 40 50 60 70 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3 2017-Q4
Number of Grievances
Health Plan Provider Sub-contractor
Grievance Dispositions Made Within 45 Calendar Days
5 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018
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Member Appeals Filed per 10,000 Member Months
Source Data: Medicaid Quality Information System Retrieved on 3/26/2018
6.4 10.4 5.9 5.1 3.7 3.1 3.9 3.3 4.0 4.1 3.4 3.2 2.3 2.6 2.5 2.5
2 4 6 8 10 12 Q1-2016 Q2-2016 Q3-2016 Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017 Rate per 10,000 member months Pharmacy Non-Pharmacy
Count of Appeals Filed: Pharmacy and Non-Pharmacy
7 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018
258 428 240 205 149 123 156 131 161 170 138 131 92 104 98 99
100 200 300 400 500 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3 2017-Q4
Appeals Pharmacy Non-Pharmacy
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Appeal Processing Time: Resolution of Standard Appeals Within 30 Calendar Days
Source Data: Medicaid Quality Information System Retrieved on 3/26/2018
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Appeals Processing Time: Resolution of Expedited Appeals Within 72 Hours
Source Data: Medicaid Quality Information System Retrieved on 3/26/2018
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Resolution of Appeals by Disposition Type
Source Data: Medicaid Quality Information System Retrieved on 3/26/2018
Note: 2016 data may include over reporting for member abandoned appeals
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Count of Appeals Elevated to State Fair Hearings
Source Data: Medicaid Quality Information System Retrieved on 3/26/2018
4 5 3 2 5
2 4 6 8 10
2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3
Fair Hearings
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Count of Fair Hearing Requests by Disposition Type
(1/1/2016 – 12/31/2017)
Source Data: Medicaid Quality Information System Retrieved on 3/26/2018
Upheld 0 Reversed by Plan 13 Withdrawn 4 Dismissed 2 Resolved by Settlement 3
Fair Hearings
Measure ID Measure Name
GRIEVANCE.01 Grievance Dispositions Made Within 45 Calendar Days GRIEVANCE.02 Grievance Log Including State Plan / 1915B Waiver Flag GRIEVANCE.03 Member Grievances Received APPEALS.01 Resolution of Standard Appeals Within 30 Calendar Days APPEALS.02 Resolution of Extended Standard Appeals Within 44 Calendar Days APPEALS.03 Resolution of Expedited Appeals Within 72 Hours APPEALS.04 Resolution of All Appeals Within 45 Calendar Days APPEALS.05 Resolution of Appeals by Disposition Type APPEALS.09 Appeals by Reason Type APPEALS.10 Fair Hearings by Disposition Type APPEALS.16 Appeals by Type of Resolution and Category of Service by State Plan, 1915B Waiver, and Total Population APPEALS.17 Pharmacy Appeals by Type of Resolution and Therapeutic Drug Class by State Plan, 1915B Waiver, and Total Population APPEALS.18 Services Authorized within 72 Hours Following A Reversed Appeal APPEALS.19 Member Appeals Received
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Data Available at: https://medicaidquality.nh.gov/
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