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24-Hour Access to Care and Crisis Services 1-866-875-1757 Customer Services 1-855-250-1539 Prepared for January 2015 Provider Meeting.

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Presentation on theme: "24-Hour Access to Care and Crisis Services 1-866-875-1757 Customer Services 1-855-250-1539 Prepared for January 2015 Provider Meeting."— Presentation transcript:

1 24-Hour Access to Care and Crisis Services Customer Services Prepared for January 2015 Provider Meeting

2 Appointments Seen Within Timeframe Executed By: Kimberly Silas Executed On: 2/11/15 2 Report: LME ATR Ver II Source: SQL/Alpha Timeframe: Jan Jan 2015

3 Executed By: Kimberly Silas Executed On: 2/11/15 3 Report: LME ATR Ver II Source: SQL/Alpha Timeframe: Aug 2014 – Jan 2015 Member Service/LME ATR Ver. II

4 Executed By: Kimberly Silas Executed On: 2/11/15 4 Report: LME ATR Ver II Source: SQL/Alpha Timeframe Aug Jan 2014 Member Service/LME ATR Ver. II

5 Source: Grievance Log Timeframe: Jul 2014 – Jan 2015 Risk Management/Grievance Tracking Executed By: Barbara McQuery Executed On: 2/12/ Grievance - any expression of dissatisfaction about any matter other than a managed care action (i.e. UM appeal) filed by a member or by someone who has been authorized in writing to file on behalf of the member.

6 Risk Management/Grievance Tracking Reasons for Grievances Executed By: Barbara McQuery Executed On: 2/12/ Source: Grievance Log Timeframe: Jan 2015 Grievance - any expression of dissatisfaction about any matter other than a managed care action (i.e. UM appeal) filed by a member or by someone who has been authorized in writing to file on behalf of the member.

7 Internal Performance/ Utilization Management Average Days to Complete Service Authorization Requests Report: SAR Report (SQL) Source: Alpha MCS Medicaid Timeframe: February 2014 – January 2015 Executed By: Dawn Mullins Executed On: 2/3/ Medicaid

8 Internal Performance/Clinical Denials Executed By: Dawn Mullins Executed On: 2/3/ Report: SAR Report (SQL) Source: Alpha MCS Medicaid Timeframe: January 2015 Top Providers with Most Medicaid Clinical Denials ProviderTotal # of denials% of total denials A 6 18% D 5 15% C 4 12% Information contained in tables above are independent and does not necessarily mean there is a relationship between top providers and top services. Top 3 Clinical Denials by Service N= 32 Denial by Service Type#% of denials H2022 – Intensive-In-Home 618% H2012HA – Day Treatment Child 515% Inpatient Hospitalization 412%

9 Internal Performance/ Utilization Management Average Days to Complete Service Authorization Requests Report: SAR Report (SQL) Source: Alpha MCS State Timeframe: Feb January 2015 Executed By: Dawn Mullins Executed On: 2/3/ STATE

10 Internal Performance/Clinical Denials Executed By: Dawn Mullins Executed On: 2/3/ Report: SAR Report (SQL) Source: Alpha MCS State Timeframe: January 2015 Top Providers with Most State Clinical Denials ProviderTotal # of denials% of total denials C1 100% Information contained in tables above are independent and does not necessarily mean there is a relationship between top providers and top services. Top 3 Clinical Denials by Service N= 1 Denial by Service Type # % of denials H2022 – Intensive-In-Home 1100%

11 Internal Performance/ Utilization Management Medicaid Denials Report: SAR Approved and Denial Report (SQL) Source: Alpha MCS Medicaid Timeframe: February 2014 – January 2015 Executed By: Dawn Mullins Executed On: 2/3/

12 Internal Performance/ Utilization Management State Denials Report: SAR Report (SQL) Source: Alpha MCS State Timeframe: February 2014 – January 2015 Executed By: Dawn Mullins Executed On: 2/3/

13 Claims Processing/Claims Report: Claims Status Summary (SQL) Source: Alpha/Medicaid & State Funds Timeframe: Jan, 2014 –Jan, 2015 Executed By: Kimberly Silas Executed On: 2/2/

14 Claims Processing/Claims Denials Report: CoastalCare Claims Status Summary (SQL) Source: Alpha/State Funds Timeframe: Jan, 2015 Executed By: Kimberly Silas Executed On: 2/2/

15 Claims Processing/Claims Denials Report: CoastalCare Claims Status Summary (SQL) Source: Alpha/Medicaid Funds Timeframe: Jan, 2015 Executed By: Kimberly Silas Executed On: 2/5/

16 Source: Alpha, Appeals Log Timeframe: Jan 2015 Executed By: Barbara McQuery Executed On: 2/11/2015 Risk Management/Appeals Tracking

17 Risk Management/Fraud, Waste, and Abuse Report: Fraud, Waste, and Abuse Source: EthicsPoint Timeframe: Jan, 2015 Executed By: Anna Abbey Executed On: 2/6/15 17

18 Risk Management/Fraud, Waste, and Abuse Report: Fraud, Waste, and Abuse Source: EthicsPoint Timeframe: Jan, 2015 Executed By: Anna Abbey Executed On: 02/06/15 18

19 Consumers Served by Care Coordination Report: Caseload Assignment Source: Alpha MCS/SQL Timeframe Feb 2014 – January 2015 Executed by: Dawn Mullins Executed on: 2/9/ Totals are unduplicated by Care Coordination service (ie I/DD, MH/SUD, TCL), however, consumers may be in TCL as well as I/DD Care Coordination or MH/SUD Care Coordination. Total number served has decreased because Care Coordination tags have been updated to end date the tags for old Care Coordination cases.

20 Internal Performance/Provider Monitoring Executed By: Kimberly Silas Executed On: 1/21/15 20 Report: Provider Monitoring Tracking Source: Network Monitoring Tracking sheet Timeframe: July Jan 2015


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