Cosmetic $51.00 Obtain vision services from provider of your choice. Pay entire cost up front, then submit claim to carrier for reimbursement up to the above allowed amounts. VISION SERVICES - PEDIATRIC Vision – Medical “sick” visit 100% of allowed benefit after $15 copay Vision – Routine exam 100% of allowed benefit Vision Supplies – Frames/Lenses or Contacts. 100% of allowed benefit Limited to dependent children age 18 and under. Medically necessary Frames/Lenses or Contacts. Contacts in lieu of Frames/Lenses. No deviations will be considered
FA2 Attachment S-5: Access to Adult PCPs Instructions: Provide access two ways: 1) all employees currently in EPO and 2) all employees. Matches must be determined based on criteria outlined in Section III Participants Access to Providers in "Attachment S-1: Plan Information.” A. For Response Attachment S-1: GeoAccess® GeoNetworks® Report, provide the following report format for Access to Adult Primary Care Physicians: Zip Code Average Distance to Adult PCPs Number of Employees Employees Matched Employees Not Matched Number Percent Number Percent B. Provide subtotals for all employees currently in EPO by County of residence and by region of residence as shown in the table below: Metropolitan/ Geographic Area Average Distance to Adult PCPs Total Number of Employees Employees Matched Employees Not Matched Number Percent Number Percent Anne Arundel County Baltimore City Baltimore County Carroll County Harford County Howard County Central Maryland Caroline County County Dorchester County Kent County Queen Anne's County Somerset County Talbot County Wicomico County Worcester County Eastern Shore Calvert County Charles County St. Mary's County Southern Maryland District of Columbia Montgomery County Prince George's County Washington Metro Allegany County Frederick County Garrett County Washington County Western Maryland
Describe your mental health/substance abuse case management service from structural and functional perspectives and how these lend to long-term stability of a member. PLAN ADMINISTRATION - ELIGIBILITY The State of Maryland would like direct access to the Offeror's eligibility systems for review and input purposes. Describe your ability to provide the State with direct access to the eligibility system only. Describe your eligibility system used to keep track of SLEOLA’s eligibility files, including: System "trade name" System organization Date system was put in place Number of system upgrades since inception Is eligibility processing real-time with the claim system? If no, what is the time? Briefly describe your process for correcting data in the event of a data tape which contains "bad data.” REPORTING What limitations do you have with customizing standard reports? Please explain. The State requires online access to standard reports; describe how you will make your reports available online. Describe your organization’s ability to provide the following at a minimum in your reports, including your ability to report member detail to the State. Billed amount Paid amount Network savings Non-Medicare COB savings Medicare COB savings Negotiated savings
handling the SLEOLA account. Frequency of report: Quarterly Processing of Enrollment Eligibility Update Information Plan will process electronic interchange of SLEOLA enrollment information by 5:00PM of the second business day receipt. If information is received after 12:00PM, record as having been received as of the next business day. Time over which standard is measured: Quarter Report Card - Vendor to maintain log for review by the State's contract auditor. Frequency of report: Quarterly 0.20% of fees for each calendar day, or portion thereof, of delay. Accuracy of Processing Enrollment Eligibility Information Plan will process electronic interchange of SLEOLA enrollment with at least 98% accuracy. Time over which standard is measured: Quarter Report Card - Vendor to maintain log and system generated reports for review by the State's contract auditor. Frequency of report: Quarterly 0.20% of fees for each percentage point, or fraction thereof, under 98%. Contractor attendance at State-sponsored Open Enrollment meetings Attendance by plan representatives trained on SLEOLA plan benefits at 100% of meetings scheduled by the State, for 100% of the meeting's duration. Representative must arrive early enough to have their table set-up prior to meeting start time. Display must be organized and include appropriate covering of table. Representative must have detailed plan knowledge, interact with members, and exhibit professional Sign-in sheets at meetings or minutes of State meetings. Frequency of report: Annually 0.05% of fees for each scheduled meeting date vendor fails to attend.
appearance and behavior. Time over which standard is measured: Annual Delivery of Quarterly Utilization, Case Management, and Disease Management Data Reports to State's Consultant Delivery to the State by 6:00PM on the following dates**: Documentation of receipt by State's Benefit Consultant, i.e., date-stamp of mailing package for data information and verification of completeness. (All required fields must be filled in correctly.) Frequency of report: Quarterly 0.20% of fees for each week, or fraction thereof, the data report is not received or is incomplete. First Quarter (Jan – Mar) Due: May 1st Second Quarter (Apr – Jun) Due: August 1st Third Quarter (Jul – Sep) Due: November 1st Fourth Quarter (Oct – Dec) Due: February 1st Delivery of Rate Renewal Reports Delivery to the State and to the State's actuarial consultant of reports required for annual rate renewal process by 6:00PM March 1 of each contract year. At a minimum, the renewal reports must include (but not be limited to) the following: Date-stamp of receipt by the State and verification of completeness of required documentation. Frequency of report: Annually Projection of incurred claim costs for renewal year. Estimate of IBNR reserves at end of current year; including the most recent 36 months of incurred/paid triangular reports. Complete documentation of the methodology and assumptions utilized to
develop the projected costs. Disclosure of supporting data used in the calculations, including monthly paid claims and enrollment, claims analysis, trend analysis, demographic analysis, etc. Substantiation of any proposed increase in fixed costs via a thorough analysis of activities and costs covered by those fees. Explanations for any unusual trend results (high relative to the market, low relative to the market). Claims Standards Financial Accuracy Measures the gross dollars paid incorrectly (overpayments plus underpayments) subtracted from total paid claim dollars, divided by total paid claim dollars within the audit sample 99% of dollars processed accurately. Measured by the State's independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal places. 2.00% of fees if 99% but at least 97%. 4.00% of fees if less than 97%. Claims Standards Payment Accuracy Measures the number of incorrect drafts of payments made on behalf of the State, subtracted from the total draft or payment 97% of claims with benefit payments are processed accurately. Measured by the independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal places. 2.00% of fees if below 97% but at least 95%. 4.00% of fees if less than 95%.
transactions, divided by the total draft or payment transactions. Claims Standards Processing Time 95% of all claims are adjudicated within 10 business days; and 98% of all claims are adjudicated within 20 business days. Measured by the State's independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal places. 3.00% of fees if performance is less than standard. Provision of claims and eligibility data to third party vendors. Delivery of agreed-upon claims and eligibility data to third party vendors in the format and frequency required by the applicable vendor(s). Date-stamp of receipt by the third-party vendor and verification of completeness of required documentation. 0.05% for each calendar day the data is not received or is incomplete. Annual Hospital Records Claims Audit Conduct hospital records (including clinical and billing issues) audits for every admission with paid claims in excess of $25,000, subject to a minimum of 2% of all hospital claims. Audits are to be conducted to ensure accuracy of billed charges in relation to the clinical services delivered. Provide quarterly reporting of the number of audits conducted, the amount of recoveries to the SLEOLA Plan. 3.00% of fees if performance is less than standards. SLEOLA Member Satisfaction Satisfactory or better results from an annual State-conducted Participant satisfaction survey. 90% of members indicate satisfied or very satisfied. Survey results. 1.00% of fees if less than 90% of members indicate satisfied or very satisfied.