vendor, Trizetto, to manually key paper claims and scan the paper claim image. Paper claims were turned into EDI claims and followed the same process as electronic claims. NHP used its vendor, Beacon Health Options (Beacon), to handle behavioral health claims. Beacon had adequate processes in place to handle EDI and paper claims. Beacon used acknowledgement and response files for notifying providers of receipt of EDI submissions. Beacon processed claims within FlexCare 360. CVS Caremark was contracted by NHP to process pharmacy claims. Pharmacy claims data were received daily from the pharmacy vendor and there were adequate processes in place to monitor pharmacy encounter volume by month. There were no issues identified with claims or encounter data processing or data completeness. Enrollment Data NHP processed Medicaid enrollment data using the QNXT system. All necessary enrollment fields were captured for HEDIS reporting. Medicaid enrollment data in an 834 format were received daily from the State and processed by NHP. The daily file included additions, changes, and terminations. Enrollment data were loaded into NHP’s enrollment system, QNXT, and the system captured current and historical enrollment spans. NHP also received a full monthly refresh file and conducted reconciliation between QNXT and the State file. QNXT retained Medicaid identification (ID) numbers and the plan assigned a unique QNXT system ID. NHP had adequate data quality monitoring and reconciliation processes. There were no issues identified with enrollment processes. Medical Record Review NHP used Verscend software to produce the postpartum component of the Prenatal and Postpartum Care measure. Verscend’s data abstraction tool materials were reviewed and found to be compliant with HEDIS technical specifications. NHP used its own internal abstraction training and the training manual was reviewed and found to be compliant with HEDIS technical specifications. NHP had sufficient oversight processes in place for medical record abstraction activities and demonstrated adequate processes for inter-rater reliability and ongoing quality monitoring throughout the medical record review process. No issues were identified with the medical record review process. Supplemental Data NHP used multiple standard supplemental data sources, including electronic medical record data from many entities. NHP provided all required supplemental data source documentation. There were no concerns or issues identified with the use of these supplemental data sources. Data Integration NHP’s performance measure rates were produced using Verscend software. Data from the transaction system were loaded to NHP’s data warehouse for a monthly build. Vendor data
Performance Improvement Project Score KEPRO evaluates a MCO’s performance against a set of pre-determined criteria. The Technical Reviewer assigns a score to each individual rating criterion. The Reviewer rates individual standards as either 1 (does not meet item criteria); 2 (partially meets item criteria); or 3 (meets item criteria). A rating score is calculated by dividing the sum of all available points by the sum of all points received. This ratio is presented as a percentage. Fallon Health received a rating score of 100% on its AMM PIP. Exhibit 62: Fallon Health MCO’s AMM PIP Scores Results of Validation Ratings (for Y/N Values) Number of Items Total Available Points Points Scored Rating Averages General Information 1 1 1 100% Reassessing Intervention Parameters & Strategies 3 3 3 100% Performance Indicator Data Collection 3 3 3 100% Validation Rating Score (for Y/N Items) 7 7 7 100% Summary Results of Validation Ratings (for 3, 2, or 1 Values) Number of Items Total Available Points Points Scored Rating Averages Reassessing PIP Goals & Barriers 5 15 15 100% Reassessing Intervention Parameters & Strategies 4 12 12 100% Performance Indicator Parameters 1 3 3 100% Performance Indicator Data Analysis 4 12 12 100% Performance Indicator Results 1 3 3 100% Member Population Analysis 2 6 6 100% Conclusions & Future PIP Improvements 4 12 12 100% Rating Score for (3, 2, or 1 Values) 21 63 63 100% Overall Validation Rating Score 34 74 74 100% Updates on 2016 Recommendations
Reassessing Intervention Parameters & Strategies 3 3 3 100% Performance Indicator Data Collection 3 3 3 100% Validation Rating Score (for Y/N Values) 7 7 7 100% Results of Validation Ratings (for 3, 2, or 1 Values) Number of Available Points Points Scored Rating Averages Reassessing PIP Goals & Barriers 5 15 12 80% Reassessing Intervention Parameters & Strategies 4 12 6.3 53% Performance Indicator Parameters 1 3 2 67% Performance Indicator Data Analysis 4 12 12 100% Performance Indicator Results 1 3 3 100% Member Population Analysis 2 6 2 33% Conclusions & Future PIP Improvements 4 12 8 67% Validation Rating Score (for 3, 2, or 1 Values) 21 63 45.3 72% Overall Validation Rating Score 28 70 52.3 75% Follow Up to 2016 Recommendations KEPRO is required by CMS to determine the status of recommendations made in the previous reporting year. An update on recommendations made in 2016 to Health New England follows: Calendar Year 2016 Recommendation 2017 Update When a member needs to schedule a postpartum visit, the care coordinator could offer to stay on the line on a three-way call with the member and postpartum care provider. HNE did not present related analysis in 2017. During an outreach call, the care coordinator could inquire about the member’s use of Text4Bbaby and record use for later tabulation. This would help HNE both better HNE did not present related analysis in 2017.