Calculation Methodology The measurement begins from the date Insurer receives the request and ends the date Insurer makes a final decision and communicates such decision to the requesting Provider. Requests for prior authorization pending additional information from the requesting Provider are not included in the measurement so long as the prior authorization was extended appropriately as described in 42 CFR 438.210. Prior authorizations for which Insurer extended beyond the fourteen (14) Calendar Days as permitted by law are excluded from this measurement. For purposes of determining compliance with this PG and for determining any financial consequences, Insurer shall report the percentage of prior authorizations processed within fourteen (14) Calendar Days. Performance reported in any other manner, including the number of Calendar Days to process one hundred percent (100%) of prior authorizations is insufficient to meet the requirements of this PG. Financial Consequences shall be calculated as the difference between the guarantee and the actual result, multiplied by one thousand dollars ($1,000). Related Contract Reference: Section 26 Expedited, Non-prescription Drug Prior Authorization Processing Timeliness Insurer shall process 100 percent (100%) of all expedited, non-prescription drug prior authorizations within seventy-two (72) hours. Financial Consequences: one thousand dollars ($1,000) per percentage point below guarantee. Calculation Methodology The measurement begins from the date and time Insurer receives the request and ends the date and time Insurer makes a final decision and communicates such decision to the requesting Provider. Requests for prior authorization pending additional information from the requesting Provider are not included in the measurement so long as the prior authorization was extended appropriately as described in 42 CFR 438.210. Prior authorizations for which Insurer extended beyond the seventy-two (72) hours as permitted by law are excluded from this measurement. For purposes of determining compliance with this PG and for determining any financial consequences, Insurer shall report the percentage of prior authorizations processed within seventy-two (72) hours. Performance reported in any other manner, including
Financial Consequences apply to each Calendar Day beyond the allowable forty-eight (48) hours, including the date the systems regain availability. Related Contract Reference: Section 6 Network Access Insurer shall provide ninety percent (90%) of Enrollees residing in Insurer’s Service Area with access to one Provider for each of the provider types below within the timeframe and distance listed for rural and urban counties. Provider Type Time (in minutes) Distance (in miles) Rural Urban Rural Urban PCP – Pediatrician 30 20 30 20 PCP – Family Physician 20 20 20 20 OB/GYN 30 30 30 30 Behavioral Health – Pediatric 60 30 45 30 Behavioral Health – 60 30 45 30 Allergy/immunology 60 30 45 30 Dermatology 60 30 45 30 Optometry 60 30 45 30 Otolaryngology (ENT) 60 30 45 30 Specialist – Pediatric 40 20 30 20 Specialist – Other 20 20 20 20 Hospital 30 30 30 20 Pharmacy 15 15 10 10 Financial Consequences: one thousand dollars ($1,000) per percentage point below guarantee per measurement. Calculation Methodology Network access be calculated separately for each provider type and access type (time or distance) and geographical location type (rural or urban). This PG requires fifty-two (52) separate measurements. Financial Consequences shall be assessed for each of the fifty-two (52) measurements, including each access and geographical type and for each Provider type, for which Insurer fails to meet the guarantee.