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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.9 Participation in Information Systems Work Groups/Committees When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:
Mercy Maricopa Integrated Care (MMIC) recognizes that integrating the delivery of behavioral
and physical health care requires the effective gathering, management and reporting of data. We
will work with all relevant stakeholders to develop an information systems program that
facilitates the exchange of data as information across system partners. MMIC’s non-profit
sponsors, Maricopa Integrated Health System (MIHS) and Mercy Care Plan (MCP), have
extensive experience working with the state, stakeholders and providers on information systems.
Through this experience, we have learned that working closely with the state, stakeholders and
providers during implementation/readiness review is critical to a successful program.
MMIC is committed to successful implementation of the integrated model and will dedicate the
necessary resources to make this a successful program, including working with all providers,
including behavioral health providers on adopting electronic health records and health
information exchanges. Additionally, we have the ability to leverage the considerable resources
available through our affiliated plans and Aetna, which affords us access to a vast pool of
expertise. Our affiliated plans and Aetna have extensive expertise in developing technical
initiatives for integrated models across the country.
MMIC’s non-profit sponsors, MIHS and MCP, have been collaborating with AHCCCS to
provide resources and technology in support of Arizona’s Health Information Exchange (HIE)
platform, and any future enhancements, assisting with the development of the state’s Health-e
project plan and e-prescribing initiatives, implementing all required data exchange interfaces,
and building upon existing EHR capabilities. For example, MCP recently collaborated with
AHCCCS to discuss implementation of the Arizona Exchange Care Coordination initiative.
Similarly, our affiliates continue to work together with multiple state agencies in the
development of HIT and related (e.g., Electronic Health Record (EHR)) technology. For
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 1
MAG-331-000001
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
example, Delaware Physicians Care, Inc., (DCPI) a MMIC affiliate, has been actively involved
in the development and deployment of a clinical information sharing utility as part of the
Delaware Health Information Network (DHIN) initiative for many years. Currently considered
by many as the most advanced utility for health information exchange in the nation, DHIN
provides electronic sharing of Electronic Medical Record (EMR) information among
participating health care providers including primary care, specialist, hospital and ancillary
providers.
17.9.1 Participation in AHCCCS Workgroups Including Technical Consortiums
MMIC will actively participate with stakeholders and system partners in the AHCCCS Technical
Consortium, previously the National Provider Identification (NPI) Consortium; the HIPAA 5010
Consortiums; AHCCCS 5010 834 Consortium; ICD-10 Consortiums; and electronic data
interface (EDI) committee meetings. Following contract award, and as part of our
implementation plan outlined in RFP Section 18.24.5, MMIC’s IT management team will reach
out to AHCCCS’ technical consortiums and schedule introductory meetings. Going forward, our
Information Systems Administrator will serve as the MMIC Representative for all IT-related
workgroups and committees.
MMIC intends to use this contract award as a key driver to address historical gaps in accuracy of
the assignment of the primary care providers as managed under AHCCCS. In order to fulfill the
state’s vision of the patient’s whole health, the ability to identify and maintain the patient’s
primary care provider within the AHCCCS enrollment is strategic to facilitate that care. MMIC
envisions AHCCCS will work with the AHCCCS plans to raise the importance of maintaining
that information and closely with HINAz on the proposed provider directory.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 2
MAG-331-000002
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.9.2 Participation as a Data User in HinAZ
MMIC is committed to being an active participant as a data user in the Health Information
Network of Arizona (HINAz). Our partner organizations, Mercy Care Plan and Maricopa
Integrated Health Systems (MIHS), currently participate in AHCCCS work groups, including the
HINAz work group. The MIHS COO, Bill Vanaskie, is Chairman of the HINAz Board of
Directors, and MIHS has also participated in AMIE, the AHCCCS predecessor to HINAz.
MMIC will be committed to furthering HINAz’s goal of building the state’s largest non-profit
health information exchange system where authorized health care providers can safely access
electronic records anywhere, any time. We will contribute our Information Technology team’s
expertise to HINAz to develop an exchange that allows physicians to make appropriate, safe
decisions about care, even if they have never seen that patient before, to improve the access,
quality, and safety of health care while reducing the costs of care in Arizona. MMIC will
continue to collaborate and build towards enhancing access to timely information, including:
MMIC will work with HINAz and Behavioral Health Providers to determine the best strategy
towards integrating with HINAz, as currently HINAz does not permit Behavioral Health
information to be shared across the HINAz exchange.
MMIC will work with Arizona Strategic Enterprise Technology Office (ASET) to identify
opportunities to utilize other funding sources, similar to the State of Arizona Health
Information Exchange (AZHIE) Unconnected Providers’ grant program supporting Health
Information Exchange (HIE) planning and implementation for health care organizations and
healthcare providers who have not yet planned or implemented a HIE solution.
MMIC will engage Arizona Health-e Connection, a network of companies, organizations and
individuals dedicated to better health and wellness through advancing health IT and a health
information infrastructure for all of Arizona. We will work with Arizona Health-e
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 3
MAG-331-000003
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Connection to advocate and advance secure and private health IT, and to create a health
information infrastructure for Arizona through a public-private partnership of all health care,
business and government stakeholders to bridge the gap of the behavioral health and primary
care services.
MMIC is committed to the successful implementation of the integrated model, and we will
dedicate the necessary resources to make this a successful program by working with all
providers, including behavioral health providers on adopting electronic health records and health
information exchanges.
17.10 Enrollment and Eligibility Data Exchange When responding, include
a. Offeror’s strategies for its Implementation Plan consistent with 18.24.5. b. Information to show capability of its Enrollment and Eligibility Data Exchange System (System) in
accordance with the following. Exhibit 14, Member History Test Document, includes redacted HIPAA-compliant 834 enrollment records for thirteen (13) members. This member information is a representation of the actual data Contractor is required to load and interpret in significant volume. Offerors should process the records in Exhibit 14 and create accurate enrollment histories for each member by submitting Attachment 6.4. Offerors should use the guidance provided in Exhibit 7, Client Information System (CIS) File Layouts and Specifications Manual, and IT Guidance Documents.
Offeror Response:
Mercy Maricopa Integrated Care’s (MMIC) sponsor, Mercy Care Plan (MCP), has been
successfully supporting enrollment and eligibility management processes in Arizona Medicaid
since 1986. MCP’s experience includes multi-program enrollment and eligibility including
AHCCCS Acute Care, Kids Care, ALTCS, DES DD, Medicare Advantage Special Needs Plan
(SNP) and Health Care Group. Each of these programs has unique eligibility requirements. We
have the experience and infrastructure to support all aspects of the RBHA enrollment and
eligibility process.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 4
MAG-331-000004
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Better Health Enterprise System Platform™ (BH-ESP) will support the required EDI
transactions and complies with all applicable HIPAA requirements, as well as the procedures,
policies, rules and statutes in effect during the term of our contract. Figure 1: BH-ESP accepts
and generates enrollment and eligibility transactions required to and from all stakeholders
involved in the process.
BH-ESP will process HIPAA-compliant transactions easily and efficiently, allowing MMIC to
accept information electronically from almost any HIPAA-compliant contractor or provider.
BH-ESP will invoke data transformation services that translate data to and from the full spectrum
of HIPAA transactions sets in a highly configurable, agile, and robust system environment.
Primarily, BH-ESP will utilize the following electronic transactions to support enrollment and
eligibility data exchange (including SMI status) for all clients, including Non-Title XIX/XXI
eligible members, as detailed in Table 1 below.
Table 1: Electronic Transactions Utilized Transaction Description
ANSI X12 834 Benefit Enrollment and Maintenance
ANSI X12 270 Eligibility, Coverage or Benefit Inquiry
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 5
MAG-331-000005
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Transaction Description
ANSI X12 271 Eligibility, Coverage or Benefit Information/Response
BH-ESP also includes support and complies with ADHS/DBHS’ data processing and interface
requirements including:
Client Information System (CIS) File Layouts and Specifications Manual
ADHS/DBHS Operations and Procedures Manual
ADHS/DBHS Policy and Procedure Manual
ADHS/DBHS Covered Behavioral Health Services Guide
ADHS/DBHS Office of Grievances and Appeals Database Manual Docket Tracking
Application Users Guide
Demographic and Outcome Dataset User Guide (42 CFR 438.242(a))
MMIC will have dedicated considerable resources to develop the functionality and support to
keep pace with the changes in HIPAA requirements. We will engineer our systems to meet the
requirements of the current HIPAA Transactions and Code Sets regulations and the Client
Information System (CIS) File Layout and Specifications Manual. We will also be active at the
federal level to address future HIPAA mandates as they arise. We will follow the Strategic
National Implementation Project (SNIP) recommendations for testing created by the Workgroup
for Electronic Data Interchange (WEDI).
17.10.1 Accept and Utilize Electronic Client Eligibility/Enrollment Information
To support the management of client enrollment and eligibility information across RBHA
stakeholders, BH-ESP will facilitate data exchange and data sharing of Client
Eligibility/Enrollment Information utilizing the 834 CMS-Prescribed version standard formats
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 6
MAG-331-000006
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
for eligible members in conformance with the Client Information System (CIS) File Layouts and
Specifications Manual.
17.10.2 Require Subcontracted Providers to Collect Enrollment Information in the 834
CMS-Prescribed Version Standard Formats for Non-Title XIX/XXI Eligible Members
MMIC will share and require our subcontracted providers to share enrollment information in the
834 CMS-Prescribed version standard formats for Non-Title XIX/XXI-eligible members as well.
17.10.3 Submit Enrollment Information in the 834 CMS-Prescribed Version Standard
Formats for Non- Title XIX/XXI Eligible Members
MMIC will submit enrollment information in the 834 CMS-prescribed version standard formats
for Non- Title XIX/XXI eligible members to ADHS/DBHS. As described above, this will be our
standard and preferred protocol for all client enrollment transactions.
17.10.4 Share Information as Needed with AHCCCS/SSI-MAO to Assist in the Title
XIX/XXI Eligibility Determination
MMIC will also facilitate the Title XIX/XXI eligibility determination process with
AHCCCS/SSI-MAO by sharing through structured transaction protocol the appropriate
information, including the applicant’s screening information, behavioral health history and SMI
status, with AHCCCS/SSI-MAO.
Please see the Attachments tab of ProcureAZ for MMIC’s Member History Test files.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 7
MAG-331-000007
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.11 Claims and Encounter Submission and Processing Requirements When responding, include:
a. Offeror’s strategies for its Implementation Plan consistent with 18.24.5. b. A detailed flowchart and narrative description of the claims/ encounters adjudication processes,
addressing both paper and electronic claims submissions that contain a description of the following:
1) The monitoring process for accurate and timely claim adjudication; 2) How deficiencies are identified and resolved; 3) Timeliness standards and cost avoidance/TPL activities; and 4) How claim inquiries are addressed and resolved.
c. A sample of the remittance advice (front and back) or a written narrative of the remittance advice. d. For encounters, describe the process to ensure the accuracy, timeliness, completeness is and
the remediation process when standards are not met.
Offeror Response:
Mercy Maricopa Integrated Care (MMIC) will subcontract management of all administrative
services to Schaller Anderson (Schaller), LLC, an Aetna company, with more than 25 years’
experience managing the care of the most medically vulnerable. Schaller owns and administers
Medicaid managed health care plans for more than one million members, and provides care
management services to hundreds of thousands of high-cost, high-need Medicaid members. It
utilizes a variety of delivery systems, including fully capitated health plans, complex care
management, and administrative service organizations. MMIC will use these innovative
approaches to achieve both successful health care results and maximum cost outcomes.
MMIC’s Chief Operating Officer (COO), Michel Fronske, will be responsible for and has
authority over Schaller’s claims performance. The COO will be supported by the Vice President
of Health Plan Operations (HPO), together they will oversee MMIC’s full compliance with all
applicable AHCCCS and federal requirements, maintaining processes that meet claims processing
timelines, maximize cost avoidance, and minimize claims recoupment.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 8
MAG-331-000008
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Our Vice President of Health Plan Operations and Claims Administrator, John Monte will
review, approve, date and sign all claims Policies and Procedures (P&Ps) annually to verify their
agreement with current practices and support continued compliance with applicable AHCCCS
standards and requirements.
Through Schaller, MMIC is confident we will be able to provide encounter accuracy and
implement corrective action plans to maintain high levels of accuracy.
MMIC’s Information Technology (IT) staff, under the direction of the Information Systems
Administrator, will review all strategies for implementing the Management Information System,
claims and encounter processing, and other systems that rely on data or data processing to
achieve full compliance with all contractual obligations. Key IT staff will coordinate our efforts
to collect, analyze, integrate and report data. They will utilize the following documents to assist
in implementation activities:
AHCCCS HIPAA Transaction Companion Guides & Trading Partner Agreements
AHCCCS Encounter Manual
AHCCCS Technical Interface Guidelines
Client Information System (CIS) File Layouts and Specifications Manual
Additionally, MMIC will comply with all data submission standards required by this Contract,
and accept ADHS/DBHS rejection of non-compliant submissions.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 9
MAG-331-000009
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.11.1 ADHS/DBHS Claims and Encounter Submission Requirements
17.11.2 ADHS/DBS Claims and Encounter Submission Deadlines
17.11.3 Deadlines for Eligible Federal Drug Rebate Processing Pharmacy Encounter
Submissions
MMIC has subcontracted with Schaller Anderson, LLC (Schaller), LLC, an Aetna company, to
maintain a centralized, HIPAA-compliant claims processing and payment system capable of
processing, cost avoiding and paying claims in accordance with A.R.S. §§ 36-2903 and 2904 and
AHCCCS Rules R9-22 Article 7.
Schaller, as part of its management subcontracting agreement, will provide full claims
administration through a claims management organization. It will be led by a local Claims
Director. Centralizing claim processing functions at Schaller allows MMIC to take advantage of
economies of scale and quality efficiencies. Schaller's claim processing team adjudicates for
more than a million Medicaid lives.
MMIC's Chief Operating Officer (COO) has responsibility and authority over Schaller's claims
performance. During implementation, the COO will oversee the development of written policies
and along with the Information Systems Administrator and the Vice President of Health Plan
Operations will be accountable for our testing procedures so that our systems and processes are
in full compliance with all applicable AHCCCS and federal requirements, and maintain claims
processing timelines, maximize cost avoidance, and minimize claims recoupment. Our Vice
President of Health Plan Operations and Claims Director will review, approve, date and sign all
claims Policies and Procedures (P&Ps) annually to confirm their agreement with current
practices, and support continued compliance with applicable AHCCCS standards and
requirements.
The cornerstone of the claims adjudication process, QNXT™, was upgraded to version 4.8 as
recently as January 2012, and passed an independent post-migration audit. Future plans include
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 10
MAG-331-000010
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
additional upgrades in anticipation of approaching ICD-10 requirements. This HIPAA-
compliant, rules-based claims adjudication system has processed more than 1,214,023 claims for
our sponsor MCP’s Arizona Long Term Care System (ALTCS) line of business from January 1,
2012, through November 30, 2012.
Building on the QNXT™ experience in Arizona, MMIC will have the capacity to process
copious amounts of claims
data. The QNXT™ system is
so effective that, for the 10
months ending February 2011,
an average of 98.8 percent of
MCP’s claims were finalized
within 30 calendar days or less,
with 99.5 percent within 60
calendar days.
Using the Plan-Do-Study-Act (PDSA) protocols, Schaller will continue to make process
improvements that increase financial and payment accuracy. For example, during past calendar
years, system audit results for MCP have averaged 99.3 percent (financial) and 98.3 percent
(payment) accuracy rates.
Schaller's claim system runs on a high-speed Local Area Network (LAN) and Wide Area
Network (WAN) and cluster of servers with built in redundancy. This system and its
configuration provide all necessary computing power, redundancy and scalability to meet both
enrollment growth and increases in AHCCCS specifications or requirements. Schaller is able to
add servers to increase performances vertically, and they are designed to accept increases in
RAM and processing power to grow horizontally. That scalability allows the claims system to
The QNXT™ system is so effective that, for the 10 months ending February 2011, an average of 98.8 percent of MCP’s claims were finalized within 30 calendar days or less, with 99.5 percent within 60 calendar days.
Using the Plan-Do-Study-Act (PDSA) protocols, Schaller will continue to make process improvements that increase financial and payment accuracy. For example, during past calendar years, system audit results for MCP have averaged 99.3 percent (financial) and 98.3 percent (payment) accuracy rates.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 11
MAG-331-000011
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
match any escalation in volume associated with enrollment growth while maintaining
responsiveness, up-time and performance. The Schaller system will enable MMIC to:
Submit claims and encounters to ADHS/DBHS or AHCCCS, as directed by ADHS/DBHS
and in conformance with the Client Information System (CIS) File Layouts and
Specifications Manual, ADHS/DBHS Office of Program Support Operations and Procedures
Manual, ADHS/DBHS Provider Manual, 6.2 Submitting Claims and Encounters to the
RBHA, the ADHS/DBHS Covered Behavioral Health Services Guide, and the ADHS/DBHS
Financial Reporting Guide for GSA 6
Submit claims and encounters to ADHS/DBHS or AHCCCS, as directed by ADHS/DBHS,
in conformance with the HIPAA Transaction Companion Guides & Trading Partner
Agreements, the AHCCCS Encounter Manual, no later than 210 days after the end of the
month in which the service was rendered, or the effective date of the enrollment with the
Contractor, whichever date is later
Submit pharmacy encounter data and other encounters involving services eligible for Federal
Drug Rebate processing no later than 30 days after the end of the quarter in which the
pharmaceutical item was dispensed.
Claims Adjudication
MMIC, through Schaller, will have the experienced to process medical and behavioral health,
and Medicare claims, and understands that all
three types will be included in the RBHA
contract. We will accommodate both electronic
and paper claims submission. However, we
prefer and actively encourage providers to take
advantage of our HIPAA-compliant electronic
transaction capabilities. They include electronic claims submission (EDI), Electronic Remittance
Advice (ERA) distribution, and Electronic Funds Transfer (EFT). In fact, for the rolling 12
For the rolling 12 months ending November 2012, an average of 75.7 percent of Schaller’s ALTCS claims were received through our HIPAA compliant Electronic Data Interchange (EDI) system.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 12
MAG-331-000012
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
months ending November 2012, an average of 75.7 percent of Schaller’s ALTCS claims were
received through our HIPAA compliant Electronic Data Interchange (EDI) system. MMIC
claims processing will be able to support the needs of all of provider types that render services to
the RBHA population, such as paying claims for Home- and Community-Based Services
(HCBS) providers for ALTCS.
17.11.4 Requirement for Compliant Provider Claims and Encounter Submissions
MMIC will require providers to submit claims or encounters in conformance with the
ADHS/DBHS Provider Manual, 6.2 Submitting Claims and Encounters to the RBHA, the
ADHS/DBHS Office of Program Support Operations and Procedures Manual, the ADHS/DBHS
Covered Behavioral Health Services Guide, the ADHS/DBHS Financial Reporting Guide for
GSA 6, the Client Information System (CIS) File Layouts and Specifications Manual
requirements, in accordance with HIPAA for each covered service delivered to a member.
Claims received in a paper format will be scanned by Future Vision Technologies, a Schaller
vendor. They will then be loaded into the QNXT™ system for adjudication. Claims received
electronically via one of MMIC's clearinghouse partners will be loaded directly into the
QNXT™ system. Once the electronic files are loaded, the IT department will run a daily batch
process to auto adjudicate 75.5 percent (average contract year to date) of our ALTCS claims.
During that process, a series of CCI-compliant claims edits will be applied based on QNXT™,
ClaimCheck® and iHealth software applications. These applications consistently and uniformly
apply comprehensive edits to automatically pay, pend or deny each claim.
As an example, Figure 1 on the following page illustrates All Claims Received via EDI and All
Claims Auto-Adjudicated by Month.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 13
MAG-331-000013
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 1: KIR #8 All Claims Received via EDI and All Claims Auto-Adjudicated by Month – ALL SAI
QNXT™ applies claims adjudication logic to reimburse non-participating providers at no more
than the established AHCCCS Fee-For-Service rate at the time the service was rendered, based
on the location of service. This is done by automatically applying AHCCCS' reimbursement
schedules and reference files, authorization requirements, provider configuration and processing
rules to the claim as part of the adjudication process. Claims that fail to auto adjudicate,
regardless of reason, are automatically pended for manual review. With the exception of those
that pend for medical or HCBS review, a Claims Analyst with appropriate experience,
knowledge and training, will perform the manual review and adjudicate the claim. The Claims
Analyst, using a comprehensive set of claim P&Ps, will analyze and resolve the edits in order to
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 14
MAG-331-000014
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
adjudicate the claim. The goal will be to resolve all clean claims pended for manual review
within 30 days.
Claims will pend for medical review because of outliers, facility authorization mismatch and
reconsiderations based on additional medical information. They will be pended for further
review to a medical management team under the direction of the Medical Management
Administrator. An RN, with appropriate training and expertise, will review the claim, applying
MMIC’s P&Ps and clinical practice guidelines or similar medical criteria, to determine final
adjudication status of the claim. The Deputy Medical Officer (DMO) or Medical Director
designee will be available to assist if necessary. Our goal will be to resolve all clean claims
pended for manual review within 30 calendar days.
Claims will pend for HCBS review because of mismatched HCBS authorizations, member share
of cost clarification and member room and board clarification. They will be pended to a
specialized HCBS unit, reporting to the Vice President of Health Plan Operations for further
review. An MMIC Claims Analyst, with appropriate training and experience in both case
management and claims adjudication, will apply our P&Ps to determine final status of the claim.
The goal will be to resolve all claims pended for manual review with 30 calendar days.
Claims are set to finalized status if they are auto adjudicated, or have had a manual intervention
that sets them to pay. MMIC will then conduct weekly check runs or make EFT payments to
providers, and send a remittance advice for all finalized claims. We will monitor internal claims
reports to make certain payment is within AHCCCS timeliness standards.
17.11.5 Compliance with All Timeliness, Accuracy and Omission of Data Requirements
MMIC will comply with all timeliness, accuracy and omission of data requirements for
processing encounters in conformance with the ADHS/DBHS Office of Program Support
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 15
MAG-331-000015
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Operations and Procedures Manual, and be subject to financial sanction for non-compliance with
encounter or claim submission standards.
Coordination of Benefits (COB) and Third Party Liability (TPL)
MMIC's standard operating procedure will be to coordinate benefits with primary insurance or
recover payments from other liable parties before applying Medicaid as a source of payment. As
85 percent of ALTCS members are dually eligible, we will apply claims-specific edits to
maximize cost avoidance according to ACOM Medicare Cost Sharing policies.
We will identify potential COB opportunities through information received from AHCCCS;
Health Management Systems (HMS); internal staff, including Care Managers; members; claims,
and Explanation of Benefits (EOB). If we verify Other Insurance (OI), we will move to last
payer position and adjudicate the claim in accordance with our COB protocols.
When we receive a claim without an EOB attached, and the member's eligibility record identifies
OI, we will deny the claim. Our internal training department will provides training to all staff
with exposure to claims and encounters to identify and report COB and TPL opportunities.
Once OI is confirmed, we will update the member's eligibility record. If OI is retroactive, a
Claims Analyst will research the member's claims history, and any funds paid as primary are
slated for recoupment.
MMIC’s sponsor, Mercy Care Plan (MCP), operates a CMS Medicare Advantage Special Needs
Plan (SNP) called Mercy Care Advantage (MCA). For members who are dually eligible and
enrolled with both MMIC and MCA, we will auto adjudicate claims to apply first to the
Medicare benefit, and then apply the remainder to the Medicaid benefit.
We will refer MMIC members who may be eligible for Children's Rehabilitative Services (CRS)
and who also have private insurance or Medicare coverage to CRS for determination of
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 16
MAG-331-000016
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
eligibility for CRS Service. We will update the member benefits profile as necessary, and handle
care coordination and payment responsibility accordingly.
Our COB team, utilizing the AHCCCS protocols, will report verified OI that has not been
received via AHCCCS files to AHCCCS no later than 10 calendar days from the date of
discovery. In addition, we will notify AHCCCS of any known change in coverage, including
Medicare, via the appropriate technical interface.
For TPL, our standard operating procedure will be to "pay and chase". We will contract with
Recovery Management Services (RMS) to recover payment when applicable. We will route
claims received with indication of potential TPL opportunities, based on diagnosis codes, to
RMS for recovery. RMS will investigate and pursue recoveries, and return to MMIC any
remuneration from other payers or insurers.
We will contract with Health Management Systems (HMS) to recover payments MMIC makes
as primary when the member had OI for the dates of service. Recoveries that HMS pursues on
our behalf will be for claims payments that are older than a year. HMS will work directly with
the identified insurance carrier,
not the provider.
MMIC will submit, on a
quarterly basis, a summary of
our cost avoidance/recovery
activity as specified in the
AHCCCS Program Integrity Reporting Guide. MMIC will adopt our sponsor’s MCP, standard
operating procedures. In calendar year 2011, MCP successfully avoided $73,540,581 in
overpayments. A flowchart of TPL/COB process can be found as Figure 5 at the end of this
section.
MMIC will submit, on a quarterly basis, a summary of our cost avoidance/recovery activity as specified in the AHCCCS Program Integrity Reporting Guide.
MMIC will adopt our sponsor’s MCP, standard operating procedures. In calendar year 2011, MCP successfully avoided $73,540,581 in overpayments.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 17
MAG-331-000017
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Provider Claims Inquiries
MMIC’s staff, comprising our Network Development Administrator and 31 local Full Time
Equivalents (FTEs) including a Provider Services Director, two Provider Services Managers,
and a cadre of Provider Services Representatives (PSRs), will respond to provider inquiries and
complaints, as well as offer education to providers and their staffs. In addition, the Claims
Administration department will have 24 local FTEs including full-time Claims Inquiry and
Claims Research (CICR) Representatives to respond to provider questions, status inquiries and
payment issues via our claims inquiry line. It will be staffed from 8 a.m. to 5 p.m., Monday
through Friday (excluding holidays), and an automated telephone system will allow callers to
speak with a Representative or leave a detailed message regarding their inquiry.
QNXT™'s call tracking module maintains a record of any provider inquiry, request, or
complaint. We will research, resolve or respond to all reported issues within 10 business days,
with response timeliness and resolution monitored via call management tracking reports.
Whenever possible, reported issues will be resolved immediately. We will submit issues
requiring in-depth research and resolution to the Health Plan Operations department. Provider
Services personnel will also respond to inquiries and requests for claims review received via e-
mail, fax transmission or mail. Finally, providers will be able to access detailed information
through our secure HIPAA-compliant web portal. An illustration of our provider claim inquiry
process can be found as Figures 2-4 at the end of this section.
Please see the Attachments tab of ProcureAZ for a front and back sample of Mercy Maricopa
Integrated Care (MMIC)’s Remittance Advice.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 18
MAG-331-000018
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.11.6 Development and Implementation of Policies and Procedures:
17.11.6.1 To process encounters accurately, timely and complete 17.11.6.2 For encounters to describe the services provided 17.11.6.3 To accurately adjudicate encounters in conformance with AHCCCS and ADHS/DBHS requirements 17.11.6.4 Comply with all state and federal requirements
MMIC will implement highly developed claims processing policies and procedures to make sure
we process encounters accurately, promptly and completely. Utilizing a proprietary encounter
system, we will make certain encounters describe the services provided, accurately adjudicate
encounters in conformance with AHCCCS and ADHS/DBHS requirements, and comply with all
state and federal requirements.
MMIC’s sponsor Mercy Care Plan (MCP)’s proprietary Encounter Management System (EMS)
will be used to provide for accurate, timely and complete submission of encounter data –
including all billed, paid and denied units and charges, as well as the National Provider Identifier
(NPI) – to AHCCCS in HIPAA compliant 837(I/P) format. EMS will receive and process
encounter data from behavioral health, vision, dialysis, transportation and lab providers as well.
Developed with the functionality to manage encounter data across the encounter submission
continuum – including preparation, review, verification, certification, submission and reporting,
it will consolidate required claims data from multiple sources (such as QNXT™ and our
Pharmacy Benefits Manager) for all services (including those in the prior period) for which
MMIC will incur a financial liability, as well as claims for services eligible for processing where
no financial liability was incurred. Comprehensive, coordinated edits and workflow management
tools, including those described below, will identify and address potential data issues at the
earliest opportunity. MCP’s collaboration with the AHCCCS encounter processing unit
contributed to the successful acceptance of more than 99 percent of all submitted encounters in
calendar year 2010.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 19
MAG-331-000019
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
MMIC will use EMS to monitor encounter submissions on a monthly basis by comparing
encounter production to revenue distributed to providers, factoring in lag time. We will be able
to identify and respond to a provider‘s over- or under-production of encounters in a timely
manner. Additionally, we will also be able to monitor encounter production by service delivery
site, and have procedures in place to respond to outliers.
Completeness, Timeliness and Accuracy
Claims Processing: Our core claims and eligibility processing system, QNXT™, will use a
series of active claim edits, including state reference file information, to determine whether
select claim fields contain required values, and will deny completely, or in part, claims submitted
with missing or invalid information. The provider must then resubmit the claim with complete,
valid information to receive payment. To better support improved processing, completeness and
accuracy, MMIC will reconcile our member files with AHCCCS' monthly 834 transaction, then
resume posting daily 834 transactions, reporting any discrepancies to AHCCCS' Member File
Integrity Services Unit.
Encounter Staging Area: Upon successful adjudication and payment within QNXT™, claims
will be exported to the EMS encounter staging area, a quality control measure utilizing
intermediate data tables, wherein receipt of all claims data will be verified by way of a transfer
validation report, reconciling the paid claim counts in the system to those in EMS. Valid claims
data will then be loaded into EMS, while encounter management staff will research, track and
report any discrepancies to resolution.
EMS Scrub Edits: Encounter management and staff will design and apply custom AHCCCS-
specific edit profiles to encounter data in EMS, aligning our internal encounter edit configuration
with that of AHCCCS. The result of this process will be improved encounter acceptance rates,
as data unlikely to pass AHCCCS edits are pended or rejected until the underlying issue can be
identified and resolved.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 20
MAG-331-000020
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Encounter Tracking Reports: Encounter management and staff will utilize a suite of reports to
monitor, identify, track and resolve issues concerning encounter data at any point in the
submission process. These reports will enable us to monitor the status of each encounter in
EMS, providing accurate, timely and complete submission of data to AHCCCS. They will make
sure that encounter data arrives no later than 210 days after the end of the month when the
service was rendered, or the effective date of enrollment with MMIC, whichever is later.
Additionally, pharmacy-related encounter data will also arrive no later than 30 calendar days
after the end of the quarter in which the pharmaceutical item was dispensed.
Encounter Aging Reports: These reports will provide the aging and status of any encounter in
process, enabling encounter management staff to prioritize their efforts, further supporting the
accurate, timely and complete submission of data.
Review & Verification: As part of our continuous process improvement activities and
compliance procedures, MMIC will periodically conduct scheduled chart audits, comparing
providers' medical records to claims data, to verify that there are no discrepancies between the
service codes, number of units and diagnosis codes documented in the medical record and
submitted claims data. We will cooperate with AHCCCS' annual encounter validation studies by
coordinating collection of member medical records from providers.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 21
MAG-331-000021
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.11.8 Monitoring Encounter Submissions Monthly
17.11.9 Identification and Response to Providers’ Over- or Under-Production of
Encounters
17.11.10 Monitoring Encounter Production by Service Delivery Site
MMIC will continually monitor claims processing and work with providers to resolve any claims
and encounters issues in a timely manner. The goal will always be reducing confusion at the
provider level. MCP created its Health Plan Operations (HPO) team in April 2009 to address
provider complaints and claims processing issues. The team, led by the Vice President of Health
Plan Operations, is responsible for the approval and validation of all system changes related to
claims adjudication activities.
Under the COO's oversight, the team follows the Plan-Do-Study-Act (PDSA) model for
continuous improvement, identifying opportunities for improvement via:
Monthly meetings on clinical edits
Weekly cross functional meetings
Claim reports that target, track and trend claims-related issues
Direction and validation of any new system configurations and contracts
Regular monitoring of AHCCCS website for required updates
Research and resolution of all provider complaints about claims payment
Issues identified in claim audits
Encounter pends and denials
Audits of the system benefits by the HPO department
Targeted claims review
The HPO team researches all issues identified by the various sources, and implements system
changes, provider record changes, claims P&Ps changes, and corrective action plans, then
validating all changes, evaluating the results, and repeating the process to promote continuous
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 22
MAG-331-000022
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
improvement. It tracks all issues and corrective action plans in a QuickBase database until they
are resolved. Recent successes include the transition from manual downstream provider file
maintenance to an automated front-end process that downloads provider files directly from
AHCCCS, resulting in significantly higher claims processing accuracy.
MMIC's Provider Claims Educator will support its HPO team by facilitating the inter-
departmental exchange of information and the external exchange of information between these
departments and our providers. We will then inform providers of any issue(s) potentially
impacting claim adjudication, or any opportunities for provider education.
MMIC will utilize a suite of tools, including scheduled and ad hoc reports to monitor claim
receipts, automated claims processing, manual claims adjudication, and check and remittance
advice production/distribution. These tools and reports will include:
Pended Claims and Aging Report – It will allow management to effectively intervene,
when and where necessary, to improve accurate and timely adjudication of claims. Populated
hourly and reviewed daily, the report will present claims counts and billed dollars by pend
reason and claim age, with drill-down capabilities to gather detailed claims information for
review.
In-Process Claim Reports – Our Claims and Health Plan Operations Department will daily
review and monitor the in-process claims report to enable management to effectively track
and manage all claims, so needed interventions may be applied to improve the accuracy and
timeliness of adjudication.
Claims Payment Processing Reports – This set of retrospective claims adjudication reports
will be produced and reviewed weekly to provide the Claims department, Health Plan
Operations, and the Finance department data to support reconciliation of claim volume and
adjudicated dollars, including information to support the reinsurance process.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 23
MAG-331-000023
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Monthly Claims Dashboard – AHCCCS will use this management tool to identify trends
related to critical claims metrics. The claims dashboard is reviewed monthly by the
following departments to identify appropriate action plans: Compliance, Encounters, Health
Plan Operations, and Finance.
On a daily basis, MMIC will use these reports to proactively manage claims workflow. Based on
this analysis, HPO will take appropriate action to address any trends that indicate a potential
issue, such as turnaround times or inventory levels for aging claims. It will be our standard
operating procedure to immediately determine a root cause and implement the appropriate action
plan. These plans will include system reconfiguration, staff overtime, workload balancing,
additional training of staff and providers, and hiring and training temporary workers to assist
with the reduction of claim inventories. Based on our claims volume, we will adjust hiring to
accommodate any increased trends. Additional information on our claims monitoring and
resolution of deficiencies process can be found in an illustration following our response.
Claim Quality Reviews and Claim Audits
MMIC will fully audit the work of all new Claims Analysts after they complete their orientation
and training for a minimum of one month. Initially, we will review 100 percent of their work
product and, by percentage tiers, decrease to a standard two percent by the fifth week, provided
the new Claims Analyst continues to meet claims accuracy standards. Finally, we will review 16
provider calls per Claims Inquiry Representative per month to assess the quality of service
interaction and the accuracy of information provided. We will present individual quality reports
to the Representative and Supervisor for corrective action, such as live call monitoring, if
appropriate.
Our Claims Audit Department will conduct a series of pre-payment audits, including a one
percent random sample of system-adjudicated claims; a two percent random sample of all
analyst-adjudicated claims; and 100 percent of claims with billed charges above $50,000. When
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 24
MAG-331-000024
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
we discover pre-payment errors during these audits, we will pend claims for analysis and
adjusted as required for final adjudication. If an adjudication error indicates a system
configuration problem, we will route the issue to Health plan Operations personnel for further
review, analysis, testing and correction. If adjudication errors are identified relative to manually
adjudicated claims, we will conduct a review of P&Ps and additional analyst training. If our
audit identifies a provider billing issue, we will forward the information to Provider Services
personnel for provider outreach and education as necessary. To further support quality reviews
of claims processing accuracy for acute, HCBS and other specialty claims, an independent post-
payment audit department will be responsible for conducting stratified random samples and
focused audits of paid and denied claims. The purpose of these activities will be to audit
compliance of claims adjudication with AHCCCS regulatory requirements and provider
contracts. We will distribute audit findings to HPO for root cause analysis and corrective action.
Per the ACOM Verification of Receipt of Services Policy, Mercy Maricopa Integrated Care
(MMIC) will survey a sample of our membership on a quarterly basis to verify that reimbursed
services are, in fact, delivered. Any service authorized but not performed within the allotted time
is flagged for investigation by quality management staff.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 25
MAG-331-000025
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.11.7 Verification Of Encounters For Services (42 CFR 438.455(1)(a)(2)).
17.11.11 Attestation Of Encounter Data Accuracy, Completeness and Truthful
17.11.12 Collecting And Verifying Reported Data Accuracy and Timeliness (42 CFR
438.242(b)(2)).
Certification: MMIC will include with any encounter submission a certification signed by the
CEO, CFO, or designee attesting that listed services were actually rendered [42 CFR
455.1(a)(2)]. We will submit encounters AHCCCS in its prescribed format.
Submission: MMIC will create HIPAA-compliant encounter files according to AHCCCS'
submission requirements and schedule.
Encounter Error and Acceptance Reports: Generated upon receipt of AHCCCS' response
files (277, 277U, NCPDP / PAH - post adjudicated history), these reports will include the age
and description of submission errors and provide necessary information for encounter
management staff to promptly identify, track and resolve encounter errors. Should a claim
require re-adjudication as the result of an encounter error, we will resubmit it to QNXT™ for
processing, and import it to the EMS for resubmission to AHCCCS, in accordance with
encounter correction protocol. EMS will then generate, as required, the appropriate void,
replacement and/or corrected records. If re-adjudication is unnecessary, the encounter
management unit will perform the corrections necessary to allow resubmission of the associated
encounter per protocol.
Reporting: MMIC's policies and procedures will comply with AHCCCS requirements regarding
reports, content and frequency of submission, providing for AHCCCS receipt of any deliverable
(for example, Corrected Pended Encounter Data, New Day Encounters or Medical Records for
Data Validation) by 5 p.m. on or before the indicated due date or, should it fall on a weekend,
state mandatory furlough day or holiday, by 5 p.m the next business day. For an example of
accuracy submission, please see Table 1 below:
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 26
MAG-331-000026
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 1: Accuracy Submission Plan ID
Plan Name YEAR MONTH Accepted
Total Sent
Accuracy %
MCRP MCRP 2012 1 1049316 1070101 98%
MCRP MCRP 2012 2 1282618 1309030 98%
MCRP MCRP 2012 3 1176188 1206079 98%
MCRP MCRP 2012 4 1015413 1052768 96%
MCRP MCRP 2012 5 1201785 1243497 97%
MCRP MCRP 2012 6 241793 268435 90%
Reinsurance Eligibility/Aging Reports: To maximize utilization of the AHCCCS reinsurance
program, MMIC’s Finance department will manage a separate, closely coordinated process,
wherein dedicated staff will run a monthly query against QNXT™ to identify, through
predetermined thresholds, claims eligible for reinsurance. They will then compare these claims
to EMS to isolate pended or denied encounters less than three months from their respective
Prepaid Medicaid Management Information System (PMMIS) adjudication deadlines, allowing
them to prioritize and handle them accordingly. Staff will void encounters for any claims
recouped in full, with replacement encounters submitted when any recoupment/adjustment
results in reduced/increased claim value. Training and internal policies and procedures will
address the specific nuances associated with the four types of reinsurance cases.
Remediation Strategies
MMIC’s Health Plan Operations (HPO) team, under the direction of the Vice President of HPO,
will be supported by two Encounter Specialists who research each pend or denial edit from
AHCCCS. The team will employ diverse strategies to track related issues to their point of origin,
utilizing continuous improvement methodologies to identify, assess, remediate and control
sources of error:
Manual Adjudication: MMIC’s standard operating procedures will utilize aggressive measures
to address Claims Analyst error with regard to procedural, payment or financial accuracy. These
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 27
MAG-331-000027
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
procedures will include documented coaching, Performance Improvement Plans and, if
necessary, further corrective action up to termination. If a manual adjudication error is traced to
an existing claims policy and procedure, a Claims Training Update (CTU) will be distributed to
Claims Analysts to prevent further errors. We will update policies and procedures, along with
training materials, as necessary.
Auto Adjudication: To validate correct application to all submitted claims processing, the HPO
team will review all encounter edits, pends and denials in relation to the QNXT™ system set up
for member enrollment, benefits, edits, provider set-up and reference files. The HPO team will
pend and adjust impacted claims in process, if necessary, and adopt manual workarounds as
needed until the issue is resolved.
Provider Education: The HPO department will identify opportunities for targeted provider
education regarding specific errors related to unacceptable claim and billing practices. Based
upon specific identified errors, HPO will work with Provider Services personnel to complete
outreach, education and training for providers. They will concentrate on reducing the frequency
of providers with a history of submitting incomplete, inaccurate or untimely claims by way of
additional training and support.
Encounter Workgroup: The HPO department will lead cross-functional group comprising
System Configuration Specialists, Provider Claim Educator, and personnel representing IT,
claims and claims audit departments, compliance, encounters, provider data management and
services and the Medicaid Provider Solutions Team. This workgroup will meet weekly to address
issues with resolving pends and denials, improving workflows, and any open encounter system
concerns.
Collaboration: MMIC personnel will attend a monthly meeting wherein encounter management,
claims, compliance, finance, and HPO personnel collaborate with AHCCCS staff to resolve
pended encounter issues.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 28
MAG-331-000028
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
MMIC will follow the lead of our sponsor, MCP, in all of the above. Examples of its HPO
team's success include:
Recognizing that manual input and maintenance of data poses an unnecessary risk to the
accuracy of provider information, MCP implemented an automated front-end process,
downloading provider reference files from AHCCCS every two weeks, then editing against
them to mitigate associated downstream errors.
When MCP identified improper configuration of edits related to "age" and "maximum units
available" as a source of error, it reconfigured edits, and modified the process for maintaining
them to utilize AHCCCS reference files.
Following MCP’s example, our HPO team will monitor all claim audit findings and Claim
Dashboard results, and will approve and validate all system changes, such as reference file and
fee schedule updates, as well as benefit changes. This team will also be responsible for post-
production validation of all claim processing-related projects and system change activities.
Flowcharts illustrating MMIC's encounter submissions process can be found as Figure 7 at the
end of this section.
Encounter Submission Initial and Global Acceptance Rates
MMIC will adopt MCP’s processes, which have resulted in superior encounter submission
acceptance rates with AHCCCS as evidenced in Tables 2-3 on the following pages.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 29
MAG-331-000029
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 2: Initial File Acceptance (Month of Submission regardless of DOS)
Plan ID Plan
Name YEAR MONTH Sum of
Accepted Sum of Total
Sent Accuracy %MCRP MCRP 2011 1 1246404 1267766 98%
MCRP MCRP 2011 2 1316112 1337949 98%
MCRP MCRP 2011 3 661447 677632 98%
MCRP MCRP 2011 4 1794804 1828407 98%
MCRP MCRP 2011 5 1706612 1735152 98%
MCRP MCRP 2011 6 1326277 1398988 95%
MCRP MCRP 2011 7 1053395 1070014 98%
MCRP MCRP 2011 8 1395783 1493143 93%
MCRP MCRP 2011 9 1151704 1181793 97%
MCRP MCRP 2011 10 1158826 1188320 98%
MCRP MCRP 2011 11 1371028 1394603 98%
MCRP MCRP 2011 12 880702 910403 97%
MCRP MCRP 2012 1 1049316 1070101 98%
MCRP MCRP 2012 2 1282618 1309030 98%
MCRP MCRP 2012 3 1176188 1206079 98%
MCRP MCRP 2012 4 1015413 1052768 96%
MCRP MCRP 2012 5 1201785 1243497 97%
Table 3: Global File Acceptance: Overall Accuracy
(MOS view for 2012 DOS regardless of submission date - numbers will change as claim lags process through
claims and encounter systems)
Plan ID Plan
Name YEAR MONTH Accepted Total Sent Global
Accuracy %MCRP MCRP 2011 1 1272777 1300777 97.8%
MCRP MCRP 2011 2 1208647 1241589 97.3%
MCRP MCRP 2011 3 1287638 1314745 97.9%
MCRP MCRP 2011 4 1196145 1218446 98.2%
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 30
MAG-331-000030
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Plan ID Plan
Name YEAR MONTH Accepted Total Sent Global
Accuracy %MCRP MCRP 2011 5 1174510 1195004 98.3%
MCRP MCRP 2011 6 1124083 1193871 94.2%
MCRP MCRP 2011 7 1113886 1131923 98.4%
MCRP MCRP 2011 8 1157333 1229152 94.2%
MCRP MCRP 2011 9 990840 1005557 98.5%
MCRP MCRP 2011 10 991064 1003533 98.8%
MCRP MCRP 2011 11 763603 772494 98.8%
MCRP MCRP 2011 12 171584 173831 98.7%
The following chart illustrates 12 months of MCP encounter acceptance data with AHCCCS by
hospital systems, physicians and ancillary, and pharmacy.
Table 4: MCP Encounter Acceptance Data (12 months) Form Type 2011 JAN FEB MAR APRIL MAY JUNE JULY AUG SEPT OCT NOV DEC
1500 97.86% 97.77% 97.83% 97.95% 98.07% 98.01% 98.24% 98.16% 98.67% 98.82% 98.77% 99.26%
Dental 99.78% 99.75% 99.65% 99.70% 99.75% 99.74% 99.79% 99.69% 99.74% 99.79% 99.79% 100.00%
NCPDP 97.45% 95.96% 97.84% 98.43% 98.55% 83.51% 98.63% 83.61% 98.52% 98.45% 98.76% 98.62%
UB04 97.08% 96.93% 96.70% 96.87% 97.04% 96.93% 96.40% 95.31% 94.19% 96.91% 98.61% 99.03%
MMIC’s sponsor Mercy Care Plan (MCP)’s experience in claims and encounter processing will
allow us to continue to refine and bolster our internal procedures. We will leverage MCP’s
expertise in this arena to effect changes in the way we will deliver health care to our members
and enhance our ability to serve diverse populations. Figures 2-5 on the following pages outline
our claims processing flows.
Also, please see the Attachments Tab in ProcureAZ for Mercy Maricopa Integrated Care
(MMIC)’s Sample Remittance Advice.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 31
MAG-331-000031
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 2: Claims Payable Flow Chart – Electronic Claims
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 32
MAG-331-000032
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 3: Claims Payable Flow Chart – Paper Claims
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 33
MAG-331-000033
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 4: Manage Claims Editing Flowchart (3 pages)
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 34
MAG-331-000034
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 35
MAG-331-000035
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 36
MAG-331-000036
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 5: Third Party Liability (TPL) / Coordination of Benefits (COB) Process Flowchart
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 37
MAG-331-000037
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 6: Medicaid Pharmacy Future State Process Flows
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 38
MAG-331-000038
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 7: Encounter Process
17.12 Encounter Reporting When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:
Mercy Maricopa Integrated Care (MMIC) understands that to be considered an effective
organization, we must be able to report data to the regulatory agencies that is clear, concise, and
timely. We are committed to maintaining a robust encounter reporting system that serves to
report on the services we provide to our members and supports future enhancements through the
analysis of timely and complete data.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 39
MAG-331-000039
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.12.1 Monitoring Submissions of Encounters
MMIC’s proprietary Encounter Management System (EMS) will provide for the accurate,
timely, and complete submission of encounter data, and will be used for all encounter reporting
activities. We will rely on the experience of our sponsors, Mercy Care Plan (MCP) and
Maricopa Integrated Health System (MIHS), to successfully process encounters for both
Medicaid and the Medicare/Medicaid dual eligible programs. Through EMS, MMIC will be able
to submit reports to ADHS/DBHS for tracking, trending, reporting process improvement, and
monitoring submissions of encounters and encounter revisions in conformance with the
AHCCCS Encounter Manual, or as directed by ADHS/DBHS (42 CFR 438.242(b)(3)).
17.12.2 Loading Periodic Data Files
To comply with contractual requirements and enhance the accuracy of our encounter reporting,
MMIC will load, at a minimum, twice monthly, data files containing provider and medical
coding information as defined in the AHCCCS Encounter Manual.
17.12.3 Monitoring Contractor’s Encounters Adjudication Accuracy
17.12.4 Monitoring and Reporting the Completeness of Encounters
Under the direction of the MMIC Encounters Director, encounter management personnel will be
responsible for managing encounter inventory using the following controls:
Monthly review of GLB Dashboard by Encounter Management and Project Managers
Weekly review of Progress Tracker by Encounter Management and Project Managers
Weekly review of GLB Compliance Dashboard by Encounter Management and Project
Managers
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 40
MAG-331-000040
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Weekly meetings held with encounter management and plan-specific teams to discuss aging
of encounter inventory
Weekly meetings with the Medicaid health plans to discuss aging of encounter inventory
Monthly CPSO Results report, outlining encounter inventory, to CPSO executive
management
The staff will cooperate with ADHS/DBHS in monitoring MMIC‘s encounters adjudication
accuracy against our internal criteria. These controls will allow us to track, monitor and correct
all encounter errors, so we can verify the accuracy of information reported to ADHS/DBHS and
AHCCCS.
17.12.5 Quarterly Fee for Service Check Register Review Report
17.12.6 Encounter Reconciliation Files
17.12.7 Compare Encounter Financial Data Reported with Plan Claims Data
Encounter Tracking Reports: MMIC Encounter management staff will utilize a suite of reports
to monitor, identify, track and resolve issues concerning encounter data at any point in the
submission process. These reports will allow us to monitor the status of individual encounters
within the Encounter Management System (EMS) to facilitate accurate, timely and complete
submission of encounter data to AHCCCS – thus delivering that encounter data no later than 210
days after the end of the month in which the service was rendered or the effective date of MMIC
enrollment, whichever is later. Additionally, we will submit pharmacy-related encounter data no
later than 30 calendar days after the end of the quarter in which the pharmaceutical item was
dispensed.
Encounter Aging Reports: These reports provide the aging and status of any encounter in
process. Reviewing these reports will allow encounter management staff to prioritize their
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 41
MAG-331-000041
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
efforts to track movement through the system, as well as detect and resolve any errors, further
supporting accurate, timely and complete submission of data.
Encounter Error and Acceptance Reports: Generated upon receipt of AHCCCS’ response
files (277, 277U, NCPDP, PAH Post Adjudication History), these reports will include the age
and description of submission errors. They will provide the information necessary for encounter
management staff to promptly identify, track and resolve errors. Should a claim require re-
adjudication as the result of an encounter error, it will be resubmitted to QNXT™ for processing,
with an adjusted claim imported to the EMS for resubmission to AHCCCS in accordance with
encounter correction protocol. EMS will then generate, as required, the appropriate voided,
replacement and/or corrected records. If re-adjudication is unnecessary, the encounter
management unit will perform necessary corrections to allow resubmission of the associated
encounter per protocol.
Reinsurance Eligibility/Aging Reports: To maximize utilization of AHCCCS’ reinsurance
program, MMIC’s Finance Department will manage a separate, though closely coordinated
process, wherein dedicated staff will run a monthly query against QNXT™ to identify, given
predetermined thresholds, claims eligible for reinsurance. These claims will then be compared to
EMS to isolate pended or denied encounters less than three months from the respective Prepaid
Medicaid Management Information System (PMMIS) adjudication deadline, allowing
reinsurance staff to prioritize and handle them accordingly. Encounters for any claims recouped
in full will be voided, with replacements submitted in the case of any recoupment/adjustment
resulting in reduced/increased claim value. Training and P&Ps will address the specific nuances
associated with the four types of reinsurance cases.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 42
MAG-331-000042
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Additional Reports will be used to determine the accuracy levels of encounter reporting,
including:
Encounter Correction Analyst Workflow Report (weekly/ad hoc)
Encounter Error Crystal Report (daily)
Encounter Financial Reconciliation Report (quarterly)
File Transfer Validation Crystal Report (daily/weekly)
Flash Metric Report (daily/weekly)
GLB Compliance Dashboard (monthly)
GLB Dashboard (weekly)
Master Encounter Inventory Report (weekly)
Progress Tracker (weekly)
State Dependent Encounter Status Report (monthly)
MCRP Top 10/5 Error Report (weekly)
Timely Reporting: MMIC’s reporting process will comply with ADHS/DBHS’ and AHCCCS’
requirements regarding reports, report content and frequency of submission, utilizing internal
policies and procedures that provide direction to guarantee AHCCCS’ receipt of any deliverable
by 5:00 p.m. on or before the due date indicated or, should the due date fall on a weekend, state
mandatory furlough day, or a state holiday, 5:00 p.m. the next business day.
Our timely reporting policies and procedures will direct claims management staff to submit the
Quarterly Fee for Service Check Register Review report ten (10) business days after the first
(1st) of the month following the quarter to be reviewed per the ADHS/DBHS Operations and
Procedures Manual. Also, as required, MMIC will accept, on a monthly basis, encounter
reconciliation files containing the prior eighteen (18) months of approved, voided, plan-denied,
pended and AHCCCS-denied encounters received and processed by AHCCCS.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 43
MAG-331-000043
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
MMIC will utilize the encounter reconciliation files to compare the encounter financial data
reported with the plan claims data, and to validate the completeness of submitted encounters as
compared to processed claims. To verify accuracy, MMIC has developed and will implement a
system for monitoring and reporting the completeness of encounters and encounter data
processed internally and received from subcontractors and providers. MMIC understands the
importance of maintaining a robust encounter reporting system, and we are committed and have
systems in place to provide accurate, timely, and complete submission of encounter data.
17.13 Encounter Corrections When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:
Mercy Maricopa Integrated Care (MMIC) recognizes that it is critically important to obtain
timely, accurate, and complete encounter submissions from providers. MMIC will take a multi-
pronged approach to make sure that encounter submissions are successful, including: adherence
to our written Policies and Procedures, provider contract requirements, training and interactive
tools, sanctions, and recoupments. We will monitor encounter reporting on a weekly basis and
encounters will be subject to data validation audits. MMIC will also work with the providers on
pended encounters in a proactive fashion in order to minimize/eliminate the number of
encounters aging past 120 days. MMIC will support its providers that are going to submit
encounters from day one of the start of the program. We understand the frustrations of providers
when they lack the experience or the knowledge necessary to successfully submit encounters.
Therefore, we will offer a training module for providers that is dedicated to encounter
submission; it will be detailed in our provider training plan that will be submitted to
ADHS/DBHS for review as directed, during implementation. Upon approval of the Department
and prior to contract start and we will initiate training. Ongoing monitoring and continued
follow-up and support will be provided.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 44
MAG-331-000044
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
As part of our corporate principles, we will hold our staff to the highest level of competency
when dealing with encounter data. MMIC, through its sponsors, will bring experience and
commitment regarding data accuracy and integrity into every facet of our organization. Staff
will be trained to effectively utilize the knowledge they gain, therefore delivering quality
outcomes at every step of the process.
17.13.1 Monitoring and Resolution of Pended Encounters
MMIC will establish best practices regarding the monitoring and resolution of encounter issues.
An active hands-on approach will be taken by the MMIC Encounter Unit staff to identify
consistent data issues. The proprietary Encounter Management System (EMS) will provide for
the accurate, timely and complete submission of encounter data. MMIC will leverage the
experience in processing medical, behavioral health and Medicare claims of our sponsor
agencies and instill the same quality in monitoring and resolving encounter issues. MMIC will
utilize the following documents to achieve full compliance in its efforts to collect, analyze,
integrate and report data:
AHCCCS HIPAA Transaction Companion Guides & Trading Partner Agreements;
AHCCCS Encounter Manual;
AHCCCS Technical Interface Guidelines; and
Client Information System (CIS) File Layouts and Specifications Manual.
Encounter corrections will be processed in EMS. The EMS meets the AHCCCS requirements for
encounters corrections by identifying encounter errors timely and correcting them immediately.
If re-adjudication is not necessary, mass corrections can be implemented so that records can be
re-submitted as quickly as possible. Records requiring re-adjudication will be automatically
accounted for as the corrected-claims data is loaded into the system. The system will generate
the appropriate void, replacement and/or corrected records as required. Mass correction logic is
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 45
MAG-331-000045
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
then translated into a scrub edit that proactively identifies and flags affected records prior to
submission as part of the data validation process.
Reports that will be utilized by the Encounter Unit staff to identify and correct encounter errors
include:
Error Reports (weekly, monthly)
Third Party Encounter Error Report (weekly)
Provider Error Report (weekly)
Member Error Report (weekly)
Under the direction of the Encounter Management Team, the Encounter Unit will be responsible
for correction of encounter data. The Encounter Management team reviews, approves and
communicates associated updates of state, federal or health plan encounter changes to
Information Technology (IT).
To identify and quantify all encounter errors by type, age and to confirm that each is resolved
and resubmitted accurately and on a timely basis, MMIC will implement the following measures
for Encounter staff to achieve:
Correction rate of four (4) claims/encounters per hour
Meet state requirements as defined in the Encounter Timeliness and Accuracy Requirements
Tool Kit
Achieve 100%, plus or minus 3%, encounter acceptance of finalized claims and dollars paid
in the claims processing system
Encounter remittance information is integrated with existing encounter submission data for the
following objectives:
Update the encounter status
Monitor/report encounter submission results
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 46
MAG-331-000046
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Identify encounter issues
The Encounter Unit will utilize the knowledge and strengths of specially trained encounter
correction analysts who bring extensive experience in claim adjudication and claim research to
their role. These highly skilled analysts are dedicated to researching and resolving unique
encounter issues.
17.13.2 Be Subject to Corrective Action or Financial Sanctions for Poor Overall Encounter
Performance
MMIC will accurately verify and document performance problems during the encounter process.
With proper monitoring such as weekly encounter reports, data validation audits, and technical
assistance to providers, MMIC will be able to begin corrective action as soon as it may be
required. MMIC will identify the problem with the provider and seek their commitment to take
remedial action. Once the plan is in place, MMIC will use data validation audits to follow up
and validate correction. If a provider is found to be in noncompliance, MMIC will administer
follow-up steps which could include sanctions, fines or potential recoupment based upon the
severity of the issue. MMIC understands that it could be subject to corrective action or financial
sanctions and will submit to ADHS 90 percent (90%) of encounters for all services within one
hundred twenty (120) days and 95 percent (95%) of encounters for all services within one
hundred eighty (180) days fully complying with requirements for timelines, accuracy, and
omission of data in accordance with ADHS/DBHS Office of Program Support Procedures
Manual.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 47
MAG-331-000047
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.13.3 Submit Replacement or Voided Encounters for Claims Subsequently Corrected
17.13.3.1 Void Encounters for Claims that are Recouped in Full
MMIC will submit a void request to ADHS/DBHS. MMIC will document the reason the
encounter was deleted and maintain a record of the deleted Internal Control Number (ICN).
Replacement encounters will be submitted for pended encounters for AHCCCS member ID,
service provider ID, plan ID, financial data, paid units, payer data and claim adjustment status
data as required.
17.13.3.2 Submit Replacement Encounters for a Recoupment that Results in a Reduced Claim Value
MMIC will submit replacement encounters in conformance with the AHCCCS Encounter
Manual. In addition to the replacement, MMIC will also include the following as required: the
systemic causes resulting in the need for the refund and/or an explanation of why the refund
occurred, the corrective actions that will be implemented to avoid future occurrences, if
applicable, cumulative refund amount, total number of claims and range of dates for the claims
impacted by the refund.
17.13.3.3 Submit Replacement Encounters for Recoupments Requiring Approval from ADHS/DBHS or AHCCCS
MMIC’s Claims Administrator, John Monte is responsible for the establishment of written
Policies and Procedures that direct our encounter and recoupment processes. Our P & Ps will
require that we always obtain ADHS/DBHS’ prior approval for any individual recoupment in
excess of fifty thousand dollars ($50,000) per provider within a contract year, and to notify
ADHS/DBHS of any cumulative recoupment greater than fifty thousand dollars ($50,000) per
provider Tax Identification Number per contract year. We will only submit replacement
encounters for recoupments with ADHS/DBHS/AHCCCS approval. Weekly recoupment reports
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 48
MAG-331-000048
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
will be monitored by the MMIC Finance department to verify compliance with the requirement
and to identify track trends and issues.
By following our dynamic oversight processes for the management of encounters, our processes
will be consistent and the flow of information from claims to MMIC’s other operational and
clinical departments will be smooth. This will enhance our company’s agility and
responsiveness to changing conditions. Additionally, the steps followed in our encounter
management and recoupment processes will enable us to accurately identify, manage and reduce
risk exposure, improve member service, gain operational efficiency, and adapt to change quickly.
17.14 AHCCCS Encounter Data Validation Study (EDVS) When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:
17.14.1 Cooperate with ADHS/DBHS and AHCCCS to Conduct an Annual Encounter
Data Validation Study
MMIC will cooperate with ADHS/DBHS and AHCCCS to conduct encounter data validation.
MMIC will require providers to bill services using a diagnosis code that is documented in the
service recipient’s medical record and in effect at the time the service was provided. Diagnosis
codes will be required to be clearly documented in the provider’s recipient medical records.
Examples of valid diagnosis code documentation include an annual assessment, most recent
doctor’s note (where the diagnosis was changed), or other appropriate documentation signed by
someone who is properly licensed and credentialed to determine a service recipient's diagnosis
code as defined in R9-20-209, Universal Rules, Assessment and Treatment Plan, of the Arizona
Administrative Code. If the diagnosis code changes over the course of the service recipient’s
treatment, that change must be documented and any services provided after the change are
required to be billed using the new diagnosis code.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 49
MAG-331-000049
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 1 below illustrates the process our sponsor agencies use, which MMIC will leverage to
extrapolate the data requested by AHCCCS for the Encounter Validation Study.
Figure 1: Data Validation Workflow Chart
17.14.2 Be Subject to Sanctions for Failure to Meet the Criteria Used in Encounter Data
Validation Studies
17.14.7 Be Responsible for All Sanctions Imposed Against ADHS/DBHS by AHCCCS
MMIC is keenly aware that reporting inaccuracies is not acceptable to AHCCCS, and we
understand that we may be subject to sanctions for failure to meet the criteria used in encounter
data validation studies, which may include timeliness, correctness, and omission of encounters as
described in Exhibit 7, AHCCCS Data Validation Technical Assistance Document. We are also
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 50
MAG-331-000050
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
aware that inconsistencies in our encounter validation processes may hold us responsible for all
sanctions imposed against ADHS/DBHS by AHCCCS as a result of data validation studies
according to the process in Section 19.5.9.
17.14.3 Comply with any Revisions Made by ADHS/DBHS or AHCCCS to the Study
Methodology, Timelines, and Sanction Amounts Based On Agency Review
17.14.4 Cooperate with ADHS/DBHS or AHCCCS in Special Reviews of Encounter Data
17.14.6 Conduct Targeted Encounter Data Validation Studies
MMIC will comply with any revisions made by ADHS/DBHS or AHCCCS to the EDV Study.
We will also notify all contracted providers of changes through written communication of any
significant change in methodology. In addition to communications, MMIC will incorporate the
change within provider training modules. An example would be if changes to our audit
methodology related to assessments and service plans occurred, then these tools would be
updated for providers. By doing this, MMIC will be able to implement this change in its
quarterly data validation audits in order to implement a seamless transition of the change.
As part of MMIC’s continuous improvement project, we will conduct targeted encounter
validation studies on providers who are found to be noncompliant. These audits and their
findings will be made available to ADHS/DBHS upon request. We will have a well-defined
Encounter Data Validation Study process as outlined in the following steps. The following areas
of study are included in the electronic file match: acute, ALTCS, dental, case management, non-
emergency transportation, and pharmacy studies.
1. Approximately nine months after the end of a contract year for AHCCCS validation and
quarterly for ADHS/DBHS requirements, encounter extract files by the Contractor will be
requested through the Information Management Subsystem on the Prepaid Medicaid
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 51
MAG-331-000051
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Management Information System (PMMIS). Files for each Contractor are downloaded and
the sample list of members by Contractor is generated.
2. The sample list is sent to each Contractor, with a request for PCP information and medical
record files from the sample members’ PCPs.
3. The Contractors give the Encounter Validation Unit a list of PCPs by sample members. This
information will be used to request the medical records directly from PCPs.
4. PCPs send copies of the members’ medical record files to the Encounter Validation Unit.
5. The number of medical record files received will be tracked. Status reports will be sent to the
Contractors until sufficient medical record files have been received.
6. MMIC will work with providers to obtain medical records that are outstanding.
MMIC’s sponsor agencies have developed and implemented a collaborative process for working
with providers on correct encounter submissions. In our sponsors’ Patient-Centered Medical
Home (PCMH) models, they provide claims and encounter data to providers to assist them in
understanding member medical trends. MMIC will implement a similar approach in order to
continuously educate our providers about correct and timely encounter and data submission.
17.14.5 Conduct Encounter Data Validation Studies of Subcontractors
MMIC will properly conduct validation audits so that covered behavioral health services are
appropriately documented and billed/encountered and that they support the identification of
opportunities for improvement in billing practices. MMIC will perform data validation studies
of our providers on a quarterly basis at the minimum per Branch for Program Operations Office
of Program Support Operations and Procedures Manual. MMIC will verify that all services
delivered to MMIC members are being reported accurately, timely and are documented in the
medical record. MMIC will conduct targeted encounter data validation studies of providers that
are not in compliance with ADHS/DBHS or MMIC’s encounter submission requirements.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 52
MAG-331-000052
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
MMIC will document the results of encounter data validation studies and provide the findings to
ADHS/DBHS upon request. In addition, MMIC will report summary findings to ADHS/DBHS
Compliance quarterly.
At a minimum, the following information will be provided in the quarterly report based on the
prescribed reporting format: Med Records Reviewed, Non-Compliant Assessments, Total
Encounters Reviewed, and Total Encounters with Errors, Type of Service Code Error, and Error
Issue. In addition, MMIC may collect the following areas that will not be included in the error
rate calculation. However, these areas will be addressed as findings in the audit report:
documentation that the provider screened the service recipient for TXIX/XXI eligibility in
accordance with Section 4.2.6-D; Behavioral Health Medical Record Standards; Comprehensive
Clinical Record of the Provider Manual; documentation that the provider screened the service
recipient for Medicare and third party liability (TPL) insurance in accordance with Section 3.5,
Third Party Liability and Coordination of Benefits, of the Provider Manual; provider billed
services to Medicare and TPL prior to MMIC, when applicable, in accordance with Section 3.5,
Third Party Liability and Coordination of Benefits, of the Provider Manual; medical record
includes a HIPAA access log as required in Section 4.1.7-B, General Procedures for All
Disclosures, of the Provider Manual; provider makes amendments to medical record
documentation using the process described in Section 4.2.6-A, Behavioral Health Medical
Record Standards, of the Provider Manual; document services on the date the service was
provided or otherwise identify the note as a late entry as required in Section 4.2.6-A, Behavioral
Health Medical Record Standards, of the Provider Manual; and Section R9-20-211(C), Client
Records, of the Arizona Administrative Code.
MMIC will bring a wealth of tools and resources for use in the EVDS both in collaboration with
AHCCCS as well as studies as required by ADHS/DBHS. We will demonstrate our
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 53
MAG-331-000053
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
understanding of the critical role that providers play in the care of our members. The studies can
bring to life areas for improvement, compliance and risk reduction, but most importantly, will
help to improve the lives of the people we serve and the health of our communities.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 54
MAG-331-000054
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.15 Claims Payment System Requirements When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:
Mercy Maricopa Integrated Care (MMIC) values members’ rights to privacy, and views
protecting their personal health information as paramount. Based on this belief, we have
developed and maintained a HIPAA-compliant claims processing and payment system capable
of processing, controlling costs and paying claims in accordance with all regulatory
requirements.
MMIC’s Information Technology (IT) staff, under the direction of the Information Systems
Administrator, will review all strategies for implementing its Management Information System,
claims and encounter processing, and other systems that rely on data or data processing to
achieve full compliance with all contractual obligations. Key IT staff will coordinate collection,
analysis, integration and data reporting. They will utilize the following documents to assist in
implementation activities:
AHCCCS HIPAA Transaction Companion Guides & Trading Partner Agreements
AHCCCS Encounter Manual
AHCCCS Technical Interface Guidelines
Client Information System (CIS) File Layouts and Specifications Manual
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 55
MAG-331-000055
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.15.1 HIPAA-Compliant Claims Processing and Payment System
17.15.1.1 Adapting to Updates 17.15.1.2 Utilize Nationally Recognized Methods to Correctly Pay Claims 17.15.1.3 Benefit Package Variations, Timeliness Standards Data Accuracy; Adherence to ADHS/DBHS and AHCCCS Policy; Provider Qualifications; Member Eligibility and Enrollment, and Over-Utilization Standards 17.15.1.4 Remittance Advice 17.15.1.5 Denial and Adjustments 17.15.1.6 Reasons for the Denial and Adjustments 17.15.1.7 Amount Billed 17.15.1.8 Amount Paid 17.15.1.9 Application of Coordination of Benefits and Co-pays 17.15.1.10 Provider Rights to Assert a Claim Dispute
17.15.6 Integrated Claims Payment System
MMIC, through a subcontract arrangement with Schaller Anderson, LLC (Schaller), an Aetna
company, and by virtue of Schaller’s existing contracts with AHCCCS, maintains a centralized,
HIPAA-compliant claims processing and payment
system. It is capable of processing, controlling costs
and paying claims in accordance with A.R.S. §§ 36-
2903 and 2904 and AHCCCS Rules R9-22 Article 7.
In fact, QNXT™, the cornerstone of its claims
adjudication process, was upgraded to version 4.8 in
January 2012 and passed an independent post-migration audit. Future plans include additional
upgrades in anticipation of approaching ICD-10 requirements.
MMIC’s business will be similar in size and operation, and this data illustrates our capacity to
process copious amounts of claims data. Schaller’s system is so effective that, for the 10 months
ending February 2011, an average of 98.8 percent of claims were finalized within 30 calendar
days or less, and 99.5 percent within 60 calendar days.
Schaller’s HIPAA-compliant, rules-based claim adjudication system has processed more than 1,214,023 claims for ALTCS lines of business from January 1, 2012, through November 30, 2012.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 56
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Using the Plan-Do-Study-Act (PDSA) approach to performance improvement, MMIC will make
process improvements that increase our financial and payment accuracy. For example, for the
third quarter of calendar year 2012, Schaller audit results averaged 99.29 percent (financial) and
99.43 percent (payment) accuracy rates.
MMIC will leverage Schaller’s experience with processing medical, behavioral health and
Medicare claims, and understands that all three types will be included in the RBHA contract.
We will monitor both federal (CMS) and state (AHCCCS) publications, websites, and notices of
changes to maintain cutting edge systems for correct claims payment. From this information, we
will implement necessary changes to our processing edits.
Figure 1 on the following page illustrates the following: All Claims Received via EDI and All
Claims Auto-Adjudicated by Month.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 1: KIR #8 All Claims Received via EDI and All Claims Auto-Adjudicated by Month – ALL SAI
Schaller, as part of its subcontracting agreement, provides full claims administration through a
claims management organization led by a local Director of Claims. Centralizing claim
processing functions at Schaller allows MMIC to take advantage of economies of scale and
quality efficiencies. Schaller’s claim processing team adjudicates for more than a million
Medicaid lives annually.
MMIC’s Chief Operating Officer (COO) and Claims Director will have responsibility and
authority over Schaller’s claims performance. The COO will oversee the system’s full
compliance with all applicable AHCCCS and federal requirements, maintaining processes that
meet claims processing timelines, maximize cost avoidance, and minimizing claims recoupment.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Our Claims Director will review, approve, date and sign all claims Policies and Procedures
(P&Ps) annually to verify their agreement with current practices and support continued
compliance with applicable AHCCCS standards and requirements.
The claims department will monitor and update regulatory changes monthly, and integrate them
into the editing functionality of the claims processing system. In addition, it will analyze
monthly reference files published by AHCCCS, and incorporate changes to editing, coding or
provider registration into the claims system.
Schaller’s claims system runs on a high-speed Local Area Network (LAN) and Wide Area
Network (WAN), with a cluster of servers providing built-in redundancy. It is configured to
provide all necessary computing power and redundancy. It is scalable to meet both enrollment
growth and expansions of AHCCCS specifications or requirements.
Schaller is able to add servers to increase performances vertically. They are designed to accept
increases in RAM and processing power to grow horizontally. This scalability enables the
claims system to match any escalation in volume arising from enrollment growth, while
maintaining responsiveness, up-time and performance.
Through our subcontract arrangement with Schaller, we will maintain claims processing
activities that include the application of comprehensive clinical and data-related edits to support
the efficient, effective adjudication of claims.
QNXT™, the core claims adjudication application, has data-related edits configured within its
software, and is supplemented by two clinical claims editing solutions. The first, iHealth
Technologies’ (iHealth) Integrated Claims Management Services (ICM Services), applies select
payment policies from one of the industry's most comprehensive correct coding and Medical
Policy content libraries. The second is McKesson’s ClaimCheck®, which expands those
capabilities by enabling our claims management team to define and combine specific claims data
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
criteria, such as provider or diagnosis, to set up unique edits that deliver enhanced auditing
power.
Those three applications utilize historic and “new day” claims information to detect questionable
billing practices, such as new patient billing codes submitted by the same provider for the same
member within a six-month period. They also assist in identifying fraudulent and abusive billing
patterns by generating reports that indicate trending and outliers of provider billing behavior.
Inbound claims are initially reviewed for critical items, such as member eligibility, covered
services, excessive or unusual services for gender or age (“medically unlikely”), duplication of
services, prior authorization, invalid procedure codes, and duplicate claims. Claims billed in
excess of $50,000 are automatically pended for manual review, as are any requiring additional
documentation (such as medical records) to determine the appropriateness of the service
provided. Professional claims (HCFA 1500s) that reach an adjudicated status of “Pay” are
automatically reviewed against nationally recognized standards, such as the Correct Coding
Initiative (CCI); medical policy requirements, such as the American Medical Association
(AMA); and maximum unit requirements supplied by AHCCCS, with recommendations applied
during an automatic re-adjudication process. Other methodologies utilized throughout the auto-
adjudication process include Multiple Surgical Reductions and Global Day E & M Bundling.
QNXT™ Data Edits
QNXT™ has more than 400 business rules that MMIC will configure to support enforcement of
our claims policies and procedures (P&Ps). The application of specific conditions, restrictions,
and validation criteria will promote the accuracy of claim processing against AHCCCS
standards. The edits can result in claims pending or denying, depending on the editing logic. For
example, if the member is ineligible on the date of service, QNXT™ will automatically deny the
claim. If the provider of record’s category of service does not match the procedure code billed,
the claim will pend for manual review to validate accuracy of provider set-up.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Examples of data edits specific to QNXT™ include the following:
Benefits Package Variations
QNXT™ automatically analyzes member information (age, sex, eligibility), provider registration
and licensure information (specialty and provider type), and diagnosis, CPT, REV and HCPCS
codes to determine whether specific services are covered under contract or benefit rules. If they
are not, the system will automatically deny the respective claim line. The denial will have the
appropriate HIPAA remittance remark on the EOB. MMIC will incorporate multiple business
specific requirements into the system as needed.
Data Accuracy
QNXT™ is continually updated, based on the most current code sets available (ICD-9, HCPCS,
REV, CPT codes) by year. As new codes are added, terminated or changed, we will update the
codes so the system will always be in compliance with HIPAA standards. We will also
leverage AHCCCS reference files to update our coding configuration on a monthly basis. If a
provider bills a code that has been terminated or invalidated, QNXT™ will deny the claim line
and notify the provider via remittance advice.
Adherence to Prior Authorization Requirements
QNXT™ is configured to enforce the supporting documentation requirements of certain services.
It also is capable of configuring Prior Authorization (PA) by code, provider type and place of
service. It is configured to automatically identify certain types of authorizations for Medical
Director review. Claim edit rules are set to validate the claim against network provider, member,
dates of service, services rendered and units authorized.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.15.2 Remittance Advice
MMIC will send related remittance advice with each payment, unless it is made by electronic
funds transfer (EFT). In that case, it must be mailed or sent to the provider, no later than the date
of the EFT.
QNXT™, our core claims adjudication application, produces a remittance advice that describes
payments and denials to providers, including the following:
An adequate description the denial and adjustments
The reasons for the denial and adjustments
The amount billed
The amount paid
Application of coordination of benefits and co-pays
Provider rights to assert a claim dispute
An example of a standard remittance advice can be found in the Attachments Tab of ProcureAZ.
17.15.3 Electronic Health Care Claim Payment/Advice 835 Transaction
17.15.4 HIPAA Securing Measurements
MMIC will submit, upon provider request, an electronic Health Care Claim Payment/Advice 835
transaction in accordance with HIPAA requirements. We will comply with the requirements in
Section 17.15.1.4 when sending remittance advices along with payment to providers. Through
Schaller Anderson, LLC, an Aetna company, MMIC will have a well-defined process for
addressing providers’ rights to file claim disputes and requests for hearing stemming from an
action issued by the health plan. Claims dispute rights are also included with each remittance
advice following adjudication of the provider’s claim.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
The Appeals department will be responsible for management of claims disputes and requests for
hearing, including documenting individual disputes, coordinating resolutions, and tracking,
trending and reporting data. Filing a claims dispute or requesting a State Fair Hearing will not
negatively affect or impact members or their providers.
Claims disputes must be filed with MMIC in writing no later than 60 days after the date of the
adverse action. Those challenging claim issues, including claim denials, must be filed with
MMIC in writing no later than 12 months from the date of service or initial eligibility posting
date, whichever is later, (for a hospital inpatient claim, the date of discharge) for which payment
is claimed, or within 60 days from the date of a timely claim submission. MMIC will strive for
timely acknowledgement and resolution of claim disputes.
We will appoint specific individuals with the requisite experience to administer the claims
dispute process and the authority to require corrective action, as noted in greater detail in other
sections of this response.
MMIC key IT staff, under the direction of the Information Systems Administrator, will review
all strategies for implementing the Management Information System, claims and encounter
processing and other systems that rely on data or data processing to achieve full compliance with
all contractual obligations. They will coordinate MMIC’s efforts to collect, analyze, integrate
and report data.
Member privacy and data correctness are key values of our company. We will spend significant
time and effort to protect our members’ privacy and their personal health information. MMIC is
committed to providing the most accurate, timely claims processing system in the health care
arena. Our dedication enhances the way we deliver health care to our members.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.15.5 National Provider Identifier
QNXT™ provider files are configured by specialty and category of service, according to
information from the AHCCCS reference files. This enables enforcement of categories of service
and provider type on claims validation. Certain procedures can only be performed by select
network provider types. For example, QNXT™ will not permit the processing of a claim for in-
office heart surgery by a podiatrist.
iHealth lends additional support in this regard, reviewing any claim line set to “Pay” for billing
appropriateness by specialty. QNXT™ checks other provider-specific items as well, verifying,
for example, that each provider has obtained the requisite National Provider Identifier (NPI) or
its equivalent, and has included it on all claims submissions.
Member Eligibility and Enrollment
QNXT™ validates the date of service against members’ enrollment segments to determine their
eligibility on the date of service. If a member was ineligible on the date of service, the system
will automatically deny the claim using the appropriate HIPAA-approved remittance comment.
Duplicate Billing Logic
QNXT™ uses a robust set of edits to determine duplication of services. Examples include same
member, date, network provider, service or any combination of these criteria. In addition, claim
lines set to “Pay” are subjected to iHealth’s duplicate logic. That will protect MMIC from
paying for services rendered by the same physician or other physicians within the same provider
group.
ClaimCheck® Edits
ClaimCheck® is a comprehensive code auditing solution that supports QNXT™ by applying
expert industry edits from a provider-recognized knowledge base to analyze claims for accuracy
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 64
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
and consistency with MMIC’s P&Ps. ClaimCheck clinical editing software identifies coding
errors in the following categories:
Procedure unbundling
Mutually exclusive procedures
Incidental procedures
Medical visits, same date of service
Bilateral and duplicate procedures
Pre- and post-operative care
Assistant surgeon
Modifier auditing
Medically unlikely
MMIC will offer network providers access to Clear Claim Connection®, a reference tool that
helps them optimize their claims submission accuracy. Currently there are 2,300 provider
groups registered to use this web-based tool. Providers can use it to explain MMIC's clinical
editing logic, allowing them to better understand the rules and clinical rationale affecting
adjudication. Providers will access Clear Claim Connection® through our web portal via secure
login. They can then enter various coding combinations to determine why, for example, a
particular one resulted in a denial. The provider may also review coding combinations prior to
claim submission, to determine whether applicable auditing rules and clinical rationale will deny
the claim. Figures 2 & 3 on the following page are screen shots of the Clear Claim Connection
access portal.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 2: Clear Claim Connection Claim Audit Results
Figure 3: Clear Claim Connection Edit Clarification
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
iHealth Edits
iHealth will clinically edit claims to assist MMIC to promote the proper, fair payment of
professional DME and outpatient claims.
Coding Accuracy
If services are up-coded, or unbundled, iHealth will alert the Claims Department to deny the
claim line, along with the specific clinical editing policy justification for the denial. The claim
line denial will include the appropriate HIPAA remittance remark on the Explanation of Benefits
(EOB).
Duplicate Billing Logic
In addition, claim lines set to “Pay” are subjected to iHealth’s duplicate logic. It will protect
MMIC from paying for services rendered by the same physician or other physicians within the
same provider group.
Durable Medical Equipment (DME) Editing
iHealth performs edits related to select DME payment policies aligned with covered service
policies. These edits include DME rentals, oxygen and oxygen systems, hospital beds and
accessories, external infusion pumps and anatomic/functional modifiers required for services.
Procedure Code Guidelines - iHealth
MMIC will follow the AMA CPT-4 Book and CMS HCPCS Book, which both provide
instructions regarding code usage. iHealth has developed these guidelines into edits. For
example, if a chemotherapy administration code is billed without the correct pharmacy codes,
MMIC would deny the code as inappropriate, based on industry standards.
Procedure Code Definition Policies - iHealth
iHealth supports correct coding initiatives based on the definition or nature of a procedure code
or combination of procedure codes. These editing policies will either bundle or re-code
procedures based on the appropriateness of code selection. For example, if a provider attempts
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
to unbundle procedures, iHealth will apply editing logic that will bundle all of the procedures
billed into the most appropriate code.
MMIC will also use the MDE OPFS pricer to edit outpatient facility claims and apply AHCCCS
edits for bundling, modifier code use, and other scenarios according to the OPFS decision tree.
Fraud and Abuse
MMIC’s Fraud and Abuse Department, under the direction of the COO, will utilize claims
payment tracking and trending reports, claims edits, audits and provider billing patterns as
indicators of potential fraud and abuse. The Fraud and Abuse department will use this
information to detect aberrant provider billing behavior, which will prompt additional analysis
and investigation. Our fraud and abuse personnel will work in conjunction with Provider
Services and Compliance departments to address any questionable behavior(s) through provider
education and outreach. If MMIC discovers, or becomes aware, that an incident of
potential/suspected fraud and abuse has occurred, internal P&Ps will mandate that we report the
incident to AHCCCS within ten (10) business days by submitting the confidential AHCCCS
Referral for Preliminary Investigation form.
Claims Education
MMIC’s Provider Claims Educator will work to educate providers on appropriate claims
submission requirements, coding updates and available resources, such as Provider Manuals,
websites and fee schedules. In addition, the Provider Claims Educator will participate in an
AHCCCS work group tasked with developing uniform guidelines for standardizing hospital
outpatient and outpatient claim requirements, sharing information accordingly.
Claims Editing Results
In the first three quarters of 2012, through its robust and comprehensive claims editing programs,
Schaller cost-avoided/recovered in excess of $30 million related to the ALTCS program.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 68
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Claim Edits $
1st Quarter $7,123,919
2nd Quarter $9,860,388
3rd Quarter $13,173,557
4th Quarter
Total: $30,157,864
MMIC key IT staff will review all strategies for implementing its management information
system, claims and encounter processing and other systems that rely on data or data processing to
achieve full compliance with all contractual obligations. They will coordinate our efforts to
collect, analyze, integrate and reports data.
Please see Figure 4 on the following page for an example of the Claims Data Dashboard MMIC
will use to track, trend and monitor claims activity.
Additionally, please see the Attachments Tab of ProcureAZ for further examples of the Claims
Data Dashboard MMIC will use to track, trend, and monitor claims activity:
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 69
MAG-331-000069
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 4: MMIC Claims Data Dashboard
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 70
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.16 General Claims Processing Requirements When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:
Mercy Maricopa Integrated Care (MMIC) recognizes the need to provide a seamless, integrated
claims processing function across the organization, while managing the process for maximum
efficiency, visibility and flexibility with our dynamic claims processing approach.
MMIC’s key Information Technology staff will review all strategies for implementing its
management information, claims, encounter processing and other systems that rely on data or
data processing to achieve full compliance with all contractual obligations. These staff will
coordinate MMIC’s efforts to collect, analyze, integrate and report data. MMIC’s IT staff will
utilize the following documents during implementation:
AHCCCS HIPAA Transaction Companion Guides & Trading Partner Agreements
AHCCCS Encounter Manual
AHCCCS Technical Interface Guidelines
Client Information System (CIS) File Layouts and Specifications Manual
During the initial implementation process, MMIC will have an audit plan in place to monitor the
transition. Upon completion of implementation, we will audit 100 percent of all benefits for
correctness to ascertain no forward issues with the processing system. We will comply with all
data submission standards required by this contract, and will work to make timely corrections to
any data files rejected by ADHS/DBHS.
17.16.1 Claim Processing Requirements and the Balanced Budget Act of 1997
MMIC will base all of our claims processes on the Claim Processing Requirements defined by
the Balanced Budget Act of 1997 and 42 CFR 447.45. We will adhere to all requirements
related to:
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Timely processing of claims for payment
Prepayment and post-payment claims reviews
Our internal policies and procedures will define a claim as:
A bill for services
A line item of service
All services for one recipient within a bill
A clean claim is one that can be processed without obtaining additional information from the
service provider or a third party. It includes a claim with errors originating in a state’s system. It
does not include a claim from a provider who is under investigation for fraud or abuse, or a claim
under review for medical necessity.
17.16.2 Staff Training on HIPAA Requirements For Electronic Payment/Advice 835
Transaction
MMIC’s Medicaid Core Skills training will be designed to equip our claims specialists to process
claims accurately and efficiently. This 12-week training course will be delivered through a
tiered approach following New Hire Training, which addresses basic HIPAA requirements. The
course will specifically introduce staff to each type of claim and its processing, and the ability to
audit the results for training purposes. This course will also cover HIPAA requirements for
electronic Health Care Claim Payment/Advice 835 transactions.
Staff training will build on a foundation that includes topical knowledge of MMIC, regulatory
compliance requirements, and business practices relating to claims. Our staff training includes
the following components:
A complete review of the state’s submission and data demographic requirements
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
The next level of training will include knowledge of specific claims processing procedures
for authorizations, review of benefit and contract descriptions, member eligibility, claim
check edit resolution, re-submissions, coordinating benefits, claim form validation against
QNXT, and review of provider-submitted documentation. This phase will emphasizes the
appropriate resources and tools for accurate and timely claims processing.
Plan-specific training comprises the final phase, building on knowledge obtained during the
Core Skills program. It will examine specific topics and procedures for the selected plan.
At the completion of each phase of training, each staff must achieve successful error rate testing
scores. Each participant must achieve a minimum score of 85 percent to achieve certification of
training completion. We will also implement a core skills assessment as a level two assessment
throughout the training period, measuring comprehension and application of procedures. In
addition to training our staff, MMIC will offer the same claims processing training to our
providers and will maintain documentation of the training in the provider’s credentialing file.
17.16.3 Post Claims Inquiry Information to Providers on Website
MMIC will maintain a separate provider module on its website for viewing claims status.
Providers will receive detailed instructions on accessing the claims query module during
orientation, and will be informed of any updates to the system through provider site visits,
Newsletters, and updates to the Provider Manual.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.16.4 Claims Submission Deadlines
17.16.14 Recoup of Funds from a Provider After Twelve Months from Original Payment
17.16.15 Provider Reimbursement for Recouped Funds
17.16.16 Providers to Submit a New Claim Within 90 Days
17.16.17 Processing the Provider’s Claim
17.16.18 Providers Have 90 Days to Submit a Clean Claim for Payment
17.16.19 Not Deny Claims Submitted as a Result of a Final Agency Decision
As previously stated, Mercy Maricopa Integrated Care (MMIC) will follow the set guidance of
the Balanced Budget Act of 1997 and 42 CFR 447.45. Our claims processing policies and
procedures detail our response to individual situations and direct our claims adjudicators on the
following:
Not recoup funds from a provider more than twelve months after the date of original payment
on a clean claim without prior approval of ADHS/DBHS, in conformance with the its Office
of Program Support Operations and Procedures Manual and the AHCCCS Contractor
Operations Manual Claims Reprocessing Policy
Reimburse providers for recouped funds if the provider was subsequently denied payment by
the primary insurer based on timely filing limits or lack of prior authorization, and the
member failed initially to disclose coverage other than Medicaid, when the provider made an
initial timely claim to MMIC
Require a provider to have ninety days to submit a new claim and documentation from the
primary insurer that payment will not be made. Documentation that MMIC will accept
includes any of the following items establishing that the primary insurer has or would deny
payment based on timely filing limits or lack of prior authorization:
An EOB
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Policy or procedure
The MMIC Provider Manual excerpt
Process the provider’s claim consistent with applicable statutes, rules, policies and contract
terms when a final agency decision is made to deny, limit or delay authorization of services,
and the member received the disputed services while an appeal was pending
Require the provider to have ninety days from the date of the final agency decision to submit
a clean claim for payment, and not deny it as untimely if submitted within that time frame
Not deny claims submitted as a result of a final agency decision because the member failed to
request continuation of services during the appeals/hearing process
Unless a shorter time period is specified in contract, not pay a claim initially submitted more
than six months after date of service, or a clean claim submitted more than twelve months
after date of service, except as directed by ADHS/DBHS, or otherwise noted in this contract
MMIC’s claims processing policies and procedures will stipulate that claim payment
requirements will apply to both contracted and non-contracted providers. Claims will be tracked
in our system as follows:
The receipt date of the claim is its date stamp, or the date it was electronically received.
The receipt date is the day the claim is received at the contractor’s specified mailing address.
The paid date of the claim is the date on the check or other form of payment.
Submission deadlines are calculated from the claim end date or the effective date of
eligibility posting, whichever is later.
The filing limit is configured within QNXT, and claims received more than six months from
the last date of service, as indicated on the claim, will be automatically denied, unless
submitted as a reconsideration or with specific direction by AHCCCS.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.16.5 Adjudication of Clean Claims Within 30 Days of Receipt
MMIC’s processing guidelines will require providers to submit all claims no later than 12
months from the date of service. When timely submissions are received:
MMIC will pay 95 percent of all clean claims from providers in individual or group practice
or who practice in shared health facilities within 30 days of receipt.
MMIC will pay 99 percent of all clean claims from providers in individual or group practice
or who practice in shared health facilities within 60 days of receipt.
MMIC will pay all other claims within 12 months of receipt, except in the following
circumstances:
Retroactive adjustments paid to providers who are reimbursed under a retrospective
payment system
If a claim for payment under Medicare has been filed in a timely manner, MMIC will pay
a Medicaid claim relating to the same services within six months after the agency or the
provider receives notice of the disposition of the Medicare claim.
The time limitation does not apply to claims from providers under investigation for fraud
or abuse.
Additionally, MMIC will conduct prepayment review for all claims based on the following
criteria:
Verification that the recipient was included in the eligibility file and that the provider was
authorized to furnish the service at the time.
Checking that the number of visits and services delivered are logically consistent with the
recipient’s characteristics and circumstances, such as type of illness, age, sex and service
location
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Verification that the claim does not duplicate or conflict with one reviewed previously or
currently being reviewed
Verification that a payment does not exceed any reimbursement rates or limits
Checking for third party liability within the requirements of § 433.137
Finally, MMIC will conduct post-payment claims review utilizing our state-of-the-art analytic
software that meets the requirements of parts 455 and 456 of42 CFR 447.45.
17.16.6 Reimbursement for In-State and Out-Of-State Non-Contracted Emergency
Services at the AHCCCS Fee-For-Service Rate
17.16.7 Reimbursement for Non-Contracted, Non-Emergency In-State Providers
MMIC’s internal claims procedures and Provider Manual information will address
reimbursement rates for both in- and out-of-state non-contracted emergency services providers.
We will reimburse these entities at no more than the AHCCCS Fee-For-Service rate in
conformance with the Deficit Reduction Act of 2005, Section 6085. If there is no written
negotiated rate for the particular service rendered, MMIC will reimburse non-contracted, non-
emergency, in-state providers according to the AHCCCS fee schedule and methodology, or
pursuant to A.R.S. §36-2905.01, at ninety-five percent of AHCCCS FFS rates for urban hospital
days in conformance with A.R.S. §§36-2903 and 36-2904. All payments will be subject to other
limitations, such as provider registration, prior authorization, medical necessity and covered
service.
Our claims processing flow is outlined in Figure 1 on the following page.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 1: MMIC’s Claims Process Flow
17.16.8 Interest on Late Payments for All Non-Hospital Clean Claims
MMIC’s claims processing policies and procedures will direct our claims adjudicators to pay
interest on late payments for all non-hospital clean claims, unless there is a contract specifying
other terms. We will define late payments as those paid more than forty-five days after receipt of
a clean claim. Interest payments will be calculated systematically for the difference, in days,
from the clean date entered on the claim and the check date (interest days).
For non-hospital (participating and non-participating) unadjusted claims, MMIC will pay interest
on clean claims if the payment is not made within 45 calendar days of receipt (calculated clean
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
claim date through check date), using a flat rate of 10 percent per annum as determined by the
Arizona Health Care Cost Containment System (AHCCCS), and highlighted in the Contractor
Operations Manual. The interest period will begin the day after payment is due and end on the
date of payment. It will be calculated using the following formula: payment amount x interest
rate x interest days divided by 365.
In grievance situations, or when a claim is adjusted through the reconsideration process, MMIC
policy will direct that interest may be paid retroactively to the date it would have started to
accrue at the rate of ten per cent (10%) per annum – unless a different rate is specified in the
contract – if it was determined that the claim was not paid appropriately based on initial available
information. In the absence of terms in a subcontract, interest will accrue starting on the first day
after a clean claim is contracted to be paid. MMIC will apply interest on adjustments to payment
amounts in excess of the original payment (for instance, if the claim underpaid by $25, interest
would only be applied to the $25 adjustment) for any claim where the clean date on the adjusted
claim is the same as the original claim. Any interest applied to the original claim will be added
in to the second payment. If the clean date for the adjusted claim is different from the original,
we will calculate interest the same as an unadjusted claim for the full amount of the payment.
MMIC will document specific guidelines for appropriate application of the clean date for
adjusted claims in the Claims Desktop.
17.16.9 Slow Payment Penalty for Hospital Clean Claims
When a hospital clean claim is pended or delayed for any reason, causing MMIC to fall into a late
payment situation, we will pay a slow payment penalty in conformance with A.R.S. § 36-2903.01.
Our data management system will be configured to pay interest automatically, based on days over
the late payment threshold according to the date the claim was received and the date payment was
made. Interest penalties will be based on a 30-day calendar month, starting at 1 percent for the first
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
month and increasing by 1 percent each successive month. Claims paid within 61-90 days of clean
claim date will accrue a 1 percent interest penalty, 91-120 days a 2 percent penalty, and so forth.
17.16.10 Report Interest Paid
17.16.11 Minimize Likelihood of Recouping Funds from Paid Claims
17.16.12 Individual Recoupment in Excess of $50,000 Per Provider Within a Contract Year
17.16.13 Cumulative Recoupment Greater than $50,000 Per Provider Tax Identification
Number Per Contract Year
To minimize the likelihood of recouping funds from paid claims, MMIC expects its payment
processes to remunerate on time for clean claims received within established time frames. We
will report any interest paid for late payment in conformance with the AHCCCS Encounter
Manual. It will be our standard practice to always obtain the prior approval of ADHS/DBHS for
any individual recoupment in excess of $50,000 per provider within a contract year. We will
also notify ADHS/DBHS of any cumulative recoupment greater than $50,000 per provider Tax
Identification Number per contract year. We will monitor weekly payment reports to verify
compliance with the requirement.
MMIC’s dynamic claims processing approach will standardize our processes and improve the
flow of information from claims to all other departments, thereby enhancing our agility and
responsiveness to changing conditions. By improving traditionally static, disconnected and
inflexible claims processes, we will accurately identify, manage and reduce risk exposure;
improve member service; gain operational efficiency, and adapt to change more quickly and
easily.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.17 Claims System Reporting When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:
Mercy Maricopa Integrated Care (MMIC)’s will manage the claims reporting process efficiently,
aligning it with business objectives, and achieving real-time operational awareness.
Modernizing the process for efficiency and flexibility will be a mission-critical function that
touches all parts of the organization, affecting member service, fraud and abuse management,
risk exposure, cost control, and Information Technology (IT) infrastructure.
Our key IT staff will review all strategies for implementing the management information system,
claims and encounter processing, and other systems that rely on data or data processing to
achieve full compliance with all contractual obligations. They will coordinate MMIC’s efforts to
collect, analyze, integrate and report data. MMIC’s IT staff will utilize the following documents
to assist in implementation activities:
AHCCCS HIPAA Transaction Companion Guides & Trading Partner Agreements
AHCCCS Encounter Manual
AHCCCS Technical Interface Guidelines
Client Information System (CIS) File Layouts and Specifications Manual
MMIC will also comply with all data submission standards required by this contract and accept
ADHS/DBHS rejection of data submissions not in compliance.
17.17.1 Monthly Claims Dashboard
MMIC will submit a monthly Claims Dashboard to ADHS/DBHS, in conformance with the
AHCCCS Claims Dashboard Reporting Guide, which includes the Cost Avoidance/Savings/
Recoveries Report, as specified in the Office of Program Support Operations and Procedures
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Manual, the AHCCCS Program Integrity Reporting Guide, and the Number of Claims and
Amounts Paid Report.
MMIC will be responsible for paying claims. We will develop an internal Claims Dashboard to
conform to the AHCCCS Claims Dashboard Reporting Guide, edition revised October 2010.
Following the guidance of the AHCCCS Claims Dashboard Reporting Guide, we will submit the
Cost Avoidance/Savings/ Recoveries Report and the Number of Claims and Amounts Paid
Report as directed by the ADHS/DBHS Office of Program Support Operations and Procedures
Manual, and the AHCCCS Program Integrity Reporting Guide.
Each MMIC dashboard will be dedicated to one line of business. The dashboard(s), along with
all attachments, will be sent to the Contractor’s Acute Operations and Compliance Officer
(ACO) via email. If hard copies are requested, MMIC will send them to the appropriate ACO at:
AHCCCS Division of Health Care Management (DHCM)
701 E. Jefferson, MD 6500
Phoenix, Arizona 85034
MMIC is prepared to submit a separate Claims Dashboard for each of the following claim form
types:
UB92 or 837I
CMS1500 or 837P and, Dental Claim Form or 837D combined
All claim form types combined
The following items will be included in the dashboard(s) as of the last day of the reporting
month:
Claims inventory
Days of work on hand
Percentage of pended claims
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Number of pended claims
Number of medical review pended claims
Per guidance from the AHCCCS Claims Dashboard Reporting Guide, the MMIC Finance and
Health Plan Operations departments will highlight and explain the variance for each area that is
out of compliance with contracted standards, areas where there is a five percent increase from the
previous report in the number of denied and/or pended claims, areas where claims receipts have
decreased by more than five percent, areas where average time to process claims has increased
by more than five days, and areas where total claims processed have decreased by five percent.
Additionally, MMIC will report on the Total Claims Dashboard Template the percent of claims
paid correctly for the reporting period as determined from our internal audit procedures, and the
total amount of advances paid to providers in the reporting period.
We understand that ADHS/DBHS may request that we review claim requirements, including
billing rules and documentation requirements, and submit a report to them in an approved format
that includes the rationale for the requirements. Our Finance department will be designated as
the internal asset to review claims requirements and prepare reports for submission to
ADHS/DBHS.
MMIC will pull dashboard(s) information from its reporting system. Our dashboards will be
designed to track claims processes and enable accurate, timely and complete payments. Please
see Table 1 below and continuing on the following pages for details regarding the three standard
claims management reports to supply dashboard(s) data:
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 1: Three Standard Claims Management Reports Report Name
Description Accuracy/ Measurement
Claims Dashboard
Tracking of claims processes including: Membership Total Claims Receipts % Paper Claims % Electronic % Paid ETF % Remittances via 835 Total Inventory Average Days Receipts; Days of Work on Hand; Total number of Claims Pended Claims pended for Medical Review Total Claims Denied % Denied Dollars denied Average Time to process all Claims Total claims processed EOM Total amount of advances paid Total Medical Claims Liability IBNR
Reports the percentage of clean claims paid claims that fall within the following categories: 0 – 30 days old 31 to 45 days old 46 to 60 days old 61 + days old % Pended not paid in 30 days # Pended 61+ Days Average age of claims’ pended for medical review % of claims processes within contracted deadline % of Claims Processed in 0 to 30 days % of Claims processes in 60 days EDI auto-processing rate
Pend Summary
Claims processes tracked: Received Type Billed_5K_25K_50K Pay to PAR NON PAR Contract Form Type Program Description Specialty As Of Date Department Name and Reason Category Count of Claim ID Category Sum of Total Billed
Report of claims payment managed through the following pend types: B01 – DRG/Microdyn Updates B02 – Service code updates B03 – Fee schedule updates B05- Implementation/Benefit Research B06 – Implementation/Contract Research C00 – NO REASON C01 – Enrollment Restriction Required C02 – COB Review C05 – Benefit/Contract flagged for Manual Review C06 – Provider research C07 – Data Entry – Keying Research for missing claim information C10 – System Configuration Review C11 – Claim for required documentation review C12 – Auth Review C13 – FIFO returned manual pends
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Report Name
Description Accuracy/ Measurement
C17 – Claims Supervisor Review C19 – Enrollment restriction review C20 – Broken OB package review C21 – DRG Review C23 – Transplants C25 – HCBS Room & Board review C27 – Invalid Revenue Code C29 – Invalid POA indicator or diagnosis code when diagnosis requires POA indicator C30 – High dollar claims C31 – CI/CR-COB Supervisor Review C33 – SNP Medicare COB C35 – Return From Medplans C36 – LTCH/IPF/ORF Manual pricing C37 – PPOS/RUGS pricing review C38 – OPFS Pricing failure C46 – H, S, T Codes C47 – SNF – Acute C48 – CMS Manual Pricing C54 – EDI Provider Not Found C55 – EDI Pay to Issues C56 – Edit 201 w/ Unknown EDI or FV C57 – Age/Gender Conflict C58 – Line DOS spans timely filing C59 – Auto adjust / re-import claim pends C60 – CC & Project returned manual pends C61 – CICR COB pends C62 – Claims Support Assistant – Void Claim C64 – OPFS Rejects C66 – LOA C68 – Split Claims/Eligibility C69 – McKesson Claim Check C70 – Re-submissions C71 – FV over 999 units C72 – FV anesthesia unit review C73 – FV Provider selection review C74 – FV Pay to Issue C75 – FV – Member enrollment review C76 – FV Member Unknown C77 – FV Incomplete provider information C78 – FV – DOS review
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 85
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Report Name
Description Accuracy/ Measurement
C79 – FV – Bill type review C80 – FV CPT code review C86 – Future Vision-Provider Not Registered with AHCCCS C94 – Provider Preventable Conditions C97 – Split claims for annual rate changes Accuracy of training is also managed through the use of the following Claims QR Training Pend Codes: E02 – Analyst Review (QR) E04 – Claims Analyst Rebuttal E13 – Massa Adj E14 – Med Plans Adj E07 – CICR Review (QU) E22 – Encounter Correction-Mercy Care H01 – Provider Services for provider contract add H02 – Provider Watch H03 – Member Solutions/Eligibility update H04 – Prior Authorization/Medical Management review H05 – Retro review for inpatient claims H07 – Medical review for HCAC H08 – Medical review for Reconsiderations H25 – HCBS Room & Board review H31 – Pending provider system changes H98 – HPO research for reconsiderations H99 – Health plan review for manual payments L01 – Medicare development call L02 – Medicare – 2nd development call L03 – Medicare – Final development call L04 – Medicare development pending provider response L05 – Medicare – development letter required L09 – Holding for development – letter sent M01 – Medical review of outlier payment M02 – Medical review for payment of PPC P01 – Provider record review required P05 – Provider record pay to update P06 – Provider record affiliation update
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Report Name
Description Accuracy/ Measurement
P07 – Provider record not found P09 – Provider ID needed for Microdyn pricer P14 – Rendering provider name mismatch P15 – Provider not active on DOS P23 – Provider transplant pends S01 – Special investigation claim review S02 – Special investigation payment hold
Non-Final Manages timeliness and completeness of Claims Adjudication processes by tracking the number of claims pended or otherwise not finalized and the age categories of all the reason codes described in the Pend Summary Report above.
Age categories are tracked as follows: 0-5 06-10 11-15 16-20 21+
17.17.2 Review Claim Requirements and Submit a Report to ADHS/DBHS
In compliance with the requirements in the AHCCCS Claims Dashboard Reporting Guide,
MMIC will supply the following information on a monthly basis:
Top five reasons for claim denials and how many claims were denied during the reporting
period for each reason
The five providers with the greatest number of claims denials, including how many for each
provider
All providers for which MMIC is working on a special claims processing or claims review
project including the following information:
Reason for project
How many claims are affected
Stratify claim count by age of claim (0-30 days, 31-60 days, etc.) using each of the
following:
Date of receipt
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 87
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Start of project date
MMIC’s commitment to the accuracy of claims reporting will be a cultural dynamic integrated
into every facet of our organization. We will take reporting seriously, and will comply with all
data submission standards required by this Contract.
Please see the Attachments Tab of ProcureAZ for examples of our Claims Dashboard reports.
17.18 Claims Audits Offeror Response:
Mercy Maricopa Integrated Care (MMIC), through its sponsors Mercy Care Plan (MCP) and
Maricopa Integrated Health Systems (MIHS), will offer a unique audit and control approach.
Our comprehensive approach will be based upon linking rigorous audit systems and procedures
together to identify possible claims processing deficiencies. Our approach will seek not only to
identify errors and recoveries, but more importantly to reveal, prioritize and remedy their
underlying causes.
Our key Information Systems (IS) staff will review all strategies for implementing the
management information system, claims and encounter processing, as well as other systems that
rely on data or data processing to achieve full compliance with all contractual obligations. They
will coordinate MMIC’s efforts to collect, analyze, integrate and report data and will utilize the
following documents to assist in implementation activities:
AHCCCS HIPAA Transaction Companion Guides & Trading Partner Agreements
AHCCCS Encounter Manual
AHCCCS Technical Interface Guidelines
Client Information System (CIS) File Layouts and Specifications Manual
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 88
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Additionally, MMIC will comply with all data submission standards required by this contract
and accept ADHS/DBHS rejection of any data submissions that are not in compliance. We will
then work to make timely corrections to the file for re-submission.
17.18.1 Internal Claims Audit Function That Will Include the Following
17.18.1.1 Verify that Provider Contracts are Loaded Correctly 17.18.1.2 Verify Accuracy of Payments Against Provider Contract Terms
MMIC will be responsible for paying claims. Through its sponsor, MCP, we will have robust
internal claims auditing process to establish accuracy and compliance with established policies,
procedures, management service agreements and contracts. This process will be the pivot point
for all MMIC functions related to internal claims auditing, and will be managed by the Claims
Audit department. The process will be designed to verify accuracy of contracts and payments,
perform necessary audit functions, document audit findings, and prepare audit finding
submissions for regulatory agencies.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 89
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.18.2 Audits of Provider Contract Terms
17.18.4 Document the Findings of Audits and Initiate Corrective Action for Deficiencies
MMIC’s Claims Audit Services team will conduct audits. The team will comprise experienced
auditors and management team that comply with Sarbanes Oxley standards to meet specific
controls. We will use MCP’s audit standards, which exceed the requirements, as demonstrated
by random, statistically valid audits with a 95 percent confidence level, two percent expected
error rate and a plus/minus two percent confidence level.
All audits will validate system configuration for plan, contract and benefit structures, and claim
adjudication and processing for each claim reviewed. We will review claim entry from images
pulled from Alchemy or from EDI data submitted. MMIC will share all results by e-mail
notification, post audit files on a SharePoint site and track the results in an internal database.
Audit Purpose and Objectives
The following represent MMIC’s audit purposes and objectives:
Audit adjudicated claims and system configuration to maintain accuracy and compliance
with established policies, procedures, management service agreements and contracts.
Analysis using independent source documentation to identify root cause
Timely identification, communication and resolution of identified issues
Provide independent assessment and accuracy rates for claim population
Audit files distributed to the Health Plan and all impacted departments
Identify potential provider billing issues and report them to the respective Health Plan’s
Compliance Officer
Generate reports of audit files and results monthly and quarterly, and utilize them to track
open audits, trend claims processes, and identify system configuration accuracy and
efficiency.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 90
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Frequency of Audits
The frequency of claim, contract or benefit audits will depend on the number of members,
complexity of services, frequency of changes to the operational system, or regulatory
requirements. The Claims Audit Services department will conduct at least two statistically valid
claim audits per month per form type.
Claim Audit Process:
1. Validate the contractual appropriateness of the provider attachment to the contract and fee
schedules.
Audit Process - Provider Validation: All PAR providers must have a signed contract that is
accessible for use by the Claims Audit department. It will validate the contractual
appropriateness of the provider attachment to source documentation, and report any
discrepancies to the Health Plan and the Network Development department and track on the
audit file. (SOX Control – 1A)
2. Filter the contract to review the different contract types individually for proper application of
reimbursement methodologies and calculations.
Audit Process - Contract Validation: All PAR contracts will be accessible for use by the
Audit department. It will validate contract system configuration for payment appropriateness
to the source documentation, report any discrepancies to the Business Applications
Management department, and track the audit file. Each claim line will be analyzed for
appropriateness of contract term selection during the audit process. (SOX Control – 1B)
3. Filter to review the benefit and identify various reimbursement methodologies to apply
correct payment calculations and identify specific requirements, such as PA, accumulators,
age limitations, exclusions, co-pays, deductibles and coinsurance.
Audit Process - Benefit Validation: Benefits will be validated using Summary Plan
Documents (SPD) and/or Explanation of Coverage (EOC) and/or the Health Plan Medicare
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 91
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Summary of Benefits (SOB), which will be accessible for use by the Audit department. We
will validate benefit system configuration for payment appropriateness to source
documentation, report any discrepancies to the health plan and the Business Applications
Management department, and track the audit file. Each claim line will be analyzed for
appropriateness of the benefit term selection during the audit process. (SOX Control – 1C)
4. Audit Process - Claim Validation: Complete form data field validation through viewing the
paper claim submitted via Alchemy or viewing EDI data submitted. All claims will be
subjected to analysis that includes valid coding, timely filing, prior authorization
requirements, benefit application (including limitations and exclusions), coordination of
benefits application, claim history review for duplicate claims, manual pricing application,
special provider agreements, modifier discounts, and claims bundling/unbundling. (SOX
Control – 1D)
In addition to the standard audits identified above, as provider contracts and new/existing
contract/benefit changes are implemented, we will audit all impacted terms for a high-level
review of the following:
Contract Terms
General Information
Payment
Location
A very high level review may or may not be done for Services, ICD9, Procedures and
Service Groups
Benefit Terms
General Information
Services
Co-pay
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 92
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Restrictions
Limits
A very high level review may or may not be done for ICD9, Procedures and Service Groups
17.18.3 Audit Sampling Methodology
If no changes are made to a provider’s contract, MMIC will audit the provider at least every five
years based on a random sampling of ten percent of the claims submitted by the provider for the
review period. At the conclusion of scheduled or ad hoc audits, the Claims Audit department will
be responsible for documenting the findings and initiating corrective action for deficiencies.
Providers who do not achieve acceptable rates of compliance may be subject to more frequent
audits until they achieve compliance.
17.18.5 Independent Audit of its Claims Payment/Management Information System
17.18.6 Scope of an Audit
MMIC recognizes the value of a true cooperative relationship with ADHS/DBHS, and welcomes
the opportunity to collaborate to expand the scope of our internal claims audit processes to
include areas such as a verification of eligibility and enrollment information loading, contract
information management (contract loading and auditing), claims processing and encounter
submission processes. In the event of a system change or update, or when directed by
ADHS/DBHS, MMIC will cooperate with an independent audit of its Claims
Payment/Management Information System.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 93
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.18.7 Submit Audit Findings to ADHS/DBHS
As contractually required, MMIC will submit audit findings to ADHS/DBHS. Additionally, we
will submit audit findings performed by other external entities when completed.
Per our sponsor Mercy Care Plan (MCP)’s current internal policies and procedures, the MMIC
Claims Audit department will perform four statistically valid audits each for Medicaid and
Medicare claims each month. They will consist of two monitoring audits per two week period
for each form type. Claims types include both medical and behavioral health. As with MCP, our
overall percentage of claims audited are expected to reflect ninety-five percent confidence, with
an error rate of two percent, and a desired precision of plus/minus two percent. An example of
MCP’s audit process follows.
Auditing was performed in April of 2012 with the objectives of:
Timely identification, communication and resolution of identified issues
Independent assessment and accuracy rates for claim population
Audit of adjudicated claims and QNXT system configuration to maintain accuracy and
compliance with established policies, procedures, management service agreements and
contracts
Reports of audit results used to improve claims processing and system configuration
accuracy and efficiency
Eight random, statistically valid standard audits when “paid/denied” status is completed
within a live environment:
Four – UB04
Four – CMS 1500
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 94
MAG-331-000094
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
MCP’s most recent audits have resulted in the following results that confirm the accuracy of its
provider and contract validation processes:
Provider validation overall accuracy: 99.8 percent
Through this process, MCP was able to identify two issues relative to provider validation, as
illustrated in Table 1 on the following page:
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 95
MAG-331-000095
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 1: Issues Relative to Provider Validation
Rank Issue # Lines% of
Contract Issues
Comments
1 Contracting – Contract Needed 22 68.75% Missing copy of contract to validate Par provider for SOX Compliance.
2 Provider – Contracts 10 31.25% Review provider contract attached.
Total 32 100%
Contract validation overall accuracy: 100 percent
Contract validation issue detail – top issue: N/A
Utilizing MCP’s internal claims auditing process, MMIC expects to be able to review benefit
validation using the Summary Plan Documents (SPD), the Explanation of Coverage (EOC), and
the Health Plan Medicare Summary of Benefits (SOB) – all provided through the Claims Audit
department. MCP assesses each claim line to evaluate the appropriateness of the benefit term
selection. It also reviews the documents listed above to validate system configuration and
confirm the appropriateness of source documentation. When discrepancies are found, MCP
reports them to the Health Plan and Business Applications Management department for review
and action.
Recent findings for the third quarter of 2012 are as follows:
Benefit validation overall accuracy – one hundred percent (100%)
Benefit validation issue detail – top issue: N/A
Additionally, MCP monitors the claim validation process by examining data fields for each
claim, viewing paper claims submitted through Alchemy or EDI data. It reviews all claims for
valid coding, timely filing, prior authorization requirements, benefit application (including
limitations and exclusions), coordination of benefits application, claims history review for
duplicates, manual pricing application, “Special Provision” provider agreements, modifier
discounts and claims bundling/unbundling. Recent findings for 3Q 2012 are as follows:
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 96
MAG-331-000096
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Claim validation overall accuracy – 99.29 percent
Through this process we were able to identify two issues relative to claim validation, as
illustrated in Table 2 below:
Table 2: Issues Relative to Claim Validation
Rank Issue # Lines% of
Claim Issues
Comments
1 Claims - Processing 109 97.32% Various manual processing issues
2 Claims - Memo 3 2.68% Claim memo missing information or inappropriate.
Total 112 100%
2012 3rd Quarter Claims Audit Summary Report
MCP conducted a total of eight standard audits on claims with the status of “paid/denied,” based
on a random, statistically valid sample within a live environment. The objectives of these audits
included:
Timely identification, communication and resolution of identified issues
Independent assessment and accuracy rates for claim population
Audit of adjudicated claims and QNXT™ system configuration to maintain accuracy and
compliance with established policies, procedures, management service agreements and
contracts
Reports of audit results to improve claims processing and system configuration accuracy and
efficiency
Recent findings are illustrated in Table 3 on the following page:
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 97
MAG-331-000097
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 3: Quarterly Summary of Standard Claim Audit Findings
Month 2012
Number of Audits Distributed
Number of Claims Audited
Number of Claim Lines
Audited
Payment Accuracy
Financial Accuracy
July 4 745 7321 99.87% 99.98%
August 2 373 4129 98.39% 96.62%
September 2 373 4367 99.20% 99.93%
3rd Qtr. Total
8 1491 15817 99.33% 99.27%
To guarantee transparency in the claims process, and facilitate accuracy and timeliness, MCP
conducts additional audits that provide supplementary statistical information for management
reports. Those reports include:
Summary of findings for standard audits
Target audits
Issues identified
Monthly top 5 issues report
Procedural issue detail – Top 5 issues, the spotlight and actions resulting from findings
Systematic issue detail – Top 5 issues, the spotlight and actions resulting from findings
Outstanding claims audits
Claims audits closed during the month (TAT- turnaround time to close an audit)
Quarterly summary of standard claim audit findings
Quarterly summary of target claim audit findings
Quarterly aging summary
Quarterly key issues identified
As a visual report example, a combined “Summary of All Audit Findings” is presented in the
format illustrated in Figures 1 and 2 on the following page.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 98
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 1: Key Controls Measures for SOX – 3rd Quarter 2012 MCP
Figure 2: SOX Key Issues – 1st Quarter 2011 MCRP-MCA
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 99
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
MMIC is keenly aware of the constantly changing technical environment that drives claims
management, and will maintain cutting-edge auditing processes to keep abreast of new
technology. Therefore, when changes are made or systems are updated, we will fully participate
and cooperate with any independent external audit of our Claims Payment/Management
Information System as requested by ADHS/DBHS or any other regulatory agency.
Our Claims Audit department will be accountable for preparing submissions of claims auditing
findings, and submitting them directly to ADHS/DBHS or any other regulatory agency requiring
this information. MMIC will follow submission formats as specified contractually by
ADHS/DBHS.
MMIC’s ability to control claims expenses through a streamlined audit process will have a
dramatically positive impact while providing new and unique differentiating flexibility in
processing. That flexibility will enable MMIC to innovate and react quickly to unpredictable
events creating a system that provides effective health care and enhanced member satisfaction.
17.19 Demographic Data Submission When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:
Mercy Maricopa Integrated Care (MMIC) understands the importance of demographic data and
timely submission. MMIC’s sponsor agency, Mercy Care Plan (MCP), serves over 340,000
Medicaid, Medicare Advantage Special Needs Plan and developmentally disabled members.
With experience collecting demographic data as required by AHCCCS Medical Policy Manual
940.1, MCP brings expertise that MMIC will use in order to provide the data necessary to
support the RBHA system.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
17.19.1 Submit Behavioral Health Member Demographic Data
MMIC will use the Better Health Enterprise System
Platform™ (BH-ESP) to meet and exceed the RFP system
expectations and requirements with respect to demographic
data submission. The platform is powered by the Aetna EDI
Gateway that serves mission critical information sharing for
the state of Arizona today, including demographic data
submissions.
MMIC will thoroughly review and comply with the
submission of demographic data to ADHS/DBHS as
specified in the CIS File Layout and Specifications Manual
and according to the submission timelines in the ADHS/DBHS Provider Manual, 7.5 Enrollment,
Disenrollment and Other Data Submission, the DBHS Demographic and Outcome Data Set User
Guide and the ADHS/DBHS Office of Program Support Operations and Procedures Manual.
17.19.2 Include a Written Attestation with Each Demographic Data Submission
In conformance with section 17.2.6 of this RFP, MMIC will provide attestation at the time of
submission that any data transmitted is accurate, complete and truthful, to the best of the
contractor‘s Chief Executive Officer (CEO), Chief Financial Officer (CFO) or designee‘s
knowledge in conformance with the AHCCCS HIPAA Transaction Companion Guides and
Trading Partner Agreements, and the AHCCCS Encounter Manual (42 CFR.438.606).
Figure 1: EDI Gateway currently processes
demographic transactions with the state and complies
with CIS file layout and specifications.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Demographic data is the driving force behind monitoring and reporting on enrolled clients’
outcomes, ensuring compliance with federal and state funding and/or grant requirements,
assisting with financial-related activities such as budget development and rate setting, supporting
quality management and utilization management activities, and responding to requests for
information. In order to achieve the timelines regarding enrollment, change, annual or six-
month outcome measures updates and disenrollment, the RBHA needs to provide a top-notch
technology solution combined with process knowledge and capable staff. MMIC will leverage
the experience of MCP combined with best in industry technology to establish a consistent
workflow of data from provider to RBHA and RBHA to ADHS/DBHS.
17.20 Grievance, Appeals, and Claims Dispute Data Submissions When responding, include Offeror’s strategies for its Implementation Plan consistent with 18.24.5. Offeror Response:
Mercy Maricopa Integrated Care (MMIC) recognizes that members may face issues requiring a
means for them to express complaints and resolve disputes. One of our organization’s core
values is member satisfaction, and we will support it through the careful recording and reporting
of member issues.
MMIC – through its sponsors, Mercy Care Plan (MCP) and Maricopa Integrated Health System
(MIHS) – will have a complete, integrated system in place to record, track, resolve and report
grievances and appeals. Our grievance and appeals processes will provide a mechanism for our
members or their representatives to express complaints, resolve disputes, or bring attention to
incidents, conditions, practices and/or policies that may violate their rights.
We will maintain individual complaint records that include adequate, dated documentation,
including:
Copies of communication generated during the resolution process
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Documentation of actions taken to meet immediate health care needs
Documentation of all steps taken to resolve the issue, including the date the complaint was
acknowledged and the date the complainant was notified of resolution
Documentation of plans for resolution
Documentation of plans for correction
Evidence that the resolution and any plans for correction have been implemented
Evidence that identified issues are referred for additional follow up as indicated, including
referrals to Quality Management, Network Management, Grievance and Appeals, Fraud and
Abuse departments and/or regulatory agencies
The reason for delay for complaints taking more than 10 business days from filing to resolve
17.20.1 Submit Grievance and Appeal Information to ADHS/DBHS Database
17.20.2 Submit Initial and Updated Entries within Three Working Days
MMIC will submit grievance, appeal, request for hearing information and provider claim dispute
information into the ADHS/DBHS Office of Grievances and Appeals database, as required. In
addition, we will submit initial and updated entries to the ADHS/DBHS Office of Grievances
and Appeals database within three working days of an event requiring entry.
We will track and maintain a log of all grievances received, utilizing the following data fields for
submission to the ADHS/DBHS Office of Grievances and Appeals database:
The enrollee’s first and last name
The date the complaint was made
Title XIX/XXI eligibility status
The source of the complaint
A description of the grievance
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Any identified communication need, such as a translator
The outcome reached
The length of time for outcome
Covered service category
Treatment setting
Behavioral health category
Our Grievance Administrator will have responsibility for collecting, recording and maintaining
this data for submission to the ADHS/DBHS Office of Grievances and Appeals database.
Defining Complaints, Grievances and Appeals
MMIC will define a complaint as an expression of dissatisfaction with any aspect of care other
than the appeal of an action involving Title XIX/XXI recipients. Complaints will include
concerns about the quality of care or services, aspects of interpersonal relationships with service
providers, and lack of respect for recipients’ rights. Complaints will be promptly resolved by
informal means, such as immediate staff action or phone call.
MMIC will define a grievance as a complaint filed by a member with SMI or other concerned
person regarding violation of the rights of the member with SMI or a condition requiring an
investigation. It can be a formal written or verbal complaint (when the verbal complaint about
member care is unresolved at the time by staff present) by a member or representative, regarding
care, abuse or neglect, issues related to the hospital’s compliance with Centers for Medicare and
Medicaid Services (CMS) Conditions of Participation, or a Medicare beneficiary billing
complaint related to rights and limitations provided by 42 CFR§489. The following are
considered to be grievances:
A member care complaint that cannot be resolved at the time by staff present, is postponed
for later resolution, referred to other staff for later resolution, requires investigation and/or
further actions for resolution
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Situations where members or their legal representatives contact the hospital after discharge
about concerns related to care or services that were not resolved during their stay or that they
did not wish to address during their stay
Whenever a member or legal representative requests that the complaint be handled as a
formal complaint or grievance, and/or requests a response from the hospital
A written complaint, whether from an inpatient, outpatient, released/discharged member or a
representative, regarding care provided, abuse or neglect, or the hospital’s compliance with
CMS Conditions of Participation. E-mail or fax is considered “written.”
When an identified member writes or attaches a written complaint to a patient satisfaction
survey and requests resolution
MMIC defines an appeal as a request for review of a decision made by ADHS/DBHS, T/RBHA
or T/RBHA provider. There are three types of appeals as follows:
Appeal Section 5.2/GA 3.1: A request for review of an adverse decision by T/RBHA or
ADHS/DBHS for a person determined to have a serious mental illness
Appeal Section 5.1/GA 3.3: A request for review of an action
Appeal Section 5.5/Appeal GA 3.5: A request for review of a decision made by
ADHS/DBHS, a T/RBHA or a T/RBHA provider
Handling Grievances Appropriately and Expeditiously
MMIC is committed to handling grievances in an appropriate and expeditious manner. To this
end, we will develop the following procedures for specific resolution time frames, key
individuals responsible for acting to resolve the grievance, and processes for reporting the
grievance, appeal, request for hearing information and provider claim dispute information into
the ADHS/DBHS Office of Grievances and Appeals database as required.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Our Grievance Administrator will be responsible for:
Tracking to make sure that all grievances are reviewed, investigated and resolved as soon as
possible, depending on the severity of the issue. Once a Member Advocate receives a
grievance, it will be documented according to the appropriate facility reporting process.
Grievances about situations that endanger the member, such as abuse or neglect, will be
investigated immediately
Involving applicable departments, such as Risk Management, Quality Improvement, and
Compliance, and staff, such as Department Manager and/or Director, Chief Medical Officer,
Chief Operating Officer and/or Chief Executive Officer, as necessary, to appropriately
investigate and resolve the grievance
Responding in writing to each member grievance within five days of submission
Upon resolution, the Grievance Administrator will include in the written response
Name of the hospital contact person
Steps taken on behalf of the member to investigate the grievance
Results of the grievance process
Date of completion
If the grievance is unresolved, the investigation is incomplete, or corrective action is still being
evaluated, required written response, within seven days of submission, the notice will explain
that MMIC is still working to resolve the complaint and those we will follow up with further
written responses, within specified time frames, until the process is completed.
We will provide written notice of determination regarding the grievance to the member or
member representative in a language and manner that is easily understood. MMIC will keep the
completed grievance file in the Risk Management department for record keeping and data
management purposes. If the grievance involves allegations of malpractice, negligence or is an
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
actual claim against MMIC, it will be immediately directed to Risk Management for review and
follow up.
When MMIC receives notice, either orally or in writing, that an individual has Limited English
Proficiency (LEP) or any other communication need, we will follow internal policies regarding
oral interpretation services, translation of written materials, and services for the deaf and
hearing-impaired:
We will make oral interpretation service available for all individuals with LEP.
We will provide written translation for individuals needing assistance in the prevalent non-
English language within the region.
We will provide oral interpretation of written materials, or make alternative communication
formats, (such as TTY/TTD), available for those needing assistance in a language not
considered a prevalent non-English language, as needed.
Our Appeals Manager will ascertain that individuals making decisions regarding appeals have
not been involved in any previous level of review. The Appeals Manager will also make sure
that individuals making decisions about appeals involving denial of an expedited resolution, or
involving clinical issues are health care professionals with the appropriate clinical expertise with
the member’s condition.
Strategies for An Implementation Plan Consistent with 18.24.5
MMIC’s Grievance Administrator, in collaboration with our Implementation team, will initiate
strategies concerning Complaint, Grievance and Appeal processes. They include:
Developing written Policies and Procedures in accordance with State and Federal regulations,
including:
How we will define Complaints, Grievances and Appeals and respond to each
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 107
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
How we will track and log Complaints, Grievances and Appeals in our QNXT system,
including all required state and federal databases
How we will enter and submit appeals data to ADHS/DBHS Office of Grievances and
Appeals
Use of peers as member advocates
The role of the Human Rights Administrator
Pertinent language concerning our processes in our Member Services Handbook
Posting both the Member Handbook and Provider Manual on our website, and providing hot
links to the ADHS/DBHS Provider Manual
Establishing requirements for QNXT’s internal tracking of Complaints, Grievances and
Appeals, performing gap analyses, and creating enhancements to the system as needed
Conducting follow-up testing prior to “go-live” as part of readiness review
Collaborating with ADHS/DBHS on development, and participating in meetings at their
discretion
Developing training curricula on relevant processes for internal and provider staffs
Providing training to internal and provider personnel on relevant processes
Mercy Maricopa Integrated Care (MMIC) will handle all grievances and appeals in an
appropriate and expeditious manner. Our processes will provide uniform, equitable treatment
and prompt response of grievances and appeals. We believe that member satisfaction is achieved
through the expeditious resolution of grievances and appeals, and will endeavor to provide a high
level of issue resolution across all organization departments in pursuit of excellence.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
18.4 Peer Involvement and Participation Offeror Response:
Mercy Maricopa Integrated Care (MMIC) is committed to a system of care that engages the
individuals receiving services at every level: through driving their own treatment planning
process, providing peer delivered services, engaging in community development work, and
making system improvements in administration and service delivery. MMIC’s Office of
Individual and Family Affairs will take on a leadership role in creating opportunities for and
confirming peer involvement at all levels of the system. In addition to quality oversight to
confirm peer involvement in treatment planning, MMIC, through its sponsor organizations, has
established the following mechanisms for peer involvement:
1. Office of Individual and Family Affairs-sponsored activities and forums including but not
limited to: round table discussions, information sessions, participatory dialogues, and system
of care planning meetings.
2. Peer representation on MMIC committees and governing bodies including the Governance
Committee, Board of Directors, Strategy Committee and all its sub-committees, Integrated
Clinical Care and Quality Management Committee and all its sub-committees, Audit and
Compliance Committee, Member Advocacy Committee, Youth Leadership Council, Finance
Committee, and CLAS Committee.
3. Participation in quality management activities, including but not limited to: conducting
surveys and review mechanisms such as the Recovery Oriented Systems Indicators (ROSI)
and the Recovery Assessment Scale (RAS), as outlined in more detail in the Quality
Management Section of this proposal.
4. Participation in joint review efforts when assessing adherence to the Intergovernmental
Agreement and Collaborative Protocol between AZ Department of Economic
Security/Rehabilitation Services Administration and MMIC’s government partner, Maricopa
Integrated Health System (MIHS).
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 109
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
5. Participation and leadership on the SMI Clinic Advisory Councils for each SMI Clinic.
6. Participation in the interview process when hiring for all direct service staff positions.
7. Increased use of peer support services, number of certified Peer Support Specialists, and
Consumer Operated Service Programs.
8. Use of peer and family advocacy groups to serve as Member Advocates for members
participating in the grievance and appeals process.
9. Provision of educational/training opportunities to assist peers in gaining the skills needed to
be effective self-advocates and system-advocates, including an emphasis on taking charge of
one’s own treatment and the treatment planning process.
10. Peers and peer/family advocacy groups involvement in delivery of training to provider staff
and other workforce development efforts – such as NAMI’s Signature Provider Training and
In Our Own Voice presentation.
11. Peer leadership in the planning and implementation of Annual Conference for Change.
12. Participation in ADHS/DBHS initiatives to improve communication and input such as
participatory dialogues (Arizona Dialogues), recovery roundtables, and a collaborative
approach to completing Recovery Roadmaps.
13. Sharing recovery stories in committee meetings, reports, and Newsletters to highlight
strengths and success while creating a culture of celebration.
18.4.1 Participation of At Least One Peer or Family Member During the Interview Process
MMIC believes peers should be an integral part of the interview process and treated like anyone
else conducting interviews. Peers bring an important perspective to the interview process when
hiring staff. They bring lived experience and experiential knowledge into play in addition to
traditional knowledge about providing support. They can assess candidates from a very personal
perspective, providing valuable information to the rest of the team. As such, they will have a
voice in the hiring decision equivalent to any other interviewer.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 110
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
MMIC will require that providers demonstrate documentary evidence that they have involved
peers (including youth when applicable) in the interview process when hiring all direct service
staff. Provider adherence to this requirement will be monitored quarterly by the MMIC Quality
Management Department. Peers will not only be involved in interviewing direct service staff but
key administrative staff as well. Administrative staff will include positions that are in the
supervisory chain of command for direct service staff, such as Supervisors, Site Managers,
Clinical Directors, and Chief Executive Officers. We believe that including peers in interviews
for these positions sends both candidates and peers an important message about the centrality of
recovery to all that we do, while also creating a mechanism to select candidates who believe in
recovery.
Through MMIC’s Office of Individual and Family Affairs and a partnership with local National
Alliance on Mental Illness (NAMI) affiliates, peers will be identified and recruited to participate
in provider interviews. The Technical Assistance Center (TAC), created in partnership with
Arizona State University (ASU), Maricopa Integrated Health System (MIHS), and community
stakeholders (as outlined in more detail in section 4.4-4.6), will also play a major role in
recruiting peers to participate in interviews. The TAC will offer self-advocacy and system-
advocacy training for peers. Many participants in these training programs may be matched with
paid opportunities to get involved in the system, especially through participating in interviews.
The TAC staff will use their expertise in industrial/organizational psychology to provide
assistance to peers and providers in developing meaningful training programs for peers.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
18.4.2 Develop a Process for Members to have Regular and Ongoing Input
SMI Clinic Advisory Councils
MMIC will enable members to have regular and ongoing input to assist in decision-making,
development, and enhancement of customer service at each provider site where case
management services are delivered through participation and leadership on the SMI Clinic
Advisory Councils for each SMI clinic, in addition to the aforementioned quality management
efforts and committee involvement as outlined above.
Each SMI clinic will be required to continue its SMI Clinic Advisory Council, which allows
members, families, and other stakeholders to address concerns and make recommendations for
improvement via monthly meetings. The SMI Clinic Advisory Councils will be authorized to
make recommendations and decisions. They will have regular opportunities to meet with clinic
leadership and MMIC administrators. The goal of the SMI Clinic Advisory Council is to bring
staff, individuals receiving services, family members, neighboring businesses, and other
community members together to collaborate and take ownership of their clinic, their
neighborhood, and their community. MMIC embraces the fact that the best ideas and solutions
come from the individuals who are directly affected by the system; especially those receiving
services and those providing services at the front line. This strategy builds community through:
Creating shared ownership;
Increasing neighbors/community members awareness of the value of the clinic and the
realities of mental illness and recovery;
Helping staff feel empowered and develop stronger connections to their jobs;
Helping individuals receiving services feel empowered and develop ownership of their
recovery journey while increasing leadership and employment skills;
Decreasing the power differential as staff and individuals receiving services work side-by-
side to make meaningful changes.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
To assist all councils in improving their impact, we will contract with Recovery Empowerment
Network to offer a condensed version of its Arizona Transformation Statewide Consumer
Network (ATSCN) training to members of all advisory councils. This training is designed to
provide individuals with the skills needed to be effectively involved in transforming the
integrated system of care through participation and involvement in advocacy efforts and decision
making/advisory bodies.
ATSCN training will be provided in a one-day session at each SMI clinic that decides to take
advantage of it. Through this training, advisory council members gain a thorough understanding
of recovery, its principles, and what a recovery-oriented system might look like. The training
covers attitudes and self-esteem, group process, advisory council functions and policy
development. In addition to preparing various stakeholders to become effective advocates on the
advisory council and to develop a stronger understanding of recovery, such training efforts have
been proven to make a significant impact on individuals with mental illness – leading to
significant improvements in symptom control, social relationships, personal care and vocational
skills.
MMIC will require that SMI clinic leadership commit to each SMI Clinic Advisory Council
taking on meaningful roles and decision making authority. Some of the roles will include:
Completing the ADHS/DBHS Recovery Roadmap, making recommendations for continued
improvement, implementing recommendations, and monitoring progress;
Establishing mechanisms to assess customer satisfaction;
Reviewing customer satisfaction data, including clinic-based complaints and suggestions,
and make and monitor recommendations for continued improvement.
Other roles will be determined by each individual Advisory Council. As an example, such
activities may include:
Neighborhood beautification projects and other community-based volunteer projects;
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Strategies for outreaching and engaging the community;
Suggesting trainings/workshops and other activities to offer individuals receiving services;
Identifying system gaps and working with the community to organically fill these gaps.
SMI clinic leadership/administrators will be expected to be available and meet with the Advisory
Council upon the Council’s request. MMIC administrators will also be available to meet with or
attend Council meetings upon request. The MMIC Office of Individual and Family Affairs will
meet with each Council quarterly to confirm their presence, to monitor that the provider agency
is meeting its requirements to utilize the Council’s feedback and to afford them meaningful roles
and decision making authority; and to offer any support needed. Furthermore, the Office of
Individual and Family Affairs will gain new insights through meeting with each Council and will
utilize these insights in system of care planning efforts.
In addition to the SMI clinic advisory councils at the provider level, MMIC is committed to
having meaningful peer involvement in all its advisory and decision-making bodies. Below is a
more detailed description of two of these bodies.
Governance Board
The composition of MMIC’s Governance Board and its functions are described in Section 18.22.
To encourage active participation from members, MMIC will make special efforts to increase the
involvement of members who are on the Board in discussions during the meeting and help
strengthen their ability to impact decisions.
We will contract with Recovery Empowerment Network to provide a condensed version of its
Arizona Transformation Statewide Consumer Network (ATSCN) training to all Governance
Board members. This training is designed to provide individuals with the skills they need to be
effectively involved in transforming the integrated system of care through involvement on
groups such as the Governance Board.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
ATSCN training will be provided in a one-day session. It will help all Governance Board
members gain a thorough understanding of recovery, its principles, and what a recovery-oriented
system might look like. It will cover attitudes and self-esteem, group process, and Board
functions and policy development.
In order to create an environment that promotes advocacy and professional growth, Governance
Board members may have access to a professional mentor and/or may be asked to become a
mentor to newer advocates.
Member Advisory Council
MMIC will form a Member Advisory Council to advise on issues that are important to members.
Composed of twelve members that meet monthly, the Council will promote choice and the
development of peer-operated services. Attendance at meetings will be a requirement of
membership and transportation will be provided to those without a source of transportation.
MMIC is committed to creating paid professional positions for individuals with lived experience.
Members of the Advisory Council will receive a stipend for their services.
Members will serve on the Council for two years and will go through the same trainings as
members who serve on our Governance Board. They will also receive ongoing training in areas
such as quality assurance and member rights during their terms.
The Council will provide system oversight and will address and recommend solutions on issues
related to access, complaints and grievances, customer service, satisfaction, quality
improvement, member concerns, provider availability, among others. The Council will review
and make recommendations on information developed for members, such as Newsletters and
website content.
The Council will also make recommendations about practice guidelines, utilization data, and
outcome tools. It will identify gaps in services and make suggestions regarding additional
services, suggest ways to improve the effectiveness of services, and make recommendations as to
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
how best to meet the needs of members. Council members will also be asked to participate in
provider monitoring and quality management review efforts as appropriate.
Underscoring the value of the Council’s input, MMIC’s leadership, including clinical leadership,
will be present for each meeting to provide information and listen to recommendations from the
participants.
Meetings of the Council will be open to all members and widely publicized with attendance
encouraged. Discussions will be open to all members in attendance whether or not they are a
member of the Council. Members who are not a part of the Council may also be a part of task
groups formed by the Council.
Feeding into the Council will be a Youth Leadership Council composed of eight youth. Two
members of this Council will serve on the Member Advisory Council. A MMIC staff member,
selected by the youth, will serve as a mentor to the Council. The Youth Leadership Council will
provide an opportunity for youth to have a meaningful voice in our operations. It will address
issues of concern to youth, develop recommendations, and bring those recommendations into the
Member Advisory Council. Involvement in this group will not only enrich MMIC, but also
prepare youth for leadership roles in their communities.
MMIC’s Office of Individual and Family Affairs will interact closely with both advisory
councils and will play an active role in member recruitment and support.
18.4.3 Develop a Written Description of the Process for Members to Have Regular and
Ongoing Input and
18.4.4 Required Inclusions to Written Description
We have outlined twelve mechanisms for peer involvement and participation at every level of the
system. Upon contract award and prior to contract implementation, MMIC will develop a
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
written description which details the process for each of these twelve strategies. This description
will include requirements that the members attend regular meetings with clinical leadership and
that they be authorized to make decisions. MMIC will collaborate with established peer and
family advisory bodies, such as the Arizona Peer and Family Coalition, to seek input in the
development of these important processes. MMIC will submit the description to ADHS/DBHS
for review, input, and approval. After implementation, MMIC will revise descriptions as needed
based on the feedback of the peers and family members who are involved in implementing these
twelve strategies.
18.8 Training of Contractor Personnel, Subcontractors and Providers When responding, include Offeror’s strategies for training and cross-training the behavioral and physical
health care workforce to operate in an integrated health care system. Offeror Response:
Leveraging the resources and experience of its non-profit sponsors Mercy Care Plan (MCP) and
Maricopa Integrated Health System (MIHS), Mercy Maricopa Integrated Care (MMIC) will
provide training and educational opportunities at no cost to providers, members and the
community as a whole. Through a centralized Learning and Performance Center, we will offer
tailored training curricula and content to meet training requirements in the ADHS/DBHS
Provider Manual 9.1 as well as build awareness, skills and knowledge to support an integrated
delivery system. Our training program will help link people, learning and performance to:
Promote a consistent philosophy and equip employees and providers with the appropriate
knowledge of the delivery system
Facilitate education and cross-training of the behavioral and physical health workforce to
maximize the effectiveness of an integrated health care system
Support the delivery of services in a manner consistent with Arizona system principles
Provide timely information on new initiatives, technological advances, and best practices that
impact the delivery of integrated services
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
MMIC will monitor the effectiveness of its training programs and refine training content and
delivery as necessary to increase effectiveness. Training will be delivered using a variety of
methods, including:
Traditional classroom-led training
Interactive learning (group activities, role playing, discussion)
Online training through Essential Learning for more convenient access to courses
Self-study materials that can be reviewed independently
Technical assistance, coaching and mentoring provided by training professionals, peers and
family members
18.8.1 Sufficient Number of Qualified Trainers who are Subject Matter Experts in
Training Topic
As part of implementation, MMIC will hire dedicated and qualified training staff. Training
personnel will develop curricula and deliver initial and ongoing trainings to enhance the
knowledge and skills of all MMIC personnel, network providers, members, family members who
provide peer support and system stakeholders.
MMIC will employ a Training and Workforce Development Administrator who will oversee the
development, implementation and oversight of training programs as well as workforce
recruitment. Additionally, MMIC will build upon its sponsor organization Mercy Care Plan’s
(MCP) existing Learning and Performance Center (LPC). The LPC offers dedicated trainers to
support employees. All trainers hold bachelor’s degrees or equivalent training; trainers who
provide clinical training all hold degrees. All have relevant health care knowledge and are
seasoned professionals in the training field.
MMIC will use existing provider training staff at MCP where possible, given that some training
required by existing contracts will also be required by this contract (cultural competency, fraud
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
and abuse). MMIC will also augment the existing personnel with additional staff possessing
specific clinical, administrative, operational or personal (e.g., a peer or family member)
knowledge of behavioral health and of the Maricopa County system.
Additionally, MMIC will implement an electronic learning (e-learning) component, such as
Essential Learning, to provide increased training capacity in the most cost-effective manner. E-
learning will provide online learning resources to all stakeholders, including members and their
families, members of the community, providers, internal staff members and system partners in a
convenient and easily accessible manner.
18.8.2 Allocate Financial Resources to Provide Initial and Ongoing Training
MMIC will allocate financial resources both to provide and to maintain a comprehensive initial
and ongoing training program. A training budget will be set aside for staff salaries and e-
learning implementation and maintenance. MMIC will have 17 Full Time Equivalents (FTEs)
fully dedicated to the training of RBHA staff and providers. These staff will be supplemented
during implementation and as needed thereafter by our administrative services subcontractor,
Schaller Anderson’s Learning and Performance Center. MMIC’s Training and Workforce
Development Administrator will be fully responsible for our training program and collaboration
with the Learning and Performance Center administrator. The Training and Workforce
Development Officer will report to the Vice President of Operations. Annually, we will
appropriate the necessary funding for internal staff and provider staff training programs
including dedicated monies for e-learning initiatives and programs for Continuing Medical
Education (CME) and Continuing Education Units (CEUs).
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 119
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
18.8.3 Provide Training, Coaching, Modeling, Technical Assistance and Observation
Training is a term often used in a nebulous manner to describe the various activities an entity
will offer with the intent of educating involved parties. MMIC defines training differently:
training includes the delivery of specific actions designed to disseminate knowledge and enhance
skills and performance.
MMIC’s comprehensive training program will be intensive, focused and aligned with company
guidelines, federal and state requirements and the requirements of the following agencies,
entities or legal documents as referenced in Exhibit 7:
Arizona Department of Health Services/Division of Behavioral Health Services
The Arizona Health Care Cost Containment System (AHCCCS)
The Arnold v. Sarn and JK v. Humble settlement agreements
The Maricopa County Superior Court
We will disseminate information to external parties in the form of curricula and technical
assistance primarily via live presentations, e-training modules and collaborative meetings.
MMIC employees will participate in the aforementioned activities and will also receive
supervision in accordance with regulatory requirements and MMIC policy. We will provide
supervision with the intent to maximize individual and departmental functioning and may
include techniques such as observation, coaching and modeling to help employees develop and
or enhance the skills necessary to make them an effective part of the team.
MMIC will identify and continually monitor the need for knowledge transfer, skill building and
performance improvement of personnel, providers, members and family members and other
stakeholders in order to tailor the training we provide. The following describes the customized
activities we intend to provide in order to both educate and support all involved parties.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 120
MAG-331-000120
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Training MMIC Personnel
Through the centralized LPC, we will provide training
specifically related to an employee’s job responsibilities and
goals via classroom sessions, web-based learning, shadowing
and mentoring. MMIC will provide a comprehensive
orientation and training program designed to educate new staff
on the mission, values and commitment to high-quality,
integrated care for members served as the RBHA for Maricopa
County. Essential program components will include:
Creating a comprehensive overview of our culture, including values and ethics, and how
these elements support our commitment to focus on members and providers
Building cultural competency and health literacy knowledge and skills to address member-
specific cultural and language needs
Dispelling the myths, stigmas, or other misperceptions associated with mental illness through
current and factual information
Verifying that staff participated and successfully completed required training
Completing position-specific on-the-job training, shadowing experienced staff in a hands-on
setting, accessing position-specific policies, procedures and other helpful resources.
Providing extensive and detailed information on technology and system tools that will
support personnel in performing their duties and enhance their ability to work efficiently
To measure the effectiveness of training, MMIC will use Kirkpatrick’s Four-Level Evaluation
Model, a nationally accepted, well-known model for objectively analyzing the effectiveness and
impact of training. The first level includes surveys completed after completion of training; the
second level includes assessments that are infused in the training to measure comprehension; and
the third level measures impact. MMIC’s sponsor, Mercy Care Plan (MCP), currently uses the
On a scale of 1 through 5, the current score based on survey feedback for the year is
4.77 indicating employee satisfaction with the delivery and content of training.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 121
MAG-331-000121
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
first and second levels, and is developing plans to implement the third level, which measures an
employee’s job performance 45-90 days after training.
Ongoing Training
MMIC will require mandatory ongoing training for key areas including but not limited to
compliance, quality of care concerns/services, cultural competency, reporting member/provider
complaints, code of conduct, and fraud and abuse. Managers and Supervisors will be
accountable for ongoing employee training specific to job functions. Ongoing training will be
delivered primarily through the Learning and Performance Center’s online classes, but may also
occur through instructor-led training sessions, in-services, presentations and handouts. Training
will be reinforced and updated through periodic departmental meetings and in annual training
classes.
Training Providers
We are committed to offering a well-developed provider training program that promotes
consistency, culturally competency, best practices, and that equips all behavioral and physical
health providers with the information necessary to operate in an integrated delivery system and
to provide the highest quality of services to members. This comprehensive provider training
program will comply with ADHS/DBHS requirements as outlined in Exhibit 7 and the
ADHS/DBHS Provider Manual, Section 9.1. We will solicit input from providers on training
topics needed as well as the development and delivery of training content. MMIC will also offer
technical assistance to providers when issues or deficiencies are identified.
In addition, we will require providers to train their staff in meeting the needs of members served.
These requirements vary by provider type and qualifications of staff. Ongoing staff training at
provider offices will be designed to improve overall staff competencies and, at a minimum, occur
when policies and procedures change, the Provider Manual changes, when new ADHS/DBHS or
RBHA initiatives are instituted, and in accordance with contract requirements. Training methods
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 122
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
will include computer-based, live, coaching/mentoring, technical assistance and self-study.
MMIC will monitor providers to assess competency on required topics.
Through Essential Learning, MMIC will give providers access to a variety of training
opportunities. E-learning capabilities allow our providers and stakeholders to receive
information and training at times that are most convenient while also helping them track and
monitor their progress. The function also allows for customization of courses to meet specific
requirements. Many courses also provide nationally accredited continuing education units.
Training Peers and Family Members
MMIC will incorporate a variety of approaches to educate, inform and train peers and family
members. We understand the importance of involving and collaborating with peers, family
members, peer- and family-run organizations and stakeholders as part of transforming the system
to one driven by integrated care and recovery. To that end, we will offer training, technical
assistance, and skill-building programs for members and their families in areas such as
leadership and advocacy, program development, resource identification and coordination.
Training will be a component of MMIC’s Office of Individual and Family Affairs, staffed by
peers and family members. The Office of Individual and Family Affairs is designed to increase
adult, youth and family voice at all levels and place peers and family members at every level of
the system. We will support the development of peer and family support services and will
partner with local organizations to offer peer support training.
18.8.4 Input from Members and Family Members in Training Curricula and Delivery
We believe obtaining members’ and family members’ perspectives and feedback is pivotal; thus,
we will involve members and families at all levels of the system, including development and
delivery of training. Members and family members will be key participants in our annual
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 123
MAG-331-000123
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
conference for change as well as through participation in community meetings, on our
Governance Board and Member Advisory Council, and other advisory committees.
MMIC will engage members to not only participate but also have an impact. We will use family
members, peer-run, family-run and parent-support organizations to provide technical assistance,
training, coaching and support to peers, family members and youth who assume leadership roles
within the delivery system.
Recognizing the importance of family-run organization, MMIC will be committed to building
and maintaining partnerships with these organizations. MMIC’s sponsors, Mercy Care Plan and
MIHS, have extensive experience working with local, peer and family-run organizations. MCP
works cooperatively with these organizations in current AHCCCS programs managed by the
plan and MIHS makes use of these resources in conjunction with its community health centers,
outreach programs and hospital services.
We believe these organizations can play an integral leadership role in sustaining family
involvement and support as well as in system transformation. Via leadership and technical
assistance activities, these family-run organizations can help connect an “authentic” family voice
to the delivery system. As part of this, we will engage family-run organizations to provide
coaching, mentoring and training to family members employed in the system and family leaders
in the community. Further, we will work with family-run organizations to assist in designing
curriculum for families on the Arizona Vision, Principles, Child and Family Team (CFT)
practice, and family-driven and youth-guided care.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 124
MAG-331-000124
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
18.8.5 Provide Initial and Ongoing Training for Staff, Providers, and Stakeholders to
Become Knowledgeable and Skilled in an Integrated Health Care Service Delivery System
MMIC will provide initial and ongoing training on the integrated health system and related
topics for staff, providers and stakeholders. Our goal is to educate members and providers so
they can be full participants in the integrated delivery system and achieve the greatest benefits
from the system as a result. We will also infuse information on the integrated delivery system
throughout our educational materials and reinforce this through ongoing training.
MMIC’s sponsors, MCP and MIHS, bring extensive experience in educating and training
providers to promote the integration of care. MMIC will build upon this experience and success
to offer similar and enhanced training programs so that staff, providers and stakeholders will be
educated and knowledgeable on an integrated health care delivery system. For example, MCP
currently offers the Integrated Care Training Academy, a training initiative that focuses on
supporting healthcare professionals in delivering integrated care services. Via a series of
campus-based training services, MCP educates primary care physicians, skilled nursing
facilities/assisted living facilities and behavioral health professionals on addressing the whole
person, including physical and behavioral needs.
Technical Assistance Center
Through a partnership with MIHS and Arizona State University (ASU), MMIC will develop a
community-embedded Technical Assistance Center (TAC). The TAC will, among other
initiatives, provide continuing educating, technical assistance and programmatic consultation.
This includes using ASU’s more than 10-year history as a SAMHSA-funded Addiction
Technology Transfer Center to operate a system-wide continuing education center, comprised of
online and in-person learning opportunities for physical and behavioral health practitioners on
evidence-based health topics. In addition, the center will provide organizational coaching and
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 125
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
consultation to provider agencies to assist in integrated physical and behavioral health program
conceptualization, implementation and evaluation.
In addition, MMIC will leverage relationships with ASU, the Aetna Foundation, MIHS and
SCHN Graduate Medical Education Programs to develop integrated health programs that offer
continuing education units. We will also establish local relationships with the National Alliance
for the Mentally Ill (NAMI). Education on an integrated health care service delivery system
must include evidence-based behavioral health practices and chronic condition management for
conditions prevalent in the SMI population and engagement strategies for persons receiving
services and their families. Multiple training delivery methods will be used to include webinars,
presentations, and toolkits.
18.8.6 Include a Cultural Competency Component in Each Training Topic
MMIC values and understands the importance of delivering culturally responsive services. To
that end, we will incorporate a cultural competency component in each training topic delivered to
staff, providers and stakeholders. MMIC will address the cultural relevance and considerations
pertinent to each training topic in accordance with the ADHS/DBHS Provider Manual Section
9.1 Training Requirements and our Cultural Competency Plan. All of our trainings will be
reviewed for cultural appropriateness, relevance and delivery.
18.8.7 Collaboration with ADHS/DBHS to Coordinate and Deliver Training
We understand the transforming the system requires a strong partnership between MMIC
ADHS/DBHS, AHCCCS and all system stakeholders. MMIC will collaborate with
ADHS/DBHS to coordinate and deliver training initiated by ADHS/DBHS in response to
identified needs.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
18.8.8 Orientation and Training for Providers New to the Field of Health and Network
MMIC will provide orientation and training for all providers new to the network. In addition,
through our sponsor organization, MIHS, MMIC will provide orientation and training for
providers new to the field of health. In accordance with the ADHS/DBHS Provider Manual,
Section 9.1, we will require behavioral health providers to complete the following training
content before providing services and within 90 days of the staff person’s hire date, as relevant to
each staff person’s job duties and responsibilities: Table 1 below and continuing on the following
pages describes the training that is required.
Table 1: Behavioral Health Provider Training (within 90 Days of Start Date)
Specific Training
Screening for eligibility, enrollment for covered behavioral health services (when eligible), and referral
Use of assessment and other screening tools (e.g., substance-related, crisis/risk developmental, etc.), including the Birth-to-Five Assessment depending upon population(s) served
Application of diagnostic classification systems and methods depending upon population(s) served
Use of effective interview and observational techniques that support engagement and are strengths-based, recovery-oriented, and culturally sensitive
Behavioral health service planning that addresses the client’s/family’s needs as identified through initial and ongoing assessment practices
Behavioral health service planning that addresses the client’s/family’s needs as identified through initial and ongoing assessment practices
Use of effective interview and observational techniques that support engagement and are strengths-based, recovery-oriented, and culturally sensitive
Behavioral health service planning that addresses the client’s/family’s needs as identified through initial and ongoing assessment practices
Confidentiality/HIPAA
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Specific Training
Coordination of care requirements with Primary Care Providers (PCPs)
Sharing of treatment/medical information
Management of difficult cases, including high-risk persons and persons court ordered for treatment
Covered behavioral health services (including information on how to assist persons in accessing all medically necessary covered behavioral health services regardless of a person’s behavioral health category assignment or involvement with any one type of service provider)
Overview of Substance Abuse Prevention and Treatment Block Grant: Priority placement criteria, interim service provision, consumer wait list reporting, and expenditure restrictions of the Substance Abuse Prevention and Treatment Block Grant
Early, Periodic, Screening, Diagnosis and Treatment (EPSDT) Program
Rights and responsibilities of eligible and enrolled behavioral health recipients, including rights for persons determined to have Serious Mental Illness
Appeals, grievances and requests for investigations
Complaint Process
Customer/member service
Fraud and abuse requirements and protocols
Managed care concepts, including information on the T/RBHA and the public behavioral health system
Overview of Arizona behavioral health system policies and procedures, including the ADHS/DBHS system principles
Arizona Vision and 12 Principles in the children’s system 9 Guiding Principles for Recovery Oriented Adult Behavioral Health Services and Systems in
the adult system
Best practices in the treatment and prevention of behavioral health disorders
Clinical training as it relates to specialty populations and/or conditions
Information regarding the appropriate clinical approaches when delivering services to children in the care and custody of ADES/DCYF
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Specific Training
Overview of partnership with Department of Economic Services/Rehabilitative Services Administration
Cultural competency
Child and Family Team (CFT) practice, depending on the population(s) served
Third party liability and coordination of benefits
Claims/encounters submission process
Advance Directives
Identification and reporting of persons in need of Special Assistance for individuals who have been determined to have a Serious Mental Illness (SMI) and ensuring involvement of persons providing Special Assistance
ADHS/DBHS Demographic Data Set, including required timeframes for data submission and valid values
Medicare Prescription Drug Modernization and Improvement Act of 2003 (MMA), including the following (as required by the Balanced Budget Amendment):
Assisting persons in choosing a Medicare Part D plan; Accessing relevant resources (e.g., plan formularies); and Answering questions and obtaining informational materials
In accordance with the Office of Behavioral Health Licensure (OBHL) training requirements,
MMIC will train behavioral health technicians and behavioral health paraprofessionals so that
they have the skills, knowledge and core competencies necessary to perform duties consistent
with the position and services the agency is authorized to provide. Table 2 below and on the
following page describes the core competencies providers will achieve following our trainings.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 2: Behavioral Health Provider Training – Core Competencies Core Competencies
Meet the unique needs of the client populations served by the agency or the staff member, such as children, adults age 65 or older, individuals who have substance abuse problems, individuals who are seriously mentally ill, or individuals who have co-occurring disorders
Recognize, prevent, and respond to a situation in which a client:
May be a danger to self or a danger to others
Behaves in an aggressive or destructive manner
May be experiencing a crisis situation, or
May be experiencing a medical emergency
Meet the unique needs of the client populations served by the agency or the staff member, such as children, adults age 65 or older, individuals who have substance abuse problems, individuals who are seriously mentally ill, or individuals who have co-occurring disorders
Recognize obvious symptoms of a mental disorder, personality disorder, or substance abuse
Protect and maintain the confidentiality of client records and information
Provide treatment that promotes client dignity, independence, individuality, strengths, privacy and choice
Provide the behavioral health services that the agency is authorized to provide and that the staff member is qualified to provide
Assist a client in accessing community services and resources
Record and document client information
Demonstrate ethical behavior, such as by respecting staff member and client boundaries and recognizing the inappropriateness of receiving gratuities from a client
Identify types of medications commonly prescribed for mental disorders, personality disorders, and substance abuse and the common side effects and adverse reactions of the medications
Recognize and respond to a fire, disaster, hazard, and medical emergency
Provide the activities or behavioral health services identified in the staff member's job description or the agency's policy and procedure
Training will be completed and documented in accordance with OBHL requirements (see R9-20-204(F) and R9-20-206)
Specialized Training
MMIC will provide abbreviated but specialized training as required by the Arizona Department
of Economic Security (ADES) and the Arizona Department of Health to Professional Foster
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Homes Providing Home Care Training to Home Care Client (HCTC) Services and Adult
Therapeutic Foster Homes.
Homes Serving Children
MMIC will monitor professional foster homes licensed by ADES for compliance with training
requirements in R6-5-5850. Training will include:
CPR and first aid training
30 hours of pre-service training utilizing Partnering for Safety and Permanence: the Model
Approach to Partnerships in Parenting (PS-MAPP)
18 hours of pre-service training utilizing the Arizona Home Care Training to Client Service
Curriculum
Behavioral health management of crisis situations including:
Prevention of violent behaviors,
Behavior management skills, and
De-escalation techniques
Medical/health care issues, procedures, and techniques, including the purpose/use/
administration of medications, interactions, and potential medication reactions
Homes Serving Adults
MMIC will require providers delivering HCTC services to adults to complete and credibly
document annual training as required by R9-20-1502. HCTC training will include:
Reading and implementing a person’s treatment plan; and
Recognizing and responding to a fire, disaster, hazard or medical emergency
Community Service Agencies (CSAs)
Community service agencies (CSAs) will submit documentation to MMIC as part of the initial
and annual CSA application indicating that all direct service staff and volunteers have completed
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
training specific to CSAs prior to providing services to behavioral health recipients. Additional
training will be required for behavioral health providers in specific roles such as:
Assessors conducting the behavioral health assessment and children age birth to five
assessment
Providers responsible for service plan development and implementation
Child and family team facilitators
Child and family team coaches and Supervisors of CFT facilitators
Providers delivering services through distinct programs (e.g., Assertive Community
Treatment teams);
Providers offering specialized therapeutic approaches (e.g., Dialectical Behavioral Therapy,
Multi-Systemic Therapy);
Providers offering expertise in specialized areas (e.g., developmental disabilities, trauma,
substance abuse, children age birth to five);
Providers involved in Level I facilities;
Behavioral health providers providing services to children and families involved with Child
Protective Services (CPS) will be required to attend “Unique Needs of Children Involved with
CPS” training offered on a regular basis. In addition, specific situations may necessitate the need
for additional training. For example, quality improvement initiatives may require focused
training efforts. New regulations that impact the public behavioral health system may also
require concerted training strategies (e.g., Balanced Budget Act (BBA), Medicaid Modernization
Act (MMA) and Deficit Reduction Act (DRA)).
Training Expectations for ADHS/DBHS Clinical and Recovery Practice
MMIC will require behavioral health providers to complete training on published, selected
ADHS/DBHS Practice Protocols with required elements before providing services. We will also
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
require providers to access and complete training expectations set forth by ADHS/DBHS on
required elements that are revised.
Continuing Training Requirements
In addition to training required within the first 90 days of hire, we will require our providers to
undergo ongoing training for the following content areas:
Ongoing provider training on procedures for encounter submissions. We will also provide
training to any provider with a data validation review rate greater than ten percent.
ADHS/DBHS Demographic Data Set, including required timeframes for data submission and
valid values
Ongoing education and training in culturally and linguistically appropriate service
Training Providers New to the Field of Health
As one of MMIC’s non-profit sponsors, training and education is a major component of the
mission of MIHS and by extension, MMIC. A major source of medical and allied health
education in the state, MIHS serves as a hub for all teaching institutions in Maricopa County as
well as all of Arizona providing teaching and educational experience for undergraduate as well
as graduate education programs.
Undergraduate Training Programs
From July 1, 2011 through June 30, 2012, 448 individual students completed 742 rotations
through MIHS clinical departments. Also, during the 2011-12 training year, 1636 individual
nursing and allied health students completed training at MIHS. A total of 20 foreign medical
graduates completed 20 observerships in the Department of Internal Medicine. Additionally, 56
individuals shadowed physician and nurses during the 2011-12 training year.
Graduate and Medical Residency Program
In 2011-12, MIHS employed 231 residents. In addition, integrated residency programs provided
an additional 96 residents who spent much of their training time as participants in MIHS
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
allopathic training programs. The OB/GYN residency program is integrated with St. Joseph’s
Hospital and the integrated Phoenix Children’s Hospital/Maricopa Medical Center Pediatrics
training program include residents from the Med/Peds program at Banner Good Samaritan.
Residents from the pharmacy and dental programs bring the total number of MIHS trained
residents to 330.
18.8.9 Develop and Maintain Systematic Processes
MMIC will collect and analyze data from case file reviews, complaint data, utilization data,
member and stakeholder input, and grievance and appeal data to identify providers who require
additional training or technical assistance. We will use this information to identify trends in
provider performance and areas that require additional training development. We will make
additional training and technical assistance available to providers where deficiencies are
identified. When provider trends or outliers are identified, such as a specific provider
continuously experiencing difficulty in a particular area, MMIC’s Quality Management
Department may initiate a corrective action to help a provider achieve competency.
18.8.10 Training to Child Serving State Agencies
MMIC will be committed to integrating Arizona’s Twelve Principles for Children Service
Delivery and the ADHS/DBHS Arizona Children’s Vision and Principles into programs and
services that maximize the involvement of youth and families, increase resilience and improve
outcomes.
MMIC will provide training to child serving state agencies, including but not limited to the
Arizona Department of Economic Security (ADES), Arizona Department of Juvenile Corrections
(ADJC), Arizona Department of Education (ADE) and local courts. MMIC will also coach state
agency personnel in working with children and family who have behavioral health needs.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
MMIC’s qualified trainers will meet with each agency individually to assess each agency’s level
of understanding and need. Meeting with each agency individually presents the opportunity to
build strong relationships, coordinate the roles and responsibilities of MMIC and the agency, and
to tailor training plans based on each agency’s unique educational needs. Our goal is to facilitate
consistent understanding and universal application of the Twelve Principles to all children and
families through the use of Child and Family Team (CFT) practice. MMIC will work with each
child serving state agency to train staff on the nine activities that support the implementation of
the 12 Arizona Principles, including:
1. Engagement of the Child and Family
2. Immediate Crisis Stabilization
3. Strengths, Needs and Culture Diversity
4. CFT Formation/Coordination of CFT Practice
5. Behavioral Health Service Plan – Development
6. Ongoing Crisis, Planning
7. Behavioral Health Service Plan – Implementation
8. Tracking and Adapting
9. Transition
In accordance with DBHS’ Practice Protocol on Child and Family Team Practice, behavioral
health agency staff will also be required to participate in DBHS designated Child and Adolescent
Service Intensity Instrument (CASII) training, education, and technical assistance.
To help facilitate training that is convenient and easily accessible, MMIC will also make e-
learning resources available to help train state agency staff. State agency staff will have the
ability to access our course catalog, complete online courses, and request technical assistance
when needed.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
18.8.11 Education and Training for Providers on Step Therapy
MMIC will educate and train providers on step therapy and related policies and procedures in
accordance with the AHCCCS Contractor Operations Manual Chapter 400 – Operations and the
ADHS/DBHS Provider Manual Sections 3.15 Psychotropic Medication: Prescribing and
Monitoring and 4.3 Coordination of Care with AHCCCS Health Plans, Primary Care Providers
and Medicare Providers. Behavioral Health Medical Practitioners must coordinate with primary
care providers or other health care providers to minimize the potential for adverse clinical
outcomes when prescribing psychotropic medications. Additionally, we will educate behavioral
health providers that they are required to continue members who have been stabilized and are
transitioning from the RBHA to a PCP for their behavioral health needs and medications. If
clinically appropriate, the behavioral health practitioner will be required to continue medication
prescribed at the point of transition.
18.8.12 Member Service Training on GSA 6 - Geography
Our Member Services Department (within Customer Service Operations) staff will receive
comprehensive orientation and ongoing training that provides a geographic overview of GSA 6
and teaches staff to use online technology, such as mapping search engines, and to assist
members in authorizing services, recommending providers and transporting members to the most
geographically appropriate location.
18.8.13 Evidence of Staff Orientation and All Trainings
MMIC will provide specific training modules; monitor and document scheduled attendance; and
audit providers to assess compliance with required training courses. As part of the training plan,
MMIC will record evidence of employee orientation and all trainings to personnel, service
providers and members. E-learning classes will be tracked and confirmed electronically; reports
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
can also be generated to verify attendance. Through the learning management system, training
activities will be tracked, including registration and completion of courses as well as
performance scores where applicable. For classroom-led training, we will use sign in sheets
record name, course duration, instructor name, date and subject of the course. For employees
who do not attend or complete training, we will notify Supervisors to take appropriate action.
18.8.14 Develop and Implement an Annual Training Plan
MMIC’s training programs, as described throughout Section 18, will serve as the basis for
developing and implementing an annual training plan. MMIC will submit an initial training
curricula and plan for approval as directed and will subsequently submit both items annually, 45
days after the close of the fiscal year.
18.8.15 Require Training Staff to Attend Quarterly Training Coordinators Meeting
MMIC will require all training staff to attend the ADHS/DBHS Quarterly Training Coordinators
Meeting.
MMIC will be committed to delivering an integrated, high-quality, consistent system of care that
fully embraces Arizona’s system values and principles. Through the experience of our sponsors,
Mercy Care Plan and Maricopa Integrated Health System, we will offer well-established training
and education programs to provide all staff, providers and stakeholders the information
necessary to fully understand the integrated delivery system and to attain the greatest benefits
from the system. By fostering collaborative relationships and encouraging active involvement,
we will incorporate input from members, family members, providers and community
stakeholders so that they have an active role in the development of training curricula and
delivery of training.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
18.21 Integrated Health Care Development Program Offeror Response:
Mercy Maricopa Integrated Care’s (MMIC) non-profit sponsors, Mercy Care Plan (MCP) and
Maricopa Integrated Health System (MIHS), have provided integrated services for more than 25
years. The experience of our sponsors have afforded us core competencies in managing
integrated health services for individuals with complex needs and excelling at integrating
physical health, behavioral health, and community-based programs for our members. Our model
is holistic and member-centric, with an emphasis on meeting the individual needs of our
members. We are focused on our members’ total health, including the interconnection between
social, cultural and environmental circumstances.
Mercy Maricopa Integrated Care (MMIC) will integrate all aspects of service delivery within our
organization including administrative, financial and clinical services. We will achieve integration
by offering: Care Coordinators to augment the existing behavioral health system; a technology
and data platform that supports the information necessary to integrate care; and through staff
expertise and resources that understand managed care delivery and the value of person-centered,
integrated care. Our model will transform the system in a way that promotes recovery, resiliency
and wellness by:
Providing recovery-oriented service delivery to members: We will do this by providing
our members with strategies and tools to achieve a progression through four phases of change
including:
Engagement: The member and primary Case Manager develop an effective working
relationship and begin the work to move the member to improved health outcomes.
Recovery: The member shows a sustained decrease in current avoidable utilization and
problematic symptoms, as well as sustained progression toward optimal quality of life
and reduction moderation of risk factors.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Resiliency: The member decreases his/her risk of future utilization by decreasing current
risk factors and enhancing current protective factors.
Autonomy: The member takes increasing responsibility for his/her own health and well-
being, including managing his/her own health conditions effectively.
Offering robust care integration: Our care management approach will weave together
physical, behavioral health, and psychosocial support needs in a holistic manner.
Taking a holistic person-centered focus: We will focus on each member’s life goals, not
their diagnosis, while incorporating their strengths, preferences, and needs in a culturally and
linguistically appropriate manner.
Maintaining and supporting the current behavioral health system and adding supports
that strengthen it: MMIC will strengthen the existing behavioral health system with a focus
on integration by supporting the SMI Case Manager with additional resources and, by
teaching providers to deliver integrated care.
Identifying and helping provide the right service, at the right time, in the right place, at
the right level of intensity: Through data analysis and risk stratification, we will provide
care management services at varying levels of intensity, based on member strengths,
preferences, and need.
Enhancing access and coverage to services: Informed by our Care Management program,
MMIC will collaborate with network partners to increase the strength of our network to
provide access and coverage based on geographic, temporal, and physical considerations.
Enhancing member outcomes: Our Integrated Care Management approach is designed to
improve member outcomes at an individual and at a population-based level.
Supporting integrated care for members through technology and data: Through use of
technology, we will fully integrate administrative, financial, and clinical functions to support
ongoing management, monitoring, and continuous quality improvement.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
18.21.1 Establish an Integrated Health Care Program
Our Integrated Health Care Program will be an innovative and proactive approach to care. It is
designed to deliver clinical services that address the full spectrum of whole health needs –
medical, behavioral and social. It is specifically designed to support the “carved-in” integration
of medical and behavioral health services for 13,474 persons with Serious Mental Illness (SMI)
who are both AHCCCS-eligible and enrolled with the Maricopa County Regional Behavioral
Health Authority (RBHA). However, it also addresses the “carved-out” service coordination
needs of 50,523 AHCCCS eligible adults and children, and the coordination and referral needs of
21,546 people who receive NTXIX behavioral health services via the RBHA provider network
via state subvention funds. As demonstrated in Table 1 below, our integrated approach will make
a significant difference for RBHA members, who will experience many benefits as a result of
both system and member-level integration.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 1: What Integrated Care WILL Look Like
System Level Member Level
X Integrated health plan functions – operations, medical management, utilization management, member services, provider services, financial
Physical and behavioral health care services provided in an integrated care setting with member choice as to the setting
X Aligned incentives Member and family-centered
X Performance measurement and shared accountability for member outcomes
Team-based care and provider engagement
X A single administrative entity that oversees both BH and PH services with shared accountability across all providers serving the members
Members are treated from a whole person perspective; ease of accessing the health plan
X Real time information exchange to support care coordination
Access to peer supports and community resources
X Risk stratification and triage to identify members with complex and co-morbid conditions who need additional support
Self-management and self-advocacy
X Dedicated commitment across providers to increase access to preventive care and reduce Emergency Department use and repeat hospitalizations
Leveraging technology for care coordination and health promotion
MMIC recognizes that a “one size fits all” approach to integrated care will not adequately and
appropriately serve the complex needs of our members with SMI. Consistent with our approach
to recovery, we believe that affording members’ choice in where and how they access health care
services is critical for engaging members in care and supporting them in their journey toward
wellness. Based on the experience of our non-profit sponsors, Mercy Care Plan (MCP) and
Maricopa Integrated Health System (MIHS), we also know that members who have an
established relationship and are comfortable with their provider are more likely to access
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
preventive services, resulting in better health and well-being. We will offer our members with
SMI a choice of care coordination through three integrated/co-located health home options.
These health home models not only provide member choice but also support integration across
various settings in the provider network, as described in Table 2 below.
Table 2: Service Delivery Models Service Delivery Model Description
Whole Health Clinics Whole Health Clinics (WHC) at SMI Clinics, offer co-located PCP services, aligned incentives for integrated health outcomes.
Patient Centered Medical Homes
PCMH clinics are often operated in FQHCs or FQHC lookalikes intended to serve members in the communities in which they reside.
Care coordination in the PCMH model will occur through a practice-based Care Coordinator who facilitates ongoing communication between all providers involved in the member’s care. Clinical and non-clinical data will be shared electronically with all providers involved in the member’s care through a health information exchange to further support care coordination.
Patient Centered Health Care Home
The PCHCH model will use a wellness approach to offer members with complex needs a robust array of physical health services, and wellness education to support them in self-management.
In addition to the integrated ad co-located health home models, described above, MMIC will
support members with existing relationships with Primary Care Physicians (PCPs) to continue
receiving their physical health services with that provider. The virtual health home will allow
members who have long-standing or close relationships with their PCPs to continue to receive
physical health care services in a traditional office setting with the additional support of care
coordination tools to facilitate integration of behavioral health services in care planning and
delivery. In the virtual health home model, care coordination will be provided by MMIC
centralized care coordination function, which offers the same high touch coordination seen in
other models from a centralized location. MMIC Care Coordinators will support multiple PCP
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
offices, facilitating communication between providers and supporting member health by offering
educational materials and resources.
In year one of the contract, our primary focus will be to work with each member’s clinical team
to engage the member in accessing both physical and behavioral health services. We will
establish performance goals to continuously increase the number of members with SMI
accessing physical health services. We will also work with members who have not visited a
physical health provider to establish a relationship with a co-located Whole Health Clinic
(WHC) or integrated Patient Centered Medical Home (PCMH) or Patient Centered Health Care
Home (PCHCH) health home. Members with SMI who have an existing relationship with a
physical health provider or health home will be supported in maintaining that relationship, even
if the provider is not a participant in MMIC’s network. Our Provider Services Department will
work diligently to develop contracts or single case agreements with non-participating providers
to facilitate continuity of care for each member.
Simultaneously, MMIC will work to transform the service delivery system to a fully integrated
model. Our ultimate goal is to provide fully integrated care options to all members through the
PCHCH model. We will begin the system transformation by identifying high volume PCPs that
may be interested in transforming their practice into a Patient-Centered Health Home. We will
leverage the experience of our non-profit sponsor, Mercy Care Plan (MCP), to offer providers
with the technical assistance they need to modify their practices and systems. Additionally, for
paper-based practices, we will provide technical assistance and incentives such as our Health
Information Exchange (HIE) platform free of charge to encourage providers to utilize electronic
health records (EHRs) and participate in electronic data-sharing.
MMIC will also work with our contracted Whole Health Clinics, co-located in the SMI clinics,
to assist them in moving toward a more integrated Patient Centered Medical Home, and
ultimately, Patient Centered Health Care Home model. We will provide technical assistance,
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
leadership and support to each provider to assist them in their transformation efforts. Throughout
the transformation process, we will incorporate a provider pay-for-performance (P4P) program
with the goal of improving member health status, promoting the creation of health homes for our
members, increasing care coordination for all members, and reducing unnecessary utilization and
health care costs.
Additionally, MMIC will incentivize health homes to achieve accreditation through the National
Council for Quality Assurance (NCQA) to further promote quality of care. We will base our
incentive program on the MCP model, which offers incentives for health homes that achieve
level II or level III accreditation through the National Council for Quality Assurance (NCQA) or
the Utilization Review Accreditation Commission (URAC).
The Integrated Care Director will work closely with the PCMH provider to assist the practice in
achieving NCQA accreditation. Once they are ready to submit their paperwork, MMIC will
provide them with the $2500 application fee. We will also provide similar support for PCHCHs
during the Utilization Review Accreditation Commission (URAC) accreditation process.
MMIC’s timeline for system transformation, associated activities and performance targets are
outlined in Table 3 on the following page.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 3: MMIC’s Timeline for System Transformation, Associated Activities and Performance Targets
Timeframe Activity
Contract Award – 3 Months Post-Contract Award
Identify all PCPs of currently enrolled persons with SMI (determine %s with PCP, PCMH, PCHCH
Identify SMI members with no PCP contact in previous 12 months
Establish integrated performance measures for BH and Primary Care Providers
Develop capitated contracts for PCPs
Develop block funding contracts for BH providers
Begin contracting with providers
3 Months Post-Contract Award –
30 Days Before Contract Start
Identify high volume PCPs for potential evolution to PCMH
Identify PCMHs for potential evolution to PCHCHs and initiate discussion
Initiate discussions with high volume PCPs appropriate for evolution to PCMH model
Complete contracts with WHCs, PCMHs, PCHCHs
Establish outreach strategies for members without PCP engagement
30 Days Before Contract Start – Contract Start
Establish PCP Panel for New Members and Member Requesting PCP changes to include WHCs/PCMHs/ PCHCHs
Contract Start – 6 Months Post Contract Start
Decrease % of members who have not received PCP services by 25%
Increase # of PCHCHs/Support WHC Evolution
Collaborative discussions of aligned incentives for future state evolution
6 -9 Months Post Contract Start
Decrease % of members who have not received PCP services by 50 %
Finalization of aligned incentives with BH and PCP providers for future state evolution
9-12 Months Post Contract Start Decrease % of members who have not received PCP services
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Timeframe Activity
by 75%
Year 2 contracting language for aligned incentives and capitation developed for WHCs and PCHCHs
New contracts ratified with WHCs and PCHCHs
12-18 Months Post Contract Start
Analysis of CY1 Integrated Performance Results
Capitated payments for WHCs and PCHCHs implemented
Continue to evolve high volume PCPs to PCMH’s and PCHCHs
Implementation of quarterly performance measures and shared aligned measures
Initiation of performance-based monitoring
Decrease % of members who have not received PCP services to no more than 5% of TXIX SMI
Majority of High Volume PCPs now PCMHs or PCHCHs
As part of our system transformation efforts, MMIC proposes to change the way services are
delivered with unprecedented care coordination between members, service providers, benefit
managers, and ADHS/DBHS. Through a unique and innovative partnership between members,
family members, physical and behavioral health providers, we will manage the resources and
provide coordinated services in an integrated system of care. Based on the experience of our
non-profit sponsors, Mercy Care Plan (MCP) and Maricopa
Integrated Health System (MIHS), we know that our care
coordination model achieves improved health outcomes and
cost savings in care delivery, utilization of services, and
maximization of existing health information technology.
The infrastructure of our Care Coordination program will be designed to integrate information
from the member’s entire multi-disciplinary care team. Our structure will not embed additional
layers into an already complex system. Instead, it will use people, processes and technology to
The PCMH model has resulted in a 7% reduction in ED visits, a 20% reduction in inpatient admissions and a 36% reduction in pharmacy costs.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
link the member to the right services, at the right time and the right place. Data, such as
periodicity information concerning preventive care, health risk assessments, the comprehensive
assessment and individual service plans, will be exchanged in near real time through our
innovative health information exchange platform to promote the state’s total population health
and health promotion goals.
In year one of the contract, we will fund Care Coordinators at the provider level for SMI clinics,
PCHCHs and PCMHs, as well as provide a centralized care coordination function at MMIC to
coordinate care for members served by PCPs or specialty providers. During the first year, we
will evaluate PCP panel sizes and volumes and work to transform the system by increasing the
number of fully integrated sites available to members. At the completion of our first year of
operation, it is our goal to transition as many MMIC employed Care Coordinators as possible to
provider sites to promote a model of care coordination that occurs as close to the member as
possible.
Care Coordinators will work with all participants involved in the treatment team to facilitate
integrated care at the member and practice level. This position is intended to augment the role of
the Case Manager and serve as a change agent to transform the service delivery system to a fully
integrated model.
Care Coordinators will work collaboratively with the member’s treatment team to provide the
necessary supports to fully integrate care. Initially, Care Coordinators will fully support the
activities of the clinical team and provide additional resources to support integration. Members
of the clinical team will provide care coordination by directly interfacing with the member on an
ongoing basis, engaging the member in access both physical and behavioral health services, and
facilitating communication as described below. In years two and three of the contract, we intend
to transform care coordination from being a specific position and move to embed these activities
into the functions of the clinical team.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
18.21.2 Support the Integrated Health Care Program to Provide Leadership in
Collaborating with Providers and System Stakeholders
MMIC’s non-profit sponsors, Mercy Care Plan (MCP) and Maricopa Integrated Health System
(MIHS), are Arizona leaders in the movement toward integrated health care service delivery.
MCP’s network providers include many models based on the patient-centered medical home.
Additionally, our sponsors have pioneered many case management and care management models
that have integrated services through active coordination. The Maricopa Integrated Health
System (MIHS) has led the state in its collaborative development of SMI and integrated family
clinic services. As the Regional Behavioral Health Authority (RBHA), MMIC will continue to
develop these services, resulting in efficiencies and effective improvements for the adult system
of care.
MMIC will build upon the relationships developed by MCP and MIHS to develop collaborative
relationships with providers and stakeholders when implementing our integrated health model.
We will actively seek out opportunities to work with other health plans, physical and behavioral
health providers, members and community stakeholders (e.g., advocates, provider associations,
government entities) to develop collaborative agreements for data sharing, program
development, and system enhancements that support integrated care.
Our SMI Services Administrator will be responsible for collaborating with providers and system
stakeholders to evaluate the behavioral health and physical health needs of persons with SMI and
determine service expansion and/or program development needs. Additionally, we will maintain
an Integrated Care Committee made up of both medical and behavioral health providers and
system stakeholders. This committee will provide input and advisement on our system
transformation efforts as well as identify and address barriers to fully integrated care. MMIC
will utilize this information to take action, including working with ADHS/DBHS and AHCCCS
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
to resolve system barriers (e.g., licensure or funding issues) in addition to actively working with
system partners to promote a fully integrated system of care for members with SMI.
Behavioral Health Training – CMEs for PCPs
MMIC’s non-profit sponsor, Mercy Care Plan (MCP), identified that a large number of PCPs
lacked the training and knowledge necessary to comfortably manage the medical care of persons
with SMI. In response, MCP developed the Integrated Care Training Academy to provide
training and education to PCPs, offering Continuing Medical Education (CME) credits.
As an example, in June of 2012, 54 practitioners received training from MCP’s Medical
Director, Dr. Shelly Doumani-Semino, who is a board-certified psychiatrist. She presented on
the treatment and management of mood disorders in primary care. The program included a
discussion on “When and How to Refer for Behavioral Health Services.” The training was well-
received with 90% of the attendees citing that the learning activity met the educational objective.
The Post Training Summary Report indicates the following:
78% of the attendees felt that as a result of their training they would make changes in their
practices. They also provided a list of what that one change would be. Responses included:
“Following up more closely with BH patients.”
“Increased coordination with health plan Case Manager”
“The referral process. More contact.”
“More comfortable managing patient with d/o and with more comfort with additional
meds.”
56% of the attendees said that their major reason for attending was their interest in the topic
or an interest in the “Integrated Care” factor.
90% of the attendees requested office-based training on insomnia, pain management,
behavior modification, anti-psychotic drug reaction and Attention Deficit Hyperactivity
Disorder (ADHD).
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
The degree of interest in future behavioral health trainings indicates the likelihood that ongoing
scheduled trainings serve as a strong means to improve PCP comfort level with managing
persons with SMI and retaining these providers in the network. Therefore, MMIC will offer
quarterly trainings to PCPs for CEUs in contract year one, and semi-annually thereafter. The
trainings will be determined through PCP feedback.
Approximately, 83% of training attendees indicate that they prefer site-based events to those
offered in their offices or over the web. However, in order to meet the needs of all PCPs, MMIC
will offer both. Our web-based training will be available via our website’s secure provider
portal, CEUs and will be offered by e-Learning, our vendor for web-enabled provider training.
Graduate Medical Education - Planned Enhancement to Workforce Development
Our sponsor, MCP, has worked with St. Joseph’s Medical Center’s Residency program to fill
network gaps when identified. MMIC plans to work even more closely with partners such as
Creighton University, Midwestern University, MIHS, SJMC, Arizona School of Dentistry, and
Phoenix Children’s Hospital to provide regular network development reporting to identify
specialty and geographic needs throughout MCP’s contracted Geographic Service Areas in order
to encourage development of physician capacity through GME programs. Additionally, MCP
will offer financial incentives to programs and individuals that assist in filling network gaps
through placement efforts, similar to Teach for America loan forgiveness.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
18.21.3 Develop an Integrated Health Care Report that
18.21.3.1 Describes Contractor’s Challenges, Lessons Learned, Priorities, Past Experience 18.21.3.2 Describes Contractor’s Short and Long Term Strategies 18.21.3.3 Describes Contractor’s Programs to Educate About Integrated Health Care Programs 18.21.3.4 Describes Input from Members, Providers, and System Stakeholders About Their Experiences 18.21.3.5 Approved by Contractor’s Governing Body
18.21.4 Submit the Initial Integrated Health Report to ADHS/DBHS Two Months After
Contract Performance Start Date
During implementation, our Integrated Health Administrator, Kate Rhodes, will be responsible to
develop an Integrated Health Report that complies with the requirements outlined in 18.21.3.1-
18.21.3.4. The report will be submitted to MMIC’s Governance Board for approval.
Subsequently, the report will be completed and provided to the ADHS/DBHS two months after
Contract Performance State Date and annually thereafter. Figure 1 on the following page is a
sample of the first page our Integrated Health Report.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 1: Integrated Health Report Sample (page 1)
MMIC will bring the power and passion of a mission-focused and values-driven nonprofit
organization to integrated public health care in Maricopa County. Indeed, for the past 25 years,
families and individuals have trusted our sponsors, MCP and MIHS, to deliver care for
individuals with complex needs. We will leverage this experience and expertise to develop an
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
integrated care model that brings physical health and behavioral health providers together in a
shared mission to provide members with the services they need to achieve their recovery goals.
18.22 Governance Board Offeror Response:
Mercy Maricopa Integrated Care (MMIC) appreciates the importance that collaboration with a
variety of stakeholders brings to organizational governance. Persons served by the RBHA, their
families, behavioral, physical and integrated health providers, and system stakeholders all offer
valuable perspectives that can support our approach to person-centered care. Ultimately,
facilitating and continually improving the member experience will require a commitment to open
communication and decision-making focused on a true understanding of the needs of people
receiving RBHA services and their desired health outcomes. We believe that the degree of
collaboration required to attain the level of system transformation desired by ADHS/DBHS can
only be achieved by including members of all these key groups throughout our Governance
Structure.
We recognize that the effectiveness of the health care delivery system depends on its innovative
methods, dedication to collaboration and effective leadership. To that end, MMIC will design a
Governance Structure that demonstrates our process transparency, focus on shared decision-
making and our passion to achieve the best outcomes possible for the people we serve. We will
use data to drive innovative organizational decisions while we maintain the checks and balances
necessary for RBHA oversight. Our Governance Structure’s processes and actions will foster
collaboration with members, families, providers and system stakeholders, as well as coordination
with ADHS/DBHS.
Our governance model will contribute to the transformation of a bifurcated system of care into a
fully integrated model in multiple ways, including the following:
Advising and monitoring the status of implementation activities and milestones
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Acting on information and advice from stakeholder committee members representing all
populations served programs offered by the RBHA
Overseeing establishment of best practices to promote integration and quality services across
systems of care
Reviewing the implementation of Pay for Performance measures, per member/ per month
(PM/PM) premiums and aligned incentive programs for high-functioning provider groups
Monitoring measures of performance, and member and provider satisfaction
18.22.1 Governance Board Structure
Mercy Maricopa Integrated Care (MMIC)’s Governance Structure includes both a Board of
Directors (the Board) and a Governance Committee, each with peers and family members
representing at least 25 percent of voting membership. We strongly believe the voice of peers
and families must be heard throughout all levels of our Governance Structure. Therefore, peers
and families will also participate in committees reporting to the Governance Committee.
Our recruitment of peers and family members for participation on the Board and other
committees will comprise an open process designed to promote transparency, accountability,
regional participation and collaboration. During implementation, we will invite people receiving
services through the RBHA and their families to submit a letter of interest (LOI) to be members
of the Board. Our Individual and Family Affairs Administrator will make recommendations to
the Governance Committee based on those LOIs that demonstrate the strongest philosophical
alignment with the MMIC mission statement. Membership tenure of these committees will be
limited to two years, to increase exposure to the Board by more peers and their families.
Our Governance Structure is illustrated by Figure 1 on the following page.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Figure 1: MMIC Governance Committee Structure
In the paragraphs that follow, we detail the Governance Structure and the responsibilities of each
of its committees.
MMIC Board of Directors
(Meets 6 times per year, more frequently during implementation)
As a non-profit entity, our Board of Directors will be the governing body with ultimate oversight
of MMIC. The Board is responsible for establishing policies and objectives in alignment with
ADHS/DBHS transformational objectives, as well as the vision of MMIC in alignment with the
Adult and Child System of Care principles espoused by ADHS/DBHS. The Board will assess
the availability of adequate financial resources and oversee performance for the GSA 6 Regional
Behavioral Health Authority (RBHA). Twenty-five percent of its membership will consist of
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
peers and family members who are, or have, been active participants in the Maricopa County
Behavioral Health System.
MMIC’s Board will also include members from its sponsoring organizations, Mercy Care Plan
(MCP) and Maricopa Integrated Health System (MIHS). MCP is sponsored by Dignity Health
(d.b.a. St Joseph’s Hospital and Medical Center), and Carondelet Health Network, a ministry of
Ascension Health. These organizations will also be represented on MMIC’s Board.
Immediately after award, during contract implementation, MMIC will establish its Board of
Director’s bylaws, structure and leadership, as well as its reporting committees.
Committees reporting to the MMIC Board of Directors
Two committees will report directly to MMIC’s Board of Directors – the Governance and
Executive Committees. They will be designed to support the Board’s strategic direction to
oversee the transformation of RBHA. These committees will be heavily invested during
implementation and transition, meeting as often as necessary to make policy, programmatic and
operational changes in collaboration with ADHS/DBHS and AHCCCS. The Board will
empower them to expediently act upon implementation concerns addressed by members, families
and system stakeholders. These committees are described in Table 1 on the following page.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 1: Committees Reporting to the MMIC Board of Directors Name Frequency Description/Activities Attendees
Governance Committee
Six times per year, more frequently during implementation, until successful transition
Carry out strategic direction of the Board
Central decision-making mechanism for the contract, and the avenue through which concerns about the program are systematically addressed,
Review of contract performance
Receives feedback from all other committees to evaluate contract performance
Review and determination of community reinvestment opportunities.
Twenty-five percent (25%) of the membership will be equal representation between peers and family members who are currently in the system or have been active participants
Behavioral and physical health care community providers
System and community stakeholders
Representatives from sponsoring organizations and MMIC management
Executive Committee
Six times per year, more frequently during implementation, until successful transition
Decisions regarding stewardship of the RBHA’s funding
Oversight of the RBHA’s adherence to ADHS/DBHS Financial Reporting Guide
Review of financial, auditing and compliance reports and activities
Oversight of management services administrator
Chair of the MMIC Board of Directors
Co-Chair of the MMIC Board of Directors,
Chief Financial Officer (CFO) of Carondelet, St. Joseph’s, and MIHS
Chief Executive Officer of MMIC
MMIC CFO, CMO and COO
Representatives from sponsoring organizations and MMIC management
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Subcommittees of MMIC Governance Committee
Five committees will report to the Governance Committee. They include Integrated Care and
Quality Management, Advocacy, CLAS, Youth Leadership and Implementation.
Each will have targeted responsibilities that are aligned to provide the Governance Committee an
overall picture of the RBHA’s effectiveness in meeting its mission and ADHS/DBHS directives.
These committees will provide feedback and recommendations on the status and needs at both
the system and population level. All populations served by the RBHA will be represented in
these committees, as illustrated in Table 2 below and on the following pages.
Table 2: Subcommittees of MMIC Governance Committee Name Frequency Description/Activities Attendees
Integrated Clinical Care and Quality Management Committee
Six times per year, more frequently during implementation, until successful transition
Integrate clinical care and quality activities throughout the organization, among its departments, contractors, and stakeholders
Oversee clinical and quality activities
Make recommendations to the Governance Committee
Peers and family members
Community-based behavioral and physical health provider agencies
Representatives from the Board of Directors of MMIC
MMIC management team as invited and select subcommittee members
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Name Frequency Description/Activities Attendees
Member Advocacy Committee (Referred to as Advocacy Committee)
Once per month Advise, assist, and give guidance to MMIC related to clinical programs, and the service delivery system
Provide input and feedback on behavioral health programs
Determine effectiveness of adult and child system of care in improving the whole health of those served by the system
Collaborate with ADHS/DBHS and system stakeholders for changes and improvements when necessary
Peers and family members
Community and behavioral health advocates
Communications / Public Relations Administrator
Director of Stakeholder Collaboration
Chaired by the Individual and Family Affairs Administrator
Make recommendations to the Governance Committee
Youth Leadership Council
Once per month Provide a forum for youth to provide leadership and input into the behavioral health system
Review program development and enhancements needed to promote recovery and resiliency in children, youth, and families
Determine mechanisms and supports necessary to penetrate services into at-risk youth populations
Make recommendations to the MMIC Governance Committee
Youth currently receiving services through the RBHA who are between the ages of 14-26
Chaired by the Transitional Youth Coordinator.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Name Frequency Description/Activities Attendees
Culturally and Linguistically Appropriate Services (CLAS) Committee
Once per month Oversee the network’s adherence to CLAS standards
Establish initiatives to reduce health disparities
Determine outreach strategies needed to increase service penetration into at-risk populations
Makes recommendations to the MMIC Governance Committee
Peers and family members
Community advocates representatives
Representatives include specialty providers serving high percentages of at-risk, underserved populations
Cultural Sensitivity Administrator
Chaired by the CEO through CY1 and Co-Chaired
by the Cultural Sensitivity Administrator in subsequent years
Implementation Committee
Weekly during Implementation through successful transition then sunsets
Review implementation plan and its tracking of milestones
Provide pulse of community regarding implementation activities
Identify revisions necessary to achieve vision of MMIC
Make recommendations to the MMIC Governance Committee
Peers and family members
Peer- and family-run Provider Organizations
Adult, Child and Crisis Behavioral Health Providers
Integrated Health providers
MMIC Executives Chaired by the Chief
Operating Officer
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Subcommittees of the Integrated Clinical Care and Quality Management Committee
The subcommittees of the Integrated Clinical Care and Quality Management Committees will
provide essential feed-back and recommendations on the RBHA’s quality, medical and
utilization management operations and outcomes. These subcommittees are described in Table 3
on the following pages. The committee will use that information for recommendations of
emerging innovations, resources and tools necessary to support evolution of system
transformation and outcomes.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 3: Subcommittees of the Integrated Clinical Care and Quality Management Committee
Name Frequency Description/Activities Attendees
Quality Management Committee
Meets once per month
Evaluation of quality improvement activities, and performance measurement data
Establish recommendations for improvement of member care and services.
Review and approve studies, standards, clinical guidelines, and trends identified in measured outcomes and results of provider medical record reviews and satisfaction surveys
Make recommendations to the Integrated Clinical Care and Quality Management Committee
Peers and family members
Representatives from Integrated Health, Behavioral Health, community providers and peer- and family-run organizations
Deputy Medical Officer, Medical Management
Administrator Quality Management
Administrator Integrated Health Care
Development Administrator, Management,
Chief Clinical Officer Select subcommittee
members and support staff.
Chaired by the CMO
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Name Frequency Description/Activities Attendees
Continuous Innovation Committee
Six times per year, more frequently during implementation, until successful transition
Identify cutting edge solutions and best practices to improve programs, processes, and systems
Research and evaluate emerging innovations, resources, and tools that provide value to member care and services
Make recommendations to the Integrated Clinical Care and Quality Management Committee
Peers and family members
Representatives from Integrated Health, Behavioral Health, community providers and Peer- and family-run organizations
CMO Deputy Medical Officer Medical Management
Administrator Chief Clinical Officer Adult Services
Administrator Children’s Services
Administrator Children’s Service
Medical Administrator Select subcommittee
members
Medical Management/
Utilization Management Committee
Six times per year, more frequently during implementation, until successful transition
Evaluate new technologies Utilization management
decisions Clinical review criteria for
approval, adoption, and implementation
Review and make recommendations for performance improvement activities related to trends in complaints, grievances and appeals, quality of care concerns as well as a result of provider medical record reviews and satisfaction surveys
Make recommendations to the Integrated Clinical Care and Quality Management Committee
Peers and family members
Representatives from Integrated Health, Behavioral Health, community providers and peer- and family-run organizations
Deputy Medical Officer Medical Management Administrator
Quality Management Administrator
Integrated Health Care Development Administrator
Chief Clinical Officer Chaired by the CMO
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Subcommittees of the Quality Management Committee
The subcommittees of the Quality Management Committee – described in Table 4 on the
following pages – will provide essential feedback and recommendations on all Quality activities
of the RBHA. They will provide relevant information needed to develop a global view of the
status of RBHA’s Quality functions, improvement activities and outcomes. These committees
will provide the CEO, CMO, and Quality Management Administrator with data necessary to
determine strategies and enhancements needed to promote system evolution and the whole health
of persons served by the RBHA.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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MAG-331-000164
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 4: Subcommittees of the Quality Management Committee Name Frequency Description/Activities Attendees
Quality Improvement Committee (QIC)
Meets bi-weekly
Advises the Chief Medical Officer and Chief Operating Officer on quality improvement strategies
Oversees compliance with AHCCCS, ADHS/DBHS and Medicare quality improvement strategies
Responsible for oversight of Performance Improvement Projects, AHCCCS, ADHS/DBHS performance measures, HEDIS, member and provider satisfaction surveys, health literacy, cultural competency, member grievances, and service performance measures
Members and family members
Representatives from Integrated Health, Behavioral Health, community providers and peer- and family- run organizations
Chief Clinical Officer Deputy Medical Officer Medical Management
Administrator Quality Management
Administrator Integrated Health
Network Administrator Medicare Administrator Adult Services
Administrator Children’s Services
Administrator Children’s Medical
Administrator Customer Service
Administrator, Select subcommittee
members Chaired by the CMO
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Name Frequency Description/Activities Attendees
Delegation Oversight Committee
Meets quarterly, and as needed during implementation’
Advise and make recommendations about issues related to delegated entities
Evaluate reports stemming from sub-contractor audits
Review all subcontractors’ performance for adherence to their contracts
Members and family members
Representatives from Integrated Health, Behavioral Health, community providers and peer- and family- run organizations
Chief Operating Officer Vice President of
Operations Network Development
Administrator Chief Compliance
Officer Contract Compliance
Administrator Additional Subject
Matter Experts
Credentialing/Re-credentialing Committee
Meets monthly Evaluate credentialing and re-credentialing information to recommend selection, approval, or denial of healthcare providers for participation in the network
Review policies related to credentialing/
re-credentialing and analyzes health facility site reviews and medical record reviews
Representatives from Integrated Health, Behavioral Health, community providers
Quality Management Administrator
Network Development Administrator
Credentialing Manager Medical Management
Administrator Chaired by CMO
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Name Frequency Description/Activities Attendees
Adult QM Committee
Meets six times per year, more frequently as needed in implementation
Evaluate quality improvement activities
Examine performance measurement data to provide recommendations related to the services provided to adults with a serious mental illness and adults with a general mental health/substance abuse issue.
Review the results of provider medical record reviews,
Evaluate fidelity audits (ACT, supported employment, consumer operated services, and peer support) and satisfaction surveys
Members and family members
Representatives from Integrated Health, Behavioral Health, community providers and peer- and family-run organizations
System stakeholder organizations
Network Development Administrator
Credentialing Manager Adult Services
Administrator SMI Services
Administrator General Mental
Health/Substance Abuse Administrator
Prevention Administrator
Crisis Administrator Medical Management
Administrator Quality Management
Administrator Individual and Family
Affairs Administrator Children’s Services
Administrator Deputy Medical Officer Chaired by the CMO
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Name Frequency Description/Activities Attendees
Children’s QM Committee
Meets six times per year, and more frequently as needed during implementation
Evaluate quality improvement activities
Examine performance measurement data to provide recommendations related to the services provided to children including those with CMDP and SED
Review the results of Child and Family Team audits, provider medical record reviews, fidelity and satisfaction surveys
Family members Representatives from
children’s providers, peer- and family-run organizations
System stakeholder representatives
Network Development Administrator – Children’s Supervisor
Credentialing Manager Children’s Services
Administrator Children’s Medical
Administrator Crisis Administrator Medical Management
Administrator Quality Management
Administrator Adult Services
Administrator Individual and Family
Affairs Administrator Chaired by the CMO
Peer Review
Meets quarterly Make recommendations to the Chief Medical Officer related to actions to be taken in response to quality of care reviews and investigations related to specific providers
Present findings to the Credentialing /Re-credentialing Committee for consideration/actions
Representatives from Integrated Health, Behavioral Health, community providers
Medical Management Administrator
Quality Management Administrator
Deputy Medical Officer Integrated Health
Development Officer Subcommittee
members and support staff
Chaired by the CMO
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Subcommittees of the Medical Management Committee
The subcommittees of the Medical Management Committee – described in Table 5 on the
following pages – will provide essential feedback and recommendations on all Medical
Management activities of the RBHA. They will provide the relevant information needed to
develop a global view of the status of RBHA’s medical management trending of behavioral and
physical health services across all populations. Along with the committees reporting to the
Quality Management Committees, these subcommittees of Medical Management will provide
the CEO, CMO, and Quality Management Administrator with the data necessary to determine
strategies and enhancements needed to promote evolution of the system and the whole health of
persons served by the RBHA.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Table 5: Subcommittees of the Medical Management Committee Name Frequency Description/Activities Attendees
Utilization Management Intra-Department Committee
Meets monthly Identify and establish utilization targets and goals
Review trends in complaints, grievances and appeals, potential quality of care issues
Evaluate trends in utilization and develop initiatives to make improvements to internal processes
Peer and family members
Representatives from Adult and Children’s, Integrated Health providers, and peer- and family- run organizations
Medical Management Administrator
Deputy Medical Officer UM Administrator Adult Services
Administrator SMI Services
Administrator Chief Clinical Officer Prior Authorization
Manager Crisis Administrator Grievance System
Administrator General Mental Health
and Substance Abuse Administrator
Children’s Medical Administrator
Children’s Services Administrator
Integrated Health Care Administrator
Network Development Administrator
Chaired by CMO
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 170
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Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Name Frequency Description/Activities Attendees
Pharmacy and Therapeutics (P&T)
Meets four times a year
Advise and make recommendations regarding MMIC’s pharmacy program
Developing/update the MMIC Preferred Drug List
Review drug utilization data
Evaluate member and provider educational programs
Evaluate new technology related to pharmacy and reviews information related to contracted pharmacy services
Peer and family members
Representatives from Adult and Children’s, Integrated Health providers, and peer- and family-run organizations
Representatives from PBM
CMO Deputy Medical Officer Chief Clinical Officer Children’s Medical
Administrator MMIC internal staff Chaired by Pharmacy
Administrator
Member Advisory Committee (MAC)
Meets monthly Provide recommendations to the Medical Management/Utilization Management and Quality Management Committees on a variety of activities, communications, program interventions, and service
Review outreach plans, cultural competency plans, and education materials to assess content and readability
Provide advice on performance improvement and quality improvement projects
Responsible for oversight and review of prevention programs and satisfaction survey tools
Members and family members
Member Advocates Communications/ Public Relations
Administrator Customer Services
Administrator Representatives from
functional departments Chaired by Individual
and Family Services Administrator
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 171
MAG-331-000171
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Subcommittees of the Continuous Innovation Committee
These committees and their membership – described in Table 6 below and on the following
pages – will support MMIC’s collaboration with adult and child behavioral health and crisis
providers. It will also promote our evolutionary care coordination program by including
integrated health, physical health and Serious Mental Illness clinic providers. The Continuous
Innovation Committee will use information obtained during work group meetings to identify
cutting-edge solutions and best practices to improve programs, processes and systems; research
and evaluate emerging innovations, resources and tools that provide value to member care and
services; and make recommendations to the Integrated Clinical Care and Quality Management
Committee.
Table 6: Subcommittees of the Continuous Innovation Committee Name Frequency Description/Activities Attendees
Adult Provider Workgroup
Meets six times per year, more frequently as needed in implementation
Bring providers together to share ideas and success stories related to innovative clinical practices
Provide training and education about new initiatives.
Opportunity for providers to network, communicate, facilitate real-time discussions, and bring up issues or concerns
Monitor clinical outcomes and make recommendations for changes in pay for performance initiatives and aligned incentives
Peers and family members
Representatives from Integrated Health, Behavioral Health, Crisis, community providers, and peer- and family-run organizations
Deputy Medical Officer SMI Services
Administrator Chief Clinical Officer General Mental Health
and Substance Abuse Administrator
Crisis Administrator Chaired by Adult
Services Administrator
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 172
MAG-331-000172
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Name Frequency Description/Activities Attendees
Children’s Provider Workgroup
Meets 6 times a year
Bring providers together to share ideas and success stories related to innovative clinical practices
Provide training and education about new initiatives
Opportunity for providers to network, communicate, facilitate real-time discussions, and bring up issues or concerns
Monitor clinical outcomes and make recommendations for changes in pay for performance initiatives and aligned incentives
Peers/youth and family members
Representatives from children’s providers, peer- and family-run organizations
Chief Clinical Officer Children’s Medical Crisis Administrator Chaired by Children’s
Services Administrator
Provider Integration Group
Meets 6 times a year
Review member-specific cases to identify and resolve systemic issues related to integration of care
Make recommendations to overcome cultural barriers and promote consistency in practices across all providers
Monitor clinical outcomes and make recommendations for changes in Pay for Performance initiatives and aligned incentives
Peers and family members
Representatives from Adult and Children’s providers, Integrated Health, Crisis Providers, and peer-and family-run organizations
Deputy Medical Officer Chief Clinical Officer Adult Services
Administrator Tribal Liaison Cultural Sensitivity
Administrator SMI Services
Administrator Chaired by the
Integrated Health Development Officer
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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MAG-331-000173
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
Subcommittees of the Executive Committee
These subcommittees will provide the necessary information for the Executive Committee to use
to oversee MMIC’s audit and compliance functions in support of legal and regulatory
requirements, as well as quality of care and ethical business practices. They will also review the
financial detail used for budgeting purposes and stewardship of the RBHA.
Table 7: Subcommittees of the Executive Committee Name Frequency Description/Activities Attendees
Audit & Compliance Committee
Meets six times per year and as needed during implementation
Overseeing MMIC’s audit and compliance functions in support of legal and regulatory requirements, as well as quality of care and ethical business practices
Review, monitor and promote compliance with the organization’s policies, procedures and practices
Executive Committee Members
CEO COO Corporate Compliance
Administrator CMO CFO
Finance Committee
Meets monthly Continuously review and make recommendations for improvement, where needed, concerning the organization’s fiscal affairs
Provide recommendations to the Executive Committee on the annual budget and business plan
Executive Committee Members
CEO COO CMO Corporate Compliance
Administrator CFO
18.22.2 No Contractor Staff as Peer or Family Representatives on Governance Board
Mercy Maricopa Integrated Care (MMIC) will not have employees serve as peer and family
member representatives on its Board of Directors (the Board) or Governance Committee. They
will include members from Mercy Care Plan (MCP) sponsors, Carondelet Health Network, St.
Joseph’s Health System, and Maricopa Integrated Health System (MIHS). The Board and
Governance Committee will include an equal number of peers and family members who are
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
Attachment 6, Method of Approach, Volume 7 174
MAG-331-000174
Attachment 6 Method of Approach
ARIZONA DEPARTMENT OF HEALTH SERVICES
SOLICITATION NO: ADHS13-00002257
1740 West Adams Street Phoenix, Arizona 85007
(602) 542-1040 (602) 542-1741 Fax
Mercy Maricopa Integrated Care (MMIC) is sponsored by Mercy Care Plan and Maricopa Integrated Health System. Mercy Care Plan is sponsored by Dignity Health, d.b.a. St Joseph’s Hospital and Medical Center, and Carondelet Health Network, a ministry of Ascension Health. Maricopa Integrated Health System is the Special Health Care District in Maricopa County. Mercy Maricopa Integrated Care will subcontract the management of all administrative services to Schaller Anderson, LLC, an Aetna company. Throughout our proposal, we draw upon Schaller Anderson’s experience with like populations.
active or past participants in the Maricopa Behavioral Health System, and will comprise no less
than 25 percent of the governing membership.
Mercy Maricopa Integrated Care’s (MMIC) Governance Structure will be based on, and
facilitate, meaningful collaboration with persons served by the RBHA, their family members,
behavioral and physical health providers, and system stakeholders. We believe that the evolution
from the current bifurcated system of behavioral and physical health services to an integrated
model, as desired by ADHS/DBHS, can only be achieved by the inclusion of these groups
throughout our Governance Structure. Our Board of Directors, committees and structural
reporting lines will enable thorough oversight of RBHA activities and the alignment of
organizational goals necessary to drive dramatic, sustainable improvements in health care
outcomes. The composition of our Board will rely on strong leadership with strong community
ties, and will incorporate the perspectives of various stakeholders to afford true transparency.
18.23 Offshore Performance of Work Prohibition When responding, include Offeror’s intent to comply. Offeror Response:
Mercy Maricopa Integrated Care (MMIC) will comply with the Scope of Work 18.23.1
requirement to perform all contract services within the defined territories of the United States.
This will include work related to indirect or “overhead” services, redundant/back-up services or
services that are incidental to the performance of the contract.
Offeror: Mercy Maricopa Integrated Care ADHS13-00002257
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