COMPARISON OF MANAGED CARE E DATA TO ACCOUNTING … · Comparison of Managed Care Encounter Data to Accounting System Data for UHC 4 This report consists of UHC’s encounters and

vJanuary 1, 2014

APPENDIX D-1: INITIAL ENCOUNTER RECONCILIATION REPORT-APRIL 7, 2017

JANUARY 1, 2014 THROUGH APRIL 30, 2016

COMPARISON OF MANAGED CARE ENCOUNTER DATA TO ACCOUNTING SYSTEM DATA FOR UNITED HEALTHCARE OF NEW MEXICO, INC.

APRIL 7, 2017

2

EXECUTIVE SUMMARY ................................................................................................. 3

DEFINITIONS AND ACRONYMS ................................................................................... 5

STUDY PURPOSE .......................................................................................................... 7

DATA SOURCES ............................................................................................................ 8

ANALYSIS ...................................................................................................................... 9

POTENTIAL DATA ISSUES AND ANALYSIS ASSUMPTIONS ................................... 10

UHC – ENTIRE PLAN ................................................................................................... 12

CALCULATED VOID AND DUPLICATE SUMMARY ................................................... 14

SUMMARY REPORTING CHARTS .............................................................................. 15

UHC – DENTAL SERVICES ......................................................................................... 16

UHC – PHARMACY BENEFITS ................................................................................... 17

UHC – PLAN PROCESSED AND OTHER VENDORS ................................................. 18

RECOMMENDATIONS ................................................................................................ 19

TABLE OF CONTENTS

Comparison of Managed Care Encounter Data to Accounting System Data for UHC

3

New Mexico MCO Encounter and ASD Comparison The New Mexico Human Services Department (HSD) has contracted with HealthInsight New Mexico (HealthInsight) as the external quality review organization (EQRO). Myers and Stauffer LC (Myers and Stauffer) is subcontracted and under the direction of HealthInsight for the encounter data validation (EDV) project. HSD requires that each Managed Care Organization (MCO) submit encounter data to HSD’s fiscal agent (FA), Conduent, Inc. (known as Xerox Health Solutions prior to January 2017). As part of the External Quality Review (EQR) Protocol 4 process, Myers and Stauffer analyzed Medicaid encounter data that had been submitted by the MCOs to the FA and completed a comparison of the encounters to accounting system data (ASD) provided by each MCO. Validated encounter data have many uses in rate setting analyses by actuaries, as well as in fulfilling the federal reporting requirements related to the Medicaid Managed Care Final rule, in providing program management and oversight, and other ad hoc analyses. This encounter reconciliation will help fulfill part of the work requirements set forth in activity number 3 of the Centers for Medicare & Medicaid Services (CMS) EQR Protocol 4, which requires a determination of the completeness, accuracy and quality of the encounter data being submitted by each MCO. CMS’ EQR Protocol 4, is a way to assess whether the encounter data can be used to determine program effectiveness, accurately evaluate utilization, identify service gaps and make management decisions. In addition, the Protocol requires an evaluation of both departmental policies, as well as the policies, procedures and systems of the health plans to identify strengths and opportunities to enhance oversight. The full results of our Protocol 4 work will be issued as a separate report. The April 2017 New Mexico Encounter Reconciliation report is an analysis of the encounter data compared to the payments to service providers in the accounting system data. Below is a summary of the cumulative completion percentages for all encounter paid claims submitted to Conduent Inc. (Conduent), the FA, by United Healthcare of New Mexico, Inc. (UHC) for the reporting period of January 1, 2014 through April 30, 2016. Included with this report, are the potential data issues and assumptions utilized during the completion of this report, as well as our recommendations to the MCO, FA, and HSD to help identify and correct the root causes of the issues identified. HealthInsight and Myers and Stauffer recommend that the Human Services Department utilize this report as a management oversight tool to track the progress made by the MCO over time and to monitor the MCO’s contract compliance with providing complete and accurate encounter information.

EXECUTIVE SUMMARY


4

This report consists of UHC’s encounters and ASD.

Table A UHC― Cumulative Completion Percentages UHC/Delegated Vendor % of Cumulative Total Entire Plan 112.61% Dental Services 91.95% Pharmacy Benefits 99.09% Plan Processed and Other Vendors 114.30%

Potential issues that may impact the completion percentages are listed below (a full list and description of all potential are included in the main report):

1) There may be encounters included without a matching ASD transaction. UHC’s

data were particularly difficult to match since the plan’s transaction control number field was not used in such a way that it facilitated matching with the corresponding ASD claim number.

2) It is possible that there were duplicate claims in the encounter data that we were unable to identify and remove.

3) Some ASD transaction dates may not have matched the payment dates that were reported in the encounter data resulting in potential timing issues.

4) The ASD transaction total is low for January 2014. The completion percentage could be overstated as a result of the low transaction totals in the ASDs.

5) The pharmacy encounters for February through May 2014 show very low paid amounts. The absence of paid encounters for that time period may explain the overstated completion percentage of pharmacy encounters noted for July 2014.

EXECUTIVE SUMMARY


5

The following terms are used throughout this document:

• Accounting System Data (ASD) Monthly Reported Total – The sum of all payments from an MCO or delegated vendor to service providers for a given month as reported by the MCO to HSD.

• ASD Cumulative Reported Total – The sum of all payments from an MCO or delegated vendor to service providers for the reconciliation period as reported by the MCO to HSD.

• Calculated Void Encounter (CV) – An encounter that Myers and Stauffer has identified as being a replacement or adjustment that does not appear to have a corresponding void of the original encounter in the FA’s data warehouse.

• Conduent, Inc. (Conduent) – State fiscal agent (Formerly known as Xerox Health Solutions).

• Cumulative Encounter Total – The sum of all encounter submissions stored in the fiscal agent’s encounter data warehouse. This amount is inclusive of all amounts submitted in prior months.

• Cumulative Variance – The difference between the cumulative encounter total and the ASD cumulative reported total.

• Denied Encounter- An encounter, which has met all Health Insurance Portability and Accountability Act (HIPAA) and front end data checks and was accepted by the FA; however, once the encounter was checked against the MMIS business rules, was denied due an exception in a business rule. These denied encounters may be resubmitted by the MCO to correct the issue which case the denial by the FA.

• Fiscal agent (FA) – A contractor selected to design, develop and maintain the claims processing system (Medicaid Management Information System); Conduent, Inc (known as Xerox Health Solutions prior to January 2017) is the current FA.

• FOCoS Online (FOCoS) – A subcontractor of Conduent, Inc. • Human Services Department (HSD) – The division in the Office of the Governor

that is responsible for administering Medicaid in New Mexico. • Medicaid Management Information System (MMIS) – The claims processing

system used by the FA to adjudicate New Mexico’s Medicaid claims. MCO submitted encounters are loaded into this system and assigned a unique claim identifier.

DEFINITIONS AND ACRONYMS


6

• Managed Care Organization (MCO) – A private organization, or health plan, that has entered into a risk-based contractual arrangement with the New Mexico Human Services Department (HSD) to obtain and finance care for enrolled Medicaid members. MCOs receive a capitation or per member per month (PMPM) payment from HSD for each enrolled member. There are four MCOs operating in New Mexico under a contract that was effective February 5, 2013: Blue Cross and Blue Shield of New Mexico, Molina Healthcare of New Mexico, Presbyterian Health Plan, Inc. and United Healthcare of New Mexico, Inc.

• Monthly Encounter Total – The sum of all encounter submissions for a given month stored in the FA’s encounter data warehouse.

• Monthly Variance – The difference between the monthly encounter total and the ASD monthly reported total.

• Plan Processed Encounters- All encounters processed by the health plan, which would include the encounters that represent medical (institutional and professional) claims and all other claims processed by the plan, which were not subcontracted or delegated to a vendor (i.e., vision, dental, pharmacy, transportation.

• Potential Duplicate Encounter (PDUP) – An encounter that Myers and Stauffer has identified as being a potential duplicate of another encounter in the FA’s data warehouse.

• Rejected Encounter - An encounter that has been submitted to the FA but did not meet HIPAA or other front end data checks and was not accepted into the MMIS.

• Xerox Health Solutions (Xerox) – Former name of Conduent, Inc., the state’s fiscal agent. The name change went into effect January 2017.



7

HealthInsight New Mexico (HealthInsight) engaged Myers and Stauffer to analyze Medicaid encounter data that has been submitted by the MCOs to the FA and complete a comparison of the encounters to accounting systems data provided by UHC. For purposes of this analysis, “encounter data” are the set of encounters which represent claims that have been paid by MCOs or delegated vendors (e.g., vision and pharmacy) to health care providers that have provided health care services to members enrolled with the MCO. Such encounters are submitted by the MCOs to HSD via the FA for HSD’s use in rate setting, federal reporting, program management and oversight, tracking, accounting and other ad hoc analyses. Section 4.19.2.2.11 of the contract between HSD and the MCO states, “[The Contractor shall] meet HSD Encounter timeliness requirements by submitting to HSD at least ninety percent (90%) of its Claims, both paid and denied, originals and adjustments within thirty (30) Calendar Days of the date of adjudication, and ninety-nine percent (99%) within sixty (60) Calendar Days of the date of adjudication…whether the Encounter is from a subcontractor, subcapitated arrangement, or performed by the CONTRACTOR.” Subsequently in Section 7.3.1.1, the contract states “In the event that the CONTRACTOR or any person with an ownership interest in the CONTRACTOR, affiliate, parent or subcontractor, fails to comply with this Agreement, HSD may impose, at HSD's discretion, the remedies, sanctions and damages described in this Section [7.3].” HealthInsight of New Mexico, on behalf of HSD, requested that, for this study, we estimate the percentage of each MCO and delegated vendor paid encounters that appear to be included in the FA’s data warehouse. This analysis includes these percentages for all MCO paid claims as well as separate pharmacy and dental vendor encounters paid during the period January 1, 2014 through April 30, 2016.

STUDY PURPOSE


8

Myers and Stauffer received encounter data from the FA. The data are in a standardized extract containing MCO institutional, medical and pharmacy encounters. These encounter data extracts include encounters from the four MCOs: Blue Cross and Blue Shield of New Mexico, Molina Healthcare of New Mexico, Presbyterian Health Plan, Inc. and United Healthcare of New Mexico, Inc. and having plan paid dates starting on January 1, 2014. The data used for this report includes encounters received and accepted by the FA through May 31, 2016. Myers and Stauffer also requested ASD from each MCO ranging in dates from January 1, 2014 through April 30, 2016 in a standardized format.

DATA SOURCES


9

Encounters from institutional, medical and pharmacy claim types were combined on like data fields. We analyzed the line reported information of each encounter to capture the amount paid on the entire claim. Encounter totals were calculated by summarizing the data by the MCO paid date and MCO identification number. Accounting system data submitted by the MCO were summarized by paid date. These two tables were combined using common fields between the tables and were used to produce the results. Based on criteria provided by the MCO and HSD, we identified the UHC encounters as follows: General criteria for all populations:

Submitter ID For UHC, the submitter ID is noted to be 16785851. Only

encounters with the indicated submitter ID were included in the analyses.

Filing Indicators No filing indicators were excluded from these analyses. Medicare Part A and Medicare Part B crossover claims have been included in analysis.

Criteria for specific populations:

Pharmacy Benefit

Pharmacy encounters were isolated by restricting the data to header type code ‘R’.

Dental Services Dental encounters were isolated by restricting the data to header

type code ‘D’.

Plan Processed Encounters and Other Vendors Plan Processed Encounters and Other Vendors were isolated by

excluding the data with header type code ‘D’ or ‘R’.

ANALYSIS


10

In the performance of this analysis, Myers and Stauffer makes the following assumptions and notes regarding potential data issues: 1. We assume that all data provided to Myers and Stauffer is complete and accurate.

2. This analysis only included encounters that were submitted by the MCOs to the FA and loaded into the FA’s data warehouse. Encounters submitted by any MCO that were rejected by the FA for errors in submission or other reasons are excluded from this analysis.

3. We instructed the MCOs to exclude referral fees, management fees and other non-encounter related fees in the ASD data submitted to Myers and Stauffer.

4. We identified potential duplicate encounters. We analyzed the encounter and ASD submissions to conclude that some of these potential duplicates appear to be partial payments, and some are actual duplicate submissions. We have attempted to adjust our totals to reflect the actual payment made and have removed duplicate payments from our analysis.

5. The monthly completion percentages for the entire plan exceeded 100 percent for most months of the reporting period. These overstated monthly completion percentages may be due to a variety of reasons such as encounters included without a corresponding matching ASD transaction or certain claim voids and replacements that were absent from the encounter data, but were accounted for in the ASD. Additionally, duplicate encounters may have existed in the encounter data that we were unable to identify and remove. Also, ASD payment dates may not have matched the payment dates that were reported in the encounter data resulting in potential timing issues.

6. Myers and Stauffer historically codes voided encounters contained within the encounter submissions to match the associated adjustment claim’s paid date. This allows for the proper matching of accounting system data that occurs due to this void transaction. We were unable to assign a paid date to the void transactions that was different than the date of the original submission. It appears UHC used the date of the original submission for the MCO paid date and the MCO received date on all subsequent adjustments, replacements, back outs and voids of an encounter claim.

7. Interest amounts do not appear to be included in the MCO paid amounts. We have therefore excluded the separately itemized interest expense from the ASD totals.

POTENTIAL DATA ISSUES AND ANALYSIS ASSUMPTIONS


11

8. Encounters denied by the FA were included and subjected to our potential duplicate encounter logic process which identifies and removes these claims appropriately. This methodology artificially inflates the percentages of claim counts and amounts removed as identified in Table 2 – UHC Calculated Void and Duplicate Summary, since some of these were likely already marked correctly as denied for this duplicate issue. This is currently the only fair and representative way to ensure that the actual MCO paid encounters remain in our analysis.

9. There are adjustment instances in the encounters where the adjustment backout is successful, but the corresponding replacement transaction is denied by the FA. This is creating a series of problems with the encounter data. First, these instances effectively remove paid encounters from the FA’s data warehouse that the MCO may have intended to replace. Additionally, when an MCO submits subsequent replacement transactions (to replace the replacement encounters), these too are denied due to the original encounter already being considered voided or adjusted. As a result, the plan must send the transaction as a new unrelated original encounter in order to have it accepted by the FA. This process is problematic since it can produce encounters that may not reflect the MCO’s actual encounter adjustment activity.

10. ASD payment dates may not have matched the payment dates that were reported in the encounter data resulting in potential timing issues. It seems that UHC has used the original encounter received date as the encounter received date on all subsequent adjustments to an encounter. Similarly, it seems the MCO encounter paid date for an original encounter is the same date used as the MCO encounter paid date for all subsequent adjustments of the same encounter.

11. The ASD transaction total for January 2014 is significantly lower than the transaction totals for subsequent months. This may contribute to the completion percentage exceeding 100 percent during January 2014.

12. There appear to be very few “paid” pharmacy encounters during the first half of calendar year 2014. The lack of paid encounters during those months significantly lowers the cumulative monthly completion percentages for pharmacy and the entire plan.

13. There is encounter data that indicates UHC as the provider in the provider ID field, however the batch submitter ID is not populated. Only data that indicates United in the batch submitter ID field is included in this analysis.

14. Analysis of the encounter data and accounting system data, as well as interactions with the MCOs, HSD and the FA have resulted in the identification of opportunities for improving the encounter reconciliation process. While we have attempted to account for these situations, other potential issues within the data may exist that have not yet been identified which may require us to restate this report.



12

UHC appears to have submitted approximately 100 percent of their encounter data for this period. Monthly percentages exceeded 100 percent during some months of the reporting period and for the overall study period. Please reference Potential Data Issues for an explanation of the possible causes.

Table 1 ― UHC Entire Plan

Paid Month ASD

Monthly Reported

Total

Monthly Encounter

Total Monthly Variance

ASD Cumulative

Reported Total Cumulative

Encounter Total Cumulative

Variance % of

Monthly Claims

% of Cumulative

Total

January 2014 $9,096,127 $28,877,892 $19,781,765 $9,096,127 $28,877,892 $19,781,765 317.47% 317.47% February 2014 $29,825,737 $33,375,941 $3,550,204 $38,921,864 $62,253,833 $23,331,969 111.90% 159.94% March 2014 $35,950,017 $41,674,369 $5,724,351 $74,871,882 $103,928,202 $29,056,320 115.92% 138.80% April 2014 $44,740,376 $43,279,827 ($1,460,548) $119,612,257 $147,208,029 $27,595,772 96.73% 123.07% May 2014 $46,760,758 $47,555,686 $794,927 $166,373,016 $194,763,715 $28,390,699 101.69% 117.06% June 2014 $43,560,644 $44,259,830 $699,186 $209,933,660 $239,023,545 $29,089,886 101.60% 113.85% July 2014 $49,264,143 $57,685,969 $8,421,826 $259,197,803 $296,709,514 $37,511,711 117.09% 114.47% August 2014 $50,625,420 $48,072,748 ($2,552,673) $309,823,223 $344,782,262 $34,959,039 94.95% 111.28% September 2014 $54,591,294 $51,840,036 ($2,751,257) $364,414,517 $396,622,298 $32,207,781 94.96% 108.83% October 2014 $57,679,844 $64,372,425 $6,692,581 $422,094,361 $460,994,723 $38,900,363 111.60% 109.21% November 2014 $52,576,344 $66,043,120 $13,466,776 $474,670,705 $527,037,844 $52,367,139 125.61% 111.03% December 2014 $55,708,359 $66,977,031 $11,268,673 $530,379,064 $594,014,875 $63,635,811 120.22% 111.99% January 2015 $57,260,975 $63,872,929 $6,611,954 $587,640,039 $657,887,804 $70,247,765 111.54% 111.95% February 2015 $53,883,310 $69,509,538 $15,626,228 $641,523,349 $727,397,343 $85,873,994 129.00% 113.38% March 2015 $64,544,892 $67,598,521 $3,053,629 $706,068,241 $794,995,864 $88,927,623 104.73% 112.59% April 2015 $69,568,614 $82,343,970 $12,775,356 $775,636,854 $877,339,833 $101,702,979 118.36% 113.11% May 2015 $58,157,379 $79,945,230 $21,787,850 $833,794,234 $957,285,063 $123,490,829 137.46% 114.81% June 2015 $57,092,458 $68,572,562 $11,480,104 $890,886,691 $1,025,857,624 $134,970,933 120.10% 115.15% July 2015 $72,535,296 $68,391,253 ($4,144,043) $963,421,988 $1,094,248,877 $130,826,890 94.28% 113.57% August 2015 $63,626,647 $64,055,345 $428,699 $1,027,048,634 $1,158,304,223 $131,255,588 100.67% 112.77% September 2015 $57,723,955 $63,781,046 $6,057,091 $1,084,772,590 $1,222,085,268 $137,312,679 110.49% 112.65% October 2015 $65,481,192 $70,199,317 $4,718,124 $1,150,253,782 $1,292,284,585 $142,030,803 107.20% 112.34% November 2015 $61,031,843 $65,799,642 $4,767,799 $1,211,285,625 $1,358,084,228 $146,798,603 107.81% 112.11% December 2015 $69,821,090 $77,927,621 $8,106,531 $1,281,106,716 $1,436,011,849 $154,905,133 111.61% 112.09%

UHC – ENTIRE PLAN

UHC JANUARY 2014 – APRIL 2016


13

Table 1 ― UHC Entire Plan (continued)

Paid Month

ASD Monthly Reported

Total

Monthly Encounter


ASD Cumulative

Reported Total Cumulative

Encounter Total Cumulative

Variance

% of Monthly Claims

% of Cumulative

Total

January 2016 $58,960,559 $70,687,173 $11,726,614 $1,340,067,274 $1,506,699,022 $166,631,748 119.88% 112.43% February 2016 $61,288,798 $68,062,574 $6,773,776 $1,401,356,072 $1,574,761,596 $173,405,524 111.05% 112.37% March 2016 $65,976,581 $74,623,513 $8,646,932 $1,467,332,654 $1,649,385,110 $182,052,456 113.10% 112.40% April 2016 $60,322,173 $70,939,432 $10,617,260 $1,527,654,827 $1,720,324,542 $192,669,716 117.60% 112.61%

*Please note that the ASD has been provided to Myers and Stauffer by UHC. Encounter data has been provided by the FA.


14

The calculated void (CV) and potential duplicate (PDUP) encounters that have been identified through the encounter reconciliation analysis are indicated below. These encounters have been removed from the encounter reconciliation totals.

Table 2 ― UHC Calculated Void and Duplicate Summary

Paid Month Count of

Encounter Claims

Total Sum (MCO

Submitted Paid Amount)

Count of CV PDUP

Encounters

CV PDUP Amount

Removed

% of CV PDUP

Encounter Count

% of CV PDUP

Amount Removed

January 2014 122,214 $30,377,959 9,377 $1,500,066 7.67% 4.94% February 2014 165,276 $38,754,093 21,443 $5,378,152 12.97% 13.88% March 2014 218,339 $47,768,406 21,109 $6,094,037 9.67% 12.76% April 2014 227,204 $51,385,674 23,362 $8,105,847 10.28% 15.77% May 2014 243,204 $55,671,682 27,236 $8,115,996 11.20% 14.58% June 2014 252,875 $52,127,424 27,804 $7,867,594 11.00% 15.09% July 2014 498,101 $66,819,321 27,914 $9,133,353 5.60% 13.67% August 2014 372,467 $56,371,082 22,495 $8,298,334 6.04% 14.72% September 2014 373,919 $60,347,957 22,293 $8,507,921 5.96% 14.10% October 2014 409,946 $75,318,947 31,533 $10,946,522 7.69% 14.53% November 2014 363,078 $80,790,408 32,192 $14,747,288 8.87% 18.25% December 2014 425,343 $76,343,592 27,439 $9,366,561 6.45% 12.27% January 2015 375,277 $79,000,436 32,304 $15,127,506 8.61% 19.15% February 2015 377,356 $96,714,488 42,696 $27,204,949 11.31% 28.13% March 2015 384,225 $83,370,961 30,824 $15,772,440 8.02% 18.92% April 2015 433,660 $115,859,012 48,509 $33,515,043 11.19% 28.93% May 2015 525,912 $105,114,384 55,920 $25,169,155 10.63% 23.94% June 2015 369,785 $83,969,983 20,775 $15,397,421 5.62% 18.34% July 2015 365,732 $87,074,453 19,794 $18,683,200 5.41% 21.46% August 2015 354,847 $73,035,273 15,076 $8,979,928 4.25% 12.30% September 2015 375,861 $72,353,916 26,275 $8,572,870 6.99% 11.85% October 2015 364,298 $77,359,815 20,012 $7,160,498 5.49% 9.26% November 2015 340,377 $70,608,406 16,028 $4,808,764 4.71% 6.81% December 2015 365,404 $88,290,909 22,392 $10,363,288 6.13% 11.74% January 2016 313,766 $76,565,762 13,127 $5,878,589 4.18% 7.68% February 2016 304,577 $72,995,153 9,186 $4,932,579 3.02% 6.76% March 2016 354,612 $78,076,353 14,237 $3,452,839 4.01% 4.42% April 2016 310,274 $73,781,585 8,170 $2,842,153 2.63% 3.85% TOTALS 9,587,929 $2,026,247,434 689,522 $305,922,893 7.19% 15.10%

Count of Encounter Claims – The number of encounters processed by the FA (including encounters marked as denied by the FA). Total Sum (MCO Submitted Paid Amount) – The total paid amount of encounters in a month per the encounter data provided by the FA. These amounts do not incorporate the corrections to paid amounts as explained in #4 of the Potential Data Issues and Analysis Assumptions. Count of CV PDUP Encounters – The number of encounters identified by Myers and Stauffer as potential calculated voids and duplicates. CV PDUP Amount Removed – The paid amount removed from the Monthly Encounter Total based on Myers and Stauffer ’s analysis of calculated void and duplicate encounters. % of CV PDUP Encounter Count– The percentage of CV PDUP encounters out of the total number of encounters. % of CV PDUP Amount Removed – The percentage of paid amount removed from the total MCO submitted paid amount.

UHC CALCULATED VOID AND DUPLICATE SUMMARY


15

Figure 1 – UHC’s ASD totals and encounter totals as reported monthly.

Figure 2 - UHC’s cumulative encounter submissions expressed as a percentage of

payments submitted to the FA to reported MCO ASD payments.

$0

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

$70,000,000

$80,000,000

$90,000,000

ASD Monthly Reported Total

Monthly Encounter Total

90%

115%

140%

165%

190%

215%

240%

265%

290%

315%

% of Cumulative Total

UHC SUMMARY REPORTING CHARTS


16

UHC appears to have submitted approximately 91 percent of their dental encounter data for this period, with a cumulative monthly range between 91 percent and 131 percent. Monthly percentages exceeded 100 percent during a few months of the reporting period. Please reference Potential Data Issues for an explanation of the possible causes.

UHC – DENTAL SERVICES

Table 3 ― UHC Dental Services

Paid Month ASD Monthly Reported Total


Monthly Variance

ASD Cumulative Reported Total

Cumulative Encounter Total

Cumulative Variance

% of Monthly Accounting

Transactions


January 2014 $258,563 $340,153 $81,589 $258,563 $340,153 $81,589 131.55% 131.55% February 2014 $512,549 $470,222 ($42,327) $771,113 $810,375 $39,262 91.74% 105.09% March 2014 $711,444 $608,772 ($102,672) $1,482,557 $1,419,147 ($63,410) 85.56% 95.72% April 2014 $929,027 $866,136 ($62,891) $2,411,584 $2,285,283 ($126,301) 93.23% 94.76% May 2014 $1,348,292 $1,319,168 ($29,123) $3,759,875 $3,604,451 ($155,424) 97.83% 95.86% June 2014 $1,063,679 $1,036,511 ($27,168) $4,823,554 $4,640,963 ($182,592) 97.44% 96.21% July 2014 $1,078,465 $1,071,668 ($6,797) $5,902,020 $5,712,630 ($189,389) 99.36% 96.79% August 2014 $1,245,724 $1,368,882 $123,158 $7,147,743 $7,081,512 ($66,231) 109.88% 99.07% September 2014 $1,201,628 $1,196,063 ($5,565) $8,349,371 $8,277,576 ($71,796) 99.53% 99.14% October 2014 $1,499,843 $1,476,293 ($23,550) $9,849,215 $9,753,869 ($95,346) 98.42% 99.03% November 2014 $1,468,497 $1,281,454 ($187,043) $11,317,712 $11,035,323 ($282,389) 87.26% 97.50% December 2014 $1,408,076 $1,253,174 ($154,902) $12,725,788 $12,288,498 ($437,291) 88.99% 96.56% January 2015 $1,567,218 $1,505,704 ($61,514) $14,293,006 $13,794,202 ($498,805) 96.07% 96.51% February 2015 $1,308,048 $1,217,122 ($90,926) $15,601,055 $15,011,324 ($589,731) 93.04% 96.21% March 2015 $1,237,628 $1,134,917 ($102,712) $16,838,683 $16,146,241 ($692,443) 91.70% 95.88% April 2015 $1,468,203 $1,389,828 ($78,375) $18,306,886 $17,536,069 ($770,817) 94.66% 95.78% May 2015 $1,578,094 $1,446,118 ($131,977) $19,884,981 $18,982,187 ($902,794) 91.63% 95.45% June 2015 $1,320,780 $1,214,519 ($106,261) $21,205,761 $20,196,706 ($1,009,055) 91.95% 95.24% July 2015 $1,899,027 $1,518,438 ($380,589) $23,104,788 $21,715,144 ($1,389,644) 79.95% 93.98% August 2015 $1,497,308 $1,354,423 ($142,885) $24,602,096 $23,069,567 ($1,532,529) 90.45% 93.77% September 2015 $1,999,747 $1,742,149 ($257,598) $26,601,843 $24,811,716 ($1,790,127) 87.11% 93.27% October 2015 $1,980,744 $1,856,151 ($124,593) $28,582,587 $26,667,867 ($1,914,720) 93.70% 93.30% November 2015 $1,398,425 $1,319,377 ($79,049) $29,981,012 $27,987,244 ($1,993,768) 94.34% 93.34% December 2015 $1,797,254 $1,495,945 ($301,309) $31,778,267 $29,483,189 ($2,295,077) 83.23% 92.77% January 2016 $1,413,725 $1,225,369 ($188,356) $33,191,992 $30,708,558 ($2,483,434) 86.67% 92.51% February 2016 $1,180,066 $1,002,330 ($177,736) $34,372,057 $31,710,888 ($2,661,170) 84.93% 92.25% March 2016 $1,700,096 $1,541,685 ($158,411) $36,072,154 $33,252,573 ($2,819,581) 90.68% 92.18% April 2016 $1,635,024 $1,419,908 ($215,116) $37,707,177 $34,672,481 ($3,034,697) 86.84% 91.95%


17

UHC appears to have submitted approximately 99 percent of the pharmacy benefit encounter data for this period, with a cumulative monthly range between 4 percent and 209 percent. Monthly percentages exceeded 100 percent during some months of the reporting period. Please reference Potential Data Issues for an explanation of the possible causes.

Table 4 ― UHC Pharmacy Benefits

Paid Month ASD

Monthly Reported

Total

Monthly Encounter


ASD Cumulative Reported

Total

Cumulative Encounter

Total Cumulative

Variance % of Monthly Accounting

Transactions

% of Cumulative

Total

January 2014 $217,541 $456,096 $238,555 $217,541 $456,096 $238,555 209.65% 209.65% February 2014 $1,660,891 $9,015 ($1,651,876) $1,878,432 $465,111 ($1,413,321) 0.54% 24.76% March 2014 $2,277,860 ($328) ($2,278,188) $4,156,292 $464,783 ($3,691,509) -0.01% 11.18% April 2014 $3,470,672 ($99) ($3,470,771) $7,626,964 $464,684 ($7,162,281) 0.00% 6.09% May 2014 $2,623,619 ($1,093) ($2,624,712) $10,250,584 $463,591 ($9,786,993) -0.04% 4.52% June 2014 $2,816,058 $130,893 ($2,685,165) $13,066,641 $594,484 ($12,472,157) 4.64% 4.54% July 2014 $3,175,079 $11,229,113 $8,054,034 $16,241,721 $11,823,597 ($4,418,123) 353.66% 72.79% August 2014 $4,230,050 $4,789,538 $559,488 $20,471,771 $16,613,135 ($3,858,636) 113.22% 81.15% September 2014 $4,002,571 $4,424,926 $422,355 $24,474,342 $21,038,061 ($3,436,280) 110.55% 85.95% October 2014 $4,005,516 $4,075,930 $70,414 $28,479,858 $25,113,992 ($3,365,867) 101.75% 88.18% November 2014 $3,804,399 $4,161,494 $357,095 $32,284,258 $29,275,486 ($3,008,772) 109.38% 90.68% December 2014 $4,276,673 $6,365,474 $2,088,801 $36,560,931 $35,640,960 ($919,971) 148.84% 97.48% January 2015 $3,948,809 $4,072,274 $123,464 $40,509,740 $39,713,234 ($796,506) 103.12% 98.03% February 2015 $2,955,865 $4,032,014 $1,076,149 $43,465,605 $43,745,248 $279,642 136.40% 100.64% March 2015 $5,260,042 $4,138,275 ($1,121,767) $48,725,647 $47,883,522 ($842,125) 78.67% 98.27% April 2015 $4,413,030 $4,824,417 $411,387 $53,138,677 $52,707,939 ($430,738) 109.32% 99.18% May 2015 $4,677,696 $4,628,231 ($49,465) $57,816,373 $57,336,170 ($480,203) 98.94% 99.16% June 2015 $4,384,316 $4,752,838 $368,522 $62,200,688 $62,089,008 ($111,680) 108.40% 99.82% July 2015 $4,539,008 $4,494,467 ($44,541) $66,739,697 $66,583,475 ($156,221) 99.01% 99.76% August 2015 $4,832,359 $4,428,379 ($403,980) $71,572,056 $71,011,854 ($560,202) 91.64% 99.21% September 2015 $4,475,562 $4,667,324 $191,762 $76,047,618 $75,679,178 ($368,440) 104.28% 99.51% October 2015 $4,039,637 $4,740,429 $700,792 $80,087,254 $80,419,607 $332,352 117.34% 100.41% November 2015 $5,242,256 $4,553,054 ($689,202) $85,329,511 $84,972,661 ($356,850) 86.85% 99.58% December 2015 $5,380,003 $5,035,587 ($344,415) $90,709,514 $90,008,248 ($701,265) 93.59% 99.22% January 2016 $5,395,731 $5,292,579 ($103,152) $96,105,245 $95,300,827 ($804,418) 98.08% 99.16% February 2016 $5,149,626 $5,469,344 $319,718 $101,254,871 $100,770,171 ($484,699) 106.20% 99.52% March 2016 $7,557,901 $6,769,459 ($788,441) $108,812,771 $107,539,631 ($1,273,141) 89.56% 98.82% April 2016 $6,048,786 $6,288,069 $239,283 $114,861,558 $113,827,700 ($1,033,858) 103.95% 99.09%

UHC – PHARMACY BENEFITS


18

UHC appears to have submitted approximately 100 percent of their plan processed encounters and other vendors encounter data for this period. Monthly percentages exceeded 100 percent during some months of the reporting period and for the overall study period. Please reference Potential Data Issues for an explanation of the possible causes.

Table 5 ― UHC Plan Processed Encounters and Other Vendors

Paid Month ASD

Monthly Reported

Total

Monthly Encounter



Total


Total Cumulative

Variance % of Monthly Accounting

Transactions

% of Cumulative

Total

January 2014 $8,620,022 $28,081,644 $19,461,621 $8,620,022 $28,081,644 $19,461,621 325.77% 325.77% February 2014 $27,652,297 $32,896,704 $5,244,407 $36,272,319 $60,978,348 $24,706,028 118.96% 168.11% March 2014 $32,960,713 $41,065,924 $8,105,211 $69,233,032 $102,044,272 $32,811,239 124.59% 147.39% April 2014 $40,340,677 $42,413,791 $2,073,114 $109,573,709 $144,458,063 $34,884,353 105.13% 131.83% May 2014 $42,788,847 $46,237,610 $3,448,763 $152,362,557 $190,695,673 $38,333,116 108.05% 125.15% June 2014 $39,680,907 $43,092,426 $3,411,518 $192,043,464 $233,788,098 $41,744,635 108.59% 121.73% July 2014 $45,010,598 $45,385,188 $374,589 $237,054,062 $279,173,286 $42,119,224 100.83% 117.76% August 2014 $45,149,647 $41,914,328 ($3,235,318) $282,203,709 $321,087,614 $38,883,905 92.83% 113.77% September 2014 $49,387,095 $46,219,047 ($3,168,048) $331,590,803 $367,306,661 $35,715,858 93.58% 110.77% October 2014 $52,174,485 $58,820,202 $6,645,717 $383,765,288 $426,126,863 $42,361,575 112.73% 111.03% November 2014 $47,303,447 $60,600,172 $13,296,724 $431,068,735 $486,727,034 $55,658,299 128.10% 112.91% December 2014 $50,023,609 $59,358,383 $9,334,774 $481,092,344 $546,085,417 $64,993,073 118.66% 113.50% January 2015 $51,744,948 $58,294,952 $6,550,004 $532,837,292 $604,380,369 $71,543,076 112.65% 113.42% February 2015 $49,619,397 $64,260,402 $14,641,006 $582,456,689 $668,640,771 $86,184,082 129.50% 114.79% March 2015 $58,047,221 $62,325,329 $4,278,108 $640,503,910 $730,966,100 $90,462,190 107.37% 114.12% April 2015 $63,687,381 $76,129,724 $12,442,343 $704,191,291 $807,095,825 $102,904,533 119.53% 114.61% May 2015 $51,901,589 $73,870,881 $21,969,292 $756,092,881 $880,966,706 $124,873,825 142.32% 116.51% June 2015 $51,387,362 $62,605,205 $11,217,843 $807,480,242 $943,571,910 $136,091,668 121.82% 116.85% July 2015 $66,097,261 $62,378,348 ($3,718,913) $873,577,503 $1,005,950,258 $132,372,755 94.37% 115.15% August 2015 $57,296,980 $58,272,544 $975,564 $930,874,483 $1,064,222,802 $133,348,319 101.70% 114.32% September 2015 $51,248,646 $57,371,573 $6,122,927 $982,123,129 $1,121,594,375 $139,471,245 111.94% 114.20% October 2015 $59,460,811 $63,602,737 $4,141,925 $1,041,583,940 $1,185,197,111 $143,613,171 106.96% 113.78% November 2015 $54,391,161 $59,927,212 $5,536,050 $1,095,975,102 $1,245,124,323 $149,149,221 110.17% 113.60% December 2015 $62,643,833 $71,396,089 $8,752,255 $1,158,618,935 $1,316,520,412 $157,901,476 113.97% 113.62% January 2016 $52,151,103 $64,169,225 $12,018,123 $1,210,770,038 $1,380,689,637 $169,919,599 123.04% 114.03% February 2016 $54,959,106 $61,590,901 $6,631,794 $1,265,729,144 $1,442,280,537 $176,551,393 112.06% 113.94% March 2016 $56,718,584 $66,312,369 $9,593,785 $1,322,447,729 $1,508,592,906 $186,145,178 116.91% 114.07% April 2016 $52,638,363 $63,231,455 $10,593,092 $1,375,086,091 $1,571,824,362 $196,738,270 120.12% 114.30%

UHC – PLAN PROCESSED ENCOUNTERS AND OTHER VENDORS


19

M 1. HealthInsight and Myers and Stauffer recommend that UHC populate the actual date of

adjudication and payment rather than repeating the date of a prior adjudication or payment on all subsequent iterations of an encounter. Populating the actual date of adjudication and payment is required by CMS in accordance with their Encounter Data Minimum Data Elements.

2. HealthInsight and Myers and Stauffer recommend that UHC work with their pharmacy vendor to fulfill the reporting requirements set out in the Medicaid Managed Care Services Agreement. More specifically, the encounter data used in this analysis indicate a negative paid amount for pharmacy encounters from March through May 2014.

3. HealthInsight and Myers and Stauffer recommend that UHC submit all requested ASD transactions to Myers and Stauffer for inclusion in any future encounter reconciliations in accordance with the reporting requirements set out in the Medicaid Managed Care Services Agreement and in order to ensure the most accurate results are derived from the encounter reconciliation.

RECOMMENDATIONS

UHC RECOMMENDATIONS

January 1, 2014

APPENDIX D-2: UPDATED ENCOUNTER RECONCILIATION REPORT - AUGUST 25, 2017

JANUARY 1, 2014 THROUGH FEBRUARY 28, 2017

COMPARISON OF MANAGED CARE

ENCOUNTERS TO ACCOUNTING SYSTEM DATA FOR

UNITED HEALTHCARE OF NEW MEXICO, INC

AUGUST 25, 2017

2

EXECUTIVE SUMMARY ................................................................................................. 3

DEFINITIONS AND ACRONYMS ................................................................................... 6

STUDY PURPOSE .......................................................................................................... 8

DATA SOURCES ............................................................................................................ 9

ANALYSIS .................................................................................................................... 10

POTENTIAL DATA ISSUES AND ANALYSIS ASSUMPTIONS ................................... 11

UHC – ENTIRE PLAN ................................................................................................... 14

UHC – CALCULATED VOID AND DUPLICATE SUMMARY ........................................ 16

UHC – SUMMARY REPORTING CHARTS ................................................................... 18

UHC– DENTAL BENEFITS ........................................................................................... 19

UHC – PHARMACY BENEFITS .................................................................................... 21

UHC – PLAN PROCESSED ENCOUNTERS AND OTHER VENDORS ........................ 23

RECOMMENDATIONS ................................................................................................. 25

TABLE OF CONTENTS


3

New Mexico MCO Encounter and ASD Comparison The New Mexico Human Services Department (HSD) has contracted with HealthInsight New Mexico (HealthInsight) as the external quality review organization (EQRO). Myers and Stauffer LC (Myers and Stauffer) is subcontracted and under the direction of HealthInsight for the encounter data validation (EDV) project. HSD requires that each Managed Care Organization (MCO) submit encounters to HSD’s fiscal agent (FA), which is Conduent, Inc. To ensure complete and accurate encounter data is being received, Myers and Stauffer LC (Myers and Stauffer) provides this encounter reconciliation. As part of this process, Myers and Stauffer analyzed Medicaid encounter data that had been submitted by the MCOs to Conduent, Inc. (Xerox Health Solutions prior to January 1, 2017) and completed a comparison of the encounters to accounting system data (ASD) provided by each MCO. For purposes of this analysis, “encounter data” are the set of encounters which represent claims that have been paid by United Healthcare of New Mexico (UHC) or delegated vendors (e.g., vision and pharmacy) to healthcare providers that have provided healthcare services to members enrolled with UHC. Validated encounter data have many uses in rate setting analyses by actuaries as well as in fulfilling the federal reporting requirements related to the Medicaid Managed Care Final Rule, in providing program management and oversight and in tracking account and other ad hoc analyses. Section 4.19.2.2.11 of the contract between HSD and the MCO states, “[The Contractor shall] meet HSD Encounter timeliness requirements by submitting to HSD at least ninety percent (90%) of its Claims, both paid and denied, originals and adjustments within thirty (30) Calendar Days of the date of adjudication, and ninety-nine percent (99%) within sixty (60) Calendar Days of the date of adjudication…whether the Encounter is from a subcontractor, subcapitated arrangement, or performed by the CONTRACTOR.” Subsequently in Section 7.3.1.1, the contract states, “In the event that the CONTRACTOR or any person with an ownership interest in the CONTRACTOR, affiliate, parent or subcontractor, fails to comply with this Agreement, HSD may impose, at HSD's discretion, the remedies, sanctions and damages described in this Section [7.3].”

EXECUTIVE SUMMARY


4

This encounter reconciliation will also help fulfill part of the work requirements outlined in step number 3 of the Center for Medicare & Medicaid Services’ (CMS) External Quality Review Protocol 4 EQR Protocol 4: Validation of Encounter Data Reported by the MCO, which requires a determination of the completeness, accuracy and quality of the encounter data being submitted by each MCO. The EQR Protocol 4: Validation of Encounter Data Reported by the MCO is an excellent way to assess whether the encounter data can be used to determine program effectiveness, accurately evaluate utilization, identify service gaps and make strong management decisions. In addition, the Protocol evaluates both departmental policies, as well as the policies, procedures and systems of the health plans to identify strengths and opportunities to enhance oversight. The full results of the EQR Protocol 4: Validation of Encounter Data Reported by the MCO work will be issued as a separate report.

EXECUTIVE SUMMARY


5

August 2017 Encounter Reconciliation Report The August 2017 New Mexico Encounter Reconciliation report is an analysis of encounters identified in the encounter data compared to the payments to service providers in the ASD. Below is a summary of the cumulative completion percentages for all encounter paid claims submitted to Conduent (FA) by UHC for the reporting period of January 1, 2014 through February 28, 2017. Included within this report, are the potential data issues and assumptions utilized during the completion of this report, as well as our recommendations to UHC, FA, and HSD to help identify and correct the root causes of the issues identified. HealthInsight and Myers and Stauffer recommend that HSD utilize this report as a management oversight tool to track the progress made by UHC over time and to monitor UHC’s contract compliance with providing complete and accurate encounter information. This report consists of UHC’s encounters and ASD and is summarized in Table A below.

Table A UHC ― Cumulative Completion Percentages UHC/Delegated Vendor % of Cumulative Total

Entire Plan 100.15% Dental Benefits 83.63% Pharmacy Benefits 101.26% Plan Processed & all other vendors 100.54%

Potential issues that may impact the completion percentages are listed below (a full list and description of all potential are included in the main report):

1) There may be encounters included without a matching ASD transaction. UHC data were particularly difficult to match since the plan’s transaction control number field was not used in such a way that it facilitated matching with the corresponding ASD’s claim number.

2) It is possible that there were duplicate claims in the encounter data that we were unable to identify and remove.

3) Some ASD transaction dates may not have matched the payment dates that were reported in the encounter data resulting in potential timing issues.

4) The ASD transaction total is low for January 2014, approximately 30 percent of the amount submitted for subsequent months. The compare percentage could be in excess of 100 percent when comparing the encounter data to the ASDs as a result of the low transaction totals in the ASDs. The pharmacy encounters for March through May 2014 show a negative dollar paid amount. The absence of paid encounters for that time period may explain the excessive percentage of pharmacy encounters noted for July 2014. For the first six months of calendar year 2014, pharmacy encounter data averaged $99,000 per month; however, in July 2014, the pharmacy encounter data shows over $11 million for the monthly reported total.

EXECUTIVE SUMMARY


6

The following terms are used throughout this document:

• Accounting System Data (ASD) – A journal used to record and track cash payments by an entity.

• ASD Monthly Reported Total – The sum of all payments from UHC or delegated vendors to service providers for a given month as reported by UHC to HSD.

• ASD Cumulative Reported Total – The sum of all payments from UHC or delegated vendors to service providers for the reconciliation period as reported by UHC to HSD.

• Calculated Void Encounter (CV) – An encounter that Myers and Stauffer has identified as being a replacement encounter that does not appear to have a corresponding void of the original encounter in the FA’s data warehouse.

• Centennial Care – The name given to the Medicaid managed care program administered by the state effective January 1, 2014. It replaced the previous system, which had Salud!, State Coverage Insurance, coordination of long-term services, and behavioral health all administered as separate programs.

• Conduent, Inc. (Conduent) – The state’s fiscal agent. Conduent was formerly known as Xerox Health Solutions. The name change went into effect January 2017.

• Cumulative Encounter Total – The sum of all encounter submissions stored in the FA’s encounter data warehouse. This amount is inclusive of all amounts submitted in prior months.

• Cumulative Variance – The difference between the cumulative encounter total and the ASD cumulative reported total.

• Denied Encounter- An encounter, which has met all Health Insurance Portability and Accountability Act (HIPAA) and front end data checks and was accepted by the FA; however, once the encounter was checked against the MMIS business rules, it was denied due to an exception in a business rule. These denied encounters may be resubmitted by UHC to correct the issue, which caused the denial by the FA.

• Fiscal Agent (FA) – A contractor selected to design, develop, and maintain the claims processing system (Medicaid Management Information System); Conduent, Inc. (known as Xerox Health Solutions prior to January 2017) is the current FA.

• FOCoS Online (FOCoS) – A subcontractor of Conduent, Inc. • Health Insurance Portability and Accountability Act (HIPAA) – A federal law

that restricts access to people’s private medical information.



7

• Human Services Department (HSD) – The agency of state government responsible for administering a portfolio of programs, including Medicaid.

• Managed Care Organization (MCO) – Organizations contracted with the state Human Services Department to provide Medicaid managed care services. As of this writing, the four currently contracted Medicaid managed care organizations are Blue Cross and Blue Shield of New Mexico, Molina Healthcare of New Mexico, Presbyterian Health Plan, Inc. and United Healthcare of New Mexico, Inc. MCOs receive a capitation or per member per month (PMPM) payment from HSD for each enrolled member.

• Medicaid Management Information System (MMIS) – The claims processing system used by the FA to adjudicate New Mexico’s Medicaid claims. UHC- submitted encounters are loaded into this system and assigned a unique claim identifier.

• Monthly Encounter Total – The sum of all encounter submissions for a given month stored in the FA’s encounter data warehouse.

• Monthly Variance – The difference between the monthly encounter total and the ASD monthly reported total.

• Potential Duplicate Encounter (PDUP) – An encounter that Myers and Stauffer has identified as being a potential duplicate of another encounter in the FA’s data warehouse.

• Rejected Encounter - An encounter that has been submitted to the FA but did not meet HIPAA or other front end data checks and was not accepted into the MMIS.

• Transaction Control Number (TCN) – A “smart number” whose characters indicate some information about the claim.

• TNT Fiscal Intermediary - A subcontractor of Conduent, Inc. • United Healthcare of New Mexico (UHC) – One of the four Medicaid managed

care organizations in New Mexico. • Xerox Health Solutions (Xerox) – Former name of Conduent, Inc., the state’s

fiscal agent. The name change went into effect January 2017.



8

HealthInsight engaged Myers and Stauffer to analyze Medicaid encounter data that has been submitted by UHC to the FA and complete a comparison of the encounters to accounting system data provided by UHC. Such encounters are submitted by UHC to HSD via the FA for HSD’s use in rate setting, federal reporting, program management and oversight, tracking, accounting and other ad hoc analyses. HealthInsight, on behalf of HSD, requested that for this study, we estimate the percentage of UHC and delegated vendor paid encounters that appear to be included in the FA’s data warehouse. This analysis includes these percentages for all UHC paid encounters as well as separate pharmacy and dental vendor encounters paid during the period January 1, 2014 through February 28, 2017.

STUDY PURPOSE


9

Myers and Stauffer received encounter data from the FA. The data are in a standardized extract containing institutional, medical, and pharmacy encounters from all four MCOs. These encounter data extracts include encounters having plan paid dates starting with January 1, 2014. The data used for this report includes encounters received and accepted by the FA and transmitted to Myers and Stauffer through April 30, 2017. Myers and Stauffer also requested ASD from UHC ranging in dates from January 1, 2014 through February 28, 2017 in a standardized monthly format.

DATA SOURCES


10

Encounters from institutional, medical and pharmacy claim types were combined on like data fields. We analyzed the line reported information of each encounter to capture the amount paid on the entire claim. Encounter totals were calculated by summarizing the data by the UHC paid date and UHC identification number. ASD submitted by UHC were summarized by paid date. These matching tables were combined using common fields between the tables and were used to produce the results. Based on criteria provided by UHC and HSD, we identified UHC encounters as follows: General Criteria for All Populations:

Submitter ID For UHC the submitter ID is noted to be 16785851. Encounters with

this identifier in either the submitter ID field or the provider ID field have been included in this analysis.

Filing Indicators No filing indicators were excluded from these analyses.

Criteria for Specific Populations:

Pharmacy Benefits

Pharmacy encounters were isolated by restricting the data to header type code ‘R’.

Dental Benefits Dental encounters were isolated by restricting the data to header

type code ‘D’.

Plan Processed Encounters and Other Vendors Plan Processed Encounters and Other Vendors were isolated by

excluding the data with header type code ‘D’ or ‘R’.

ANALYSIS


11

In the performance of this analysis, Myers and Stauffer makes the following assumptions and notes regarding potential data issues: 1. We assume that all data provided to Myers and Stauffer is complete and accurate.

2. This analysis only included encounter information that was submitted by UHC to the FA and loaded into the FA’s data warehouse. Encounters that were rejected by the FA for errors in submission or other reasons are excluded from this analysis.

3. We instructed UHC to exclude referral fees, management fees and other non-encounter related fees in the ASD data submitted to Myers and Stauffer.

4. We noted that there are some encounters that do not include a submitter ID, but they do include the UHC submitter ID in the Provider ID field. We have included these encounters in this analysis.

5. As identified in Table 2 – UHC Calculated Void and Duplicate Summary, we identified potential duplicate encounters. We analyzed the encounter and ASD submissions to conclude that some of these potential duplicates appear to be partial payments and some are actual duplicate submissions. We have attempted to adjust our totals to reflect the actual payment made and have removed duplicate payments from our analysis, when possible.

6. The monthly completion percentages in the entire plan exceeded 100 percent for some months of the reporting period. These overstated monthly completion percentages may be due to a variety of reasons such as encounters included without a corresponding matching ASD transaction or certain voids and replacements that were absent from the encounter data, but were accounted for in the ASD. Additionally, duplicate encounters may have existed in the encounter data that we were unable to identify and remove. Also, ASD payment dates may not have matched the payment dates that were reported in the encounter data resulting in potential timing issues.

7. Myers and Stauffer historically codes void encounters contained within the encounter submissions to match the associated adjustment claim’s paid date. This allows for proper matching of ASD that occurred due to this voided transaction. We were unable to assign a paid date (to the void encounters) which was different than the date of the original submission because it seems that UHC used the date of the original submission for their paid date and the UHC received date on all subsequent adjustments, replacements, backouts and voids of an encounter.



12

8. During the data analyses, Myers and Stauffer noted many encounters that were categorized as voids, adjustment credits or adjustment debits that did not indicate an associated original, paid encounter. Fields that are supposed to just indicate the TCN of the original encounter, the TCN of the replaced encounter and the TCN of the replacement encounter were left blank in instances where it seems they should have been completed.

9. Interest amounts do not appear to be included in the UHC paid amounts. We have therefore excluded the separately itemized interest expense from the ASD totals.

10. Encounters denied by the FA were included and subjected to our potential duplicate encounter logic process which attempts to identify and remove these encounters appropriately. This methodology artificially inflates the percentages of claim counts and amounts removed as identified in Table 2 – UHC Calculated Void and Duplicate Summary, since some of these were likely already marked as denied for this very duplicate issue. This is currently the only fair and representative way to ensure that the actual UHC paid encounters remain in our analysis.

11. There are claim adjustment instances in the encounters where the claim adjustment backout is successful, but the corresponding replacement transaction is denied by the FA. These instances effectively remove paid encounters from the FA’s data warehouse that UHC may have intended to replace.

12. ASD payment dates may not have matched the payment dates that were reported in the encounter data resulting in potential timing issues. It seems that UHC has used the original encounter received date as the encounter received date on all subsequent adjustments to an encounter. Similarly, it seems the UHC encounter paid date for an original encounter claim is the same date used as the UHC encounter paid date for all subsequent adjustments of the same encounter.

13. The ASD transaction total for January 2014 is significantly lower than the transaction totals for subsequent months. This may contribute to the completion percentage exceeding 100 percent during January 2014.

14. There appears to be very few “paid” pharmacy encounters during the first half of calendar year 2014. The lack of paid encounters during those months significantly lowers the cumulative monthly completion percentages for pharmacy and the entire plan.

15. To ensure the inclusion of all encounter claims paid by UHC, we have not excluded any claims that were system denied. The system denied claims were subjected to our potential duplicate encounter logic process which attempts to identify and remove these claims appropriately, while allowing the encounters paid by UHC to remain in the analysis.



13

16. Analysis of the encounter data and ASD, as well as interactions with UHC, HSD and the FA have resulted in the identification of opportunities for improving the encounter reconciliation process. While we have attempted to account for these situations, other potential issues within the data may exist that have not yet been identified which may require us to restate a report or modify reconciliation processes in the future.



14

UHC appears to have submitted approximately 100.15 percent of their encounter data for this period, with the cumulative monthly range between 99 percent and 299 percent. Monthly percentages exceeded 100 percent during some months of the reporting period and for the overall study period. Please reference Potential Data Issues for an explanation of the possible causes.

Table 1 ― UHC - Entire Plan

Paid Month ASD

Monthly Reported

Total

Monthly Encounter



Total


Total Cumulative

Variance % of Monthly Encounters


January 2014 $9,096,127 $27,228,382 $18,132,255 $9,096,127 $27,228,382 $18,132,255 299.34% 299.34% February 2014 $29,825,737 $30,473,614 $647,877 $38,921,864 $57,701,996 $18,780,132 102.17% 148.25% March 2014 $35,950,017 $39,096,418 $3,146,400 $74,871,882 $96,798,414 $21,926,532 108.75% 129.28% April 2014 $44,740,376 $39,875,719 ($4,864,657) $119,612,257 $136,674,133 $17,061,876 89.12% 114.26% May 2014 $46,760,758 $44,416,181 ($2,344,577) $166,373,016 $181,090,314 $14,717,299 94.98% 108.84% June 2014 $43,560,644 $41,067,392 ($2,493,252) $209,933,660 $222,157,706 $12,224,047 94.27% 105.82% July 2014 $49,264,143 $54,574,288 $5,310,146 $259,197,803 $276,731,995 $17,534,192 110.77% 106.76% August 2014 $50,625,420 $43,500,070 ($7,125,350) $309,823,223 $320,232,065 $10,408,842 85.92% 103.35% September 2014 $54,591,294 $48,325,226 ($6,266,067) $364,414,517 $368,557,291 $4,142,775 88.52% 101.13% October 2014 $57,679,844 $56,663,723 ($1,016,121) $422,094,361 $425,221,014 $3,126,653 98.23% 100.74% November 2014 $52,576,344 $57,889,396 $5,313,052 $474,670,705 $483,110,410 $8,439,706 110.10% 101.77% December 2014 $55,708,359 $59,769,291 $4,060,932 $530,379,064 $542,879,701 $12,500,637 107.28% 102.35% January 2015 $57,260,975 $58,181,592 $920,616 $587,640,039 $601,061,293 $13,421,254 101.60% 102.28% February 2015 $53,883,310 $62,962,861 $9,079,551 $641,523,349 $664,024,154 $22,500,805 116.85% 103.50% March 2015 $64,544,892 $61,186,973 ($3,357,918) $706,068,241 $725,211,127 $19,142,886 94.79% 102.71% April 2015 $69,568,614 $72,975,881 $3,407,267 $775,636,854 $798,187,007 $22,550,153 104.89% 102.90% May 2015 $58,157,379 $67,530,940 $9,373,560 $833,794,234 $865,717,947 $31,923,713 116.11% 103.82% June 2015 $57,092,458 $64,150,812 $7,058,354 $890,886,691 $929,868,759 $38,982,067 112.36% 104.37% July 2015 $72,535,296 $64,215,510 ($8,319,786) $963,421,988 $994,084,269 $30,662,282 88.53% 103.18% August 2015 $63,626,647 $59,431,522 ($4,195,125) $1,027,048,634 $1,053,515,791 $26,467,157 93.40% 102.57% September 2015 $57,723,955 $60,283,132 $2,559,177 $1,084,772,590 $1,113,798,923 $29,026,334 104.43% 102.67% October 2015 $65,481,192 $65,457,286 ($23,906) $1,150,253,782 $1,179,256,210 $29,002,428 99.96% 102.52% November 2015 $61,031,843 $61,556,262 $524,419 $1,211,285,625 $1,240,812,472 $29,526,847 100.85% 102.43% December 2015 $69,821,090 $67,637,435 ($2,183,655) $1,281,106,716 $1,308,449,907 $27,343,192 96.87% 102.13% January 2016 $58,960,559 $59,660,112 $699,553 $1,340,067,274 $1,368,110,019 $28,042,745 101.18% 102.09%

UHC – ENTIRE PLAN

UHC JANUARY 2014 – FEBRUARY 2017


15

Table 1 – UHC – Entire Plan (continued)

Paid Month ASD

Monthly Reported

Total

Monthly Encounter



Total


Total Cumulative

Variance % of

Monthly Encounters

% of Cumulative

Total

February 2016 $61,288,798 $57,395,365 ($3,893,434) $1,401,356,072 $1,425,505,384 $24,149,311 93.64% 101.72% March 2016 $65,976,581 $63,758,301 ($2,218,281) $1,467,332,654 $1,489,263,684 $21,931,031 96.63% 101.49% April 2016 $60,322,173 $60,480,741 $158,568 $1,527,654,827 $1,549,744,425 $22,089,599 100.26% 101.44% May 2016 $56,639,040 $51,208,895 ($5,430,145) $1,584,293,866 $1,600,953,320 $16,659,454 90.41% 101.05% June 2016 $65,281,697 $58,128,991 ($7,152,706) $1,649,575,564 $1,659,082,311 $9,506,748 89.04% 100.57% July 2016 $62,009,212 $57,180,016 ($4,829,196) $1,711,584,775 $1,716,262,327 $4,677,552 92.21% 100.27% August 2016 $62,984,587 $56,358,920 ($6,625,666) $1,774,569,362 $1,772,621,247 ($1,948,114) 89.48% 99.89% September 2016 $57,721,474 $53,692,660 ($4,028,815) $1,832,290,836 $1,826,313,907 ($5,976,929) 93.02% 99.67% October 2016 $53,285,488 $52,211,235 ($1,074,253) $1,885,576,325 $1,878,525,142 ($7,051,182) 97.98% 99.62% November 2016 $52,985,402 $53,847,965 $862,563 $1,938,561,727 $1,932,373,107 ($6,188,620) 101.62% 99.68% December 2016 $55,796,849 $56,030,498 $233,649 $1,994,358,575 $1,988,403,605 ($5,954,970) 100.41% 99.70% January 2017 $47,795,901 $52,328,487 $4,532,586 $2,042,154,476 $2,040,732,092 ($1,422,384) 109.48% 99.93% February 2017 $45,032,578 $49,735,131 $4,702,554 $2,087,187,054 $2,090,467,223 $3,280,170 110.44% 100.15%

*Please note that the ASD has been provided to Myers and Stauffer by UHC. Encounter data

has been provided by the FA.



16

The calculated void (CV) and potential duplicate (PDUP) encounters that have been identified through the encounter reconciliation analysis are indicated below. These encounters have been removed from the encounter reconciliation totals.

Table 2 ― UHC Calculated Void and Duplicate Summary

Paid Month Count of Encounters

Total Sum (MCO

Submitted Paid Amount)

Count of CV PDUP

Encounters

CV PDUP Amount

Removed

% of CV PDUP

Encounter Count

% of CV PDUP

Amount Removed

January 2014 115,258 $28,945,146 11,657 $2,173,187 10.11% 7.51% February 2014 171,623 $37,484,363 26,667 $7,019,863 15.54% 18.73% March 2014 225,912 $47,131,729 27,416 $8,036,077 12.14% 17.05% April 2014 239,948 $51,043,908 30,516 $11,037,197 12.72% 21.62% May 2014 478,322 $66,218,239 33,165 $10,571,852 6.93% 15.97% June 2014 355,888 $56,138,086 34,090 $10,412,049 9.58% 18.55% July 2014 362,171 $59,488,380 34,440 $11,718,278 9.51% 19.70% August 2014 359,288 $52,791,810 26,626 $10,005,347 7.41% 18.95% September 2014 370,119 $58,922,192 26,629 $10,860,398 7.19% 18.43% October 2014 445,255 $71,133,874 36,584 $12,180,606 8.22% 17.12% November 2014 358,228 $72,648,669 33,891 $14,848,494 9.46% 20.44% December 2014 386,966 $67,520,716 29,148 $10,084,886 7.53% 14.94% January 2015 380,184 $75,157,233 38,104 $16,909,640 10.02% 22.50% February 2015 385,779 $92,971,090 46,004 $29,215,826 11.92% 31.42% March 2015 395,405 $79,289,929 34,709 $17,613,000 8.78% 22.21% April 2015 425,278 $106,644,108 50,629 $33,739,807 11.90% 31.64% May 2015 504,625 $92,110,783 57,768 $24,713,607 11.45% 26.83% June 2015 366,892 $80,227,834 23,656 $16,401,482 6.45% 20.44% July 2015 366,294 $84,126,352 22,932 $19,737,984 6.26% 23.46% August 2015 347,772 $69,832,405 18,635 $10,088,832 5.36% 14.45% September 2015 372,579 $69,731,067 29,812 $9,562,205 8.00% 13.71% October 2015 369,229 $73,275,516 25,724 $7,523,071 6.97% 10.27% November 2015 344,760 $68,157,504 21,284 $5,861,717 6.17% 8.60% December 2015 377,830 $80,226,933 29,449 $12,155,741 7.79% 15.15% January 2016 347,784 $70,392,039 26,826 $9,255,047 7.71% 13.15% February 2016 325,202 $66,686,890 16,656 $8,472,800 5.12% 12.71% March 2016 357,762 $69,995,379 18,407 $7,453,725 5.15% 10.65% April 2016 355,050 $68,714,629 19,194 $8,282,254 5.41% 12.05% May 2016 339,457 $59,021,382 20,962 $7,023,666 6.18% 11.90% June 2016 387,598 $76,086,735 47,412 $19,069,001 12.23% 25.06% July 2016 351,198 $69,658,448 31,085 $13,484,285 8.85% 19.36% August 2016 394,286 $73,150,549 35,059 $16,721,829 8.89% 22.86% September 2016 374,335 $79,402,616 40,337 $25,993,679 10.78% 32.74% October 2016 349,922 $66,216,539 35,471 $14,252,388 10.14% 21.52% November 2016 355,082 $68,844,523 39,967 $15,298,268 11.26% 22.22% December 2016 353,633 $67,786,374 39,339 $13,110,177 11.12% 19.34% January 2017 245,087 $62,823,780 37,158 $15,245,641 15.16% 24.27% February 2017 211,967 $53,640,334 13,408 $7,502,064 6.33% 13.99% TOTALS 13,253,968 2,593,638,082 1,170,816 503,635,969 8.83% 19.42%



17

Count of Encounters – The number of encounters processed by the FA (including encounters marked as denied by the FA). Total Sum (UHC Submitted Paid Amount) – The total paid amount of encounters in a month per the encounter data provided by the FA. These amounts do not incorporate the corrections to paid amounts as explained in the Potential Data Issues and Analysis Assumptions. Count of CV PDUP Encounters – The number of encounters identified by Myers and Stauffer as potential calculated voids and duplicates. CV PDUP Amount Removed – The paid amount removed from the Monthly Encounter Total based on Myers and Stauffer’s analysis of calculated void and duplicate encounters. % of CV PDUP Encounter Count – The percentage of CV PDUP encounters out of the total number of encounters. % of CV PDUP Amount Removed – The percentage of paid amount removed from the total UHC submitted paid amount.



18

Figure 1 – UHC’s ASD totals and encounter totals as reported monthly

Figure 2 - UHC’s cumulative encounter submissions expressed as a percentage of payments submitted to the FA to reported UHC ASD payments

$0

$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

$70,000,000

$80,000,000

ASD Monthly Reported Total


90%110%130%150%170%190%210%230%250%270%290%




19

UHC appears to have submitted approximately 83 percent of their dental encounter data for this period, with a cumulative monthly range between 83 percent and 130 percent. Monthly percentages exceeded 100 percent during a few months of the reporting period. Please reference Potential Data Issues for an explanation of the possible causes.

UHC– DENTAL UHC– DENTAL BENEFITS

Table 3 ― UHC Dental Benefits


Monthly Encounter


ASD Cumulative

Reported Total


Total Cumulative


% of Cumulative

Total

January 2014 $258,563 $336,138 $77,574 $258,563 $336,138 $77,574 130.00% 130.00% February 2014 $512,549 $465,195 ($47,354) $771,113 $801,333 $30,220 90.76% 103.91% March 2014 $711,444 $598,752 ($112,692) $1,482,557 $1,400,085 ($82,472) 84.16% 94.43% April 2014 $929,027 $842,903 ($86,124) $2,411,584 $2,242,988 ($168,596) 90.72% 93.00% May 2014 $1,348,292 $1,291,116 ($57,176) $3,759,875 $3,534,104 ($225,772) 95.75% 93.99% June 2014 $1,063,679 $997,124 ($66,555) $4,823,554 $4,531,228 ($292,327) 93.74% 93.93% July 2014 $1,078,465 $1,025,297 ($53,169) $5,902,020 $5,556,524 ($345,495) 95.06% 94.14% August 2014 $1,245,724 $1,316,514 $70,791 $7,147,743 $6,873,039 ($274,705) 105.68% 96.15% September 2014 $1,201,628 $1,145,776 ($55,852) $8,349,371 $8,018,815 ($330,557) 95.35% 96.04% October 2014 $1,499,843 $1,437,287 ($62,556) $9,849,215 $9,456,102 ($393,113) 95.82% 96.00% November 2014 $1,468,497 $1,236,995 ($231,503) $11,317,712 $10,693,096 ($624,616) 84.23% 94.48% December 2014 $1,408,076 $1,162,244 ($245,832) $12,725,788 $11,855,341 ($870,448) 82.54% 93.15% January 2015 $1,567,218 $1,453,530 ($113,688) $14,293,006 $13,308,870 ($984,136) 92.74% 93.11% February 2015 $1,308,048 $1,172,340 ($135,708) $15,601,055 $14,481,211 ($1,119,844) 89.62% 92.82% March 2015 $1,237,628 $1,080,470 ($157,158) $16,838,683 $15,561,681 ($1,277,002) 87.30% 92.41% April 2015 $1,468,203 $1,333,522 ($134,680) $18,306,886 $16,895,204 ($1,411,683) 90.82% 92.28% May 2015 $1,578,094 $1,392,240 ($185,854) $19,884,981 $18,287,444 ($1,597,537) 88.22% 91.96% June 2015 $1,320,780 $1,157,232 ($163,548) $21,205,761 $19,444,676 ($1,761,085) 87.61% 91.69% July 2015 $1,899,027 $1,463,922 ($435,105) $23,104,788 $20,908,598 ($2,196,190) 77.08% 90.49% August 2015 $1,497,308 $1,302,075 ($195,233) $24,602,096 $22,210,672 ($2,391,423) 86.96% 90.27% September 2015 $1,999,747 $1,525,232 ($474,515) $26,601,843 $23,735,905 ($2,865,938) 76.27% 89.22% October 2015 $1,980,744 $1,597,427 ($383,317) $28,582,587 $25,333,332 ($3,249,255) 80.64% 88.63% November 2015 $1,398,425 $1,218,564 ($179,862) $29,981,012 $26,551,895 ($3,429,117) 87.13% 88.56% December 2015 $1,797,254 $1,415,779 ($381,475) $31,778,267 $27,967,674 ($3,810,592) 78.77% 88.00% January 2016 $1,413,725 $1,159,631 ($254,094) $33,191,992 $29,127,306 ($4,064,686) 82.02% 87.75% February 2016 $1,180,066 $1,006,453 ($173,613) $34,372,057 $30,133,759 ($4,238,299) 85.28% 87.66% March 2016 $1,700,096 $1,456,084 ($244,012) $36,072,154 $31,589,843 ($4,482,311) 85.64% 87.57% April 2016 $1,635,024 $1,364,507 ($270,516) $37,707,177 $32,954,350 ($4,752,827) 83.45% 87.39%



20

Table 3 ― UHC Dental Benefits (continued)

Paid Month ASD Monthly

Reported Total

Monthly Encounter



Total


Total Cumulative


% of Cumulative

Total

May 2016 $1,795,309 $1,548,836 ($246,472) $39,502,486 $34,503,186 ($4,999,300) 86.27% 87.34% June 2016 $1,595,632 $1,188,526 ($407,106) $41,098,118 $35,691,712 ($5,406,406) 74.48% 86.84% July 2016 $1,118,648 $1,452,592 $333,944 $42,216,766 $37,144,304 ($5,072,462) 129.85% 87.98% August 2016 $1,299,194 $1,364,200 $65,006 $43,515,959 $38,508,504 ($5,007,455) 105.00% 88.49% September 2016 $2,767,627 $1,659,790 ($1,107,838) $46,283,586 $40,168,294 ($6,115,293) 59.97% 86.78% October 2016 $1,365,576 $1,162,359 ($203,217) $47,649,162 $41,330,653 ($6,318,510) 85.11% 86.73% November 2016 $2,170,444 $1,283,786 ($886,658) $49,819,606 $42,614,439 ($7,205,168) 59.14% 85.53% December 2016 $2,355,502 $1,352,821 ($1,002,681) $52,175,108 $43,967,259 ($8,207,849) 57.43% 84.26% January 2017 $1,327,444 $1,014,315 ($313,129) $53,502,552 $44,981,574 ($8,520,978) 76.41% 84.07% February 2017 $1,634,451 $1,131,655 ($502,796) $55,137,003 $46,113,229 ($9,023,774) 69.23% 83.63%



21

UHC appears to have submitted approximately 101 percent of the pharmacy benefit encounter data for this period, with a cumulative monthly range between 4 percent and 209 percent. Monthly percentages exceeded 100 percent during some months of the reporting period. Please reference Potential Data Issues for an explanation of the possible causes.

Table 4 ― UHC Pharmacy Benefits


Monthly Encounter


ASD Cumulative

Reported Total


Total Cumulative


% of Cumulative

Total

January 2014 $217,541 $456,096 $238,555 $217,541 $456,096 $238,555 209.65% 209.65% February 2014 $1,660,891 $9,015 ($1,651,876) $1,878,432 $465,111 ($1,413,321) 0.54% 24.76% March 2014 $2,277,860 ($328) ($2,278,188) $4,156,292 $464,783 ($3,691,509) -0.01% 11.18% April 2014 $3,470,672 ($99) ($3,470,771) $7,626,964 $464,684 ($7,162,281) 0.00% 6.09% May 2014 $2,623,619 ($1,093) ($2,624,712) $10,250,584 $463,591 ($9,786,993) -0.04% 4.52% June 2014 $2,816,058 $130,893 ($2,685,165) $13,066,641 $594,484 ($12,472,157) 4.64% 4.54% July 2014 $3,175,079 $11,229,113 $8,054,034 $16,241,721 $11,823,597 ($4,418,123) 353.66% 72.79% August 2014 $4,230,050 $4,789,538 $559,488 $20,471,771 $16,613,135 ($3,858,636) 113.22% 81.15% September 2014 $4,002,571 $4,424,926 $422,355 $24,474,342 $21,038,061 ($3,436,280) 110.55% 85.95% October 2014 $4,005,516 $4,075,930 $70,414 $28,479,858 $25,113,992 ($3,365,867) 101.75% 88.18% November 2014 $3,804,399 $4,161,494 $357,095 $32,284,258 $29,275,486 ($3,008,772) 109.38% 90.68% December 2014 $4,276,673 $6,365,474 $2,088,801 $36,560,931 $35,640,960 ($919,971) 148.84% 97.48% January 2015 $3,948,809 $4,072,274 $123,464 $40,509,740 $39,713,234 ($796,506) 103.12% 98.03% February 2015 $2,955,865 $4,032,014 $1,076,149 $43,465,605 $43,745,248 $279,642 136.40% 100.64% March 2015 $5,260,042 $4,138,275 ($1,121,767) $48,725,647 $47,883,522 ($842,125) 78.67% 98.27% April 2015 $4,413,030 $4,824,417 $411,387 $53,138,677 $52,707,939 ($430,738) 109.32% 99.18% May 2015 $4,677,696 $4,628,231 ($49,465) $57,816,373 $57,336,170 ($480,203) 98.94% 99.16% June 2015 $4,384,316 $4,752,838 $368,522 $62,200,688 $62,089,008 ($111,680) 108.40% 99.82% July 2015 $4,539,008 $4,494,467 ($44,541) $66,739,697 $66,583,475 ($156,221) 99.01% 99.76% August 2015 $4,832,359 $4,428,379 ($403,980) $71,572,056 $71,011,854 ($560,202) 91.64% 99.21% September 2015 $4,475,562 $4,667,324 $191,762 $76,047,618 $75,679,178 ($368,440) 104.28% 99.51% October 2015 $4,039,637 $4,740,429 $700,792 $80,087,254 $80,419,607 $332,352 117.34% 100.41% November 2015 $5,242,256 $4,553,054 ($689,202) $85,329,511 $84,972,661 ($356,850) 86.85% 99.58% December 2015 $5,380,003 $5,035,587 ($344,415) $90,709,514 $90,008,248 ($701,265) 93.59% 99.22%

UHC – PHARMACY BENEFITS



22

Table 4 ― UHC Pharmacy Benefits (continued)


Monthly Encounter


ASD Cumulative

Reported Total


Total Cumulative


% of Cumulative

Total

January 2016 $5,395,731 $5,292,579 ($103,152) $96,105,245 $95,300,827 ($804,418) 98.08% 99.16% February 2016 $5,149,626 $5,469,344 $319,718 $101,254,871 $100,770,171 ($484,699) 106.20% 99.52% March 2016 $7,557,901 $6,769,459 ($788,441) $108,812,771 $107,539,631 ($1,273,141) 89.56% 98.82% April 2016 $6,048,786 $6,288,069 $239,283 $114,861,558 $113,827,700 ($1,033,858) 103.95% 99.09% May 2016 $5,522,952 $5,552,812 $29,860 $120,384,510 $119,380,512 ($1,003,998) 100.54% 99.16% June 2016 $5,489,069 $6,239,703 $750,634 $125,873,579 $125,620,215 ($253,364) 113.67% 99.79% July 2016 $5,338,692 $6,341,634 $1,002,942 $131,212,271 $131,961,849 $749,578 118.78% 100.57% August 2016 $5,015,223 $5,128,446 $113,224 $136,227,494 $137,090,295 $862,802 102.25% 100.63% September 2016 $4,075,567 $5,335,782 $1,260,214 $140,303,061 $142,426,077 $2,123,016 130.92% 101.51% October 2016 $5,779,590 $5,198,247 ($581,343) $146,082,650 $147,624,323 $1,541,673 89.94% 101.05% November 2016 $4,540,567 $5,052,058 $511,491 $150,623,217 $152,676,382 $2,053,164 111.26% 101.36% December 2016 $5,303,705 $4,951,163 ($352,542) $155,926,922 $157,627,544 $1,700,622 93.35% 101.09% January 2017 $4,778,028 $4,750,348 ($27,680) $160,704,950 $162,377,892 $1,672,942 99.42% 101.04% February 2017 $3,199,524 $3,596,862 $397,338 $163,904,474 $165,974,754 $2,070,280 112.41% 101.26%



23

UHC appears to have submitted approximately 100 percent of the UHC fee-for-service and other vendors encounter data for this period, with a cumulative monthly range between 99 percent and 306 percent. Monthly percentages exceeded 100 percent during some months of the reporting period and for the overall study period. Please reference Potential Data Issues for an explanation of the possible causes.

Table 5 ― UHC Plan Processed Encounters and Other Vendors


Monthly Encounter


ASD Cumulative

Reported Total


Total Cumulative


% of Cumulative

Total

January 2014 $8,620,022 $26,436,149 $17,816,126 $8,620,022 $26,436,149 $17,816,126 306.68% 306.68% February 2014 $27,652,297 $29,999,404 $2,347,107 $36,272,319 $56,435,553 $20,163,233 108.48% 155.58% March 2014 $32,960,713 $38,497,993 $5,537,280 $69,233,032 $94,933,546 $25,700,513 116.79% 137.12% April 2014 $40,340,677 $39,032,916 ($1,307,761) $109,573,709 $133,966,461 $24,392,752 96.75% 122.26% May 2014 $42,788,847 $43,126,158 $337,311 $152,362,557 $177,092,619 $24,730,063 100.78% 116.23% June 2014 $39,680,907 $39,939,375 $258,468 $192,043,464 $217,031,994 $24,988,531 100.65% 113.01% July 2014 $45,010,598 $42,319,879 ($2,690,720) $237,054,062 $259,351,873 $22,297,811 94.02% 109.40% August 2014 $45,149,647 $37,394,018 ($7,755,629) $282,203,709 $296,745,891 $14,542,182 82.82% 105.15% September 2014 $49,387,095 $42,754,524 ($6,632,571) $331,590,803 $339,500,415 $7,909,612 86.57% 102.38% October 2014 $52,174,485 $51,150,506 ($1,023,979) $383,765,288 $390,650,921 $6,885,633 98.03% 101.79% November 2014 $47,303,447 $52,490,907 $5,187,460 $431,068,735 $443,141,828 $12,073,093 110.96% 102.80% December 2014 $50,023,609 $52,241,572 $2,217,963 $481,092,344 $495,383,400 $14,291,056 104.43% 102.97% January 2015 $51,744,948 $52,655,789 $910,841 $532,837,292 $548,039,188 $15,201,896 101.76% 102.85% February 2015 $49,619,397 $57,758,507 $8,139,110 $582,456,689 $605,797,695 $23,341,007 116.40% 104.00% March 2015 $58,047,221 $55,968,228 ($2,078,994) $640,503,910 $661,765,923 $21,262,013 96.41% 103.31% April 2015 $63,687,381 $66,817,941 $3,130,560 $704,191,291 $728,583,864 $24,392,573 104.91% 103.46% May 2015 $51,901,589 $61,510,469 $9,608,879 $756,092,881 $790,094,333 $34,001,453 118.51% 104.49% June 2015 $51,387,362 $58,240,742 $6,853,380 $807,480,242 $848,335,075 $40,854,833 113.33% 105.05% July 2015 $66,097,261 $58,257,121 ($7,840,139) $873,577,503 $906,592,197 $33,014,693 88.13% 103.77% August 2015 $57,296,980 $53,701,069 ($3,595,911) $930,874,483 $960,293,265 $29,418,782 93.72% 103.16% September 2015 $51,248,646 $54,090,576 $2,841,930 $982,123,129 $1,014,383,841 $32,260,712 105.54% 103.28% October 2015 $59,460,811 $59,119,430 ($341,381) $1,041,583,940 $1,073,503,271 $31,919,331 99.42% 103.06% November 2015 $54,391,161 $55,784,645 $1,393,483 $1,095,975,102 $1,129,287,916 $33,312,814 102.56% 103.03% December 2015 $62,643,833 $61,186,069 ($1,457,765) $1,158,618,935 $1,190,473,985 $31,855,049 97.67% 102.74% January 2016 $52,151,103 $53,207,902 $1,056,799 $1,210,770,038 $1,243,681,886 $32,911,848 102.02% 102.71% February 2016 $54,959,106 $50,919,568 ($4,039,539) $1,265,729,144 $1,294,601,454 $28,872,310 92.64% 102.28% March 2016 $56,718,584 $55,532,757 ($1,185,827) $1,322,447,729 $1,350,134,211 $27,686,482 97.90% 102.09%

UHC- PLAN PROCESSED ENCOUNTERS AND OTHER VENDORS



24

Table 5 ― UHC Plan Processed Encounters and Other Vendors (continued)

Paid Month ASD Monthly

Reported Total

Monthly Encounter



Total


Total Cumulative


% of Cumulative

Total

April 2016 $52,638,363 $52,828,165 $189,802 $1,375,086,091 $1,402,962,376 $27,876,284 100.36% 102.02% May 2016 $49,320,779 $44,107,246 ($5,213,533) $1,424,406,871 $1,447,069,622 $22,662,751 89.42% 101.59% June 2016 $58,196,996 $50,700,763 ($7,496,234) $1,482,603,867 $1,497,770,385 $15,166,517 87.11% 101.02% July 2016 $55,551,871 $49,385,789 ($6,166,082) $1,538,155,739 $1,547,156,174 $9,000,435 88.90% 100.58% August 2016 $56,670,170 $49,866,274 ($6,803,896) $1,594,825,909 $1,597,022,448 $2,196,539 87.99% 100.13% September 2016 $50,878,280 $46,697,089 ($4,181,191) $1,645,704,189 $1,643,719,537 ($1,984,652) 91.78% 99.87% October 2016 $46,140,323 $45,850,629 ($289,694) $1,691,844,512 $1,689,570,166 ($2,274,346) 99.37% 99.86% November 2016 $46,274,391 $47,512,121 $1,237,730 $1,738,118,903 $1,737,082,287 ($1,036,616) 102.67% 99.94% December 2016 $48,137,642 $49,726,514 $1,588,872 $1,786,256,545 $1,786,808,801 $552,256 103.30% 100.03% January 2017 $41,690,429 $46,563,825 $4,873,396 $1,827,946,974 $1,833,372,626 $5,425,652 111.68% 100.29% February 2017 $40,198,603 $45,006,615 $4,808,012 $1,868,145,577 $1,878,379,241 $10,233,664 111.96% 100.54%



25

1. HealthInsight and Myers and Stauffer recommend that UHC include their submitter ID with every encounter as required by CMS in accordance with the American National Standards Institute (ANSI), Accredited Standards Committee (ASC) X12 Version 5010. We also recommend that Conduent use an integrity constraint that prevents encounters without a submitter ID from being accepted into MMIS.

2. HealthInsight and Myers and Stauffer recommend that UHC include HSD TCN of the previously paid encounter that an adjustment or void modifies as required by section 4.19.2.2.7 of the Medicaid Managed Care Services Agreement. In addition, we recommend that Conduent employ an edit that requires HSD TCN on all adjustments and voids to prevent encounters with this missing data element from being accepted into MMIS.

3. HealthInsight and Myers and Stauffer recommend that UHC populate the actual date of MCO adjudication and payment rather than repeating the date of MCO adjudication or payment on all subsequent iterations of an encounter. Populating the actual date of adjudication and payment is required by CMS in accordance with their Encounter Data Minimum Data Elements.

4. HealthInsight and Myers and Stauffer recommend that UHC submit all requested ASD transactions for inclusion in any future encounter reconciliations in accordance with the reporting requirements set out in the Medicaid Managed Care Services Agreement and in order to ensure the most accurate results are derived from the encounter reconciliation.

5. HealthInsight and Myers and Stauffer recommend that UHC match their MCO TCN in their encounters with the ASD claim number to assist with matching encounters with ASD transactions. This recommendation is based on Myers and Stauffer’s expertise and considerable experience.

RECOMMENDATIONS

UHC RECOMMENDATIONS

Appendix D-3: Claims To Encounter Matching Results

Page 1

U United Healthcare of New Mexico: Encounter Completeness Comparison to UHC-Submitted Claims Samples

Description

Medical

Dental

Pharmacy

September 2014 December 2014 September 2014 December 2014 September 2014 December 2014

Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Number of Claims Submitted

(Claim/Header Level) 239,221 100.00% 270,144 100.00% 7,387 100.00% 8,801 100.00% 74,511 100.00% 78,898 100.00%

Adjusted / Void 11,653 4.87% 12,109 4.48% 1,587 21.48% 2,832 32.18% 1,890 2.54% 2,233 2.83% Zero Paid / Capitated / TPL 24,043 10.05% 36,898 13.66% 0 0.00% 0 0.00% 0 0.00% 0 0.00%

Denied 45,685 19.10% 55,865 20.68% 0 0.00% 0 0.00% 0 0.00% 0 0.00% Paid 157,840 65.98% 165,272 61.18% 5,800 78.52% 5,969 67.82% 72,621 97.46% 76,665 97.17%

Number of Claims Submitted

(Claim/Header Level) 239,221 100.00% 270,144 100.00% 7,387 100.00% 8,801 100.00% 74,511 100.00% 78,898 100.00%

Less Denied Claims (not required to be submitted) (45,685) -19.10% (55,865) -20.68% 0 0.00% 0 0.00% 0 0.00% 0 0.00%

Less Multiple Claim Iterations and Potential Duplicates (adjustments, voids, replacements, duplicates) (15) -0.01% (23) -0.01% (209) -2.83% (396) -4.50% (67) -0.09% (93) -0.12%

Number of Non-Denied Unique (distinct) Claims 193,521 80.90% 214,256 79.31% 7,178 97.17% 8,405 95.50% 74,444 99.91% 78,805 99.88%

Number of Non-Denied Unique (distinct) Claims 193,521 100.00% 214,256 100.00% 7,178 100.00% 8,405 100.00% 74,444 100.00% 78,805 100.00%

Number of Claims NOT Traced to MMIS Encounter Data 6,794 3.51% 3,060 1.43% 2,047 28.52% 3,329 39.61% 235 0.32% 141 0.18%

Claims Traced to MMIS Encounter Data (Completeness) 186,727 96.49% 211,196 98.57% 5,131 71.48% 5,076 60.39% 74,209 99.68% 78,664 99.82%

Number of Claims Traced to MMIS Encounter Data 186,727 100.00% 211,196 100.00% 5,131 100.00% 5,076 100.00% 74,209 100.00% 78,664 100.00%

Number of Traced Claims submitted within:

0 to 30 days 90,787 48.62% 128,706 60.94% 3,697 72.05% 3,385 66.69% 71,034 95.72% 71,422 90.79%

31 to 90 days 25,898 13.87% 37,802 17.90% 238 4.64% 270 5.32% 877 1.18% 267 0.34%

91 to 180 days 22,836 12.23% 30,413 14.40% 101 1.97% 905 17.83% 197 0.27% 871 1.11%

181 to 270 days 30,112 16.13% 4,863 2.30% 381 7.43% 4 0.08% 643 0.87% 4,368 5.55%

271 to 365 days 4,065 2.18% 1,939 0.92% 131 2.55% 36 0.71% 356 0.48% 0 0.00%

Over 365 days 13,029 6.98% 7,473 3.54% 583 11.36% 476 9.38% 1,102 1.48% 1,736 2.21%

Number of Claims Traced to MMIS Encounter Data 186,727 100.00% 211,196 100.00%

Inpatient 9,562 5.12% 5,196 2.46%

Outpatient 25,984 13.92% 29,962 14.19%

Professional 151,181 80.96% 176,038 83.35% Note: Percentages that do not add to 100% are due to rounding

Appendix D-4: Key Data Element Results by Service Type

Page 1

Note: For all tables in this appendix percentages that do not add to 100% are due to rounding United Healthcare of New Mexico: Dental Encounters (837D)-Header Level

Key Data Field

Matching (Sample to MMIS data)

September 2014

Missing Values (Claims Sample not

populated)

Non-Matching Values

Erroneous Matching

Values (Not Valid)

Matching Values

Blank Values (Valid Nulls)

Values Present (Valid) Matching Values

Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent

Billing Provider NPI [and/or MMIS Billing Provider Number (Medicaid ID)]

368 7.17% 745 14.52% - - 4,018 78.31% 4,018 78.31%

Date of Service (Procedure Date) - - 1 0.02% - - 5,130 99.98% 5,130 99.98%

Former MMIS Claim TCN 350 6.82% - - 4,580 89.26% 201 3.92% 4,781 93.18%

MMIS TCN - - - - - - 5,131 100.00% 5,131 100.00%

MMIS Member Number - - - - - - 5,131 100.00% 5,131 100.00%

Plan Paid Date - - 744 14.50% - - 4,387 85.50% 4,387 85.50%

Plan Received Date - - 744 14.50% - - 4,387 85.50% 4,387 85.50%

Total Submitted Records Traced to MMIS

5,131


Page 2

United Healthcare of New Mexico: Dental Encounters (837D)-Header Level

Key Data Field


December 2014


populated)

Non-Matching Values

Erroneous Matching

Values (Not Valid)

Matching Values





138 2.72% 544 10.72% - - 4,394 86.56% 4,394 86.56%

Date of Service (Procedure Date) - - 2 0.04% - - 5,074 99.96% 5,074 99.96%

Former MMIS Claim TCN 352 6.93% - - 4,705 92.69% 19 0.37% 4,724 93.07%

MMIS TCN - - - - - - 5,076 100.00% 5,076 100.00%

MMIS Member Number - - 2 0.04% - - 5,074 99.96% 5,074 99.96%

Plan Paid Date - - 493 9.71% - - 4,583 90.29% 4,583 90.29%



5,076


Page 3

Notes: - Billed charges are generally header level key data elements. However, the UHC-submitted claims sample values appear to reflect line level amounts. Therefore, this data element was evaluated at the line level. - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated) - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or an FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 4

United Healthcare of New Mexico: Dental Encounters (837D)-Line Level

Key Data Field


September 2014


populated)

Non-Matching Values

Erroneous Matching

Values (Not Valid)

Matching Values




Billed Charges - - 26 0.19% - - 13,812 99.81% 13,812 99.81%

Place of Service - - - - - - 13,838 100.00% 13,838 100.00%

Plan Paid Amount - - 197 1.42% - - 13,641 98.58% 13,641 98.58%

Procedure Code - - 22 0.16% - - 13,816 99.84% 13,816 99.84%

Service (Rendering) Provider NPI [and/or MMIS Service (Rendering) Provider Number (Medicaid ID)]

- - 176 1.27% - - 13,662 98.73% 13,662 98.73%

Service Provider Specialty (and/or Taxonomy)

1,073 7.75% - - 45 0.33% 12,720 91.92% 12,765 92.25%

Tooth Number 14 0.10% - - 9,067 65.52% 4,757 34.38% 13,824 99.90%


13,838


Page 5

United Healthcare of New Mexico: Dental Encounters (837D)-Line Level

Key Data Field


December 2014


populated)

Non-Matching Values

Erroneous Matching

Values (Not Valid)

Matching Values




Billed Charges - - 11 0.08% - - 14,085 99.92% 14,085 99.92%

Place of Service - - - - - - 14,096 100.00% 14,096 100.00%

Plan Paid Amount - - 21 0.15% - - 14,075 99.85% 14,075 99.85%

Procedure Code 0.00% 16 0.11% - - 14,080 99.89% 14,080 99.89%

Service (Rendering) Provider NPI [and/or MMIS Service (Rendering) Provider Number (Medicaid ID)]

- - 229 1.62% - - 13,867 98.38% 13,867 98.38%


1,063 7.54% - - 38 0.27% 12,995 92.19% 13,033 92.46%

Tooth Number 14 0.10% - - 9,063 64.29% 5,019 35.61% 14,082 99.90%


14,096


Page 6

Notes: - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. -These tables were updated in the MCO rebuttal process to remove zero paid lines from consideration. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated) - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or an FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 7

United Healthcare of New Mexico: Inpatient Encounters (837I)-Header Level

Key Data Field


September 2014 Missing Values

(Claims Sample not populated)

Non-Matching Values

Erroneous Matching Values

(Not Valid)

Matching Values Blank Values (Valid Nulls)



Admission Date - 0.00% 78 0.82% - 0.00% 9,484 99.18% 9,484 99.18%

Bill Type (Type of Bill) Facility and Class

- 0.00% - 0.00% - 0.00% 9,562 100.00% 9,562 100.00%

Bill Type (Type of Bill) Frequency - 0.00% 1,779 18.60% - 0.00% 7,783 81.40% 7,783 81.40%

Billing Provider NPI (or MMIS Billing Provider Number)

- 0.00% 3 0.03% - 0.00% 9,559 99.97% 9,559 99.97%

Diagnosis Code 1 - 0.00% - 0.00% - 0.00% 9,562 100.00% 9,562 100.00%

Diagnosis Code 2 - 0.00% 1 0.01% - 0.00% 4,613 48.24% 4,948 51.75% 9,561 99.99%

Diagnosis Code 3 - 0.00% 3 0.03% - 0.00% 5,069 53.01% 4,490 46.96% 9,559 99.97% Diagnosis Code 4 - 0.00% 3 0.03% - 0.00% 5,810 60.76% 3,749 39.21% 9,559 99.97%

Discharge Date - 0.00% 8 0.08% - 0.00% - 0.00% 9,554 99.92% 9,554 99.92%

Former MMIS Claim TCN - 0.00% 95 0.99% - 0.00% 5,388 56.35% 4,079 42.66% 9,467 99.01%

Header First Date of Service - 0.00% 21 0.22% - 0.00% 9,541 99.78% 9,541 99.78%

Header Last Date of Service - 0.00% - 0.00% - 0.00% 9,562 100.00% 9,562 100.00%

Header Paid Amount - 0.00% 3,505 36.66% - 0.00% 6,057 63.34% 6,057 63.34%

MMIS TCN - 0.00% - 0.00% - 0.00% 9,562 100.00% 9,562 100.00%

MMIS Member Number - 0.00% - 0.00% - 0.00% 9,562 100.00% 9,562 100.00%

Plan Received Date - 0.00% 617 6.45% - 0.00% 8,945 93.55% 8,945 93.55%


9,562


Page 8

United Healthcare of New Mexico: Inpatient Encounters (837I)-Header Level

Key Data Field


December 2014 Missing Values


Non-Matching Values


(Not Valid)




Admission Date - 0.00% 53 1.02% - 0.00% 5,143 98.98% 5,143 98.98%

Bill Type (Type of Bill) Facility and Class

- 0.00% - 0.00% - 0.00% 5,196 100.00% 5,196 100.00%

Bill Type (Type of Bill) Frequency - 0.00% 594 11.43% - 0.00% 4,602 88.57% 4,602 88.57%


- 0.00% 1 0.02% - 0.00% 5,195 99.98% 5,195 99.98%

Diagnosis Code 1 - 0.00% - 0.00% - 0.00% 5,196 100.00% 5,196 100.00%

Diagnosis Code 2 1 0.02% - 0.00% 1,853 35.66% 3,342 64.32% 5,195 99.98%

Diagnosis Code 3 2 0.04% - 0.00% 2,008 38.65% 3,186 61.32% 5,194 99.96% Diagnosis Code 4 4 0.08% - 0.00% 2,225 42.82% 2,967 57.10% 5,192 99.92%

Discharge Date - 0.00% 7 0.13% - 0.00% - 0.00% 5,189 99.87% 5,189 99.87%

Former MMIS Claim TCN - 0.00% 3,743 72.04% - 0.00% 3,672 70.67% 1,453 27.96% 5,125 98.63%


Header Last Date of Service - 0.00% - 0.00% - 0.00% 5,196 100.00% 5,196 100.00%


MMIS TCN - 0.00% - 0.00% - 0.00% 5,196 100.00% 5,196 100.00%

MMIS Member Number - 0.00% - 0.00% - 0.00% 5,196 100.00% 5,196 100.00%



5,196


Page 9

Notes: - Billed charges and header last date of service claims sample values appear to reflect line level amounts. Data field will be evaluated at the line level. Therefore, these data element were evaluated at the line level. - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or an FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 10

United Healthcare of New Mexico: Inpatient Encounters (837I)-Line Level

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges - 0.00% 4,756 42.18% - 0.00% 6,520 57.82% 6,520 57.82% Line First Date of Service - 0.00% 93 0.82% - 0.00% 11,183 99.18% 11,183 99.18% Line Last Date of Service - 0.00% 11,062 98.10% - 0.00% 214 1.90% 214 1.90% Line Paid Amount - 0.00% 4,913 43.57% - 0.00% 6,363 56.43% 6,363 56.43% Procedure Code - 0.00% - 0.00% - 0.00% 9,498 84.23% 1,778 15.77% 11,276 100.00% Procedure Modifier 1 - 0.00% - 0.00% - 0.00% 11,031 97.83% 245 2.17% 11,276 100.00% Procedure Modifier 2 - 0.00% - 0.00% - 0.00% 11,276 100.00% - 0.00% 11,276 100.00% Procedure Modifier 3 - 0.00% - 0.00% - 0.00% 11,276 100.00% - 0.00% 11,276 100.00% Procedure Modifier 4 - 0.00% - 0.00% - 0.00% 11,276 100.00% - 0.00% 11,276 100.00% Revenue Code - 0.00% 88 0.78% - 0.00% 11,188 99.22% 11,188 99.22% Surgical Procedure Code 1 - 0.00% 46 0.41% - 0.00% 9,339 82.82% 1,891 16.77% 11,230 99.59% Surgical Procedure Code 2 - 0.00% 1 0.01% - 0.00% 10,005 88.73% 1,270 11.26% 11,275 99.99% Surgical Procedure Code 3 - 0.00% - 0.00% - 0.00% 10,465 92.81% 811 7.19% 11,276 100.00% Surgical Procedure Code 4 - 0.00% 46 0.41% - 0.00% 10,712 95.00% 518 4.59% 11,230 99.59%

Service/Rendering Provider NPI [and/or MMIS Service/ Rendering Provider Number (Medicaid ID)]

- 0.00% 1 0.01% - 0.00% 11,275 99.99% 11,275 99.99%


- 0.00% 19 0.17% - 0.00% 1,050 9.31% 10,207 90.52% 11,257 99.83%


11,276


Page 11

United Healthcare of New Mexico: Inpatient Encounters (837I)-Line Level

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges - 0.00% 2,942 37.45% - 0.00% 4,914 62.55% 4,914 62.55% Line First Date of Service - 0.00% 161 2.05% - 0.00% 7,695 97.95% 7,695 97.95% Line Last Date of Service - 0.00% 7,647 97.34% - 0.00% 209 2.66% 209 2.66% Line Paid Amount - 0.00% 3,049 38.81% - 0.00% 4,807 61.19% 4,807 61.19% Procedure Code - 0.00% - 0.00% - 0.00% 5,719 72.80% 2,137 27.20% 7,856 100.00% Procedure Modifier 1 - 0.00% - 0.00% - 0.00% 7,545 96.04% 311 3.96% 7,856 100.00% Procedure Modifier 2 - 0.00% - 0.00% - 0.00% 7,856 100.00% - 0.00% 7,856 100.00% Procedure Modifier 3 - 0.00% - 0.00% - 0.00% 7,856 100.00% - 0.00% 7,856 100.00% Procedure Modifier 4 - 0.00% - 0.00% - 0.00% 7,856 100.00% - 0.00% 7,856 100.00% Revenue Code - 0.00% 120 1.53% - 0.00% 7,736 98.47% 7,736 98.47% Surgical Procedure Code 1 - 0.00% 1 0.01% - 0.00% 5,094 64.84% 2,761 35.15% 7,855 99.99% Surgical Procedure Code 2 - 0.00% 15 0.19% - 0.00% 5,938 75.59% 1,903 24.22% 7,841 99.81% Surgical Procedure Code 3 - 0.00% - 0.00% - 0.00% 6,590 83.88% 1,266 16.12% 7,856 100.00% Surgical Procedure Code 4 - 0.00% 1 0.01% - 0.00% 6,961 88.61% 894 11.38% 7,855 99.99%

Service/Rendering Provider NPI [and/or MMIS Service/ Rendering Provider Number (Medicaid ID)]

- 0.00% - 0.00% - 0.00% 7,856 100.00% 7,856 100.00%


- 0.00% 104 1.32% - 0.00% 681 8.67% 7,071 90.01% 7,752 98.68%


7,856


Page 12

Notes: - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. -These tables were updated in the MCO rebuttal process to remove zero paid lines from consideration. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or an FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 13

United Healthcare of New Mexico: Healthcare Outpatient Encounters (837I)-Header Level

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Bill Type (Type of Bill) Facility and Class

- 0.00% - 0.00% - 0.00% 25,984 100.00% 25,984 100.00%



- 0.00% - 0.00% - 0.00% 25,984 100.00% 25,984 100.00%

Diagnosis Code 1 - 0.00% - 0.00% - 0.00% 25,984 100.00% 25,984 100.00%

Diagnosis Code 2 - 0.00% 305 1.17% - 0.00% 8,509 32.75% 17,170 66.08% 25,679 98.83%

Diagnosis Code 3 - 0.00% 379 1.46% - 0.00% 14,375 55.32% 11,230 43.22% 25,605 98.54%

Diagnosis Code 4 - 0.00% 302 1.16% - 0.00% 18,660 71.81% 7,022 27.02% 25,682 98.84%

Former MMIS Claim TCN - 0.00% 565 2.17% - 0.00% 17,439 67.11% 7,980 30.71% 25,419 97.83%


Header Last Day of Service - 0.00% - 0.00% - 0.00% 25,984 100.00% 25,984 100.00%


MMIS TCN - 0.00% - 0.00% - 0.00% 25,984 100.00% 25,984 100.00%

MMIS Member Number - 0.00% 5,746 22.11% - 0.00% 20,238 77.89% 20,238 77.89%

Plan Paid Date - 0.00% 25,984 100.00% - 0.00% - 0.00% - 0.00%



25,984


Page 14

United Healthcare of New Mexico: Healthcare Outpatient Encounters (837I)-Header Level

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Bill Type (Type of Bill) Facility and

Class - 0.00% - 0.00% - 0.00% 29,962 100.00% 29,962 100.00%


Billing Provider NPI [and/or MMIS Billing Provider

Number (Medicaid ID)] - 0.00% 25,984 86.72% - 0.00% 29,960 99.99% 29,960 99.99%

Diagnosis Code 1 - 0.00% - 0.00% - 0.00% 29,962 100.00% 29,962 100.00%

Diagnosis Code 2 - 0.00% 337 1.12% - 0.00% 9,265 30.92% 20,360 67.95% 29,625 98.88%

Diagnosis Code 3 - 0.00% 449 1.50% - 0.00% 15,673 52.31% 13,840 46.19% 29,513 98.50%

Diagnosis Code 4 - 0.00% 399 1.33% - 0.00% 20,469 68.32% 9,094 30.35% 29,563 98.67%

Former MMIS Claim TCN - 0.00% 1,098 3.66% - 0.00% 18,734 62.53% 10,130 33.81% 28,864 96.34%


Header Last Day of Service - 0.00% - 0.00% - 0.00% 29,962 100.00% 29,962 100.00%


MMIS TCN - 0.00% - 0.00% - 0.00% 29,962 100.00% 29,962 100.00%

MMIS Member Number - 0.00% 8,029 26.80% - 0.00% 21,933 73.20% 21,933 73.20%

Plan Paid Date - 0.00% 29,960 99.99% - 0.00% 2 0.01% 2 0.01%

Plan Received Date - 0.00% 304 1.01% - 0.00% 29,658 98.99% 29,658 98.99% Total Submitted Records Traced to MMIS

29,962


Page 15

Notes: - Billed charges and header last date of service claims sample values appear to reflect line level amounts. Data field will be evaluated at the line level. Therefore, these data element were evaluated at the line level. - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or an FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 16

United Healthcare of New Mexico: Outpatient Encounters (837I)-Line Level

Key Data Field




Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges 8,689 15.77% - 0.00% 46,419 84.23% 46,419 84.23% 8,689 15.77% Line First Date of Service 27 0.05% - 0.00% 55,081 99.95% 55,081 99.95% 27 0.05% Line Last Date of Service 1,991 3.61% - 0.00% 53,117 96.39% 53,117 96.39% 1,991 3.61% Line Paid Amount 8,990 16.31% - 0.00% 46,118 83.69% 46,118 83.69% 8,990 16.31% Procedure Code 910 1.65% - 0.00% 4,610 8.37% 49,588 89.98% 54,198 98.35% 910 1.65%

Procedure Modifier Code1 (Compared to All 4 Procedure Modifiers in ENCs)

346 0.63% - 0.00% 46,683 84.71% 8,079 14.66% 54,762 99.37% 346 0.63%


- 0.00% - 0.00% 55,108 100.00% - 0.00% 55,108 100.00% - 0.00%


- 0.00% - 0.00% 55,108 100.00% - 0.00% 55,108 100.00% - 0.00%


- 0.00% - 0.00% 55,108 100.00% - 0.00% 55,108 100.00% - 0.00%

Revenue Code 803 1.46% - 0.00% 54,305 98.54% 54,305 98.54% 803 1.46% Service/Rendering Provider NPI [and/or MMIS Service/ Rendering Provider Number (Medicaid ID)]

13 0.02% - 0.00% 55,095 99.98% 55,095 99.98% 13 0.02%


39 0.07% - 0.00% 4,307 7.82% 50,762 92.11% 55,069 99.93% 39 0.07%


55,108


Page 17

United Healthcare of New Mexico: Outpatient Encounters (837I)-Line Level

Key Data Field




Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges - 0.00% 11,072 16.18% - 0.00% 57,379 83.82% 57,379 83.82% Line First Date of Service - 0.00% 152 0.22% - 0.00% 68,299 99.78% 68,299 99.78% Line Last Date of Service - 0.00% 3,710 5.42% - 0.00% 64,741 94.58% 64,741 94.58% Line Paid Amount - 0.00% 11,137 16.27% - 0.00% 57,314 83.73% 57,314 83.73% Procedure Code - 0.00% 1,449 2.12% - 0.00% 5,165 7.55% 61,837 90.34% 67,002 97.88%


- 0.00% 251 0.37% - 0.00% 57,343 83.77% 10,857 15.86% 68,200 99.63%


- 0.00% - 0.00% - 0.00% 68,451 100.00% - 0.00% 68,451 100.00%


- 0.00% - 0.00% - 0.00% 68,451 100.00% - 0.00% 68,451 100.00%


- 0.00% - 0.00% - 0.00% 68,451 100.00% - 0.00% 68,451 100.00%

Revenue Code - 0.00% 1,172 1.71% - 0.00% 67,279 98.29% 67,279 98.29% Service/Rendering Provider NPI [and/or MMIS Service/ Rendering Provider Number (Medicaid ID)]

- 0.00% 6 0.01% - 0.00% 68,445 99.99% 68,445 99.99%


- 0.00% 58 0.08% - 0.00% 6,426 9.39% 61,967 90.53% 68,393 99.92%


68,451


Page 18



Page 19

United Healthcare of New Mexico: Pharmacy Encounters (NCPDP)-Header Level

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)





12,165 16.39% - - - - 62,044 83.61% 62,044 83.61%

Date Filled (DOS) - - 680 0.92% - - 73,529 99.08% 73,529 99.08%

Former MMIS Claim TCN 46 0.06% - - 70,581 95.11% 3,582 4.83% 74,163 99.94%

MMIS TCN - - - - - - 74,209 100.00% 74,209 100.00%


Plan Paid Date - - 67,852 91.43% - - 6,357 8.57% 6,357 8.57%

Prescription Number - - 680 0.92% - - 73,529 99.08% 73,529 99.08%

Refill Number - - 1,239 1.67% - - 72,970 98.33% 72,970 98.33%


74,209


Page 20

United Healthcare of New Mexico: Pharmacy Encounters (NCPDP)-Header Level

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)





12,283 15.61% - - - - 66,381 84.39% 66,381 84.39%

Date Filled (DOS) - - 1,407 1.79% - - 77,257 98.21% 77,257 98.21%

Former MMIS Claim TCN 41 0.05% - - 74,278 94.42% 4,345 5.52% 78,623 99.95%

MMIS TCN - - - - - - 78,664 100.00% 78,664 100.00%


Plan Paid Date - - 72,957 92.75% - - 5,707 7.25% 5,707 7.25%

Prescription Number - - 1,407 1.79% - - 77,257 98.21% 77,257 98.21%

Refill Number - - 2,162 2.75% - - 76,502 97.25% 76,502 97.25%


78,664


Page 21

Notes: - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. -The plan paid date element was updated in the MCO rebuttal process to remove zero paid lines from consideration. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or an FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 22

United Healthcare of New Mexico: Pharmacy Encounters (NCPDP)-Line Level

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)




Days Supply - - 2,507 3.38% - - 71,670 96.62% 71,670 96.62%

NDC 3 0.00% 139 0.19% - - 74,035 99.81% 74,035 99.81%

Plan Paid Amount - - 2,040 2.75% - - 72,137 97.25% 72,137 97.25%

Prescribing Provider NPI - - 38,216 51.52% - - 35,961 48.48% 35,961 48.48%

Quantity Dispensed (Dispensed Units)

- - 1,955 2.64% - - 72,222 97.36% 72,222 97.36%


74,177


Page 23

United Healthcare of New Mexico: Pharmacy Encounters (NCPDP)-Line Level

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)




Days Supply - - 3,633 4.62% - - 75,026 95.38% 75,026 95.38%

NDC 5 0.01% 129 0.16% - - 78,525 99.83% 78,525 99.83%

Plan Paid Amount - - 2,408 3.06% - - 76,251 96.94% 76,251 96.94%

Prescribing Provider NPI - - 42,622 54.19% - - 36,037 45.81% 36,037 45.81%

Quantity Dispensed (Dispensed Units)

- - 2,371 3.01% - - 76,288 96.99% 76,288 96.99%


78,659


Page 24



Page 25

United Healthcare of New Mexico: Professional Encounters-Header Level (837P)

Key Data Field


September 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billing Provider NPI and/or MMIS Billing Provider

17,607 11.65% - - 10,583 7.00% 122,991 81.35% 133,574 88.35%

Diagnosis Code 1 13,014 8.61% 49 0.03% - - 138,118 91.36% 138,118 91.36%

Diagnosis Code 2 65 0.04% - - 106,546 70.48% 44,570 29.48% 151,116 99.96%

Diagnosis Code 3 48 0.03% - - 125,451 82.98% 25,682 16.99% 151,133 99.97%

Diagnosis Code 4 24 0.02% - - 136,421 90.24% 14,736 9.75% 151,157 99.98%

Former MMIS Claim TCN 5,955 3.94% - - 123,388 81.62% 21,838 14.44% 145,226 96.06%

Header First Date of Service - - 584 0.39% - - 150,597 99.61% 150,597 99.61%

Header Paid Amount - - 48,185 31.87% - - 102,996 68.13% 102,996 68.13%

MMIS TCN - - - - - - 151,181 100.00% 151,181 100.00%

MMIS Member Number (Medicaid ID)

14 0.01% 18,962 12.54% - - 132,205 87.45% 132,205 87.45%

Plan Paid Date - - 127,500 84.34% - - 23,681 15.66% 23,681 15.66%



151,181


Page 26

United Healthcare of New Mexico: Professional Encounters-Header Level (837P)

Key Data Field


December 2014


populated)

Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billing Provider NPI and/or MMIS Billing Provider

24,897 14.14% - - 14,603 8.30% 136,538 77.56% 151,141 85.86%

Diagnosis Code 1 25,459 14.46% 53 0.03% - - 150,526 85.51% 150,526 85.51%

Diagnosis Code 2 71 0.04% - - 129,211 73.40% 46,756 26.56% 175,967 99.96%

Diagnosis Code 3 47 0.03% - - 148,407 84.30% 27,584 15.67% 175,991 99.97%

Diagnosis Code 4 33 0.02% - - 159,757 90.75% 16,248 9.23% 176,005 99.98%

Former MMIS Claim TCN 3,687 2.09% - - 160,266 91.04% 12,085 6.86% 172,351 97.91%

Header First Date of Service - - 468 0.27% - - 175,570 99.73% 175,570 99.73%

Header Paid Amount - - 45,813 26.02% - - 130,225 73.98% 130,225 73.98%

MMIS TCN - - - 0.00% - - 176,038 100.00% 176,038 100.00%

MMIS Member Number (Medicaid ID)

5 0.00% 19,469 11.06% - - 156,564 88.94% 156,564 88.94%

Plan Paid Date - - 139,456 79.22% - - 36,582 20.78% 36,582 20.78%



176,038


Page 27

Notes:

- Billed charges and header last date of service claims sample values appear to reflect line level amounts. Data field will be evaluated at the line level. Therefore, these data element were evaluated at the line level. - For the key data elements that fell below the 95 percent accuracy threshold (error rate greater than 5 percent), there were instances where the encounter data values appeared to be correct and the claims sample values were in error, and there were instances where the claims sample values appeared to be correct and the encounter data values were in error. - Missing Values: Key data elements in the claims sample data where values are not provided (i.e., the field/element is not populated). - Non-Matching: Valid claims sample data values that do not match (i.e., are not the same as) the corresponding MMIS encounter data value. These are labeled as "Non-Matching," as it is unclear if this is a claims sample submission issue, encounter data submission issue or an FA issue. - Values Present: Key data elements where the claim sample value is populated with (actual) valid values and the corresponding MMIS encounter data reflects the same value. - Blank (Null) Values: For some key data elements, blank (Null) values are permissible. Values are evaluated on actual values present and on blank values. If the value in the sample data is blank (Null) and the corresponding value in the MMIS encounter data is also blank (Null), it is considered a match. - Erroneous: Key data elements where the claim sample value is invalid, and the corresponding MMIS encounter data value reflected the same invalid value as the claims sample.


Page 28

United Healthcare of New Mexico: Professional Encounters-Line Level (837P)

Key Data Field




Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges - - 63,119 27.77% - - 164,172 72.23% 164,172 72.23%

Header Last Date of Service - - 48,558 21.36% - - 178,733 78.64% 178,733 78.64%

Line First Date of Service - - 3,254 1.43% - - 224,037 98.57% 224,037 98.57%

Line Last Date of Service - - 49,026 21.57% - - 178,265 78.43% 178,265 78.43%

Line Paid Amount - - 64,516 28.38% - - 162,775 71.62% 162,775 71.62%

Place of Service - - 428 0.19% - - 226,863 99.81% 226,863 99.81%

Procedure Code - - 6,341 2.79% 39 0.02% 220,911 97.19% 220,911 97.19%

Procedure Code Modifier 1 - - 367 0.16% - - 179,580 79.01% 47,344 20.83% 226,924 99.84%

Procedure Code Modifier 2 - - 1,246 0.55% - - 219,553 96.60% 6,492 2.86% 226,045 99.45%

Procedure Code Modifier 3 90 0.04% - - 227,201 99.96% 0 0.00% 227,201 99.96%

Procedure Code Modifier 4 - 0.00% - - 227,291 100.00% 0 0.00% 227,291 100.00%

Service/Rendering Provider NPI [or MMIS Service/Rendering Provider Number (Medicaid ID)]

1,553 0.68% - - 427 0.19% 225,311 99.13% 225,738 99.32%


7,709 3.39% - - 109,982 48.39% 109,600 48.22% 219,582 96.61%


227,291


Page 29

United Healthcare of New Mexico: Professional Encounters-Line Level (837P)

Key Data Field




Non-Matching Values


(Not Valid)



Count Percent Count Percent Count Percent Count Percent Count Percent Count Percent Billed Charges - - 18,373 6.89% - - 248,288 93.11% 248,288 93.11%

Header Last Date of Service - - 46,164 17.31% - - 220,497 82.69% 220,497 82.69%

Line First Date of Service - - 3,093 1.16% - - 263,568 98.84% 263,568 98.84%

Line Last Date of Service - - 48,347 18.13% - - 218,314 81.87% 218,314 81.87%

Line Paid Amount - - 18,295 6.86% - - 248,366 93.14% 248,366 93.14%

Place of Service - - 436 0.16% - - 266,225 99.84% 266,225 99.84%

Procedure Code - - 3,158 1.18% 20 0.01% 263,483 98.81% 263,483 98.81%

Procedure Code Modifier 1 - - 503 0.19% - - 205,586 77.10% 60,572 22.71% 266,158 99.81%

Procedure Code Modifier 2 - - 1,271 0.48% - - 259,236 97.22% 6,154 2.31% 265,390 99.52%

Procedure Code Modifier 3 138 0.05% - - 266,523 99.95% 0 0.00% 266,523 99.95%

Procedure Code Modifier 4 - 0.00% - - 266,661 100.00% 0 0.00% 266,661 100.00%

Service/Rendering Provider NPI [or MMIS Service/Rendering Provider Number (Medicaid ID)]

1,143 0.43% - - 1,485 0.56% 264,033 99.01% 265,518 99.57%


10,334 3.88% - - 88,748 33.28% 167,579 62.84% 256,327 96.12%


266,661


Page 30


Page 1

Appendix D-5: Member Utilization by Service Type

United Healthcare of New Mexico Total Utilization

Total Number of all Services

Age Group Total

Tribal Community

Non-Tribal Community

Total Male Female Total Male Female Total Male Female 0 - 5 96,414 52,457 43,957 5,332 3,283 2,049 91,082 49,174 41,908

6 - 18 157,151 80,797 76,354 11,693 6,895 4,798 145,458 73,902 71,556 19 - 21 99,700 30,446 69,254 1,761 541 1,220 97,939 29,905 68,034 22 - 34 645,145 285,188 359,957 31,577 15,072 16,505 613,568 270,116 343,452 35 - 49 985,405 432,780 552,625 67,554 33,895 33,659 917,851 398,885 518,966 50 - 64 1,866,734 695,424 1,171,310 117,586 47,390 70,196 1,749,148 648,034 1,101,114 65 - 74 695,592 227,952 467,640 72,945 25,544 47,401 622,647 202,408 420,239

75 and Over 871,167 250,590 620,577 91,844 28,512 63,332 779,323 222,078 557,245 Total 5,417,308 2,055,634 3,361,674 400,292 161,132 239,160 5,017,016 1,894,502 3,122,514

Centennial Care

Total Utilization Total Number of all Services

Age Group Total

Tribal Community


Total Male Female Total Male Female Total Male Female 0 - 5 2,851,530 1,504,216 1,347,314 95,054 50,355 44,699 2,756,476 1,453,861 1,302,615

6 - 18 5,749,977 2,896,287 2,853,690 152,341 73,799 78,542 5,597,636 2,822,488 2,775,148 19 - 21 848,942 240,464 608,478 15,670 5,130 10,540 833,272 235,334 597,938 22 - 34 4,670,113 1,313,046 3,357,067 120,495 42,614 77,881 4,549,618 1,270,432 3,279,186 35 - 49 4,984,986 1,804,939 3,180,047 171,465 79,117 92,348 4,813,521 1,725,822 3,087,699 50 - 64 6,386,887 2,479,085 3,907,802 253,731 103,916 149,815 6,133,156 2,375,169 3,757,987 65 - 74 1,302,971 447,337 855,634 135,650 50,512 85,138 1,167,321 396,825 770,496

75 and Over 1,489,309 422,741 1,066,568 162,194 45,952 116,242 1,327,115 376,789 950,326 Total 28,284,715 11,108,115 17,176,600 1,106,600 451,395 655,205 27,178,115 10,656,720 16,521,395

Page 2


United Healthcare of New Mexico Total Utilization Per Member

All Services on a Per Member Basis

Age Group Total

Tribal Community


Total Male Female Total Male Female Total Male Female 0 - 5 22.7 24.0 21.3 19.2 23.3 15.0 23.0 24.1 21.8

6 - 18 21.5 21.5 21.6 20.5 22.7 18.1 21.6 21.4 21.9 19 - 21 27.8 19.6 34.2 18.3 13.4 21.9 28.1 19.7 34.5 22 - 34 45.4 40.2 50.6 67.0 70.5 64.0 44.7 39.3 50.1 35 - 49 84.2 74.7 93.5 128.8 143.3 116.9 82.1 71.8 92.3 50 - 64 116.3 100.6 128.2 165.4 153.9 174.1 114.0 98.1 126.1 65 - 74 111.1 94.0 121.9 114.5 102.8 121.9 110.7 93.0 121.9

75 and Over 125.1 113.7 130.4 125.4 129.2 123.7 125.0 111.9 131.2 Total 77.0 64.4 87.6 99.6 94.1 103.7 75.7 62.7 86.5

Centennial Care Total Utilization Per Member


Age Group Total

Tribal Community



6 - 18 29.1 28.8 29.4 22.7 22.0 23.5 29.3 29.0 29.7 19 - 21 34.4 23.8 41.7 25.2 20.3 28.6 34.6 23.9 42.1 22 - 34 46.6 37.1 51.8 43.4 43.6 43.3 46.7 36.9 52.1 35 - 49 69.2 61.9 74.2 82.1 89.3 76.8 68.8 61.0 74.1 50 - 64 100.1 88.4 109.2 120.9 113.6 126.6 99.4 87.5 108.6 65 - 74 108.7 93.3 118.9 119.6 112.9 124.0 107.6 91.3 118.4

75 and Over 125.7 111.1 132.6 133.5 123.7 137.8 124.8 109.7 132.0 Total 49.2 42.8 54.4 54.8 50.1 58.6 49.0 42.6 54.2

Note: Encounters per member was calculated by dividing the number of encounters by the average number of members.

Page 3


United Healthcare of New Mexico Inpatient Utilization


Age Group Total

Tribal Community


Total Male Female Total Male Female Total Male Female 0 - 5 1,819 984 835 98 61 37 1,721 923 798

6 - 18 534 349 185 102 97 5 432 252 180 19 - 21 544 101 443 10 1 9 534 100 434 22 - 34 2,517 974 1,543 126 23 103 2,391 951 1,440 35 - 49 3,783 2,026 1,757 407 233 174 3,376 1,793 1,583 50 - 64 11,698 6,042 5,656 851 519 332 10,847 5,523 5,324 65 - 74 11,393 4,883 6,510 1,018 517 501 10,375 4,366 6,009

75 and Over 34,810 10,731 24,079 3,652 1,391 2,261 31,158 9,340 21,818 Total 67,098 26,090 41,008 6,264 2,842 3,422 60,834 23,248 37,586

Centennial Care

Inpatient Utilization Total Number of all Services

Age Group Total

Tribal Community


Total Male Female Total Male Female Total Male Female 0 - 5 22,981 12,189 10,792 894 497 397 22,087 11,692 10,395

6 - 18 16,216 8,808 7,408 826 388 438 15,390 8,420 6,970 19 - 21 5,371 1,286 4,085 147 25 122 5,224 1,261 3,963 22 - 34 19,598 4,666 14,932 659 139 520 18,939 4,527 14,412 35 - 49 16,237 7,455 8,782 898 478 420 15,339 6,977 8,362 50 - 64 34,182 17,565 16,617 1,784 1,108 676 32,398 16,457 15,941 65 - 74 20,603 9,257 11,346 1,694 906 788 18,909 8,351 10,558

75 and Over 63,298 19,804 43,494 6,010 2,308 3,702 57,288 17,496 39,792 Total 198,486 81,030 117,456 12,912 5,849 7,063 185,574 75,181 110,393

Page 4


United Healthcare of New Mexico Inpatient Utilization Per Member


Age Group Total

Tribal Community



6 - 18 0.1 0.1 0.1 0.2 0.3 0.0 0.1 0.1 0.1 19 - 21 0.2 0.1 0.2 0.1 0.0 0.2 0.2 0.1 0.2 22 - 34 0.2 0.1 0.2 0.3 0.1 0.4 0.2 0.1 0.2 35 - 49 0.3 0.3 0.3 0.8 1.0 0.6 0.3 0.3 0.3 50 - 64 0.7 0.9 0.6 1.2 1.7 0.8 0.7 0.8 0.6 65 - 74 1.8 2.0 1.7 1.6 2.1 1.3 1.8 2.0 1.7

75 and Over 5.0 4.9 5.1 5.0 6.3 4.4 5.0 4.7 5.1 Total 1.0 0.8 1.1 1.6 1.7 1.5 0.9 0.8 1.0

Centennial Care Inpatient Utilization Per Member


Age Group Total

Tribal Community



6 - 18 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 19 - 21 0.2 0.1 0.3 0.2 0.1 0.3 0.2 0.1 0.3 22 - 34 0.2 0.1 0.2 0.2 0.1 0.3 0.2 0.1 0.2 35 - 49 0.2 0.3 0.2 0.4 0.5 0.3 0.2 0.2 0.2 50 - 64 0.5 0.6 0.5 0.9 1.2 0.6 0.5 0.6 0.5 65 - 74 1.7 1.9 1.6 1.5 2.0 1.1 1.7 1.9 1.6

75 and Over 5.3 5.2 5.4 4.9 6.2 4.4 5.4 5.1 5.5 Total 0.3 0.3 0.4 0.6 0.6 0.6 0.3 0.3 0.4


Page 5


United Healthcare of New Mexico Outpatient Utilization


Age Group Total

Tribal Community


Total Male Female Total Male Female Total Male Female 0 - 5 16,781 9,375 7,406 1,472 951 521 15,309 8,424 6,885

6 - 18 24,094 10,540 13,554 2,463 1,286 1,177 21,631 9,254 12,377 19 - 21 27,967 7,052 20,915 486 161 325 27,481 6,891 20,590 22 - 34 140,276 54,551 85,725 6,595 2,855 3,740 133,681 51,696 81,985 35 - 49 182,572 80,657 101,915 16,754 9,093 7,661 165,818 71,564 94,254 50 - 64 304,609 115,079 189,530 22,013 8,080 13,933 282,596 106,999 175,597 65 - 74 107,363 38,519 68,844 12,344 4,278 8,066 95,019 34,241 60,778

75 and Over 104,279 32,664 71,615 11,468 3,598 7,870 92,811 29,066 63,745 Total 907,941 348,437 559,504 73,595 30,302 43,293 834,346 318,135 516,211

Centennial Care Outpatient Utilization


Age Group Total

Tribal Community



6 - 18 858,403 396,819 461,584 31,058 14,255 16,803 827,345 382,564 444,781 19 - 21 243,151 59,285 183,866 4,672 1,374 3,298 238,479 57,911 180,568 22 - 34 1,220,586 305,197 915,389 33,566 9,868 23,698 1,187,020 295,329 891,691 35 - 49 1,122,632 404,957 717,675 47,029 22,144 24,885 1,075,603 382,813 692,790 50 - 64 1,291,491 523,708 767,783 57,475 23,064 34,411 1,234,016 500,644 733,372 65 - 74 241,486 88,129 153,357 27,075 10,315 16,760 214,411 77,814 136,597

75 and Over 207,553 61,249 146,304 21,161 6,207 14,954 186,392 55,042 131,350 Total 5,726,224 2,124,995 3,601,229 246,651 100,881 145,770 5,479,573 2,024,114 3,455,459

Page 6


United Healthcare of New Mexico Outpatient Utilization Per Member


Age Group Total

Tribal Community



6 - 18 3.3 2.8 3.8 4.3 4.2 4.4 3.2 2.7 3.8 19 - 21 7.8 4.5 10.3 5.1 4.0 5.8 7.9 4.5 10.4 22 - 34 9.9 7.7 12.0 14.0 13.4 14.5 9.7 7.5 12.0 35 - 49 15.6 13.9 17.2 31.9 38.4 26.6 14.8 12.9 16.8 50 - 64 19.0 16.7 20.7 31.0 26.2 34.6 18.4 16.2 20.1 65 - 74 17.1 15.9 17.9 19.4 17.2 20.7 16.9 15.7 17.6

75 and Over 15.0 14.8 15.0 15.7 16.3 15.4 14.9 14.6 15.0 Total 12.9 10.9 14.6 18.3 17.7 18.8 12.6 10.5 14.3

Centennial Care Outpatient Utilization Per Member


Age Group Total

Tribal Community



6 - 18 4.3 3.9 4.8 4.6 4.2 5.0 4.3 3.9 4.8 19 - 21 9.9 5.9 12.6 7.5 5.4 9.0 9.9 5.9 12.7 22 - 34 12.2 8.6 14.1 12.1 10.1 13.2 12.2 8.6 14.2 35 - 49 15.6 13.9 16.7 22.5 25.0 20.7 15.4 13.5 16.6 50 - 64 20.2 18.7 21.5 27.4 25.2 29.1 20.0 18.5 21.2 65 - 74 20.1 18.4 21.3 23.9 23.1 24.4 19.8 17.9 21.0

75 and Over 17.5 16.1 18.2 17.4 16.7 17.7 17.5 16.0 18.2 Total 10.0 8.2 11.4 12.2 11.2 13.0 9.9 8.1 11.3


Page 7


United Healthcare of New Mexico Professional Utilization


Age Group Total

Tribal Community


Total Male Female Total Male Female Total Male Female 0 - 5 59,776 32,760 27,016 2,502 1,623 879 57,274 31,137 26,137

6 - 18 78,032 41,628 36,404 5,518 3,286 2,232 72,514 38,342 34,172 19 - 21 47,916 15,396 32,520 861 222 639 47,055 15,174 31,881 22 - 34 370,226 173,263 196,963 21,229 10,884 10,345 348,997 162,379 186,618 35 - 49 588,410 262,714 325,696 40,628 20,443 20,185 547,782 242,271 305,511 50 - 64 1,138,069 426,501 711,568 78,556 32,708 45,848 1,059,513 393,793 665,720 65 - 74 543,084 172,948 370,136 57,098 20,023 37,075 485,986 152,925 333,061

75 and Over 706,605 199,317 507,288 74,773 22,879 51,894 631,832 176,438 455,394 Total 3,532,118 1,324,527 2,207,591 281,165 112,068 169,097 3,250,953 1,212,459 2,038,494

Centennial Care Professional Utilization


Age Group Total

Tribal Community


Total Male Female Total Male Female Total Male Female 0 - 5 1,606,592 851,148 755,444 44,616 23,049 21,567 1,561,976 828,099 733,877

6 - 18 2,726,467 1,400,773 1,325,694 61,852 30,136 31,716 2,664,615 1,370,637 1,293,978 19 - 21 392,981 109,516 283,465 6,784 2,149 4,635 386,197 107,367 278,830 22 - 34 2,262,911 662,263 1,600,648 64,063 26,193 37,870 2,198,848 636,070 1,562,778 35 - 49 2,373,528 884,720 1,488,808 89,801 43,469 46,332 2,283,727 841,251 1,442,476 50 - 64 3,122,088 1,213,470 1,908,618 148,550 62,077 86,473 2,973,538 1,151,393 1,822,145 65 - 74 940,830 315,028 625,802 101,802 37,565 64,237 839,028 277,463 561,565

75 and Over 1,170,756 326,799 843,957 131,477 36,243 95,234 1,039,279 290,556 748,723 Total 14,596,153 5,763,717 8,832,436 648,945 260,881 388,064 13,947,208 5,502,836 8,444,372

Page 8


United Healthcare of New Mexico Professional Utilization Per Member


Age Group Total

Tribal Community



6 - 18 10.7 11.1 10.3 9.7 10.8 8.4 10.8 11.1 10.5 19 - 21 13.4 9.9 16.0 9.0 5.5 11.5 13.5 10.0 16.2 22 - 34 26.1 24.4 27.7 45.0 50.9 40.1 25.4 23.6 27.2 35 - 49 50.3 45.3 55.1 77.5 86.4 70.1 49.0 43.6 54.3 50 - 64 70.9 61.7 77.9 110.5 106.3 113.7 69.1 59.6 76.2 65 - 74 86.7 71.3 96.5 89.6 80.6 95.4 86.4 70.2 96.6

75 and Over 101.5 90.4 106.6 102.1 103.7 101.4 101.4 88.9 107.2 Total 50.2 41.5 57.5 70.0 65.5 73.3 49.0 40.1 56.5

Centennial Care

Professional Utilization Per Member All Services on a Per Member Basis

Age Group Total

Tribal Community



6 - 18 13.8 13.9 13.7 9.2 9.0 9.5 14.0 14.1 13.8 19 - 21 15.9 10.9 19.4 10.9 8.5 12.6 16.1 10.9 19.6 22 - 34 22.6 18.7 24.7 23.1 26.8 21.1 22.6 18.5 24.8 35 - 49 32.9 30.3 34.7 43.0 49.1 38.5 32.6 29.7 34.6 50 - 64 48.9 43.3 53.3 70.8 67.8 73.1 48.2 42.4 52.7 65 - 74 78.5 65.7 87.0 89.8 84.0 93.6 77.3 63.8 86.3

75 and Over 98.8 85.9 104.9 108.2 97.6 112.9 97.7 84.6 104.0 Total 25.4 22.2 28.0 32.1 29.0 34.7 25.1 22.0 27.7


Page 9


United Healthcare of New Mexico Dental Utilization


Age Group Total

Tribal Community



6 - 18 31,073 15,646 15,427 1,902 1,068 834 29,171 14,578 14,593 19 - 21 6,922 2,515 4,407 115 40 75 6,807 2,475 4,332 22 - 34 30,516 14,237 16,279 497 206 291 30,019 14,031 15,988 35 - 49 30,706 14,623 16,083 920 466 454 29,786 14,157 15,629 50 - 64 40,381 17,069 23,312 1,006 431 575 39,375 16,638 22,737 65 - 74 10,038 3,566 6,472 503 171 332 9,535 3,395 6,140

75 and Over 10,221 3,103 7,118 494 218 276 9,727 2,885 6,842 Total 167,889 74,828 93,061 6,087 2,903 3,184 161,802 71,925 89,877

Centennial Care Dental Utilization


Age Group Total

Tribal Community



6 - 18 1,250,975 619,797 631,178 36,365 17,605 18,760 1,214,610 602,192 612,418 19 - 21 68,920 25,252 43,668 1,256 483 773 67,664 24,769 42,895 22 - 34 249,796 82,782 167,014 3,814 1,019 2,795 245,982 81,763 164,219 35 - 49 202,754 79,460 123,294 3,590 1,487 2,103 199,164 77,973 121,191 50 - 64 185,424 77,913 107,511 3,030 1,233 1,797 182,394 76,680 105,714 65 - 74 22,030 8,024 14,006 1,078 418 660 20,952 7,606 13,346

75 and Over 18,449 5,885 12,564 904 401 503 17,545 5,484 12,061 Total 2,338,115 1,071,225 1,266,890 64,605 30,146 34,459 2,273,510 1,041,079 1,232,431

Page 10


United Healthcare of New Mexico Dental Utilization Per Member


Age Group Total

Tribal Community



6 - 18 4.3 4.2 4.4 3.3 3.5 3.1 4.3 4.2 4.5 19 - 21 1.9 1.6 2.2 1.2 1.0 1.3 2.0 1.6 2.2 22 - 34 2.1 2.0 2.3 1.1 1.0 1.1 2.2 2.0 2.3 35 - 49 2.6 2.5 2.7 1.8 2.0 1.6 2.7 2.5 2.8 50 - 64 2.5 2.5 2.6 1.4 1.4 1.4 2.6 2.5 2.6 65 - 74 1.6 1.5 1.7 0.8 0.7 0.9 1.7 1.6 1.8

75 and Over 1.5 1.4 1.5 0.7 1.0 0.5 1.6 1.5 1.6 Total 2.4 2.3 2.4 1.5 1.7 1.4 2.4 2.4 2.5

Centennial Care

Dental Utilization Per Member All Services on a Per Member Basis

Age Group Total

Tribal Community



6 - 18 6.3 6.2 6.5 5.4 5.2 5.6 6.4 6.2 6.5 19 - 21 2.8 2.5 3.0 2.0 1.9 2.1 2.8 2.5 3.0 22 - 34 2.5 2.3 2.6 1.4 1.0 1.6 2.5 2.4 2.6 35 - 49 2.8 2.7 2.9 1.7 1.7 1.7 2.8 2.8 2.9 50 - 64 2.9 2.8 3.0 1.4 1.3 1.5 3.0 2.8 3.1 65 - 74 1.8 1.7 1.9 1.0 0.9 1.0 1.9 1.8 2.1

75 and Over 1.6 1.5 1.6 0.7 1.1 0.6 1.6 1.6 1.7 Total 4.1 4.1 4.0 3.2 3.3 3.1 4.1 4.2 4.0


Page 11


United Healthcare of New Mexico Pharmacy Utilization


Age Group Total

Tribal Community



6 - 18 23,418 12,634 10,784 1,708 1,158 550 21,710 11,476 10,234 19 - 21 16,351 5,382 10,969 289 117 172 16,062 5,265 10,797 22 - 34 101,610 42,163 59,447 3,130 1,104 2,026 98,480 41,059 57,421 35 - 49 179,934 72,760 107,174 8,845 3,660 5,185 171,089 69,100 101,989 50 - 64 371,977 130,733 241,244 15,160 5,652 9,508 356,817 125,081 231,736 65 - 74 23,714 8,036 15,678 1,982 555 1,427 21,732 7,481 14,251

75 and Over 15,252 4,775 10,477 1,457 426 1,031 13,795 4,349 9,446 Total 742,262 281,752 460,510 33,181 13,017 20,164 709,081 268,735 440,346

Centennial Care Pharmacy Utilization


Age Group Total

Tribal Community



6 - 18 897,916 470,090 427,826 22,240 11,415 10,825 875,676 458,675 417,001 19 - 21 138,519 45,125 93,394 2,811 1,099 1,712 135,708 44,026 91,682 22 - 34 917,222 258,138 659,084 18,393 5,395 12,998 898,829 252,743 646,086 35 - 49 1,269,835 428,347 841,488 30,147 11,539 18,608 1,239,688 416,808 822,880 50 - 64 1,753,702 646,429 1,107,273 42,892 16,434 26,458 1,710,810 629,995 1,080,815 65 - 74 78,022 26,899 51,123 4,001 1,308 2,693 74,021 25,591 48,430

75 and Over 29,253 9,004 20,249 2,642 793 1,849 26,611 8,211 18,400 Total 5,425,737 2,067,148 3,358,589 133,487 53,638 79,849 5,292,250 2,013,510 3,278,740

Page 12


United Healthcare of New Mexico Pharmacy Utilization Per Member


Age Group Total

Tribal Community



6 - 18 3.2 3.4 3.1 3.0 3.8 2.1 3.2 3.3 3.1 19 - 21 4.6 3.5 5.4 3.0 2.9 3.1 4.6 3.5 5.5 22 - 34 7.2 5.9 8.4 6.6 5.2 7.9 7.2 6.0 8.4 35 - 49 15.4 12.6 18.1 16.9 15.5 18.0 15.3 12.4 18.1 50 - 64 23.2 18.9 26.4 21.3 18.4 23.6 23.3 18.9 26.5 65 - 74 3.8 3.3 4.1 3.1 2.2 3.7 3.9 3.4 4.1

75 and Over 2.2 2.2 2.2 2.0 1.9 2.0 2.2 2.2 2.2 Total 10.6 8.8 12.0 8.3 7.6 8.7 10.7 8.9 12.2

Centennial Care

Pharmacy Utilization Per Member All Services on a Per Member Basis

Age Group Total

Tribal Community



6 - 18 4.5 4.7 4.4 3.3 3.4 3.2 4.6 4.7 4.5 19 - 21 5.6 4.5 6.4 4.5 4.3 4.7 5.6 4.5 6.4 22 - 34 9.2 7.3 10.2 6.6 5.5 7.2 9.2 7.3 10.3 35 - 49 17.6 14.7 19.6 14.4 13.0 15.5 17.7 14.7 19.7 50 - 64 27.5 23.0 30.9 20.4 18.0 22.4 27.7 23.2 31.2 65 - 74 6.5 5.6 7.1 3.5 2.9 3.9 6.8 5.9 7.4

75 and Over 2.5 2.4 2.5 2.2 2.1 2.2 2.5 2.4 2.6 Total 9.4 8.0 10.6 6.6 6.0 7.1 9.5 8.0 10.8


Appendix D-6: Demographic Analysis

Page 1

This analysis looks at whether the largest differences in population, by demographic and as a percentage to total, are correlated with the largest differences in utilization, by demographic as a percentage to total between UHC and Centennial Care. The analysis was performed on total encounters for utilization and average member months for membership. The highlighted items show the largest positive and negative differences between UHC and Centennial Care for population and utilization. A positive difference represents a demographic where UHC had a higher percentage of population or utilization than Centennial Care. A negative difference represents a demographic where UHC had less population or utilization than Centennial Care. A lower population in a demographic would be expected to lead to lower utilization in that demographic. A higher difference in population and utilization which are not correlated could be indicative of missing encounters from those segments of the population. The differences for UHC are fairly correlated and do not appear to indicate there is any missing data.

Legend

= Top 5 Negative Differences

= Top 5 Positive Differences

Note: For all tables in this appendix percentages that do not add to 100% are due to rounding


Page 2

United Healthcare of New Mexico: Membership by Demographic Percent to Total

Age Group United Healthcare

Total Tribal Community Non-Tribal Community Total Male Female Total Male Female Total Male Female

Average Number of Members Percentage to Total 0 - 5 6.04% 3.10% 2.93% 0.39% 0.20% 0.19% 5.64% 2.90% 2.74%

6 - 18 10.37% 5.34% 5.03% 0.81% 0.43% 0.38% 9.56% 4.91% 4.65% 19 - 21 5.10% 2.21% 2.88% 0.14% 0.06% 0.08% 4.96% 2.16% 2.80% 22 - 34 20.21% 10.09% 10.12% 0.67% 0.30% 0.37% 19.54% 9.78% 9.75% 35 - 49 16.65% 8.24% 8.41% 0.75% 0.34% 0.41% 15.91% 7.91% 8.00% 50 - 64 22.83% 9.83% 13.00% 1.01% 0.44% 0.57% 21.81% 9.39% 12.42% 65 - 74 8.90% 3.45% 5.45% 0.91% 0.35% 0.55% 8.00% 3.10% 4.90%

75 and Over 9.91% 3.14% 6.77% 1.04% 0.31% 0.73% 8.86% 2.82% 6.04% Total 100.00% 45.41% 54.59% 5.72% 2.43% 3.28% 94.28% 42.97% 51.31%

Centennial Care: Membership by Demographic Percent to Total

Age Group Centennial Care


Average Number of Members Percentage to Total 0 - 5 16.19% 8.24% 7.95% 0.62% 0.31% 0.30% 15.57% 7.92% 7.65%

6 - 18 34.35% 17.51% 16.84% 1.17% 0.58% 0.58% 33.19% 16.92% 16.26% 19 - 21 4.29% 1.75% 2.54% 0.11% 0.04% 0.06% 4.18% 1.71% 2.47% 22 - 34 17.41% 6.15% 11.26% 0.48% 0.17% 0.31% 16.93% 5.98% 10.95% 35 - 49 12.52% 5.07% 7.45% 0.36% 0.15% 0.21% 12.16% 4.92% 7.24% 50 - 64 11.09% 4.87% 6.22% 0.36% 0.16% 0.21% 10.73% 4.72% 6.01% 65 - 74 2.08% 0.83% 1.25% 0.20% 0.08% 0.12% 1.89% 0.76% 1.13%

75 and Over 2.06% 0.66% 1.40% 0.21% 0.06% 0.15% 1.85% 0.60% 1.25% Total 100.00% 45.09% 54.91% 3.51% 1.57% 1.94% 96.49% 43.52% 52.97%

Difference: Membership by Demographic Percent to Total

Age Group MCO to Program Difference


Difference Average Number of Members Percentage to Total 0 - 5 -10.15% -5.13% -5.02% -0.22% -0.11% -0.11% -9.93% -5.02% -4.91%

6 - 18 -23.98% -12.16% -11.82% -0.36% -0.15% -0.20% -23.62% -12.01% -11.61% 19 - 21 0.81% 0.46% 0.35% 0.03% 0.01% 0.02% 0.78% 0.45% 0.33% 22 - 34 2.80% 3.94% -1.14% 0.19% 0.13% 0.05% 2.61% 3.81% -1.19% 35 - 49 4.13% 3.17% 0.96% 0.38% 0.18% 0.20% 3.75% 2.99% 0.76% 50 - 64 11.73% 4.95% 6.78% 0.65% 0.28% 0.37% 11.08% 4.67% 6.41% 65 - 74 6.82% 2.62% 4.20% 0.71% 0.28% 0.43% 6.11% 2.34% 3.77%

75 and Over 7.85% 2.47% 5.37% 0.83% 0.25% 0.58%

7.02% 2.22% 4.79% Total 0.00% 0.32% -0.32% 2.21% 0.87% 1.34% -2.21% -0.55% -1.66%


Page 3

United Healthcare of New Mexico: Total Utilization by Demographic Percent to Total

Age Group United Healthcare


Total Percentage of All Services by Demographic 0 - 5 1.78% 0.97% 0.81% 0.10% 0.06% 0.04% 1.68% 0.91% 0.77%

6 - 18 2.90% 1.49% 1.41% 0.22% 0.13% 0.09% 2.69% 1.36% 1.32% 19 - 21 1.84% 0.56% 1.28% 0.03% 0.01% 0.02% 1.81% 0.55% 1.26% 22 - 34 11.91% 5.26% 6.64% 0.58% 0.28% 0.30% 11.33% 4.99% 6.34% 35 - 49 18.19% 7.99% 10.20% 1.25% 0.63% 0.62% 16.94% 7.36% 9.58% 50 - 64 34.46% 12.84% 21.62% 2.17% 0.87% 1.30% 32.29% 11.96% 20.33% 65 - 74 12.84% 4.21% 8.63% 1.35% 0.47% 0.87% 11.49% 3.74% 7.76%

75 and Over 16.08% 4.63% 11.46% 1.70% 0.53% 1.17% 14.39% 4.10% 10.29% Total 100.00% 37.95% 62.05% 7.39% 2.97% 4.41% 92.61% 34.97% 57.64%

Centennial Care: Total Utilization by Demographic Percent to Total

Age Group Centennial Care


Total Percentage of All Services by Demographic 0 - 5 10.08% 5.32% 4.76% 0.34% 0.18% 0.16% 9.75% 5.14% 4.61%

6 - 18 20.33% 10.24% 10.09% 0.54% 0.26% 0.28% 19.79% 9.98% 9.81% 19 - 21 3.00% 0.85% 2.15% 0.06% 0.02% 0.04% 2.95% 0.83% 2.11% 22 - 34 16.51% 4.64% 11.87% 0.43% 0.15% 0.28% 16.09% 4.49% 11.59% 35 - 49 17.62% 6.38% 11.24% 0.61% 0.28% 0.33% 17.02% 6.10% 10.92% 50 - 64 22.58% 8.76% 13.82% 0.90% 0.37% 0.53% 21.68% 8.40% 13.29% 65 - 74 4.61% 1.58% 3.03% 0.48% 0.18% 0.30% 4.13% 1.40% 2.72%

75 and Over 5.27% 1.49% 3.77% 0.57% 0.16% 0.41% 4.69% 1.33% 3.36% Total 100.00% 39.27% 60.73% 3.91% 1.60% 2.32% 96.09% 37.68% 58.41%

Difference: Total Utilization by Demographic Percent to Total

Age Group MCO to Program Difference


Difference Total Percentage of All Services by Demographic 0 - 5 -8.30% -4.35% -3.95% -0.24% -0.12% -0.12% -8.06% -4.23% -3.83%

6 - 18 -17.43% -8.75% -8.68% -0.32% -0.13% -0.19% -17.11% -8.61% -8.49% 19 - 21 -1.16% -0.29% -0.87% -0.02% -0.01% -0.01% -1.14% -0.28% -0.86% 22 - 34 -4.60% 0.62% -5.22% 0.16% 0.13% 0.03% -4.76% 0.49% -5.25% 35 - 49 0.57% 1.61% -1.04% 0.64% 0.35% 0.29% -0.08% 1.26% -1.34% 50 - 64 11.88% 4.07% 7.81% 1.27% 0.51% 0.77% 10.60% 3.56% 7.04% 65 - 74 8.23% 2.63% 5.61% 0.87% 0.29% 0.57% 7.37% 2.33% 5.03%

75 and Over 10.82% 3.13% 7.68% 1.12% 0.36% 0.76% 9.69% 2.77% 6.93% Total 0.00% -1.33% 1.33% 3.48% 1.38% 2.10% -3.48% -2.71% -0.77%

Appendix D-7: Claims Processing Timeliness Results

Page 1

United Healthcare of New Mexico: Percentage of Total Claims Processed

Days

United Healthcare

Total Inpatient Outpatient Professional Dental Pharmacy

< = 15 74% 77% 55% 88% 88% 27%

< = 30 90% 94% 89% 99% 99% 50%

< = 90 96% 99% 99% 100% 100% 72%

Over 90 100% 100% 100% 100% 100% 100%

Average Days 22 15 18 9 10 89

Centennial Care: Percentage of Total Claims Processed

Days

Centennial Care


< = 15 73% 67% 70% 87% 90% 33%

< = 30 82% 84% 83% 94% 92% 46%

< = 90 89% 91% 89% 97% 95% 66%

Over 90 100% 100% 100% 100% 100% 100%

Average Days 38 33 35 14 17 109

Appendix D-8: Encounter Submission Rate Results

Page 1

United Healthcare of New Mexico: Percentage of Total Encounters Submitted

Days

United Healthcare


< = 30 45% 38% 30% 37% 46% 100%

< = 90 61% 54% 41% 57% 62% 100%

< = 180 80% 72% 61% 80% 89% 100%

< = 270 89% 81% 72% 91% 98% 100%

< = 365 93% 85% 80% 95% 99% 100%

Over 365 100% 100% 100% 100% 100% 100%

Average Days 106 178 188 107 79 0

Centennial Care: Percentage of Total Encounters Submitted

Days

Centennial Care


< = 30 53% 37% 45% 40% 48% 100%

< = 90 64% 49% 56% 55% 63% 100%

< = 180 77% 65% 69% 73% 77% 100%

< = 270 84% 71% 74% 81% 86% 100%

< = 365 87% 74% 80% 86% 90% 100%

Over 365 100% 100% 100% 100% 100% 100%

Average Days 133 239 185 161 124 0

Appendix D-9: Place of Service Detail

Page 1

United Healthcare of New Mexico: Utilization for Top Four Place of Services

Place of Service

United Healthcare


Office (Place of Service 11)

878,577 - - 721,939 156,638 -

Hospital (Type of Bill 11X and 12X)

1,069,124 15,650 672,163 380,818 493 -

Pharmacy (Place of Service 01)

742,339 - - 77 - 742,262

Home (Place of Service 12)

1,719,345 - - 1,719,327 18 -

All Other 1,007,923 51,448 235,778 709,957 10,740 -

Centennial Care: Utilization for Top Four Place of Services

Place of Service

Centennial Care


Office (Place of Service 11) 8,825,516 - - 6,528,275 2,297,241 -

Hospital (Type of Bill 11X and 12X) 6,736,352 80,748 4,616,095 2,039,016 493 -

Pharmacy (Place of Service 01) 5,426,453 - - 716 - 5,425,737

Home (Place of Service 12) 3,397,188 - - 3,397,150 38 -

All Other 3,899,206 117,738 1,110,129 2,630,996 40,343 -

Appendix D-10: Provider Type Detail

Page 1

United Healthcare of New Mexico: Utilization for Top Five Provider Types

Provider Type

United Healthcare


Pharmacy 729,136 - - 4,961 - 724,175

Physician, MD 737,120 144 4,846 731,116 702 312

Hospital, General Acute 637,149 13,561 623,289 299 - -

Dentist 167,076 - - 41 167,035 -

Personal Care Services 1,171,169 - - 1,171,169 - -

All Other 1,975,658 53,393 279,806 1,624,532 152 17,775

Centennial Care: Utilization for Top Five Provider Types

Provider Type

Centennial Care


Pharmacy 5,251,260 5 26 12,983 - 5,238,246

Physician, MD 5,131,509 709 24,787 5,099,744 1,814 4,455

Hospital, General Acute 4,491,520 70,756 4,380,446 40,318 - -

Dentist 2,298,968 - - 2,317 2,296,651 -

Personal Care Services 2,297,953 907 1,812 2,295,234 - -

All Other 8,813,505 126,109 1,319,153 7,145,557 39,650 183,036

Appendix D-10: Provider Type Detail

Page 2

Note: The following percentages are the percentage of the top five services in Centennial Care and not representative of the entire population; therefore, they do not add up to 100% for any of the encounter types. United Healthcare of New Mexico: Percentage of Total Service Type for Top Five Provider Types

Provider Type

United Healthcare


Pharmacy 13.46% - - 0.14% - 97.56%

Physician, MD 13.61% 0.21% 0.53% 20.70% 0.42% 0.04%

Hospital, General Acute 11.76% 20.21% 68.65% 0.01% - -

Dentist 3.08% - - 0.00% 99.49% -

Personal Care Services 21.62% 0.00% 0.00% 33.16% - -

Centennial Care: Percentage of Total Service Type for Top Five Provider Types

Provider Type

Centennial Care


Pharmacy 18.57% 0.00% 0.00% 0.09% - 96.54%

Physician, MD 18.14% 0.36% 0.43% 34.94% 0.08% 0.08%

Hospital, General Acute 15.88% 35.65% 76.50% 0.28% - -

Dentist 8.13% - - 0.02% 98.23% -

Personal Care Services 8.12% 0.46% 0.03% 15.72% - -

Appendix D-11: Dental Utilization Detail

Page 1

Dental Utilization by Category of Service

Category of Service Centennial Care United Healthcare Centennial Care United

Healthcare

Diagnostic 1,057,969 73,834 45.25% 43.98% Preventive 630,168 25,542 26.95% 15.21% Restorative 331,867 28,726 14.19% 17.11% Oral and Maxillofacial Surgery 152,745 22,056 6.53% 13.14% Adjunctive General Services 96,729 7,476 4.14% 4.45%

Note: Percentages that do not add to 100% are due to rounding

Appendix D-12: Dental Utilization Statistics

Page 1

Note: The percentages in this appendix are the percentage of total membership using dental services. They will not add to 100% United Healthcare of New Mexico: Dental Utilization Statistics

Description Dental Procedure Codes Category

United Healthcare

Total Children

(under age 21) Adults

(ages 21 and over)

Count Percentage Count Percentage Count Percentage

Member Months 843,740 164,367 679,373 Average Number of Members 70,312 13,697 56,614 Number of Members Utilizing Dental

23,244 5,628 17,616

Percentage of Member Utilization 33.1% 41.1% 31.1% Adult Oral Prophylaxis D1110 Preventive 6,711 28.9% 16 0.3% 6,695 38.0% Child Oral Prophylaxis D1120 Preventive 4,560 19.6% 4,535 80.6% 25 0.1% Dental Sealants D1351 Preventive 954 4.1% 954 17.0% 0 0.0% Fluoride Treatments D1201 - D1208 Preventive 8,611 37.0% 4,395 78.1% 4,216 23.9% Composite Fillings D2330 - D2394 Restorative 5,729 24.6% 1,312 23.3% 4,417 25.1% Extractions D7111 - D7250, D7280 Oral Maxillofacial Surgery 5,444 23.4% 752 13.4% 4,692 26.6%

Centennial Care: Dental Utilization Statistics

Description Dental Procedure Codes Category

Centennial Care

Total Children

(under age 21) Adults

(ages 21 and over)

Count Percentage Count Percentage Count Percentage

Member Months 6,903,881 3,698,486 3,205,395 Average Number of Members 575,323 308,207 267,116 Number of Members Utilizing Dental

273,843 186,552 87,291

Percentage of Member Utilization 47.6% 60.5% 32.7% Adult Oral Prophylaxis D1110 Preventive 42,106 15.4% 22 0.0% 42,084 48.2% Child Oral Prophylaxis D1120 Preventive 167,067 61.0% 167,039 89.5% 28 0.0% Dental Sealants D1351 Preventive 27,407 10.0% 27,348 14.7% 59 0.1% Fluoride Treatments D1201 - D1208 Preventive 187,209 68.4% 163,318 87.5% 23,891 27.4% Composite Fillings D2330 - D2394 Restorative 68,665 25.1% 41,344 22.2% 27,321 31.3% Extractions D7111 - D7250, D7280 Oral Maxillofacial Surgery 49,911 18.2% 23,427 12.6% 26,484 30.3%

Appendix D-13: Drug Category Detail

Page 1

United Healthcare of New Mexico: Utilization for Top Five Drug Categories

Drug Group

United Healthcare

Total Original

Prescriptions Refills Legend

Over the Counter

PSYCHOTHERAPEUTIC 100,914 54,182 46,732 100,912 2

ANTIBIOTICS 45,067 41,652 3,415 44,915 152

ANALGESICS 71,418 61,911 9,507 66,528 4,890

CARDIOVASCULAR 83,479 30,167 53,312 83,479 0

GASTROINTESTINAL 51,606 25,769 25,837 43,178 8,428

All Other 389,778 191,422 198,356 328,287 61,491

Centennial Care: Utilization for Top Five Drug Categories

Drug Group

Centennial Care

Total Original

Prescriptions Refills Legend

Over the Counter

PSYCHOTHERAPEUTIC 715,135 406,605 308,530 715,117 18

ANTIBIOTICS 550,591 505,957 44,634 549,561 1,030

ANALGESICS 488,164 420,574 67,590 457,320 30,844

CARDIOVASCULAR 487,677 178,255 309,422 487,674 3

GASTROINTESTINAL 341,871 188,511 153,360 312,034 29,837

All Other 2,842,299 1,572,802 1,269,497 2,449,610 392,689

Appendix D-14: Service Type Relationships

Page 1

United Healthcare of New Mexico: Analysis by Service Type

Services

United Healthcare

Average Number of Members

Visits Number of Services

Count Average

Per Member

Count Average

Per Visit

Average Per

Member

Ancillary

70,312

963,077 13.7 2,243,809 2.3 31.9

Outpatient 526,391 7.5 1,188,096 2.3 16.9

Primary Care 128,344 1.8 193,817 1.5 2.8

Specialty Care 460,270 6.5 671,197 1.5 9.5

Inpatient 174,426 2.5 507,254 2.9 7.2

Rx - New Prescriptions 404,114 5.7 405,103 1.0 5.8

Rx - Refills 335,294 4.8 337,159 1.0 4.8

Total 2,991,916 42.6 5,546,435 1.9 78.9

Centennial Care: Analysis by Service Type

Services

Centennial Care

Average Number of Members

Visits Number of Services

Count Average

Per Member

Count Average

Per Visit

Average Per

Member

Ancillary

575,323

2,562,951 4.5 5,922,320 2.3 10.3

Outpatient 1,938,362 3.4 6,102,233 3.1 10.6

Primary Care 1,379,576 2.4 2,705,433 2.0 4.7

Specialty Care 3,109,877 5.4 5,023,120 1.6 8.7

Inpatient 668,784 1.2 2,013,471 3.0 3.5

Rx - New Prescriptions 3,259,524 5.7 3,272,704 1.0 5.7

Rx - Refills 2,140,971 3.7 2,153,033 1.0 3.7

Total 15,060,045 26.2 27,192,314 1.8 47.3

Appendix D-15: United Healthcare Community Plan New Mexico Rebuttal and Response

Page 1

The managed care organizations (MCOs) were given the opportunity to rebut the findings and recommendations noted in this report. The MCO provided their rebuttal, which is included within this appendix. Following the MCO rebuttal is HealthInsight/Myers and Stauffer’s response to the MCO’s disagreements and requests for reconsideration. Findings and recommendations for which the MCO acknowledged, agreed or did not comment are not addressed. When reiterating the MCO’s rebuttal in our response, we included the rebuttal verbatim as stated by the MCO. There may be some variation in the response format based on the MCO’s rebuttal submission.

It should be noted that the findings and recommendations are based on the on-site visits, conference calls, documents and data provided for validation purposes. The MCO provided accounting system data, and a sample of data from their claims processing system for validation and the fiscal agent (FA) provided encounter data extracts from the Medicaid management information system (MMIS). The 837 files, which are an electronic data transaction set for communicating claim information in a Health Insurance Portability and Accountability Act (HIPAA)-compliant format, were not provided for validation. Findings and recommendations are specific to the validation period, calendar year 2014, are based on correct coding standards, HIPAA rules and regulations and industry best practices, and may not reflect the current status of the MCO’s claims and encounter systems data or the FA’s MMIS encounter systems data if subsequent modifications have been made.

UnitedHealthcare Community Plan of New Mexico 8220 San Pedro NE

Ste 300 Albuquerque, NM 87113

Via email to: [email protected] 09/26/17 Andy Romero, RHIT, CCS, CPC Project Manager, EQRO HealthInsight New Mexico 5801 Osuna Rd. NE, Suite 200 Albuquerque, NM 87109

Re: Encounter Data Validation Audit Rebuttal Dear Ms. Romero, In response to your request for UnitedHealthcare’s (UHC) review and rebuttal of the EDV draft audit report, UHC is respectfully providing the following rebuttal for your consideration. Document Title Page

Number Auditor Finding or Recommendation UHC Rebuttal

EDV Consolidated UHC Report

6 4. HSD should consider increasing the 30-day encounter submission requirement in the MCO contract (Section 4.19.2.2.11) to 95 percent, based on best practice.

Recommendation is valid, but unless remaining recommendations are enacted this requirement level is unattainable. This recommendation cannot be enacted independently of other suggestions.


6 5. HSD should direct Conduent to accept MCO denied encounter data. As of the time of the on-site visits, the MCO denied encounters were not being accepted by Conduent. By not accepting MCO denied encounter data, some encounters with both MCO denied and MCO paid detail lines were not being submitted and this would reduce the completeness of the encounter data. The MCO denied claims are necessary in order to have a complete picture of the services being provided to the members and non-submission contradicts the MCO contract (Section 4.19.2.2.5).

UHC has always submitted any paid line to Conduent even if there are some lines on the claim that are denied. Can you provide examples?


6 14. Conduent should make necessary changes to ensure the claims data is reflective of the encounter data submitted by the MCO, remains as submitted by the

The intent is unclear, please clarify.

Page 2

Document Title Page Number

Auditor Finding or Recommendation UHC Rebuttal

provider of service and values are in the appropriate field(s).


38 [Billing Provider NPI]

UHC should review their inbound and outbound processes to ensure they are capturing, storing and transmitting encounter data as submitted by their subcontractor vendors. Additionally, UHC should ensure they are capturing and retaining the billing provider information submitted by the billing provider.

The variances on billing NPI and taxonomy code are driven by how data was pulled into the claim sample data reports. The billing NPI and taxonomy code were pulled based on the provider selection process of the claim adjudication system. The encounter submissions included the billing NPI and taxonomy code that were captured from the actual claim as submitted by the provider.


38 [Diagnosis Code 1] UHC should ensure they are capturing and retaining the diagnosis information submitted by the provider.

The identified issue was isolated to the transportation vendor supplied claims data file where the data value was not populated. There may have been a misinterpretation of Dx given this is not typically applicable to non-emergent transportation services.


39 [Former MMIS Claim TCN] UHC review the requirements for submitting void, replacement and adjusted claims to ensure the TCN(s) of the original claim are included on the encounter resubmissions. Additionally, Conduent should review their process for receiving adjustments and replacements to ensure they are accurately capturing the information submitted by the MCOs.

Is it possible to get examples. In reviewing data, UHC does not see any issues. NEMIS maintains a full submission history of every claim. NEMIS also stores the MMIS ICN that’s received back from Conduent in order to use that ICN for future adjustment or void submissions for the claim.


39 [Header Paid Amount] UHC should review the requirements for submitting void, adjusted and replacement claims to ensure that all replacement, adjusted and voided claims/encounters processed by UHC are submitted to Conduent. Additionally, Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the data as submitted by UHC and/or subcontractor vendor.

The system that was used to populate the claims sample data stores the adjustment data differently than how the encounters are submitted. The system maintains the negative values for data storage, but the encounter would send the replacement that includes the new paid amount that’s net of the adjustment. When a void is submitted through the encounter process, the encounter will still have a paid amount and have a frequency code of ‘8’ to indicate it’s a void.


39 [MMIS Member Number] UHC should ensure that a valid member Medicaid ID is included on all encounters submitted to Conduent. Conduent should review requirements for receiving and accepting encounters to

For Medicare crossover claims, Conduent required that the member Medicare ID (HICN) was submitted on the encounters instead of the member Medicaid ID. Conduent changed the requirement in 2017 to allow member Medicaid ID on encounter submissions.

Page 3



ensure the member’s Medicaid ID is on all encounters submitted. Encounters without a valid member Medicaid ID should not be accepted into the encounter data system and should be rejected during the inbound encounter submission process.


40 [Plan Paid Amount] UHC should ensure that encounters submitted to Conduent reflect the date the claim was adjudicated (paid or denied) to the provider and not the date the encounter was submitted to Conduent, or the date the check was issued to the provider, or the date UHC paid the subcontractor vendor. Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the dates as submitted by UHC and/or the subcontractor vendor.

Encounter companion guide states that “Managed Care Organizations must enter into this segment the date the claim was paid by them or by their subcontractor to the provider”. UHC submits the date the provider is paid on the encounter submissions based on this guidance. The system used to generate the sample claim data files used the adjudication date.


42 [Line Paid Amount] UHC should review the requirements for submitting void, adjusted and replacement claims to ensure that all replacement, adjusted and voided claims/encounters processed by UHC and/or subcontractor vendor are submitted to Conduent. Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the data as submitted by UHC and/or the subcontractor vendor.

The system that was used to populate the claims sample data stores the adjustment data differently than how the encounters are submitted. The system maintains the negative values for data storage, but the encounter would send the replacement that includes the new paid amount that’s net of the adjustment. When a void is submitted through the encounter process, the encounter will still have a paid amount and have a frequency code of ‘8’ to indicate it’s a void.


42 [Place of Service] The location in which the treatment/service was performed is required on all professional (CMS-1500) and dental (ADA 2012) claims. UHC should ensure that all professional and dental encounters reflect the appropriate place of services code.

The identified issue was isolated to the transportation vendor supplied claims data file where the data value was not populated.


43 [Prescribing Provider NPI] UHC should ensure they are capturing and maintaining the appropriate prescribing provider NPI information within the claims system. Additionally, they should ensure the accurate prescribing provider NPI information is included in the encounter

NPI is included in the claims system and part of the encounter data submission. It was identified that a different field was pulled to populate NPI in the claims sample data provided.

Page 4



data submission. EDV Consolidated UHC Report

43 [Procedure Code] UHC should ensure that encounters submitted to Conduent reflect the procedure codes paid for by UHC or subcontractor vendor on each service/procedure/line reflected on the claim. Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the procedure codes on each service/procedure/line as submitted by UHC or the subcontractor vendor.

Line level matching issues can be attributed to how claims that have both paid and denied lines are submitted during the encounter process. Conduent does not want to receive any denied lines. When a claim has both paid and denied lines, UHC only sends the paid lines. Line numbers may have to be adjusted in order to have valid sequential line numbers.


43 [Revenue Code] UHC should ensure that encounters submitted to Conduent reflect the revenue codes paid for by UHC or the subcontractor vendor on each service/procedure/line reflected on the claim. Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the revenue codes on each service/procedure/line as submitted by UHC or the subcontractor vendor.



44 [Tooth Number] UHC should ensure that encounters submitted to Conduent reflect the tooth number indicated by the provider to UHC’s subcontractor vendor on each service/procedure/line reflected on the claim. Conduent should review the requirements for receiving and accepting encounters to ensure the tooth numbers UHC submits on the encounter are captured and stored.



61 Typo – 1. See Findings Related to Key Data

Elements in Table B-6 above. 2. See Recommendations Related to Key

Data Elements in Table B-6 above.

Please update B-6 to D-6.


64 2. UHC should ensure their subcontractor vendors have strategies in place for medical record retention and accessibility.

Please clarify. UHC did not see a trend with Subcontractor’s compliance to provide medical records. The top 3 reasons records were not received were due to rendering providers stating records not available;

Page 5



rendering providers stating they would provide records but did not follow thru; and rendering providers stating member authorization is required. Records identified in the sample ranged from 2012 – 2014, overlapping CoLTS and Centennial Care programs, the age of the records was administratively burdensome per providers. DOS prior to Centennial Care should not be included.


65 3. UHC indicated that when large issues are identified within the encounter data, their encounter team researches the issue and determines the solution. The solution is merged back into their encounter system, National Encounter Management Information System (NEMIS), across all affected encounters. However, UHC indicated that there are not any follow-up accuracy checks performed on the encounters in the mass correction to ensure accuracy.

UHC does ensure all corrections are made accurately. Any time there are changes in code, there is significant testing done to ensure changes are implemented correctly. After the code is deployed and the initial files are generated, there is review of the files to ensure accuracy. There is also special review of the response files to ensure new rejections were not created. There is significant review even of changes when there is not a code change. After development makes the necessary changes and generates the files, the NEMIS IT O&M SA will review the generated files to ensure the corrections were made accurately.


65 1. Initially, UHC’s encounters, with the exception of dental encounters, were at or above the 95 percent threshold for completeness compared to their submitted accounting system data. A second encounter reconciliation was completed in order to see the difference in completion percentages, which included additional encounter activity from May 2016 through February 2017. Once the second encounter reconciliation was completed, the cumulative percentage of completion for dental encounters remained below the 95 percent completion threshold. All other encounter types continued to be at or above the 95 percent completion threshold.

The dental encounter completeness was impacted by how the system used to pull the sample claims data file provided to Myers, stores adjustments from our dental vendor. The system that was used to create the sample claims data saves the adjustments as their own claim. NEMIS stores the adjustment under the original claim in order for accurate encounter reporting on replacements and voids.

Appendices D-1 to D-14

10 6. Myers and Stauffer historically codes voided encounters contained within the encounter submissions to match the associated adjustment claim’s paid date. This allows for the proper matching of accounting system data that occurs due to this void transaction. We were unable to assign a paid date to the void transactions that was different than the date of the

UHC has already completed a project to correctly send the latest paid date on any replacement and void.

Page 6



original submission. It appears UHC used the date of the original submission for the MCO paid date and the MCO received date on all subsequent adjustments, replacements, back outs and voids of an encounter claim.


20 2. HealthInsight and Myers and Stauffer recommend that UHC work with their pharmacy vendor to fulfill the reporting requirements set out in the Medicaid Managed Care Services Agreement. More specifically, the encounter data used in this analysis indicate a negative paid amount for pharmacy encounters from March through May 2014.

The date being used to pull the encounters is the date it was submitted to Conduent. Encounters were not submitted in production until July 2014 due to the implementation of Centennial Care. The encounters being represented in the January through June time frame are run out claims from the CoLTS. Therefore, this data does not seem appropriate to include.


33 8. During the data analyses, Myers and Stauffer noted many encounters that were categorized as voids, adjustment credits or adjustment debits that did not indicate an associated original, paid encounter. Fields that are supposed to just indicate the TCN of the original encounter, the TCN of the replaced encounter and the TCN of the replacement encounter were left blank in instances where it seems they should have been completed.

UHC does submit the original state MMIS TCN in the REF*F8 when submitting replacements or voids. Encounters would not be accepted without TCN for void or replacement. In these situations is it driven when Conduent does mass adjustments in their system?

UHC would like to provide these additional rebuttal comments to explain key themes noted in the Myers and Stauffer report and appendices.

1. UHC has identified issues that were driven by requirement differences between encounters and the sample claims data files. Encounters we are required to not send any denied line to the state, but all claim lines are to be included in the sample claims data. This requirement difference creates issues when trying to match data at the line level. When there is a mix of paid and denied lines on a claim, UHC only sends the paid lines. This could cause the line numbers to be different in the encounter file versus what’s represented in the sample claims data. Line numbers on the encounter file have to be sequential or else files fail for formatting. Encounter line number not matching to sample claim data is resulting in data elements not matching between the two sources. These differences are leading to some of the variances identified in Table D6.

2. UHC has identified an issue with the MMIS ICN field populated in the sample claim data files. The MMIS ICN is based on the latest submission of that claim, which could result in variances from the sample claim data files. The sample claim data files were created based on the claims adjudicated for that month. A claim could be originally processed in September 2014, but then be adjusted outside of September. The MMIS ICN that was included in the sample claim data files would tie to that adjustment that’s outside of September. Myers & Stauffer are now trying to match the September claim data in the sample claim data file to the most recent version of the claim in the encounter data. This is why there would be variances between the two sources. NEMIS keeps the MMIS ICN for every submission and can tie it back to the claim adjudication claim ID, but it becomes challenging to send the information to other systems when a claim has been submitted multiple times.

Page 7

3. UHC thought it would be beneficial to provide background on encounters to help explain findings in Appendices. New Mexico moved to a new Medicaid program called Centennial Care on 1/1/14. Testing for encounters didn’t begin until middle of February 2014 and didn’t start submitting encounters in production until the middle of the year. This is driving some of the variances in the first half of 2014. This is especially observed in the pharmacy Table 5 on page 17. The dollars for the first half of the year are very low or even negative. It appears that the encounter data was pulled based on when it was submitted to the Conduent versus when UHC actually paid the claim. The data populated in January 2014 through May 2014 for the encounter data seems to be actually attributed to the run out of the CoLTS product. We started submitting production pharmacy claims on 6/18/14 and only include the first 15 days of January in that submission. The July 2014 numbers were extremely higher than any other month as we were catching up on the encounters.

4. UHC identified that some of the mismatches between encounters and the sample claim data files was related to how adjustments are processed/stored. The system used for the sample claim data file keeps the data at a transactional level, which is why there are negatives in the data. For encounters, UHC would never send a negative value in the 837. If a claim is adjusted, UHC would send a replacement with the new paid amount that is net of the adjustment. If the claim was fully reversed, UHC would just send a void to Conduent in order to fully remove the claim from the system.

Thank you for the opportunity to review and provide feedback. Sincerely, Veronica Esparza Compliance Officer

Page 8


Page 9

Response to United Healthcare Community Plan New Mexico’s Rebuttal

Activity 1: Review State Requirements

1. HealthInsight/Myers and Stauffer’s Recommendation, EDV Consolidated UHC Report: HSD should consider increasing the 30-day encounter submission requirement in the MCO contract (Section 4.19.2.2.11) to 95 percent, based on best practice.

UHC’s Rebuttal: “Recommendation is valid, but unless remaining recommendations are enacted this requirement level is unattainable. This recommendation cannot be enacted independently of other suggestions.”

HealthInsight/Myers and Stauffer’s Response: UHC’s comments are valid; however, increasing the submission requirement from 90 percent to 95 percent would ensure the encounter data is complete for federal reporting, program management and oversight, tracking, accounting, and other ad hoc analyses with minimal margin of error. We recommend that HSD take into consideration UHC’s concerns should they choose to increase the encounter submission rate requirement.

2. HealthInsight/Myers and Stauffer’s Recommendation, EDV Consolidated UHC Report: HSD should direct Conduent to accept MCO denied encounter data. As of the time of the on-site visits, the MCO denied encounters were not being accepted by Conduent. By not accepting MCO denied encounter data, some encounters with both MCO denied and MCO paid detail lines were not being submitted and this would reduce the completeness of the encounter data. The MCO denied claims are necessary in order to have a complete picture of the services being provided to the members and non-submission contradicts the MCO contract (Section 4.19.2.2.5).

UHC’s Rebuttal: “UHC has always submitted any paid line to Conduent even if there are some lines on the claim that are denied. Can you provide examples?”

HealthInsight/Myers and Stauffer’s Response: As denied claims were not required to be submitted, not all MCOs included denied detail lines and/or lines with zero paid dollar amounts ($0.00) with their paid encounter claim submissions. We encourage UHC to continue to submit denied lines on paid encounter claim submissions.


Page 10

Activity 2: Review MCO’s System Capability

HealthInsight/Myers and Stauffer’s Recommendation: UHC indicated that when large issues are identified within the encounter data, their encounter team researches the issue and determines the solution. The solution is merged back into their encounter system, National Encounter Management Information System (NEMIS), across all affected encounters. However, UHC indicated that there are not any follow-up accuracy checks performed on the encounters in the mass correction to ensure accuracy.

UHC’s Rebuttal: “UHC does ensure all corrections are made accurately. Any time there are changes in code, there is significant testing done to ensure changes are implemented correctly. After the code is deployed and the initial files are generated, there is review of the files to ensure accuracy. There is also special review of the response files to ensure new rejections were not created. There is significant review even of changes when there is not a code change. After development makes the necessary changes and generates the files, the NEMIS IT O&M SA will review the generated files to ensure the corrections were made accurately.”

HealthInsight/Myers and Stauffer’s Response: We encourage UHC to continue testing, reviewing and performing accuracy checks when corrections and changes are made to code, files, data systems, etc. Activity 3: Analyze Electronic Encounter Data

1. HealthInsight/Myers and Stauffer’s Recommendation, EDV Consolidated UHC Report: Conduent should make necessary changes to ensure the claims data is reflective of the encounter data submitted by the MCO, remains as submitted by the provider of service and values are in the appropriate field(s).

UHC’s Rebuttal: “The intent is unclear, please clarify.”

HealthInsight/Myers and Stauffer’s Response: For each of the key data elements evaluated, the MCO-submitted sample claims data was traced to the encounter data extracts provided by the fiscal agent (FA), based on the plan ICN values and/or MMIS ICN values provided by the MCO in the sample claims data. Key data element values in the sample claims were compared to the corresponding encounter key data element values. Discrepancies were identified between sample claim key data element values and encounter key data element values. It could not be determined if the errors were due to the values provided by the MCOs in the sample claims data, originated during the transition from the MCO’s claims system to the encounter system, occurred during the creation of the 837 by the MCO, or a result of the FA’s intake and storage of the data. Both the MCO and the FA should investigate these discrepancies and work together to determine and correct the root cause. Additionally, Conduent should ensure that the encounter data reflects the encounter data as submitted by the MCO and the MCO should


Page 11

ensure that the encounter data remains as submitted on the claim by the provider of service.

2. HealthInsight/Myers and Stauffer’s Recommendation, Key Data Elements: A. Billing Provider NPI for Professional, Dental and Pharmacy Encounters: UHC should

review their inbound and outbound processes to ensure they are capturing, storing and transmitting encounter data as submitted by their subcontractor vendors. Additionally, UHC should ensure they are capturing and retaining the billing provider information submitted by the billing provider.

UHC’s Rebuttal: “The variances on billing NPI and taxonomy code are driven by how data was pulled into the claim sample data reports. The billing NPI and taxonomy code were pulled based on the provider selection process of the claim adjudication system. The encounter submissions included the billing NPI and taxonomy code that were captured from the actual claim as submitted by the provider.”

HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity 3: Analyze Electronic Encounter Data, Item 1, above.

B. Diagnosis Code 1 for Professional Encounters: UHC should ensure they are capturing and retaining the diagnosis information submitted by the provider.

UHC’s Rebuttal: “The identified issue was isolated to the transportation vendor supplied claims data file where the data value was not populated. There may have been a misinterpretation of Dx given this is not typically applicable to non-emergent transportation services.”

HealthInsight/Myers and Stauffer’s Response: The UHC-submitted sample claims data was traced to the encounter data extracts provided by the FA, based on the MMIS ICN values provided by UHC in the sample claims data. Instances were identified where the diagnosis code 1 value in the UHC-submitted sample claims data was not populated and the corresponding encounter data reflected a value. Additionally, there were multiple claims identified in the sample claims data with the same MMIS ICN value and different diagnosis code 1 values. We have provided UHC with examples of the issue identified.

C. Former MMIS Claim TCN for Dental Encounters: UHC review the requirements for submitting void, replacement and adjusted claims to ensure the TCN(s) of the original claim are included on the encounter resubmissions.

Additionally, Conduent should review their process for receiving adjustments and replacements to ensure they are accurately capturing the information submitted by the MCOs.


Page 12

UHC’s Rebuttal: “Is it possible to get examples. In reviewing data, UHC does not see any issues. NEMIS maintains a full submission history of every claim. NEMIS also stores the MMIS ICN that’s received back from Conduent in order to use that ICN for future adjustment or void submissions for the claim.”

HealthInsight/Myers and Stauffer’s Response: The MMIS ICN/TCN values provided in the UHC-submitted sample data appear to be the replacement ICN/TCN, and/or all claim iterations or claim sequences have been collapsed into a single claim transaction. All claim iterations or claim sequences are expected to be included and indicate the ICN/TCN of the original claim, the ICN/TCN of the replaced claim and/or the ICN/TCN of the replacement claim, if applicable. We have provided UHC with examples of the issues identified.

D. Header Paid Amount for Inpatient, Outpatient and Professional Encounters: UHC should review the requirements for submitting void, adjusted and replacement claims to ensure that all replacement, adjusted and voided claims/encounters processed by UHC are submitted to Conduent. Additionally, Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the data as submitted by UHC and/or subcontractor vendor.

UHC’s Rebuttal: “The system that was used to populate the claims sample data stores the adjustment data differently than how the encounters are submitted. The system maintains the negative values for data storage, but the encounter would send the replacement that includes the new paid amount that’s net of the adjustment. When a void is submitted through the encounter process, the encounter will still have a paid amount and have a frequency code of ‘8’ to indicate it’s a void.”

HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity 3: Analyze Electronic Encounter Data, Item 2C, above.

E. MMIS Member Number for Outpatient and Professional Encounters: UHC should ensure that a valid member Medicaid ID is included on all encounters submitted to Conduent. Conduent should review requirements for receiving and accepting encounters to ensure the member’s Medicaid ID is on all encounters submitted. Encounters without a valid member Medicaid ID should not be accepted into the encounter data system and should be rejected during the inbound encounter submission process.


Page 13

UHC’s Rebuttal: “For Medicare crossover claims, Conduent required that the member Medicare ID (HICN) was submitted on the encounters instead of the member Medicaid ID. Conduent changed the requirement in 2017 to allow member Medicaid ID on encounter submissions.”

HealthInsight/Myers and Stauffer’s Response: Based on the MCO SYSTEM REQUIREMENTS OCTOBER, 2013, PAGE 4, I. MCO SYSTEM REQUIREMENTS, it is required that an MCO’s Management Information System (MIS) be capable of accepting, processing, maintaining, and reporting specific information necessary to the administration of the managed care program. The MCO’s MIS must meet the following requirements…3. Client Information Requirements The MCO is required to accept, maintain, and transmit Client information to include, but not be limited to...d. Assign as the key Medicaid client ID number, the RECIP-MCD-CARD-ID-NO that is sent on the Enrollment Roster file…The primary client id number within Omnicaid is the System ID number. The Medicaid ID number printed on the client’s Medicaid card is the System ID number preceded by a ‘3’ (page 6 of most current systems manual).

As the Medicaid client ID is a minimum requirement for accepting and processing claims, it would be expected that encounter data submitted to the FA by the MCOs where the 10-digit Medicaid ID is not provided, would reject upon submission and not be accepted into the MMIS.

F. Plan Paid Date for Outpatient, Professional, Dental and Pharmacy Encounters: UHC should ensure that encounters submitted to Conduent reflect the date the claim was adjudicated (paid or denied) to the provider and not the date the encounter was submitted to Conduent, or the date the check was issued to the provider, or the date UHC paid the subcontractor vendor. Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the dates as submitted by UHC and/or the subcontractor vendor.

UHC’s Rebuttal: “Encounter companion guide states that “Managed Care Organizations must enter into this segment the date the claim was paid by them or by their subcontractor to the provider”. UHC submits the date the provider is paid on the encounter submissions based on this guidance. The system used to generate the sample claim data files used the adjudication date.”

HealthInsight/Myers and Stauffer’s Response: We acknowledge that the System Companion Guide requires the MCOs to submit the date the provider is paid. However, certain date values provided in the UHC-submitted sample claims data do not agree with the corresponding encounter data values. We encourage UHC and Conduent to work together to resolve these discrepancies.


Page 14

G. Line Paid Amount for Inpatient, Outpatient and Professional Encounters: UHC should review the requirements for submitting void, adjusted and replacement claims to ensure that all replacement, adjusted and voided claims/encounters processed by UHC and/or subcontractor vendor are submitted to Conduent. Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the data as submitted by UHC and/or the subcontractor vendor.

UHC’s Rebuttal: “The system that was used to populate the claims sample data stores the adjustment data differently than how the encounters are submitted. The system maintains the negative values for data storage, but the encounter would send the replacement that includes the new paid amount that’s net of the adjustment. When a void is submitted through the encounter process, the encounter will still have a paid amount and have a frequency code of ‘8’ to indicate it’s a void.”


H. Place of Service for Professional Encounters: The location in which the treatment/service was performed is required on all professional (CMS-1500) and dental (ADA 2012) claims. UHC should ensure that all professional and dental encounters reflect the appropriate place of services code.

UHC’s Rebuttal: “The identified issue was isolated to the transportation vendor supplied claims data file where the data value was not populated.”

HealthInsight/Myers and Stauffer’s Response: We acknowledge that the issue appears to be isolated to the transportation vendor claims. However, we have identified instances where the UHC-submitted sample claims data reflects a value of “99”, Other Place of Service, and the corresponding encounter data reflects a value of “41”, Ambulance – Land. We encourage UHC and Conduent to work together to resolve these discrepancies.

I. Prescribing Provider NPI for Pharmacy Encounters: UHC should ensure they are capturing and maintaining the appropriate prescribing provider NPI information within the claims system. Additionally, they should ensure the accurate prescribing provider NPI information is included in the encounter data submission.

UHC’s Rebuttal: “NPI is included in the claims system and part of the encounter data submission. It was identified that a different field was pulled to populate NPI in the claims sample data provided.”


Page 15

HealthInsight/Myers and Stauffer’s Response: We encourage UHC to develop review procedures for internal and external data requests to ensure the data elements and values captured are appropriate, accurate, and in the expected format.

J. Procedure Code for Inpatient, Outpatient and Dental Encounters: UHC should ensure that encounters submitted to Conduent reflect the procedure codes paid for by UHC or subcontractor vendor on each service/procedure/line reflected on the claim. Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the procedure codes on each service/procedure/line as submitted by UHC or the subcontractor vendor.

UHC’s Rebuttal: “Line level matching issues can be attributed to how claims that have both paid and denied lines are submitted during the encounter process. Conduent does not want to receive any denied lines. When a claim has both paid and denied lines, UHC only sends the paid lines. Line numbers may have to be adjusted in order to have valid sequential line numbers.”

HealthInsight/Myers and Stauffer’s Response: We reevaluated our line level key data element analysis. The majority of the unmatched values appeared to be for paid claims where certain line paid amounts reflected zero paid dollars ($0.00). We removed the lines with zero paid dollars from the UHC-submitted claims sample data and recalculated the matching percentages for all line level key data elements and updated the report accordingly.

K. Revenue Code for Inpatient and Outpatient Encounters: UHC should ensure that encounters submitted to Conduent reflect the revenue codes paid for by UHC or the subcontractor vendor on each service/procedure/line reflected on the claim. Conduent should review the requirements for receiving and accepting encounters to ensure they are capturing the revenue codes on each service/procedure/line as submitted by UHC or the subcontractor vendor.


HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity 3: Analyze Electronic Encounter Data, Item 2J, above.

L. Tooth Number for Dental Encounters: UHC should ensure that encounters submitted to Conduent reflect the tooth number indicated by the provider to UHC’s subcontractor vendor on each service/procedure/line reflected on the claim. Conduent should review


Page 16

the requirements for receiving and accepting encounters to ensure the tooth numbers UHC submits on the encounter are captured and stored.


HealthInsight/Myers and Stauffer’s Response: Please see our response to Activity 3: Analyze Electronic Encounter Data, Item 2J, above.

3. HealthInsight/Myers and Stauffer’s Recommendation: Initially, UHC’s encounters, with the exception of dental encounters, were at or above the 95 percent threshold for completeness compared to their submitted accounting system data. A second encounter reconciliation was completed in order to see the difference in completion percentages, which included additional encounter activity from May 2016 through February 2017. Once the second encounter reconciliation was completed, the cumulative percentage of completion for dental encounters remained below the 95 percent completion threshold. All other encounter types continued to be at or above the 95 percent completion threshold.

UHC’s Rebuttal: “The dental encounter completeness was impacted by how the system used to pull the sample claims data file provided to Myers, stores adjustments from our dental vendor. The system that was used to create the sample claims data saves the adjustments as their own claim. NEMIS stores the adjustment under the original claim in order for accurate encounter reporting on replacements and voids.”


Activity 4: Review of Medical Records

HealthInsight/Myers and Stauffer’s Recommendation: UHC should ensure their subcontractor vendors have strategies in place for medical record retention and accessibility.


Page 17

UHC’s Rebuttal: “Please clarify. UHC did not see a trend with Subcontractor’s compliance to provide medical records. The top 3 reasons records were not received were due to rendering providers stating records not available; rendering providers stating they would provide records but did not follow thru; and rendering providers stating member authorization is required. Records identified in the sample ranged from 2012 – 2014, overlapping CoLTS and Centennial Care programs, the age of the records was administratively burdensome per providers. DOS prior to Centennial Care should not be included.”

HealthInsight/Myers and Stauffer’s Response: In accordance with Amendment 5 to the Medicaid Managed Care Agreement (PSC 13-630-8000-0024 A5), the Minimum Requirements for Contract Provider Agreements (4.9.2.8), “Require Contract Providers to maintain all records relating to services provided to Members for a ten (10) year period and to make all Member medical records or other service records available for the purpose of quality review conducted by HSD, or their designated agents both during and after the term of the Contract Provider agreement.”

Additionally, Section 7.14.2.1.5, Subcontract Relationships and Delegation, states “If the subcontract is for purposes of providing or securing the provision of Covered Services to Members, the CONTRACTOR shall ensure that all requirements described in Section 4.9 of this Agreement are included in the subcontract…”

We encourage UHC to work with their providers and subcontractor vendors to improve record retention, availability and responsiveness to requests for medical records. Appendix D-1: Initial Encounter Reconciliation

1. HealthInsight/Myers and Stauffer’s Finding 1: Myers and Stauffer historically codes voided encounters contained within the encounter submissions to match the associated adjustment claim’s paid date. This allows for the proper matching of accounting system data that occurs due to this void transaction. We were unable to assign a paid date to the void transactions that was different than the date of the original submission. It appears UHC used the date of the original submission for the MCO paid date and the MCO received date on all subsequent adjustments, replacements, back outs and voids of an encounter claim.

UHC’s Rebuttal: “UHC has already completed a project to correctly send the latest paid date on any replacement and void.”

HealthInsight/Myers and Stauffer’s Response: The additional information provided in UHC’s rebuttal describes their process for correcting and sending the latest paid date on any replacement and void that is in place. However this process was not in place during the validation process.


Page 18

2. HealthInsight/Myers and Stauffer’s Finding 2: HealthInsight and Myers and Stauffer recommend that UHC work with their pharmacy vendor to fulfill the reporting requirements set out in the Medicaid Managed Care Services Agreement. More specifically, the encounter data used in this analysis indicate a negative paid amount for pharmacy encounters from March through May 2014.

UHC’s Rebuttal: “The date being used to pull the encounters is the date it was submitted to Conduent. Encounters were not submitted in production until July 2014 due to the implementation of Centennial Care. The encounters being represented in the January through June time frame are run out claims from the CoLTS. Therefore, this data does not seem appropriate to include.”

HealthInsight/Myers and Stauffer’s Response: From the encounter data extracts, we confirmed that UHC’s first pharmacy encounter data submission occurred in June 2014. However, documentation and/or HSD directives delaying the collection and submission of encounter data was not disclosed, as required by the Protocol in Activity 1 (page 4) ”States need to provide the EQRO with: 1. The State’s requirements for collection and submission of encounter data by MCOs”. Additionally, the run out of claims under the CoLTS waiver was not disclosed, by either HSD or UHC.

Encounter totals were calculated by summarizing the data by the UHC paid date and UHC identification number, and compared to the ASD submitted by UHC, which were also summarized by paid date. ASD payment dates may not have matched the payment dates that were reported in the encounter data resulting in potential timing issues. It appears that the UHC encounter paid date for an original encounter claim is the same date used as the UHC encounter paid date for all subsequent adjustments of the same encounter.

3. HealthInsight/Myers and Stauffer’s Finding 3: During the data analyses, Myers and Stauffer noted many encounters that were categorized as voids, adjustment credits or adjustment debits that did not indicate an associated original, paid encounter. Fields that are supposed to just indicate the TCN of the original encounter, the TCN of the replaced encounter and the TCN of the replacement encounter were left blank in instances where it seems they should have been completed.

UHC’s Rebuttal: “UHC does submit the original state MMIS TCN in the REF*F8 when submitting replacements or voids. Encounters would not be accepted without TCN for void or replacement. In these situations is it driven when Conduent does mass adjustments in their system?”

HealthInsight/Myers and Stauffer’s Response: We are not able to determine if this is driven by mass adjustment project(s). We encourage Conduent and UHC to work together to ensure understanding related to the encounter data submission process, including adjustment and void processing.


Page 19

UHC acknowledges the findings and recommendations provided by HealthInsight/Myers and Stauffer and provides additional comments that explain key findings addressed in this report.

UHC’s Comment 3: “UHC thought it would be beneficial to provide background on encounters to help explain findings in Appendices. New Mexico moved to a new Medicaid program called Centennial Care on 1/1/14. Testing for encounters didn’t begin until middle of February 2014 and didn’t start submitting encounters in production until the middle of the year. This is driving some of the variances in the first half of 2014. This is especially observed in the pharmacy Table 5 on page 17. The dollars for the first half of the year are very low or even negative. It appears that the encounter data was pulled based on when it was submitted to the Conduent versus when UHC actually paid the claim. The data populated in January 2014 through May 2014 for the encounter data seems to be actually attributed to the run out of the CoLTS product. We started submitting production pharmacy claims on 6/18/14 and only include the first 15 days of January in that submission. The July 2014 numbers were extremely higher than any other month as we were catching up on the encounters.”

HealthInsight/Myers and Stauffer’s Response: Please see our response to Appendix D-1: Initial Encounter Reconciliation, Item 2, above. UHC’s Comment 4: “UHC identified that some of the mismatches between encounters and the sample claim data files was related to how adjustments are processed/stored. The system used for the sample claim data file keeps the data at a transactional level, which is why there are negatives in the data. For encounters, UHC would never send a negative value in the 837. If a claim is adjusted, UHC would send a replacement with the new paid amount that is net of the adjustment. If the claim was fully reversed, UHC would just send a void to Conduent in order to fully remove the claim from the system.”

HealthInsight/Myers and Stauffer’s Response: Each claim iteration or sequence is expected to be included in the encounter data submissions. Void encounters contained within the encounter submissions are generally coded to match the associated adjustment claim’s paid date. This allows for proper matching of ASD that occurred due to this voided transaction. It appears that UHC uses the date of the original submission for their paid date and the UHC received date on all subsequent adjustments, replacements, back outs and voids of an encounter. Additionally, there are adjustment instances in the encounter data where the adjustment backout is successful, but the corresponding replacement transaction is denied by the FA. This creates a series of problems with the encounter data. First, these instances effectively remove paid encounters from the FA’s data warehouse that the MCO may have intended to replace. Additionally, when an MCO submits subsequent replacement transactions (to replace the replacement encounters), these too are denied due to the original encounter already being considered voided or adjusted. As a result, the plan must send the transaction as a new unrelated original encounter in order to have it accepted by the FA. This process is problematic


Page 20

since it can produce encounters that may not reflect the MCO’s actual encounter adjustment activity.

Appendix D-16: Response to HSD and Conduent Recommendations

Page 1

*Language was updated as a result of HSD review and discussion. Please see main report, pages 10-11, for updated language.

HSD and Conduent Recommendations (Multiple Pages)

Section Recommendation

Number Recommendation* HSD Response HealthInsight and Myers and Stauffer LC Response

Executive Summary 1

HSD review the provider registration process with Conduent to ensure that it is working efficiently and not causing delays or the inability of the MCOs to submit certain encounters to Conduent.

The provider registration process is constantly being evaluated and streamlined and we believe many of the MCO’s issues have been their failure to deny or suspend payment to providers not enrolled with New Mexico Medicaid even after explicit instruction from HSD to do so. This was, of course, most prevalent in the CY2014 that was reviewed. Another factor has been their slowness in mapping the state’s assigned provider type to the matching taxonomy codes and enforcing submission of the correct taxonomy based on the services being rendered for those providers who carry multiple lines of business under one NPI. Much of this is getting corrected at this time by the MCOs, but it created a huge backlog of provider applications for providers the MCOs had paid without requiring their enrollment. Some MCOs have reported to continue to pay claims to non-enrolled providers more than 2 years after HSD’s guidance to deny or suspend until enrollment occurs.

It was represented during the on-site visits that the MCOs were instructed by HSD, to not deny claims from providers who were not registered with the State. The MCOs indicated this directive was changed July 1, 2015 and the MCOs were then allowed to deny the claims from non-registered providers and work with those providers to register with the State. Also, in the fall of 2016, there was a work effort with HSD and the MCOs to resubmit the encounters which were initially rejected by Conduent due to provider registration issues.


Page 2




Executive Summary

Incorporated Into Recommendation

One

HSD should consider exploring aligning provider taxonomy codes used in the State’s registration process with the provider-registered taxonomy codes in the National Provider Identifier (NPI) registry.

HSD does not believe the NPI registry is the source of truth when it comes to correct designation of the provider in New Mexico’s system. The NPI registry conducts no validation of the taxonomy a provider selects when registering and there can be a large discrepancy between what the provider selects and what the provider is actually certified/licensed to perform for New Mexico Medicaid. This is complicated by providers who have multiple lines of business but do not always update the NPI Registry with the different taxonomies they are doing business under. In addition, there are State requirements for certain provider services that drive the assignment of a provider type in Omnicaid that is not consistent with the provider’s self-registered taxonomy.

It is recognized that the NPI registry may not solve the taxonomy registration issues that have been experienced in New Mexico. The NPI registry may be leveraged in the future as the provider registration process is reviewed for efficiencies as it is a national list that could provide guidance on current taxonomy codes being used by the provider community.


Page 3




Executive Summary 2

HSD evaluate the effectiveness of the affiliation process. Not only must the providers submit claims to the MCOs for payment be registered with the State with the taxonomy code indicated on the claim, the MCO must also be affiliated with the provider in order for the MCO to submit the encounter to Conduent. Based on the experience of Myers and Stauffer LC in other states, the affiliation process and the provider registration is unique and appears to be causing some delays with the submitting of encounters.

We agree; however, this would represent a major change to the structure of our provider and claims process at this time. This suggestion has already been made in relation to the State’s new MMIS-R and the plan is to discontinue the MC affiliation in the new system.

Agreement noted.


Page 4




Executive Summary 3

HSD consider increasing the 30-day encounter submission requirement in the MCO contract (Section 4.19.2.2.11) to 95 percent, based on best practice.

HSD will consider this, but is reluctant to tighten this requirement (the current standard is 90% within 30 days) further until we have better means of evaluating compliance

We encourage the State to consider all factors when determining the timing of the increase.

Executive Summary 4

HSD consider accepting MCO denied encounter data submissions. As of the time of the on-site visits, the MCOs were not required to submit denied encounters. The MCO denied claims would provide a more complete picture of the services being provided to the members. Additionally, we recommend that special consideration be given to encounters with both paid and denied lines.

HSD made the decision not to require Conduent to make the changes required to be able to take in denied encounters as originally intended because the system changes required to collect the data in any meaningful way would be too great. It is part of the plan for the MMIS-R that all claims will be captured in the MMIS-R with the MCOs reporting back paid and denied status on all claims. The MCO’s contract and Systems Manual are being revised to remove the Denied Encounter requirement.

We acknowledge HSD’s position; however, by not accepting denied claim lines on a claim with a paid header status, the encounter data does not reflect the entire paid claim as submitted by the provider.


Page 5




Executive Summary 5

HSD consider an on-going measurement of the completeness and accuracy of encounters to comply with the Medicaid Managed Care Final Rule (Mega Rule, 42 CFR 438.602(E)), as directed by CMS, such as the encounter reconciliation, which is part of this analysis.

HSD does have on-going measurement of encounter completeness and accuracy that is conducted quarterly and has been for some time. Starting with the quarter ending September, 2017, HSD will be applying monetary penalties to MCOs not meeting the 97% accuracy required in the contract. Completeness of encounters is evaluated by comparing the financial reports and claims lag data submitted by the MCOs to encounter data. No penalties have yet been applied based on encounter completeness measures.

This recommendation was included to ensure processes are in place to review encounter completeness and accuracy and based on HSD’s response, the department has begun to use a process. We encourage HSD to consider a more frequent measurement period.

Executive Summary 6

HSD and Conduent consider requiring the MCOs to attest to all encounter data submissions. It is best practice to require an attestation by the MCOs related to the accuracy and completeness of each of the encounter data submissions.

HSD is evaluating the possibility of adding an attestation to the EDI site where the MCOs upload their encounter files.

Agreement noted.


Page 6




Executive Summary 7

Conduent and HSD review the operations of the Self-Directed Community Benefit (SDCB) program to ensure the MCOs have the ability to adequately oversee its members.

Each MCO is required to have a contract with the SDCB vendor and the MCO has the ability through that contract to provide adequate oversight. HSD will work with the MCOs to ensure they are aware of and performing their responsibilities for oversight of this program for their members.

Based on the documentation and information received during the validation process, it appeared that the MCOs were not empowered to oversight this part of the program.

Executive Summary 8

Conduent consider updating its data dictionary to include a list of the code set(s) and the descriptions of each code. A code set is any set of codes used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, medical procedure codes, three-digit provider type codes, three-digit provider specialty codes, or two digit place of service codes.

The data dictionary is already complete and includes all code sets. The auditor seems to have confused a data warehouse file layout with data dictionary.

A copy of the Systems Manual was provided to Myers and Stauffer LC on 10/13/17. A list of valid values did not appear to be included in the version of the Systems Manual provided. A data dictionary should include any code sets and the description of each code used to encode data elements, such as tables of terms, medical concepts, medical diagnostic codes, or medical procedure codes; as well as information describing the contents, format, and structure of a database and the relationship between its elements.


Page 7




Executive Summary 9

Conduent consider adding MCO training regarding the resources available for accessing control totals for the enrollment files. Control totals are used to verify the accuracy of transmitted data files, so that the MCOs can ensure that it has the complete file beforeprocessing it into its enrollment and claims system and its subcontractor vendor’s claims systems.

The MCO receives a number of files and reports as files are accepted through EDI and passed to Omnicaid for processing. The confirmation report which the MCO receives within 15 minutes of their transmission of a file gives control totals for all the records in the file submitted. Further, once the file is processed in Omnicaid, the RC072 summary also gives totals of all the encounter records processed in Omnicaid. The MCOs uses these totals to question when a report has indicated it was not fully processed.

Per the Systems Manual, there is a trailer record in the enrollment file that provides control totals. We encourage HSD and Conduent to add this information to the next MCO encounter data meeting agenda to ensure the MCOs are aware that control totals are available for the enrollment data files.


Page 8




Executive Summary 10

Conduent consider increasing the amount and frequency of updates to system companion guides and provide advance communication about system changes to ensure the MCOs have adequate time to account for the changes. Keeping these documents up to date and giving advance notification to the MCOs would allow for upfront adjustments to its claims processing systems and help protect the MCOs against spikes in rejected encounters after the implementation of new exception codes and edits.

The purpose of Companion guides is to give instruction for fields that the State requires specific values on the standard format. They only get updated when there is something the State has changed about some field’s usage. We have not had such a change in years so there is no reason for an update to the companion guide. The CC Systems Manual is used for advising the MCOs about any changes to how the system is editing encounters (as well as requirements related to Enrollment, long term care spans, health homes, etc.). In addition, HSD places 13 different files on the DMZ monthly for the MCOs so that the MCOs have a complete update every month of any changes made to the Omnicaid reference files. MCOs are always advised in advance of any changes to how HSD is going to edit their encounters.

Based on the documentation and information received during the validation process, it appeared that the MCOs did not have timely, updated documentation related to changes in submission or data requirements. We encourage HSD and Conduent to educate the MCOs related to the resources available to ensure the MCOs have the most current information.


Page 9





Conduent ensure it provides advance notice, whenever possible, to the MCOs about system changes to ensure the MCOs have ample time to adjust the claims processing system to account for the changes.

It is HSD’s responsibility to communicate changes to the MCOs, not Conduent’s. HSD meets with the MCOs at least monthly, and for the past 6 months has been meeting biweekly to discuss issues and the MCOs are told ahead of time when changes are going to be made, receiving any changes in file layouts or requirements well in advance of the implementation date. The MCOs are routinely consulted with re: the amount of time required for them to make the necessary changes. Communication about changes is in the form of emails and/or Letters of Direction if the change will impact how the MCO is to do business. Once the change is implemented, the change is noted in the CC Systems Manual.

We acknowledge that HSD has the responsibility to communicate with the MCOs. We encourage Conduent and HSD to work together to ensure timely and accurate information is communicated to the MCOs.


Page 10





Conduent consider implementing additional reviews or edits to ensure the MMIS is capturing and retaining all encounter data submitted, is reflective of the encounter data submitted by the MCO, remains as submitted by the provider of service and values are in the appropriate field(s).

Conduent does with the exception of encounters that don’t make it through the very basic Level 1 and II HIPAA EDI validation edits (such claims would be unintelligible to our system). Encounter data is stored online for 7 years with archived data available beyond that. All encounter data is captured as submitted with no changes made by Conduent. Based on the examples submitted, the claims reviewed from the MCO were not the encounters that were reviewed. MCOs frequently resubmit encounters that have denied and when these encounters represent a reprocessing by the MCO, the date received and date paid have changed and thus the paid encounter will not agree with the original claim received by the MCO. If the original denied encounter had been viewed, the dates would have matched.

This recommendation was included to ensure processes are in place to review the system and its edits on an ongoing basis.

Documents

COMPARISON OF MANAGED CARE E DATA TO ACCOUNTING … · Comparison of Managed Care Encounter Data to Accounting System Data for UHC 4 This report consists of UHC’s encounters and