L.A. Care Health Plan 25, 2016 · began providing coverage directly to Medi-Cal members under its own line ... Plan policy and procedure RACH-009 including Attachment 6.2 did not

MEDICAL REVIEW ndash SOUTHERN SECTION ndash LOS ANGELES AUDITS AND INVESTIGATIONS

DEPARTMENT OF HEALTH CARE SERVICES

LA Care Health Plan

Contract Number 04-36069 A08

Audit Period July 1 2014

Through

June 30 2015

Report Issued April 25 2016

TABLE OF CONTENTS

I INTRODUCTION 1

II EXECUTIVE SUMMARY 2

III SCOPEAUDIT PROCEDURES 5

IV COMPLIANCE AUDIT FINDINGS Category 1 ndash Utilization Management7 Category 2 ndash Case Management and Coordination of Care 16 Category 3 ndash Access and Availability of Care 19 Category 4 ndash Memberrsquos Rights 30 Category 5 ndash Quality Management 40 Category 6 ndash Administrative and Organizational CapacityNA

I INTRODUCTION

LA Care Health Plan (LA Care or the Plan) was established in 1997 as the localinitiative Medi-Cal Managed Care health plan in Los Angeles County under the Two-PlanMedi-Cal Managed Care model LA Care is Knox-Keene licensed and located in LosAngeles

LA Care provides managed care health services to Medi-Cal beneficiaries under theprovision of Welfare and Institutions Code Section 140873 The Plan is a separatelyconstituted health authority governed by an independent county Board of SupervisorsThe Plan utilizes a ldquoPlan Partnerrdquo model under which it contracts with three health plansthrough capitated agreements The Plan Partners (PPs) are Anthem Blue Cross Care 1st

Health Plan and Kaiser Permanente In addition to the Plan Partner model the Planbegan providing coverage directly to Medi-Cal members under its own line of businessMedi-Cal Care Los Angeles (MCLA) in 2006 In its direct line of business the Plancontracts with 35 Participating Physician Groups (PPGs) who are paid a capitated amountfor each enrollee

As of June 1 2015 LA Carersquos Medi-Cal enrollment was approximately 1787865 members Enrollment by product line was as follows

bull Medi-Cal Members 1707169 (PPs and MCLA)

bull Healthy Kids 374 bull PASC-SEIU Plan 45857 bull LA Covered 17200 bull Cal MediConnect 17265

1 of 43

II EXECUTIVE SUMMARY

This report presents the audit findings of the Department of Health Care Services (DHCS) medical review audit for the review period July 1 2014 through June 30 2015 The on-site review was conducted from July 20 2015 through July 31 2015 The audit consisted of document reviews verification studies and interviews with Plan personnel

An Exit Conference was held on March 4 2016 with the Plan The Plan was allowed 15 calendar days from the date of the Exit Conference to provide supplemental information addressing the findings in the draft audit report The Plan submitted Post-Exit supplemental information which was evaluated and applicable changes are reflected in this report

The audit evaluated six categories of performance Utilization Management (UM) Case Management and Coordination of Care Access and Availability of Care Membersrsquo Rights Quality Management (QI) and Administrative and Organizational Capacity

The prior DHCS medical audit (for the period of April 1 2013 through March 31 2014 with an on-onsite review conducted from June 25 2014 through July 9 2014) was issued March 11 2015 The Corrective Action Plan (CAP) noted a number of provisionally closed findings and suggested this audit follow up by examining cited documentation for compliance and to what extent the Plan has operationalized their CAP Ongoing Findings were identified and appear in the body of the report

The summary of the findings by category follows

Category 1 ndash Utilization Management

The Plan did not have a complete process to ensure consistent application of Utilization guidelines and an adequate mechanism to detect potential under-utilization of PrimaryPreventative care in the capitated setting In addition the denial rate and appeal overturn data were not fully integrated in to the Quality Improvement system

Prior Authorizations (PA) and Appeals files did not clearly document the determination of its decisions An appropriate health care professional was not always involved in the prior authorization resolution Written communication to members was not always at an understandable level resolution letters were not always translated into the memberrsquos threshold language

The Plan did not ensure consistent application of utilization criteria and medical guidelines for prior authorization Final decision was not always adequately documented Prior Authorization modification Notice of Action letters to members were sometimes inaccurate Prior authorization requests for routine medical services were not consistently processed within five working days of receipt and notification to the requesting provider was not within

2 of 43

24 hours of the decision

The original prior authorization (prior to reaching the appeal level) submission did not always contain sufficient information to reach a decision The Plan did not continuously track and trend prior authorization and appeal outcome for quality improvement The overturn appeal information was not integrated with the Quality Improvement system

Category 2 ndash Case Management and Coordination of Care

The Plan did not ensure timely completion of Membersrsquo Initial Health Assessment (IHA) within 120 calendar days of enrollment Plan did not ensure the implementation of the Individual Health Education Behavioral Assessment (IHEBA) to be included in the medical records as part of an IHA for new members The Plan did not ensure that members received comprehensive age-appropriate assessments on a periodic basis

Category 3 ndash Access and Availability of Care

The Plan did not meet the required timeframe for members to receive appointments for routine care routine specialty care urgent care and prenatal care The Plan did not ensure members had emergency care services available 24-hours-a-day In addition the Plan did not ensure providers answer member telephone calls or return the calls in a timely manner The Plan did not meet the standards of the after-hours telephone access to physicians

The Planrsquos network did not maintain adequate numbers of specialists to accommodate for specialty care

The Plan did not ensure accurate provider listing as the provider directory did not accurately reflect the number of primary care providers and specialists available within the Planrsquos network

The Plan did not process emergency and family planning claims within the required 45 working days and failed to forward misdirected claims to the appropriate provider timely

Category 4 ndash Memberrsquos Rights

The Plan did not ensure resolution letter addressed all complaint issues filed with the grievance Grievances were not always reported to appropriate staff with authority to require corrective action The Planrsquos grievance system did not log and report exempt grievances for quality improvement In addition the Plan did not ensure referral of grievance cases with potential quality issues to appropriate Departments

3 of 43

The Planrsquos track and trend reports lacked sufficient details to allow for aggregation and analysis of the grievances to identify root causes

Language in the Member Handbook regarding grievance and appeal is not at an understandable level Resolutions letters to members lacked clear and concise understandable language

The Plan did not ensure that NOA letters including acknowledgement and resolution were consistently translated in the memberrsquos threshold language In addition the Plan did not always use information in their internal data base to identify the memberrsquos threshold language to send written materials translated in the memberrsquos preferred language

The Planrsquos website information is not fully translated in threshold language therefore did not ensure equal access to health care services to members who were not proficient in English

The Plan did not ensure that both 24-hours DHCS Initial Notification of Breach and the 72shyhours DHCS notification of investigation were submitted to the required DHCS personnel within the required time frames In addition the Plan did not have a policy and procedure to include instruction for a full investigative report to be completed 10 working days after the discovery of an incident

Plan policy and procedure RACH-009 including Attachment 62 did not include instructions or actions to perform when incident involving electronic PHI occurs after business hours or on a weekend or holiday nor of the submittal of the 72 hours Investigation Report In addition it did not include the DHCS Medi-Cal Managed Care Division (MMCD) Contracting Officer in the contact information

Category 5 ndash Quality Management

The Plan did not ensure adequate monitoring and oversight of its delegated credentialing functions

The Plan did not ensure new contracted providers received training within 10 working days additionally its internal policy did not specify the 10 business day timeframe requirement

Category 6 ndash Administrative and Organizational Capacity

Based on the review no deficiencies were found for the audit period

4 of 43

III SCOPEAUDIT PROCEDURES

This audit was conducted by the DHCS Medical Review Branch (MRB) to ascertain that services provided to Plan members comply with federal and state laws Medi-Cal regulations and guidelines and the Statersquos Two-Plan Contract This audit focused on MCLA the Planrsquos own line of business providing direct coverage to Medi-Cal members

PROCEDURES

DHCS conducted an on-site audit of LA Care from July 20 2015 through July 31 2015 The audit included a review of the Planrsquos contract with DHCS its policies for providing services the procedures used to implement the policies and verification studies of the implementation and effectiveness of the policies Documents were reviewed and interviews were conducted with Plan administrators and staff

The following verification studies were conducted

Prior Authorization Requests 25 routine medical and 27 pharmacy prior authorization requests were reviewed for timeliness of decision making consistent application of criteria appropriateness of review and communication of results to members and providers

Prior Authorization Appeal Procedures 22 provider and member appeals were reviewed for appropriateness and decision making in a timely manner

California Childrenrsquos Services 5 medical records were reviewed for evidence of coordination of care between the Plan and the county CCS program

Initial Health Assessments 23 medical records were reviewed for completeness and timely completion

Complex Case Management 5 medical records were reviewed for evidence of coordination of care between the Plan and Primary Care Provider (PCP) provided to members of all services medically necessary delivered within and out-of-network

5 of 43

Appointment Availability Verification Study 15 providers from the Planrsquos Participating Physician Group Health Care LA IPA (HCLA) of routine urgent specialty and prenatal care were reviewed for appointment availability The third next available was used to measure access to care

Emergency Service Claims 20 emergency service claims were reviewed for appropriate and timely adjudication

Family Planning Claims 18 family planning claims were reviewed for appropriate and timely adjudication

Grievance Procedures 53 grievances were reviewed 28 Quality of Care and 25 Quality of Service were reviewed for timely resolution response to complainant and submission to the appropriate level of review

Confidentiality Rights 7 cases were reviewed for proper reporting of all suspected and actual breaches to the appropriate entities within the required timeframe

New Provider Training 14 new provider training records were reviewed for timely provision of Medi-Cal Managed Care program training

Fraud and Abuse Reporting 7 cases were reviewed for proper reporting of all suspected fraud andor abuse to the appropriate entities within the required timeframes

A description of the findings for each category is contained in the following report

6 of 43

CATEGORY 1 - UTILIZATION MANAGEMENT

11 UTILIZATION MANAGEMENT PROGRAM

Utilization Management (UM) Program Requirements Contractor shall develop implement and continuously update and improve a Utilization Management (UM) program that ensures appropriate processes are used to review and approve the provision of Medically Necessary Covered Services hellip(as required by Contract) 2-Plan Contract A51

There is a set of written criteria or guidelines for utilization review that is based on sound medical evidence is consistently applied regularly reviewed and updated 2-Plan Contract A52C

Review of Utilization Data Contractor shall include within the UM Program mechanisms to detect both under- and over-utilization of health care services Contractorrsquos internal reporting mechanisms used to detect Member Utilization Patterns shall be reported to DHCS upon request 2-Plan Contract A54

SUMMARY OF FINDINGS

111 The Plan did not have a complete mechanism to detect potential under-utilization of PrimaryPreventive care in the capitated setting

The Contract requires the Plan to include within the UM program mechanisms to detect both under- and over-utilization of health care services (Contract Exhibit A Attachment 5(4)) Review of the Planrsquos UM Program processes showed the detection of under-utilization was insufficient as the measures for undershyutilization lacked efficacy

Policy and Procedure Number UM-150 OverUnder Utilization Monitoring Detection and Correction states that overunder-utilization monitoringdetectioncorrection mechanisms and processes shall include but not limited to monitoring inappropriate emergency room usage for routine primary care and specialty care The UM department is to monitor selected activities using developed measures to identify potential patterns and trends

The Plan did not have an adequate system in place to detect potential under-utilization in areas of Primary Care services including Preventive care in a capitated setting Although the Plan uses HEDIS data and various UM Dashboard indicators to evaluate overall over- and under-utilization trends including areas of acute care hospital admissionsre-admissions bed days various outpatient services and access to primary care the Plan did not have a method to specifically detect under-utilization

112 Prior Authorization denial rate and appeal overturn data was not fully integrated into the QI system

The Plan is responsible to ensure that UM program includes integration of UM activities into the Quality Improvement System (QIS) including a process to integrate reports on review of the number and types of appeals denials deferrals and modifications to the appropriate QIS staff (Contract Attachment 5 (1)(G))

Policy and Procedure Number UM-100 ndash Utilization Management paragraph 11112 stipulates that UM activities be integrated into the Quality Improvement System (QIS) including processes to integrate reports on review of the number and types of Appeals Denials deferrals and modification to the appropriate QIS staff

7 of 43

The Plan did not have adequate processes to fully ensure consistent integration of denial and overturn rate data for prior authorization ldquoDenial ratesrdquo are aggregated monitored and evaluated but are not fully integrated into the QIS nor utilized for improvement of UM activities

RECOMMENDATIONS

111 Implement a systematic mechanism to detect under-utilization of capitated PrimaryPreventive services

112 Ensure Prior Authorization denial rate and appeal overturn data is fully integrated into the QI system

12 PRIOR AUTHORIZATION REVIEW REQUIREMENTS

Prior Authorization and Review Procedures Contractor shall ensure that its pre-authorization concurrent review and retrospective review procedures meet the following minimum requirementshellip(as required by Contract) 2-Plan Contract A52A B D F H and I

Exceptions to Prior Authorization Prior Authorization requirements shall not be applied to emergency services family planning services preventive services basic prenatal care sexually transmitted disease services and HIV testing 2-Plan Contract A52G

Timeframes for Medical Authorization Pharmaceuticals 24 hours or one (1) business day on all drugs that require prior authorization in accordance with Welfare and Institutions Code Section 14185 or any future amendments thereto 2-Plan Contract A53F

Routine authorizations Five (5) working days from receipt of the information reasonably necessary to render a decision (these are requests for specialty service cost control purposes out-of-network not otherwise exempt from prior authorization) in accordance with Health and Safety Code Section 136701 or any future amendments thereto but no longer than 14 calendar days from the receipt of the request The decision may be deferred and the time limit extended an additional 14 calendar days only where the Member or the Memberrsquos provider requests an extension or the Contractor can provide justification upon request by the State for the need for additional information and how it is in the Memberrsquos interest Any decision delayed beyond the time limits is considered a denial and must be immediately processed as such 2-Plan Contract A52H

Denial Deferral or Modification of Prior Authorization Requests Contractor shall notify Members of a decision to deny defer or modify requests for prior authorization in accordance with Title 22 CCR Sections 510141 and 53894 by providing written notification to Members andor their authorized representativeThis notification must be provided as specified in 22 CCR Sections 510141 510142 and 53894 and Health and Safety Code Section 136701 2-Plan Contract A138A

SUMMARY OF FINDINGS

121 Prior Authorization file did not clearly document how a decision was determined

The Plan is required to develop implement and continuously update and improve a Utilization Management (UM) program that ensures appropriate processes are used to review and approve the provision of Medically Necessary Covered Services and that reasons for decisions in respect to its preshyauthorization and review procedures are clearly documented (Contract Exhibit A Attachment 5(1) amp (2)(D))

8 of 43

Verification study identified (9) nine medical prior authorization case files contained incomplete data andor lacked adequate information to evaluate how a prior authorization decision was determined

122 Prior Authorization file did not clearly document involvement of an appropriate health care professional

The Plan is required to ensure that its pre-authorization concurrent review and retrospective review procedures meet minimum requirements in which decisions to deny or to authorize an amount duration or scope that is less than requested shall be made by a qualified health care professional with appropriate clinical expertise in treating the condition and disease To the same extent that qualified health care professionals supervise review decisions including service reductions and a qualified physician will review all denials that are made whole or in part on the basis of medical necessity For purposes of this provision a qualified physician or Contractorrsquos pharmacist may approve defer modify or deny prior authorizations for pharmaceutical services provided that such determinations are made under the auspices of and pursuant to criteria established by the Plan medical director in collaboration with the Plan Pharmacy and Therapeutics Committee (PTC) or its equivalent (Contract Exhibit A Attachment 5(2)(A) amp (B))

Verification study identified (1) medical and two (2) pharmacy prior authorization case files did not clearly document whether an appropriate health care professional was involved in the resolution For instance these complex cases lacked input of a qualified Physician reviewer with appropriate clinical expertise in treating the condition and disease in addition to a Pharmacist

123 Prior Authorization files did not adequately document a complete evaluation for a final decision

The Plan is required to ensure that qualified health care professionals supervise review decisions including service reductions and a qualified physician will review all denials that are made whole or in part on the basis of medical necessity and that reasons for decisions are clearly documented As well that there is a set of written criteria or guidelines for utilization review that is based on sound medical evidence is consistently applied regularly reviewed and updated for its pre-authorization concurrent review and retrospective review procedures (Contract Exhibit A Attachment 5(2)(B)(C) amp (D))

Verification study identified (5) five medical and (6) six pharmacy prior authorizations case files did not contain adequate review andor evaluation for final decision determination

124 The Plan did not always meet required timeframes for the Prior Authorization process

The Plan is required to ensure decisions on Prior Authorizations request are made in a timely manner and are not unduly delayed for medical conditions requiring sensitive services For routine authorizations Five (5) working days from receipt of the information reasonably necessary to render a decision (these are requests for specialty service cost control purposes out-of-network not otherwise exempt from prior authorization) in accordance with Health and Safety Code Section 136701 or any future amendments thereto but no longer than 14 calendar days from the receipt of the request The decision may be deferred and the time limit extended an additional 14 calendar days only the Plan can provide justification upon request by the State for the need for additional information and how it is in the Memberrsquos interest Any decision delayed beyond the time limits is considered a denial and must be immediately processed as such (Contract Exhibit A Attachment 5(2)(F) amp (3)(G))

For Expedited Authorizations For requests in which a provider indicates or the Plan determines that following the standard timeframe could seriously jeopardize the Memberrsquos life or health or ability to attain maintain or regain maximum function the Plan must make an expedited authorization decision and provide notice as expeditiously as the Memberrsquos health condition requires and not later than three (3) working days after receipt of the request for services The Plan may extend the three (3) working days by up to 14 calendar days if the Member requests an extension or if the Plan justifies to the DHCS upon request a need for additional information and how the extension is in the Memberrsquos interest (Contract Exhibit A Attachment 5(3)(H))

9 of 43

Notification to members regarding denied deferred or modified referrals is made as specified in Exhibit A Attachment 13 Member Services which requires the Plan to notify Members of a decision to deny defer or modify requests for prior authorization in accordance with Title 22 CCR Sections 510141 and 53894 by providing written notification to Members andor their authorized representative regarding any denial deferral or modification of a request for approval to provide a health care service This notification to beneficiaries and their authorized representatives must be provided in accordance with the time frames set forth in Title 22 CCR Sections 510141 510142 53894 and Health and Safety Code Section 136701 (Contract Exhibit A Attachment 5(2)(E) amp Attachment 13(8)(A)amp (E))

MMCD All Plan Letter 04006 ndash SB 59 (Stats 1999 Chapter 539) Required Notices of Action provides instructions to Plans regarding timeframes when notifying enrollees of denials delays modifications and terminations of treatment The Plan must notify Medi-Cal enrollees of decisions to terminate deny delay or modify within five business days of receipt of information reasonably necessary but not to exceed 14 calendar days from receipt of the service requested

Policy and Procedure Numbers UM-112 ndash Timeliness Standards for UM Decision Making and Notification and UM-112 Attachment A outlines the required timelines standards for utilization review decision making and subsequent notification of the decision to both the member and provider

Policy and Procedure Number UM-108 ndash Delaying a Pre-Service Authorization Request states that when decision is made to delay a routine medical decision a formal Delay letter is prepared and sent to the member and requesting provider

The Plan did not consistently comply with its own policies and procedures outlining processes to meet these timeliness requirements

Verification study revealed (4) four medical routine prior authorization cases in which rendering decision exceeded required timeframe five working days Additionally written notification to requesting provider for one medical routine case was late (more than 24 hours after decision was made) This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan recommending to revise its policy its desktop procedures and conduct training to ensure authorization decisions are communicated (oral andor electronic) to the requesting provider in a timely manner (within 24 hours of the decision) This deficiency was provisionally closed and the Planrsquos prior authorization process to improve timely communication to requesting provider was still in the early stages

Verification study identified (4) four pharmacy prior authorization cases where notification to requesting provider andor member were late caused by Planrsquos Prior Authorization internal policies For example Pharmacy prior authorization requests for injectable drugs were denied and referred back to requesting provider instead of forwarding to Utilization Management The Planrsquos internal protocols required the requestor to resubmit with chart notes and medical orders to the UM Department In some cases the prior authorization was sent back to the requesting provider to resubmit to Medicare Part D

125 Prior Authorization written communication to members was not at an appropriate understandable level

The Plan is required to communicate to Medi-Cal Members with written Member information as specified in Title 22 CCR Section 53895 The member information must be written in clear concise and easily understood language as specified in Health and Safety Code Section 1363 and Title 28 CCR Section 130063(a) as to print size readability and understandability of text In addition the Plan must ensure all written Member information is provided to Members at a sixth grade reading level The written Member information is to ensure Membersrsquo understanding of the health plan processes (Contract Exhibit A Attachment 13 (4)(A) amp (C))

Verification study identified (2) two medical and (17) seventeen pharmacy prior authorizations which the Notice of Action letters were not written at an understandable level These letters contained language that was not clear and concise This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan which recommended the addition of quality control steps to ensure consistent use of clear and concise language in Notice of Action letters The Plan conducted Readability for Medical Management and Denial Letters training which involved the use of plain language for member

10 of 43

understanding This deficiency was provisionally closed and at the time of the review by DHCS the Plan was in the early stages of the implementation process

126 Prior Authorization modification Notice of Action (NOA) letter was inaccurate andor missing

The Plan is required to notify Members of a decision to deny defer or modify requests for prior authorization in accordance with Title 22 CCR Sections 510141 and 53894 by providing written notification to Members andor their authorized representative regarding any denial deferral or modification of a request for approval to provide a health care service This notification must be provided as specified in Title 22 CCR Sections 510141 510142 53894 and Health and Safety Code Section 136701 (Contract Exhibit A Attachment 13 (8)(A))

Verification study identified (4) four medical files where the prior authorization modification of services NOA letters to member was either missing or contained inaccurate information

127 Resolution Letters were not consistently translated into the memberrsquos threshold language

The Plan is required to provide linguistic services at no cost to Medi-Cal members including fully translated written informing materials for example form letters including Notice of Action (NOA) letters and resolution letters The Plan shall provide translated written informing materials to all monolingual or Limited English Proficient Members that speak the identified threshold language (Contract Exhibit A Attachment 9 (14)(B)(2))

The translation requirements for NOA letters including the body specific narrative sections and general ldquolanguage blocksrdquo as delineated in All-Plan Letter SB 59 (Stats 1999 Chapter 539) Required Notices of Action APL 04006 specifies that Plans are responsible for fully translating these notices including the information in the ldquoinsertsrdquo sections of the notices into the appropriate threshold languages

MMCD All-Plan Letter 05005 ndash Senate Bill 59 Notice of Action Letter and MMCD Policy Letter 99-04 ndash Translation of Written Informing Materials reiterate this requirement of providing limited English proficient (LEP) members written materials in their identified primary or threshold language including Notice of Action (NOA) and resolution letters

Verification study identified (8) eight medical and (3) three pharmacy cases where prior authorization resolution NOA letters were not consistently translated in the memberrsquos threshold language

128 Application of utilization criteria based on sound medical evidence was not consistent

The Plan is required to ensure that its pre-authorization concurrent review and retrospective review procedures meet minimum requirements of having a set of written criteria or guidelines for utilization review that is based on sound medical evidence is consistently applied regularly reviewed and updated (Contract Exhibit A Attachment 5(2)(C))

A review of (1) one prior authorization pharmacy case denial displayed inconsistent application of sound medical evidence and guidelines In this example Pharmacy Benefit Manager Prior Authorization adjudicator required the Food and Drug Administration MedWatch notification (a voluntarily program) as a pre-requisite for a Prior Authorization approval

During the follow-up interview the Plan confirmed that as part of the Prior Authorization standard process the Pharmacy Benefit Manager adjudicator required the Food and Drug Administration MedWatch notification as a pre-requisite

RECOMMENDATIONS

121 Ensure to clearly document explanations for Prior Authorization (PA) decisions

122 Ensure involvement of appropriate health care professional in the resolution of the Prior Authorization request decision

11 of 43

123 Ensure Prior Authorization evaluations are complete and clearly document a final decision

124 Adhere to the required timeframes for decisions and notifications regarding prior authorization requests

125 Ensure Notice of Action (NOA) letters to members are clear concise and understandable

126 Ensure Prior Authorization Notice of Action letter to member regarding modification request is accurate

127 Ensure resolution NOA Letters are translated into the memberrsquos threshold language

128 Ensure Prior Authorization decisions are based on consistent application of written utilization criteria and medical guidelines

14 PRIOR AUTHORIZATION APPEAL PROCESS

Appeal Procedures There shall be a well-publicized appeals procedure for both providers and patients 2-Plan Contract A52E

SUMMARY OF FINDINGS

141 Appeal file did not clearly document how a decision was determined

The Plan is required to develop implement and continuously update and improve a Utilization Management (UM) program that ensures appropriate processes are used to approve and review the provision of Medically Necessary Covered Services and that reasons for decisions of its pre-authorization concurrent review and retrospective review procedures are clearly documented (Contract Exhibit A Attachment 5(1) amp (2)(D))

Verification study identified four (4) files with incomplete data or that lacked adequate information to evaluate how a decision was determined

142 Appeal files did not clearly document involvement of an appropriate health care professional in the resolution of the Appeal

The Plan is required to ensure that any grievance involving the appeal of a denial based on lack of medical necessity appeal of a denial of a request for expedited resolution of a grievance or an appeal that involves clinical issues shall be resolved by a health care professional with appropriate clinical expertise in treating the Memberrsquos condition or disease (Contract Exhibit A Attachment 14(D))

Verification study identified three (3) files did not clearly document that actual review was performed by an appropriate health care professional

143 Written communication to members was not at an understandable level

Verification study identified (4) four appeal cases where the acknowledgement andor the resolution letters were not written at an understandable level These communication letters did not use language that is clear and easy to understand

144 Appeal Resolution Letters were not translated into the memberrsquos threshold language

12 of 43

The Plan is required to provide linguistic services at no cost to Medi-Cal members including fully translated written informing materials for example form letters including Notice of Action (NOA) letters and grievance acknowledgement and resolution letters The Plan shall provide translated written informing materials to all monolingual or Limited English Proficient Members that speak the identified threshold language (Contract Exhibit A Attachment 9 (14)(B)(2))

Policy and Procedure Number AG-007 ndash Appeal Process for Members requires that the Notices of the Appeal process provided to Members are culturally and linguistically appropriate

MMCD All-Plan Letter 05005 MMCD Policy Letter 99-04 reiterates this requirement of providing limited English proficient (LEP) members written materials in their identified primary or threshold language including Notice of Action (NOA) grievance acknowledgement and resolution letters

Verification study identified (2) two appeal pharmacy prior authorization cases which denial letters were not consistently translated in the memberrsquos threshold language

145 The original prior authorization did not consistently contain sufficient information

The Plan is required to ensure the its pre-authorization concurrent review and retrospective review procedures decisions and appeals are made in a timely manner and are not unduly delayed for medical conditions requiring time sensitive services (Contract Exhibit A Attachment 5 (2)(F)) Likewise the Plan must authorize or provide the disputed services promptly and as expeditiously as the Memberrsquos health condition requires if the services are not furnished while the appeal is pending and Plan reverses a decision to deny limit or delay services (Contract Exhibit A Attachment 14 (5)(D))

Verification study identified (2) two overturned appeal cases where initial submission (prior to reaching the appeal level) of the requested Prior Authorization service lacked information to reach a decision subsequently additional information was required at the appeal level Having insufficient information on initial PA resulted in unnecessary delays of medically necessary services

This finding was addressed in the prior year Corrective Action Plan recommending that the requesting provider provide required information in the original prior authorization necessary to render a timely decision The Planrsquos outreach and educational training provided to the network providers and its delegates to improve the Planrsquos prior authorization process were still in the early stages

146 Appeal cases were not referred tracked and trended for Potential Quality Improvement

The Plan is required to develop implement and continuously update and improve a Utilization Management (UM) program including a process to integrate UM activities such as reports on review of the number and types of appeals denials deferrals and modifications into the Quality Improvement System (Contract Exhibit A Attachment 5 (1)(G))

Policy and Procedure Number UM-100 ndash Utilization Management paragraph 11112 stipulates that UM activities be integrated into the Quality Improvement system (QIS) including processes to integrate reports on review of the number and types of Appeals Denials deferrals and modification to the appropriate QIS staff

Eight appeal cases reviewed for medical necessity and quality of care issues were not referred for potential quality improvement Initial Prior Authorization (PA) was not always adjudicated appropriately and appeals were overturned The Plan did not use this PA information to improve the UM system There was no evidence the overturned PA data was used as part of the Planrsquos Quality Improvement process to improve the PA procedure

13 of 43

14 of 43

147 The Plan did not consistently apply medical guidelines for Utilization Management activities

The Plan is required to develop implement and continuously update and improve a Utilization Management (UM) program that ensures appropriate processes are used to review and approve the provision of Medically Necessary Covered Services and to communicate to health care practitioners the procedures and services that require prior authorization and ensure that all contracting health care practitioners are aware of the procedures and timeframes necessary to obtain prior authorization for these services Additionally the Contract requires the Plan to have established criteria for approving modifying deferring or denying requested services and utilize evaluation criteria and standards to approve modify defer or deny services (Contract Exhibit A Attachment 5(1)(D) amp (E)) Similarly the Plan is required to have a set of written criteria or guidelines for utilization review that is based on sound medical evidence is consistently applied regularly reviewed and updated (Contract Exhibit A Attachment 5(2)(C))

The Plan did not ensure consistent application of guidelines to evaluate medical necessity denials Prior Authorization process was inconsistent between the Plan and its delegated PPGs For example the inconsistencies in the ldquoAuto Authorizationrdquo process at the delegated level resulted in discrepancies in the provision of medically necessary services Overturned appeals and denial rates data were not consistently integrated into the QIS to improve the UM program

Verification study identified (8) eight appeal cases where overturned Appeals caused by inadequate or misinterpretation of the applied criteria andor guidelines especially to Pharmacy Prior Authorizations

RECOMMENDATIONS

141 Ensure the Planrsquos Utilization Management program applies appropriate processes to clearly document reasons for Appeal decisions

142 Ensure involvement of appropriate health care professional in the resolution of an Appeal is clearly documented

143 Ensure written communication letters with members use clear concise and understandable language

144 Ensure Resolution Letters are translated into the memberrsquos threshold language

145 Ensure the original Prior Authorization has sufficient information

146 Ensure appeal referral tracking is integrated into Utilization Management for quality improvement

147 Ensure consistent application of medical guidelines for Utilization Management activities (appeals denials deferrals and modifications)

CATEGORY 2 ndash CASE MANAGEMENT AND COORDINATION OF CARE

INITIAL HEALTH ASSESSMENT

Provision of Initial Health Assessment Contractor shall cover and ensure the provision of an IHA (complete history and physical examination) in conformance with Title 22 CCR Sections 53851(b)(1) to each new Member within timelines stipulated in Provision 5 and Provision 6 below 2-Plan Contract A103A

Provision of IHA for Members under Age 21 For Members under the age of 18 months Contractor is responsible to cover and ensure the provision of an IHA within 120 calendar days following the date of enrollment or within periodicity timelines established by the American Academy of Pediatrics (AAP) for ages two and younger whichever is less

For Members 18 months of age and older upon enrollment Contractor is responsible to ensure an IHA is performed within 120 calendar days of enrollment 2-Plan Contract A105

IHAs for Adults Age 21 and older 1) Contractor shall cover and ensure that an IHA for adult Members is performed within 120 calendar days of

enrollment 2) Contractor shall ensure that the performance of the initial complete history and physical exam for adults includes

but is not limited to a) blood pressure b) height and weight c) total serum cholesterol measurement for men ages 35 and over and women ages 45 and over d) clinical breast examination for women over 40 e) mammogram for women age 50 and over f) Pap smear (or arrangements made for performance) on all women determined to be sexually active g) chlamydia screen for all sexually active females aged 21 and older who are determined to be at high-risk for chlamydia infection using the most current CDC guidelines These guidelines include the screening of all sexually active females aged 21 through 25 years of age h) screening for TB risk factors including a Mantoux skin test on all persons determined to be at high risk and i) health education behavioral risk assessment

2-Plan Contract A106

Contractor shall make reasonable attempts to contact a Member and schedule an IHA All attempts shall be documented Documented attempts that demonstrate Contractorrsquos unsuccessful efforts to contact a Member and schedule an IHA shall be considered evidence in meeting this requirement

SUMMARY OF FINDINGS

241 An Initial Health Assessment (IHA) for new members was not completed within 120 calendar days of enrollment

The Contract requires the Plan to cover and ensure the provision of an IHA complete history and physical examination in conformance with Title 22 CCR Section 53851 (b)(1) to each new Member within 120 calendar days following the date of enrollment (Contract Exhibit A Attachment 10 (3)(A))

MMCD Policy Letter No 08-003 (Initial Comprehensive Health Assessment) states that all new plan members must have a complete IHA within 120 calendar days of enrollment

Policy and Procedure Number UM-135 and Number CA-004 ndash Initial Periodic Health Assessment (IHA) stipulates that the Plan shall cover and ensure the provision of an IHA (complete history and physical examination and an individualized behavioral health assessment) to each new member within 120 days of enrollment

15 of 43

The Facility Site Review (FSR) Medical Record Review (MRR) Report demonstrates compliance rates based on medical records reviews conducted at primary care physician (PCP) sites in the calendar year 2014 fell below the passing compliance rate of 80 The results showed IHA as a preventive service was not received by members in a timely manner The primary reason reported for non-compliance was due to membersrsquo no-show of preventive scheduled appointments

The verification study identified three (3) new members did not have an IHA completed within 120 days of enrollment This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan The Plan has created a new Department (Clinical Assurance) to include performance monitoring and delegation oversight including a more detail internal CAP and follow up on non-compliant cases This deficiency was provisionally closed and at the time of the review by DHCS the Plan was in the early stages of the implementation process

242 Individual Health Education Behavioral Assessment (IHEBA) tool was not included in the medical records of new members

The Contract requires the Plan to ensure that the IHA includes an IHEBA as describe in Exhibit A Attachment 10 Provision 8 Paragraph A 10 which states in part that Plan shall ensure that all new members complete the individual health education behavioral assessment and that primary care providers use an age appropriate DHCS standardized ldquoStaying Healthyrdquo assessment tools or alternative approved tools that comply with DHCS criteria for the individual health education behavioral assessment In addition the Plan is to ensure that membersrsquo medical record contains a completed IHA and IHEBA tool (Contract Exhibit A Attachment 10 (3)(B)amp(C))

MMCD Policy Letter No 08-003 (Initial Comprehensive Health Assessment) as part of the IHA an age-specific IHEBA must be administered In addition MMCD Policy Letter No 13-001 (Requirements for the Staying Healthy AssessmentIndividual Health Education Assessment) notifies Managed Care Plans (MCPs) that an IHEBA is a required component of the IHA for new members within 120 days of the effective date of enrollment MCPs must ensure that each member completes a SHAIHEBA

Policy and Procedure Number UM-135 and Number CA-004 ndash Initial Periodic Health Assessment (IHA) stipulates the Plan shall ensure that medical records for IHAs include an IHEBA

Policy and Procedure Number HE-012 ndash Staying Healthy Assessment specifies that the Plan will make available and ensure the implementation of the DHCS-sanctioned Staying Healthy Assessment or an approved equivalent to all LA Care Medi-Cal including Seniors and People with Disabilities in accordance with regulatory agency requirements

Verification study identified seven (7) new members did not receive the required Individual Health Education Behavioral AssessmentStaying Healthy Assessment as part of their IHA

243 The Plan did not ensure members received comprehensive age-appropriate assessments on a periodic basis

The Contract requires the Plan to cover and ensure the provision of an IHA in conformance with Title 22 CCR Section 53851 (b)(1) to each new Member within 120 calendar days of enrollment (Contract Exhibit A Attachment 10 (3)(A)(B)amp(C)) An IHA consists of a complete history and physical examination and an Individual Health Education Behavioral Assessment enabling the primary care physician to comprehensively assess the memberrsquos current acute chronic and preventive health needs

MMCD Policy Letter No 08-003 (Initial Comprehensive Health Assessment) as part of the IHA an age-specific IHEBA must be administered The IHA components consist of A) Comprehensive History B) Preventive Services C) Comprehensive Physical and Mental Status Exam D) Diagnosis and Plan of Care and E) Individual Health Education Behavioral Assessment (IHEBA)

16 of 43

MMCD Policy Letter No 13-001 (Requirements for the Staying Healthy AssessmentIndividual Health Education Assessment) notifies Managed Care Plans that an IHEBA is a required component of the IHA For new members the SHAIHEBA must be completed on the appropriate age-specific form within 120 days of the effective date of enrollment

The verification study identified 13 membersrsquo medical records did not have sufficient documentation to support an age-appropriate comprehensive assessment and screening as provision of an IHA Examples include

bull IHEBASHA was not documented in the IHA bull Child visit assessment was insufficient (no comprehensive history and physical) bull Adult visit assessment was insufficient (no pap smear tuberculosis screening breast exam

cholesterol lab test)

This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan and the Plan revised the IHA section of the Care Coordination Audit tool and IHA file review tool pertaining to age appropriate assessment on a periodic basis This deficiency was provisionally closed and at the time of the review by DHCS the Plan was in the early stages of the implementation process

RECOMMENDATIONS

241 Ensure new members receive an IHA within 120 calendar days of enrollment

242 Ensure all new members receive an IHEBASHA as part of the IHA

243 Ensure members receive comprehensive age-appropriate assessment on a periodic basis

CATEGORY 3 ndash ACCESS AND AVAILABILITY OF CARE

31 APPOINTMENT PROCEDURES AND MONITORING WAITING TIMES

Appointment Procedures Contractor shall implement and maintain procedures for Members to obtain appointments for routine care urgent care routine specialty referral appointments prenatal care childrenrsquos preventive periodic health assessments and adult initial health assessments Contractor shall also include procedures for follow-up on missed appointments

2-Plan Contract A93A

Members must be offered appointments within the following timeframes 3) Non-urgent primary care appointments ndash within ten (10) business days of request 4) Appointment with a specialist ndash within 15 business days of request

2-Plan Contract A94B

Prenatal Care Contractor shall ensure that the first prenatal visit for a pregnant Member will be available within two (2) weeks upon request 2-Plan Contract A93B

Monitoring of Waiting Times Contractor shall develop implement and maintain a procedure to monitor waiting times in the providersrsquo offices telephone calls (to answer and return) and time to obtain various types of appointmentshellip 2-Plan Contract A93C

17 of 43

SUMMARY OF FINDINGS

311 The Plan did not ensure members obtained appointments for routine care routine specialty care and urgent care within the required timeframes

The Contract requires the Plan to establish acceptable accessibility standards and communicate enforce and monitor providersrsquo compliance with these standards The Plan is required to implement and maintain procedures for members to obtain appointments including for routine care routine specialty and urgent care (Contract Exhibit A Attachment 9 (3)(A) In addition the Plan is required to ensure that members are offered appointments for covered health care services appropriate for their condition within the timeframes (Contract Exhibit A Attachment 9 (4)(A)amp(B))

Policy and Procedure Number QI-030 Assessment of Appropriate Access to Covered Services describes the requirements for the availability and accessibility of health care services including wait times to obtain appointments

To monitor Providerrsquos compliance with access health care standards the Plan uses the Medi-Cal Provider Access Appointment Availability Report results from The Myers Group (Survey Vendor) Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS) results administrative grievances and telephone system records Results of the 2014 Medi-Cal Provider Access Appointment Availability Report indicate the Providers did not comply with the access standards implemented by the Plan see table below

PCP Appointment Type Contract Standards Work Plan Performance Goal

Survey Compliance Rate

Routine non-urgent primary care Within 10 business days 95 895 Routine well care physical exam Within 10 business days 95 816 Urgent care with no authorization Within 48 hours 98 704 Urgent care with prior authorization Within 96 hours 100 760

Specialist Appointment Type Contract Standard Work Plan Performance Goal Survey

Compliance Rate Non-urgent appointment (routine specialty exam) Within 15 days 95 868

Urgent with no authorization Within 48 hours 100 594 Urgent with prior authorization Within 96 hours 100 621

Results of the 2014 Medi-Cal Adult and Child CAHPS survey indicated the plan did not meet performance goals of members obtaining an urgent care appointment for Primary Care Physician (PCP) and Specialty Care Physician (SCP) The average waiting time to see the PCP for urgent care was 528 days (12672 hours) for adults SCP wait time was 1185 days (28440 hours) for adults and 54 days (12960 hours) for children

This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan recommending the Plan to develop methodologies to improve appointment time frames develop strategies to increase provider compliance with access to care standards and develop performance measures to monitor compliance However this deficiency requires long term correction action therefore at time of the review by DHCS the CAP was in working process

312 The Plan did not ensure first prenatal visit was available within two weeks upon request

The Contract requires the Plan to ensure the first prenatal visit for a pregnant member to be available within two weeks upon request (Contract Exhibit A Attachment 9 (3)(B))

The 2014 Medi-Cal Provider Access Appointment Availability Report indicated the Providers did not comply with the access standards for the first prenatal visit for pregnant members The Survey compliance rate was 80 whereas the Planrsquos performance goal was 100

313 The Plan did not ensure accurate information in their Provider Directory

18 of 43

The Contract requires the Planrsquos distribution of a Provider Directory to include providerrsquos name provider number address and telephone number of each service location The directories shall have the hours and days when each facility is open the services and benefits available including which if any non-English languages are spoken and the telephone number to call after normal business hours and identification of providers that are not accepting new patients (Contract Exhibit A Attachment 13 (4)(D)(4)

WampI Code section 14182(c)(2) states that Plans shall maintain an updated accurate and accessible listing of a providerrsquos ability to accept new patients and make it available to members at minimum by phone written material and Internet Web site

Policy and Procedure Number PNO-001 Web-Based Directory stipulates the Plan must provide a real time web-based Provider Directory that allows members and prospective members to find primary care and specialty practitioners online

Policy and Procedure Number PNO-006 Timeframes and Procedures for Provider Changes lists the timeframes and procedures to complete requests for ldquoProviderrdquo Adds Changes and Deletes

During the on-site interview Plan Personnel stated that LA Carersquos Provider Directory is updated in ldquoreal timerdquo in association with ldquoProviderrdquo Adds Changes and Deletes in their Master Provider Database (MPD) a hard copy of the Provider Directory is automatically generated annually and available to members In addition the Plan delegates to its PPGs the function to upload (on a monthly basis) their Provider updates (additions changes deletions) to the Planrsquos system the Plan then sends a monthly report to its PPGs regarding errors identified by the system The Planrsquos Provider Directory did not reflect the Providerrsquos current information within the Planrsquos network DHCS noted that (8) eight PCPs were no longer with the contracted PPG and (3) three PCPs were not accepting new members The information uploaded to the Planrsquos system has inaccurate provider listings Therefore members might encounter potential delays in obtaining care or unable to receive care timely

RECOMMENDATIONS

311 Continue to improve implementation of actions and processes to meet the timeframes of members obtaining appointments for routine routine specialty and urgent care

312 Ensure the first prenatal visit for a pregnant member is available within two weeks upon request

313 Ensure the Planrsquos web based Provider Directory has an accurate provider listing

32 URGENT CARE EMERGENCY CARE

Urgent Care Members must be offered appointments within the following timeframes 1) Urgent care appointment for services that do not require prior authorization ndash within 48 hours of a request 2) Urgent appointment for services that do require prior authorization ndash within 96 hours of a request

Emergency Care Contractor shall ensure that a Member with an emergency condition will be seen on an emergency basis and that emergency services will be available and accessible within the Service Area 24-hours-a-day 2-Plan Contract A97

Contractor shall have as a minimum a designated emergency service facility providing care on a 24-hour-a-day 7shyday-a-week basis This designated emergency services facility will have one or more physicians and one nurse on duty in the facility at all times

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

321 The Plan did not ensure members obtained urgent care appointments within the required timeframes

The Plan is required to ensure that members are offered appointments and receive urgent care within 48 hours if authorization is not required and within 96 hours if prior authorization is required (Contract Exhibit A Attachment 9 (4)(B)(1)amp(2))

Policy and Procedure Number QI-030 Assessment of Appropriate Access to Covered Services stipulates that members must be offered urgent care appointments within 48 hours of a request not requiring prior authorization and within 96 hours of a request requiring prior authorization

The Plan did not meet the performance goals for urgent care appointments and wait times standards This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan The Plan is modifying its Appointment Access Report Card to include year to year results and PPGs be able to compare yearly results The Plan will meet with the PPGs indicating patterns of non-compliance in order to identify potential root causes of the non-compliance as well as identifying potential barriers to timely access However this deficiency requires long term correction action therefore at time of the review by DHCS the CAP was in working process

The 2014 Medi-Cal Provider Access Appointment Availability Report illustrates Providers did not adhere to the access standards implemented by the Plan of members obtaining urgent care

Urgent care with no authorization Within 48 hours 98 704 Urgent care with prior authorization Within 96 hours 100 760

Specialist Appointment Type Contract Standard Work Plan Performance Goal

Results of the 2014 Medi-Cal Adult and Child CAHPS survey indicated the Plan did not meet performance goals of members obtaining an urgent care appointment for Primary Care Physician (PCP) and Specialty Care Physician (SCP) The table below illustrates the urgent care average days wait days between making an appointment and seeing the physicians for both PCP and SCP

Average days between making appointment and seeing specialist

[Standard 48 hours with no authorization and 96 hours with authorization] Primary Care Physician Adult CAHPS Child CAHPS

Specialty Care Physician Adult CAHPS Child CAHPS

2014 2014 2014 2014 Urgent Appointment 528 145 1185 54

322 The Plan did not ensure members have emergency care available 24-hours-a-day

The Plan is required to ensure that members with an emergency condition are seen on an emergency basis and emergency services are available and accessible within the service area 24-hours-a-day (Contract Exhibit A Attachment 9 (7))

Policy and Procedure Number QI-030 Assessment of Appropriate Access to Covered Services stipulates the Plan must ensure members have appropriate access in a timely manner for emergency care immediately 24 hours a day seven days a week

The Plan did not meet its performance goal of 100 for emergency care access standards Using a phone-only survey methodology the Myers Group (TMG) a third party surveyed the Planrsquos PCPs and Specialists offices to determine how well their providers are adhering to the access to care standards implemented by

20 of 43

the Plan The results are based on the providerrsquos response to the survey question ldquoHow soon can a patient be seen for an Emergency visitrdquo

The 2014 Medi-Cal Provider Access Appointment Availability Report shows Providers did not adhere to the access standards implemented by the Plan of members obtaining emergency care immediately 24 hours a day seven days a week

Emergency visit 24 hours-a-day 100 952

RECOMMENDATIONS

321 Continue to improve implementation of actions and processes to meet the timeframe of members obtaining urgent care appointments

322 Improve monitoring measures to ensure members with an emergency condition have emergency services available 24-hours-a-day

33 TELEPHONE PROCEDURES AFTER HOURS CALLS Telephone Procedures Contractor shall require providers to maintain a procedure for triaging Members telephone calls providing telephone medical advice (if it is made available) and accessing telephone interpreters

2-Plan Contract A93D

Contractor shall maintain the capability to provide Member services to Medi-Cal Members or potential members through sufficient assigned and knowledgeable staff

2-Plan A132A

After Hours Calls At a minimum Contractor shall ensure that a physician or an appropriate licensed professional under hisher supervision will be available for after-hours calls

2-Plan Contract A93E

SUMMARY OF FINDINGS

331 The Plan did not always answer member calls within the required 30 seconds time frame for Member Services and Nurse Advice Line

The Plan is required to ensure providers maintain a procedure for triaging members telephone calls providing telephone medical advice (if it is made available) and accessing telephone interpreters (Contract Exhibit A Attachment 9 (3)(D))

Policy and Procedure Number QI-009 Nurse Advice Line stipulates the Plan is to establish and maintain a 24 hours a day seven days a week Nurse Advice Line which members can access and assist in making informed decisions regarding their care In addition the Nurse Advice Line must meet the triage and screening service requirements

Policy and Procedure Number QI-030 Assessment of Appropriate Access to Covered Services outlines the standards to ensure members have appropriate access and availability to services in a timely manner including the speed of answering membersrsquo telephone calls by Member Services within 30 seconds

The Plan contracts with McKesson to operate and monitor the Nurse Advice Line The McKesson Monthly

21 of 43

Summary Reports indicated the average speed of answering the Nurse Advice Line phone calls was greater than 30 seconds for six months during the review period (September 2014 and December 2014 through April 2015)

The Plan uses a telephone system called CISCO to measure Member Services telephone accessibility The system data indicated phone calls were answered within 30 seconds 53 of the time the Plan did not meet its 85 performance goal

This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan The Plan is hiring additional staff to support growth of membership Phone systems have been upgraded and phone metrics have been updated to reflect only the specific call metrics The Work Force Management is being implemented to provide tools for identifying call statistics However this deficiency requires long term correction action therefore at time of the review by DHCS the CAP was in working process

332 The Plan did not meet the after-hours telephone access to physicians

The Plan is required at a minimum to ensure that a physician or an appropriate licensed professional under hisher supervision will be available for after-hours calls (Contract Exhibit A Attachment 9 (3)(E))

Policy and Procedure Number QI-030 Assessment of Appropriate Access to Covered Services outlines the standards to ensure members have access and availability to services in a timely manner for after-hours care coverage including call return time by PCP office staff or covering practitioner within 30 minutes For after-hours care PCPs are required to provide 24 hours seven days per week coverage to members PCPs or covering practitioner must return members calls upon request within 30 minutes PCPs must have either an answering device or an answering service to accept member calls when the office is closed An automated system must provide emergency 911 instructions and or a live party answering service must be able to connect the caller to the PCP or covering practitioner or offer a call-back from the PCP (or covering practitioner) within 30 minutes

The Plan monitors its Practitioners network after-hours accessibility through its annual survey conducted by The Myers Group The 2014 Access to Care Summary results indicated the Plan did not meet the 92 performance goal for after-hours access to care standards The Planrsquos compliance rate for after-hours calls to physicians was 643 and for call-back timeliness of physician response within 30 minutes was 482 The Plan has not met its performance goal for after-hours access for three consecutive years 2012 2013 and 2014 This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan The Plan must continue to implement corrective action on PPGs that are non-compliant with the performance goals This deficiency requires long term correction action therefore at time of the review by DHCS the CAP was in working process

RECOMMENDATIONS

331 Implement actions to improve answering calls within 30 seconds for Member Services and Nurse Advice Line

333 Implement actions to improve after-hours telephone access to physicians

34 SPECIALISTS AND SPECIALTY SERVICES

Specialists and Specialty Services Contractor shall maintain adequate numbers and types of specialists within their network to accommodate the need for specialty care in accordance with Title 22 CCR Section 53853(a) and W amp I Code Section 14182(c)(2) 2-Plan Contract A66

Contractor shall arrange for the provision of seldom used or unusual specialty services from specialists outside the network if unavailable within Contractorrsquos network when determined Medically Necessary 2-Plan Contract A93F

22 of 43

SUMMARY OF FINDINGS

341 The Plan did not maintain an adequate number of specialists within their network to accommodate the need for specialty care

The Contract requires the Plan to maintain adequate numbers and types of specialists within its network to accommodate the need for specialty care in accordance with Title 22 CCR Section 53853(a) and W amp I Code Section 14182(c)(2) associated to retaining sufficient professional medical staff including adequate numbers of specialists to provide access to preventive and managed care services to its members In addition to ensure and monitor an appropriate provider network including specialists (Contract Exhibit A Attachment 6 (6))

Policy and Procedure Number QI-029 Assessment of Provider Network Availability states the Plan shall maintain an adequate network of contracted Specialty Care Practitioners (SCP) In addition to ensure the availability of Specialty Care Practitioners the Plan shall establish quantifiable and measurable standards for the number of geographic distribution for high volume Specialty Care Providers Attachment 61 defines the physician ratio time and distance standards set by the Planrsquos product line

The 2014 Access and Availability Reports for 2nd Quarter 3rd Quarter and 4th Quarter showed the Plan did not meet the ratio standard Provider to Members as follows

Practice Standards Provider to Members (P-M) Ratio

2nd Quarter 3rd Quarter 4th Quarter

Cardiology 15000 - 1 6951 -Cardiovascular Disease 15000 - - 1 8245 Gastroenterology 15000 16935 1 7830 1 10791 Ophthalmology 15000 - - 1 5918 Orthopedics 15000 15674 - 1 7604

2014 Medi-Cal Adult and Child CAHPS survey of member satisfaction analysis indicated that Access to Care remains the top reason for member complaints Approximately 50 of all Access to Care complaints (combined Adult and Child) were related to delays in service delays in authorization and specialty accessavailability Further there was an inherent shortage of specialists especially at the provider group level the Plan does not meet the provider to member ratio for the overall network

During the interview Plan Personnel acknowledged the Specialists shortage problem within the Plan Network primarily for Cardiologist Gastroenterologist and Orthopedic The Plan has made its efforts to improve this condition by actively searching and has contracted with several specialists from outside the network especially for seldom and unusual specialty services on as needed basis The Plan has also made arrangements for specialty services for members residing in rural areas Additionally the Plan utilizes electronic consultation with specialist for a quick response of a memberrsquos condition to arrange for treatment On a quarterly basis the Plan assesses individual specialty networks of the Participating Physician Group (PPG) to provide feedback to its PPG of any deficiencies in their network

RECOMMENDATION

341 Ensure Plan maintains adequate numbers and types of specialists within its network

35 EMERGENCY SERVICES AND FAMILY PLANNING CLAIMS

Emergency Service Providers (Claims) Contractor is responsible for coverage and payment of Emergency Services and post stabilization care services and must cover and pay for Emergency Services regardless of whether the provider that furnishes the services has a contract with the plan2-Plan Contract A813A

23 of 43

Contractor shall pay for emergency services received by a Member from non-contracting providers Payments to non-contracting providers shall be for the treatment of the emergency medical condition including Medically Necessary inpatient services rendered to a Member until the Members condition has stabilized sufficiently to permit referral and transfer in accordance with instructions from Contractor or the Member is stabilized sufficiently to permit discharge 2-Plan Contract A813C

At a minimum Contractor must reimburse the non-contracting emergency department and if applicable its affiliated providers for Physician services at the lowest level of emergency department evaluation and management Physicians Current Procedural Terminology (CPT) codes unless a higher level is clearly supported by documentation and for the facility fee and diagnostic services such as laboratory and radiology 2-Plan Contract A813D

For all other non-contracting providers reimbursement by Contractor or by a subcontractor who is at risk for out-of-plan emergency services for properly documented claims for services rendered on or after January 1 2007 by a non-contracting provider pursuant to this provision shall be made in accordance with Provision 5 Claims Processing and 42 USC Section 1396u-2(b)(2)(D) 3 2-Plan Contract A813E

Contractor shall cover emergency medical services without prior authorization pursuant to Title 28 CCR Section 130067(g) and Title 22 CCR Section 53216 2-Plan Contract A97A

Family Planning (Claims) Contractor shall reimburse non-contracting family planning providers at no less than the appropriate Medi-Cal FFS ratehellip(as required by Contract) 2-Plan Contract A89

Claims ProcessingmdashContractor shall pay all claims submitted by contracting providers in accordance with this sectionhellipContractor shall comply with Section 1932(f) Title XIX Social Security Act (42 USC Section 1396u-2(f) and Health and Safety Code Sections 1371 through 137136 2-Plan Contract A85

Time for Reimbursement A plan and a plans capitated provider shall reimburse each complete claim or portion thereof whether in state or out of state as soon as practical but no later than thirty (30) working days after the date of receipt of the complete claim by the plan or the plans capitated provider or if the plan is a health maintenance organization 45 working days after the date of receipt of the complete claim by the plan or the plans capitated provider unless the complete claim or portion thereof is contested or denied as provided in subdivision (h) CCR Title 28 Section 130071(g)

SUMMARY OF FINDINGS

351 The Plan did not forward claims to the appropriate provider within 10 days of receipt

The Plan is required to forward the claim to the appropriate capitated provider within ten (10) working days of receipt of the claim that was incorrectly sent to the Plan (Contract Exhibit A Attachment 8 (5)(D)) and (CCR Title 28 sect130071(b)(2)(A)(B))

Five (5) Emergency Room (ER) and five (5) Family Planning misdirected claims were not forwarded to the appropriate delegated entity within 10 working days The Plan had a shared risk contract and was responsible for paying a component for two of the five ER claims These two (2) claims were not forwarded timely and the Planrsquos share risk component was not paid within the required timeframe

The Plan did not comply with the Regulation requirements and Policy and Procedure Number CLM-011 Misdirected Claims Processing and Policy and Procedure Number 2304 Claims Timeliness by not forwarding claims to the appropriate fiscally responsible provider within ten (10) working days

352 The Plan did not process complete claims within 45 working days

The Plan shall comply with Section 1932(f) Title XIX Social Security Act (42 USC Section 1396u-2(f) and Health and Safety Code Sections 1371 through 137136 (Contract Exhibit A Attachment 8 (5)(A))

24 of 43

The Plan or Planrsquos capitated provider is required to reimburse each complete claim or portion thereof whether in state or out of statehellipno later than 45 working days after the date of receipt of the claim (CCR Title 28 sect130071(g)) Further the Plan is required to contest or deny a claim or portion thereof by notifying the provider in writing that the claim is contested or deniedhellipwithin 45 working days after the date of receipt of the claim by the Plan or the Planrsquos capitated provider (CCR Title 28 sect130071(h))

The verification study identified 13 Emergency Room and seven (7) Family Planning claims were not paid within 45 working days The Plan identified in the Claims Processing system codes indicating the claims issues which included Regions do not Match Vendor not Effective Not a Valid Vendor Incorrect Payer Address Vendor Address not Listed Partial Interest Payment Only Pending Provider Network Operations Region Update and Forwarded without Shared Risk Payment

Five (5) Family Planning claims were denied after 45 working days from receipt The Plan denied the claims via Remittance Advice identifying the denied code for each line item billed Provider not Eligible Not a Covered Benefit Services not Authorized Incorrect Procedure or Revenue CodeModifier and Financial Responsibility of the Patientrsquos IPAPPG

The Plan did not comply with the Contract regulation requirements and Policy and Procedure Number 2304 Claims Timeliness by not reimbursing or denying claims within 45 working days

RECOMMENDATIONS

351 Forward misdirected claims to the appropriate provider within 10 working days of receipt of the claim

352 Process claims within the required timeframe of 45 working days

CATEGORY 4 ndash MEMBERrsquoS RIGHTS

41 GRIEVANCE SYSTEM

Member Grievance System and Oversight Contractor shall implement and maintain a Member Grievance System in accordance with Title 28 CCR Section 130068 and 13006801 Title 22 CCR Section 53858 Exhibit A Attachment 13 Provision 4 Paragraph D13) and 42 CFR 438420(a)-(c) 2-Plan Contract A141

Contractor shall implement and maintain procedureshellipto monitor the Memberrsquos grievance system and the expedited review of grievances required under Title 28 CCR Sections 130068 and 13006801 and Title 22 CCR Section 53858hellip(as required by Contract) 2-Plan Contract A142

Contractor shall maintain and have available for DHCS review grievance logs including copies of grievance logs of any subcontracting entity delegated the responsibility to maintain and resolve grievances Grievance logs shall include all the required information set forth in Title 22 CCR Section 53858(e) 2-Plan Contract A143A

SUMMARY OF FINDINGS

411 Resolution letter did not always address all complaints

The Plan is required to resolve each grievance and provide notice to the Member as quickly as the Memberrsquos health condition requires within 30 calendar days from the date of receipt (Contract Exhibit A Attachment 14 (1))

The verification study identified six (6) resolution letters sent to members that did not address all the

25 of 43

issues raised in the grievance

This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan The Plan has implemented monthly staff trainings a new resolution letter template and has an internal Quality Audit (QA) in process to ensure the resolution letters to members address all identified issues

412 Plan did not ensure grievances were escalated to the appropriate staff with authority to require corrective action

The Plan is required to implement and maintain procedures to ensure the grievance submitted is reported to an appropriate level ie medical issues versus health care delivery issues To this end the Plan shall ensure that any grievance involving the appeal of a denial based on lack of Medical Necessity appeal of a denial of a request for expedited resolution of a grievance or an appeal that involves clinical issues shall be resolved by a health care professional with appropriate clinical expertise in treating the Memberrsquos condition or disease (Contract Exhibit A Attachment 14 (2)(D))

The Contract also requires the Plan to implement and maintain procedures to ensure the participation of individuals with authority to require corrective action Grievances related to medical quality of care issues shall be referred to the Planrsquos medical director (Contract Exhibit A Attachment 14 (2)(E))

The verification study identified seven (7) grievance files that were not escalated to the appropriate level for instance a Pharmacist or Physician reviewer for medical necessity

413 Plan did not consistently translate grievance resolution letters to Memberrsquos preferred language

The Plan is required to fully translate written informing materials including but not limited to form letters as well as notice of action letters and grievance acknowledgement and resolution letters The Plan is to provide translated written informing material to all monolingual or LEP Members that speak the identified threshold language or concentration standard languages (Contract Exhibit A Attachment 9 (14)(B)(2) and California Code of Regulations Title 28 Section 130068(b)(3) and Title 22 Section 53858(e)(6))

MMCD Policy Letter 99-04 (Translation of Written Informing Materials) requires the Plan to provide translated written informing documents in the threshold languages including form letters for example resolution letters

Verification study identified three (3) grievance files with the specific narrative section on the resolution letter not translated to memberrsquos preferred language

414 Grievances cases were not consistently identified or referred for possible Potential Quality Improvement

Plan shall implement and maintain procedure for systematic aggregation and analysis of the grievance data and use for Quality Improvement (Contract Exhibit A Attachment 14 (2)(C))

Eleven (11) grievance files reviewed for medical necessity and quality of care issues were not referred for potential quality improvement The grievance issues were not referred to the QI Department for further evaluation

415 Written communication to members was not at an appropriate understandable level

Verification study identified (19) nineteen grievance cases where the resolution letter was not written at an understandable level These resolution letters did not use language that is clear and easy to understand

26 of 43

416 Grievance data was not reported tracked or monitored consistently to identity the root cause at the intake level

The Plan is required to implement and maintain procedure for systematic aggregation and analysis of the grievance data and use for Quality Improvement (Contract Exhibit A Attachment 14 (2)(C))

The Planrsquos Track and Trend report lacks sufficient details to allow for aggregation and analysis of the grievances to identify the root causes at the intake level This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan As of February 2015 the Plan implemented a new system PCT which provides better flexibility and more automated in creating statistics Track and Trend and dashboards reports With the SSO system Track and Trend reports graphs and charts were manually created based on daily data reports However the Plan is still in the process of working on the integration of the SSO system into the new PCT system

According to interviews with Plan Personnel the Plan used the Single Sign On (SSO) system to keep track of grievances However the SSO system was not able to identify the root causes The SSO system was limited and only allowed the Member Service Representative (MSR) to log in the memberrsquos main complaint The new system Process Communication Tracking (PCT) was able to process communication with more detail and to log multiple concerns up to four codes at a time This system can automatically generate Track and Trend reports as well as dashboard reports In addition the Plan has implemented monthly trainings of the new Resolution Letter template for proper identification and documentation of all grievance issues

417 Language in the Member Handbook regarding ldquoGrievancerdquo and ldquoAppealrdquo is not at an understandable level

Language in the Member Handbook relating to ldquoGrievancesrdquo and ldquoAppealsrdquo is not at an understandable level The Plan is required to ensure all written member information provided to members is at a sixth grade reading level The written member information shall ensure membersrsquo understanding of the health plan processes and ensure the memberrsquos ability to make informed health decisions In addition the Plan is required to translate written member-informing materials into the identified threshold and concentration languages discussed in Exhibit A Attachment 9 Provision 13 (Contract Exhibit A Attachment 13 (4)(C))

Member Handbook contents on the subject of appeals and grievances process lacks clarity that creates potential confusion to the reader Appeals and grievances should be identified as two different processes and handled separately Process and timeframes shall be clear and understandable so that members are able to file for each process separately

During interview the Plan was aware of the issue and agreed the Member Handbook needs clarification of the Grievance and Appeal process language Currently the Member Handbook language is not clear to distinguish between appeals that stems from the memberrsquos dissatisfaction with the Planrsquos resolution of a grievance versus an appeal due to a denial reduction or termination of service the interpretation for these two terms were used interchangeably

The Plan is currently in the process of revising the language in the 20152016 Member Handbook to distinguish between the two processes of grievance and appeal This is still in the draft phase

418 The Planrsquos grievance system did not log and report exempt grievances for quality improvement

A grievance is defined as a written or oral expression of dissatisfaction Where the Plan is unable to distinguish between a grievance and an inquiry it shall be considered a grievance (California Code of Regulations Title 28 Section 130068(a)(1))

27 of 43

Grievances received over the telephone that are non-medical necessary can be resolved by the close of the next business day These claims are exempt from the required written acknowledgement and response For these exempt grievances the Plan is required to maintain a detailed log to be periodically reviewed by the Plan (California Code of Regulations Title 28 Section 130068(d)(8))

Interviews with Plan Personnel indicated member services logged exempt grievances as inquiries exempt grievance logs were not maintained separately The Plan was unable to verify in its system that exempt grievances were classified tracked and continuously reviewed for quality improvement This is especially identified for complex or multiple issues complaint Currently the Plan has implemented new 24-Hour Exemptions procedures as well as a new training for Member Services Department The new procedure consists of criteria to follow for non-exempt grievance classification

RECOMMENDATIONS

411 Ensure the Plan addresses all grievance complaints in the resolution letter

412 Ensure grievances are escalated to the appropriate staff with authority for corrective action

413 Ensure that grievance resolution letters consistently meet language requirements

414 Ensure quality of care grievance cases are referred for Potential Quality Improvement

415 Ensure communication letters to members use clear concise and understandable language

416 Ensure the Planrsquos new system for the aggregation and analysis grievance data is completely integrated and operational

417 Revise language in Member Handbook to distinguish between grievance and appeal process

418 Develop and implement procedures to ensure exempt grievances are classified logged and reported for Quality Improvement

42 CULTURAL AND LINGUISTIC SERVICES

Cultural and Linguistic Program Contractor shall have a Cultural and Linguistic Services Program that incorporates the requirements of Title 22 CCR Section 53876 Contractor shall monitor evaluate and take effective action to address any needed improvement in the delivery of culturally and linguistically appropriate services Contractor shall review and update their cultural and linguistic services consistent with the group needs assessment requirementshellip 2-Plan Contract A913

Contractor will assess identify and track the linguistic capability of interpreters or bilingual employed and contracted staff (clinical and non-clinical) 2-Plan Contract A913B

Contractor shall develop and implement policies and procedures for assessing the performance of individuals who provide linguistic services as well as for overall monitoring and evaluation of the Cultural and Linguistic Services Program 2-Plan Contract A913F

Linguistic Services Contractor shall ensure compliance with Title 6 of the Civil Rights Act of 1964 (42 USC Section 2000d 45 CFR Part 80) that prohibits recipients of Federal financial assistance from discriminating against persons based on race color religion or national origin 2-Plan Contract A912

Contractor shall comply with Title 22 CCR Section 53853(c) and ensure that all monolingual non-English-speaking or limited English proficient (LEP) Medi-Cal beneficiaries receive 24-hour oral interpreter services at all key points of contacthellipeither through interpreters telephone language services or any electronic optionshellip 2-Plan Contract A914A

28 of 43

TYPES OF LINGUISTIC SERVICES Contractor shall provide at minimum the following linguistic services at no cost to Medi-Cal Members or potential Members 1) Oral Interpreters signers or bilingual providers and provider staff at all key points of contact These services

shall be provided in all languages spoken by Medi-Cal beneficiaries and not limited to those that speak thethreshold or concentration standards languages

2) Fully translated written informing materialshellip3) Referrals to culturally and linguistically appropriate community service programs4) Telecommunications Device for the Deaf (TDD)

Key Points of Contact Include1) Medical care settings telephone advice and urgent care transactions and outpatient encounters with health

care providers including pharmacists2) Non-medical care setting Member services orientations and appointment scheduling

SUMMARY OF FINDINGS

421 Written notices were not in the memberrsquos threshold language

The Plan is required to provide linguistic services at no cost to Medi-Cal members including fully translated written informing materials including but not limited to the Member Services Guide enrollee information welcome packets marketing information and form letters including Notice of Action (NOA) letters and grievance acknowledgement and resolution letters The Plan shall provide translated written informing materials to all monolingual or Limited English Proficient Members that speak the identified threshold or concentration standard languages (Contract Exhibit A Attachment 9 (14)(B)(2)) The Contract also requires the Plan to ensure that all written member information provided is at a sixth grade reading level and that it ensures membersrsquo understanding of the health plan processes and the memberrsquos ability to make informed health decisions (Contract Exhibit A Attachment 13 (4)(C))

MMCD All-Plan Letter 05005 MMCD Policy Letter 99-04 and LA Carersquos Policy and Procedure Number CL-013 reiterate this requirement of providing Limited English Proficient (LEP) members written materialsin their identified primary or threshold language including Notice of Action (NOA) grievanceacknowledgement and resolution letters The Plan must implement procedures for sending membersthese translated materials on a routine basis

Notice of Action letters including grievance acknowledgement and resolution letters and pharmacy prior authorization denial letters reviewed were not consistently translated in the memberrsquos threshold language The Participating Physician Grouprsquos referral and pharmacy prior authorization letters did not identify the memberrsquos preferred language although it was reflected in the medical record as a language other than English

422 The Plan did not utilize its internal data base on memberrsquos preferred language

The Plan is required to ensure that a complete medical record is maintained for each member in accordance with Title 22 CCR Section 53861 that reflects all aspects of patient care and at a minimum includes memberrsquos preferred language (if other than English) prominently noted in the record as well as the request or refusal of languageinterpretation services (Contract Exhibit A Attachment 4 (13)(D)(2))

MMCD Policy Letter 99-04 (Translation of Written Informing Materials) states the Plan must implement procedures to identify members whose primary language is a threshold language Sources for identification of LEP members include the Medi-Cal Enrollment Data Set health plan enrollment data initial health assessments or other databases generated by the health plan The Plan must implement procedures for sending these members translated materials on a routine basis

29 of 43

The Plan identifies a memberrsquos preferred language from a file received by Member Services through the State This information is uploaded monthly in the Planrsquos data base The Plan maintains a back-up screen of original member profile information However the Plan did not consistently use information in its internal data base or in the medical records to identify the memberrsquos threshold language Consequently the Plan did not send written materials translated in the memberrsquos preferred language

423 Information in the Planrsquos website was not fully translated in threshold languages

The Plan is required to ensure equal access to health care services for limited English proficient Medi-Cal members or potential members through provision of high quality interpreter and linguistic services (Contract Exhibit A Attachment 9 (12))

The Plan is required to monitor evaluate and take effective action to address any needed improvement in the delivery of culturally and linguistically appropriate services (Contract Exhibit A Attachment 9 (13))

The Planrsquos website is a tool for members to retrieve essential information of services and resources that are available through the Plan The Planrsquos website has a drop down key where members can select their preferred language Although the websitersquos home page is translated in the selected threshold language it does not have the capability of navigating the different menus for any other languages except English The members do not have full access to informational materials and resources in their preferred language Therefore the Plan did not ensure equal access to health care services to members who were not proficient in English

RECOMMENDATIONS

421 Ensure Notice of Action (NOA) letters including denial letters grievance acknowledgement and resolution letters are translated in the memberrsquos threshold language

422 Ensure the Planrsquos internal data base is utilized to identify the memberrsquos preferred language when sending written materials

423 Translate information in the Planrsquos website to threshold language

43 CONFIDENTIALITY RIGHTS

Membersrsquo Right to Confidentiality Contractor shall implement and maintain policies and procedures to ensure the Members right to confidentiality of medical information 1) Contractor shall ensure that Facilities implement and maintain procedures that guard against disclosure of confidential information to unauthorized persons inside and outside the network 2) Contractor shall counsel Members on their right to confidentiality and Contractor shall obtain Members consent prior to release of confidential information unless such consent is not required pursuant to Title 22 CCR Section 51009 2-Plan Contract A131B

Health Insurance Portability and Accountability Act (HIPAA) Responsibilities Business Associate agrees Safeguards To implement administrative physical and technical safeguards that reasonably and appropriately protect the confidentiality integrity and availability of the PHI including electronic PHI that it creates receives maintains uses or transmits on behalf of DHCS in compliance with 45 CFR sections 164308 164310 and 164312 and to prevent use or disclosure of PHI other than as provided for by this Agreement Business Associate shall implement reasonable and appropriate policies and procedures to comply with the standards implementation specifications and other requirements of 45 CFR section 164 subpart C in compliance with 45 CFR section 164316 Business Associate shall develop and maintain a written information privacy and security program that includes administrative technical and physical safeguards appropriate to the size and complexity of the Business Associatersquos operations and the nature and scope of its activities and which incorporates the requirements of section C Security below Business Associate will provide DHCS with its current and updated policies 2-Plan Contract G3B

30 of 43

Breaches and Security Incidents During the term of this Agreement Business Associate agrees to implement reasonable systems for the discovery and prompt reporting of any breach or security incident and to take the following steps 1 Notice to DHCS (1) To notify DHCS immediately by telephone call plus email or fax upon the discovery of a breach of unsecured PHI or PI in electronic media or in any other media if the PHI or PI was or is reasonably believed to have been accessed or acquired by an unauthorized person or upon the discovery of a suspected security incident that involves data provided to DHCS by the Social Security Administration (2) To notify DHCS within 24 hours by email or fax of the discovery of any suspected security incident intrusion or unauthorized access use or disclosure of PHI or PI in violation of this Agreement and this Addendum or potential loss of confidential data affecting this Agreement A breach shall be treated as discovered by Business Associate as of the first day on which the breach is known or by exercising reasonable diligence would have been known to any person (other than the person committing the breach) who is an employee officer or other agent of Business Associate 2 Investigation and Investigation Report To immediately investigate such security incident breach or unauthorized access use or disclosure of PHI or PI Within 72 hours of the discovery Business Associate shall submit an updated ldquoDHCS Privacy Incident Reportrdquo containing the information marked with an asterisk and all other applicable information listed on the form to the extent known at that time to the DHCS Plan Contract Officer the DHCS Privacy Officer and the DHCS Information Security Officer 3 Complete Report To provide a complete report of the investigation to the DHCS Plan Contract Officer the DHCS Privacy Officer and the DHCS Information Security Officer within ten (10) working days of the discovery of the breach or unauthorized use or disclosure

2-Plan Contract G3H

SUMMARY OF FINDINGS

431 The Plan did not ensure all initial notification of suspected PHI breaches are reported to DHCS within the required 24 hours timeframe

The Plan is required to ldquonotify DHCS immediately by telephone call plus e-mail or fax upon the discovery of breach of security of PHI in computerized form if the PHI was or is reasonably believed to have been acquired by an unauthorized person or within 24 hours by e-mail or fax of any suspected security incident intrusion or unauthorized use or disclosure of PHI in violation of this Contract or potential loss of confidential data affecting this Contractrdquo (Contract Exhibit G 3(H)(1))

Policy and Procedure Number RACH-009 Incident Notification and Mitigation of Inappropriate Use or Disclosure of PHI paragraph 35 states ldquoThe Privacy Officer or designee will initiate regulatory notification as required by contractual andor regulatory requirements The Privacy Officer or designee will notify the appropriate regulatory agencies within the timeframes outlined in Attachment 62 ndash Regulatory Notification Gridrdquo Attachment 62 - Regulatory Notification Grid identifies the ldquoInitial Notification Deadlinerdquo for DHCS of 24 hours by e-mail or fax if a suspected security incident intrusion or unauthorized use or disclosure in violation of the contract or loss of confidential data affecting the contract

The verification study identified two (2) cases that were not reported within the 24 hours timeframe This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan The Plan has created desktop procedures to remind staff about submission of PHI breaches upon discovery including reporting requirements to DHCS within require time frames However at the time of the review by DHCS the Plan was in the early stages of the implementation process

432 The Plan did not ensure all Investigation of Breach reports were submitted within 72 hours

The Contract requires the Plan to immediately investigate such security incident breach or unauthorized use or disclosure of PHI or confidential data and within 72 hours of the discovery to notify the DHCS Plan Contract Officer the DHCS Privacy Officer and the DHCS Information Security Officer (Contract Exhibit G 3(H)(2))

Policy and Procedure Number RACH-009 Incident Notification and Mitigation of Inappropriate Use or Disclosure of PHI paragraph 35 states ldquoThe Privacy Officer or designee will initiate regulatory

31 of 43

notification as required by contractual andor regulatory requirements The Privacy Officer or designee will notify the appropriate regulatory agencies within the timeframes outlined in Attachment 62 ndash Regulatory Notification Gridrdquo Attachment 62 - Regulatory Notification Grid identifies under the ldquoRegulatory ContractualOther Guidancerdquo instructs to follow as stated in DHCS Contract Exhibit G

The verification study identified six (6) cases which the Plan did not submit an Investigation of Breach report within the required 72 hours of discovery

433 Policy and procedure lack required instruction for an electronic breach that occurs after business hours or on a weekend or holiday

The Contract requires the Plan to notify DHCS by calling the DHCS ITSD Help Desk when an incident occurs after business hours or on a weekend or holiday and it involves electronic PHI (Contract Exhibit G 3(H)(1)) The Contract also requires the Plan to ldquomaintain a comprehensive written information privacy and security program that includes administrative technical and physical safeguards appropriate to the size and complexity of the Contractorrsquos operations and the nature and scope of its activitiesrdquo (Contract Exhibit G 3(B))

Policy and Procedure Number RACH-009 Incident Notification and Mitigation of Inappropriate Use or Disclosure of PHI paragraph 35 Attachment 62 The Regulatory Notification Grid only outlines limited set of actions to perform in the case of a breach or suspected security incident

Policy and Procedure RACH-009 including Attachment 62 did not contain the required instruction for an electronic PHI incident that occurs after business hours or on a weekend or holiday

434 Policy and procedure did not include instruction for contact information of DHCS Plan Contract Officer

The Contract requires the Plan to notify DHCS immediately by telephone call plus e-mail or fax upon the discovery of breach of security of PHI in computerized form if the PHI was or is reasonably believed to have been acquired by an unauthorized person or within 24 hours by e-mail or fax of any suspected security incident intrusion or unauthorized use or disclosure of PHI in violation of this Contract or potential loss of confidential data affecting this Contract Notification shall be provided to the DHCS Plan Contract Officer the DHCS Privacy Officer and the DHCS Information Security Officer (Contract Exhibit G 3(H)(1))

Policy and Procedure Number RACH-009 Incident Notification and Mitigation of Inappropriate Use or Disclosure of PHI paragraph 35 states ldquoThe Privacy Officer or designee will initiate regulatory notification as required by contractual andor regulatory requirements The Privacy Officer or designee will notify the appropriate regulatory agencies within the timeframes outlined in Attachment 62 ndash Regulatory Notification Gridrdquo Attachment 62 - Regulatory Notification Grid under the ldquoNotification Contact Informationrdquo for DHCS only instructs that in case of a breach or suspected security incident to notify the Privacy Officer (privacyofficerdhcscagov) and (isodhcscagov) by the Regulatory Affairs amp Compliance department however it did not include the DHCS Plan Contract Officer

Policy and Procedure RACH-009 including Attachment 62 did not include the DHCS contact information for the DHCS Plan Contract Officer as required by the Contract

435 The policy and procedure did not include instructions for submission of the Investigation Report to the DHCS Plan Contract Officer DHCS Privacy Officer and the DHCS Information Security Officer within 72 hours of discovery

The contract requires the Plan to immediately investigate such security incident breach or unauthorized use or disclosure of PHI or confidential data and within 72 hours of the discovery to notify the DHCS Plan Contract Officer the DHCS Privacy Officer and the DHCS Information Security Officer (Contract Exhibit G 3(H)(2)) Contract also requires the Plan to ldquomaintain a comprehensive written information privacy and security program that includes administrative technical and physical safeguards appropriate to the size and complexity of the Contractorrsquos operations and the nature and scope of its activitiesrdquo (Contract Exhibit G 3(B))

32 of 43

Policy and Procedure Number RACH-009 Incident Notification and Mitigation of Inappropriate Use or Disclosure of PHI Attachment 62 ndash Regulatory Notification Grid identifies the ldquoInitial Notification Deadlinerdquo for DHCS only instructs to notify within 24 hours by e-mail or fax if a suspected security incident intrusion or unauthorized use or disclosure in violation of the contract or loss of confidential data affecting the contract This policy did not have required instruction of an investigation report within 72 hours of discovery be reported to the DHCS Plan Contract Officer the DHCS Privacy Officer and the DHCS Information Security Officer

436 The Plan did not have a policy and procedure to submit the complete full investigative report 10 working days after the discovery of the incident

The MMCD All Plan Letter APL 09-14 states ldquoA full investigative report is not required until 10 working days after discovery of the incidentrdquo Therefore the Plan is required to complete a full investigative report 10 working days after the discovery of the incident In addition the Contract requires the Plan to ldquomaintain a comprehensive written information privacy and security program that includes administrative technical and physical safeguards appropriate to the size and complexity of the Contractorrsquos operations and the nature and scope of its activitiesrdquo (Contract Exhibit G 3(B))

The Plan did not have written policies and procedures to include instruction required for a full investigative report to be completed 10 working days after discovery of the incident

RECOMMENDATIONS

431 Ensure the initial notification of PHI breaches is reported within the required 24 hours timeframe

432 Ensure the Breach Investigative Report is submitted within the required 72 hours timeframe

433 Revise policies and procedures to include instructions for an electronic breach that occurs after business hours or on a weekend or holiday

434 Revise policies and procedures to include the contact information for the DHCS Plan Contract Officer

435 Revise policies and procedures to include instructions for submission of Investigation Report within the required 72 hours

436 Adopt a policy and procedure to include instruction for a full investigative report to be completed 10 working days after the discovery of an incident

CATEGORY 5 ndash QUALITY MANAGEMENT

52 PROVIDER QUALIFICATIONS

Credentialing and Re-credentialing Contractor shall develop and maintain written policies and procedures that include initial credentialing recredentialing recertification and reappointment of Physicians including Primary Care Physicians and specialists in accordance with the MMCD Policy Letter 02-03 Credentialing and Re-credentialing Contractor shall ensure those policies and procedures are reviewed and approved by the governing body or designee Contractor shall ensure that the responsibility for recommendations regarding credentialing decisions will rest with a credentialing committee or other peer review body 2-Plan Contract A412

Standards All providers of Covered Services must be qualified in accordance with current applicable legal professional and technical standards and appropriately licensed certified or registeredhellipProviders that have been terminated from either Medicare or MedicaidMedi-Cal cannot participate in Contractorrsquos provider network 2-Plan Contract A412A

33 of 43

Medi-Cal Managed Care Provider Training Contractor shall ensure that all providers receive training regarding the Medi-Cal Managed Care program in order to operate in full compliance with the Contract and all applicable Federal and State statutes and regulations Contractor shall ensure that provider training relates to Medi- Cal Managed Care services policies procedures and any modifications to existing services policies or procedures Training shall include methods for sharing information between Contractor provider Member andor other healthcare professionals Contractor shall conduct training for all providers within ten (10) working days after the Contractor places a newly contracted provider on active statushellip 2-Plan Contract A75

Delegated Credentialing Contractor may delegate credentialing and recredentialing activities If Contractor delegates these activities Contractor shall comply with Provision 6 Delegation of Quality Improvement Activitieshellip 2-Plan Contract A412B

Disciplinary Actions Contractor shall implement and maintain a system for the reporting of serious quality deficiencies that result in suspension or termination of a practitioner to the appropriate authorities Contractor shall implement and maintain policies and procedures for disciplinary actions including reducing suspending or terminating a practitionerrsquos privileges Contractor shall implement and maintain a provider appeal process 2-Plan Contract A412D

SUMMARY OF FINDINGS

521 New contracted providers did not receive training within 10 working days after being placed on active status

The Contract requires the Plan to conduct training for all providers within ten 10 working days after the provider is placed on active status (Contract Attachment A 7(5)(A))

Policy and Procedure Number PNO-024 Provider Network Training specifies that LA Care shall provide comprehensive training to its contracted PPGs network Providers and track training sessions delivered and monitor compliance with training timeline standard and requirements However it does not specifically state the required timeframe ldquowithin 10 working daysrdquo of training completion after being placed on active status

The Plan delegates new provider training and orientation responsibility to their Participating Physician Groups (PPGs)

Services Agreement between LA Care Health Plan and Contracted PPGs Section 134 PPG Service Requirements states that PPG shall develop orientation program for all new physicians and shall orient all new physicians within the first 10 business days from their affiliation effective date (including but not limited to Primary Care Physicians and Affiliated Providers) PPG shall have developed training and education program for Primary Care Physicians Affiliated Providers and office staff PPG shall conduct on-going provider training and education as set forth in the Provider Manual The Plan monitors and conducts audits of its PPGs to ensure compliance with the new provider training from their affiliation effective date

Provider Manual states that Provider orientation sessions and on-site visits for newly contracted providers will be conducted by PPGs to provide training and the contents of LA Carersquos provider manual within ten business days of their affiliation date

The verification study identified 14 new providers did not receive the training within 10 working days of being placed on active status This is an ongoing finding This finding was addressed in the prior year Corrective Action Plan recommending the Plan to submit the Provider Manual highlighting the 10 business day training requirement and to submit an Oversight and Monitoring Policy and Procedure along with proposed audit tool for the review of the training completion This deficiency was provisionally closed and at the time of the review by DHCS the Plan was in the early stages of the implementation process

34 of 43

522 Policy and Procedure Number PNO-024 does not specifically state the required training timeframe of 10 business days

RECOMMENDATIONS

521 Ensure all new providers receive training within 10 business days after being placed on active status

522 Update Policy and Procedure Number PNO-024 to include the required 10 business day timeframe

53 DELEGATION OF QUALITY IMPROVEMENT ACTIVITIES

Delegation of Quality Improvement Activities A Contractor is accountable for all quality improvement functions and responsibilities (eg Utilization

Management Credentialing and Site Review) that are delegated to subcontractors If Contractor delegates quality improvement functions Contractor and delegated entity (subcontractor) shall include in their Subcontract at minimum 1) Quality improvement responsibilities and specific delegated functions and activities of the Contractor

and subcontractor 2) Contractorrsquos oversight monitoring and evaluation processes and subcontractorrsquos agreement to such

processes 3) Contractorrsquos reporting requirements and approval processes The agreement shall include

subcontractorrsquos responsibility to report findings and actions taken as a result of the quality improvement activities at least quarterly

4) Contractorrsquos actionsremedies if subcontractorrsquos obligations are not met B Contractor shall maintain a system to ensure accountability for delegated quality improvement activities that

at a minimum 1) Evaluates subcontractorrsquos ability to perform the delegated activities including an initial review to assure

that the subcontractor has the administrative capacity task experience and budgetary resources to fulfill its responsibilities

2) Ensures subcontractor meets standards set forth by the Contractor and DHCS 3) Includes the continuous monitoring evaluation and approval of the delegated functions

2-Plan Contract A46

SUMMARY OF FINDINGS

531 The Plan was not fully accountable for its responsibilities regarding the delegated credentialing functions to its subcontractors

The Contract requires the Plan to maintain a system to ensure accountability for delegated QI activities and responsibilities (eg Utilization Management Credentialing and Site Review) through continuous monitoring evaluation approval and oversight of the delegated functions to its subcontractors (Contract Exhibit A Attachment 4 6(A) amp (B))

Policy and Procedure Number QI-007 Delegated Oversight states that the delegated QI activities are reviewed annually according to specifications described in Delegation Agreement and NCQA standards Therefore the Plan remains accountable for maintaining appropriate structures and mechanisms to oversee delegated QI activities The Plan monitors these delegated activities through ongoing reports meetings andor onsite audits of the delegate

Policy and Procedure Number CR-010 Ongoing Monitoring states that the Plan maintains a comprehensive ongoing monitoring process monthly and quarterly of practitionerprovider sanctions complaints and adverse issues between credentialing cycles Further the Credentialing Committee will evaluate specific complaints history of issues of the practitionerrsquos and depending on the nature of the event the Credentialing Committee will take action based on its policies and procedures

Policy and Procedure Number CR-013 Delegation of Credentialing states that the Plan delegates credentialing and recredentialing activities to entities with established programs and policies with accreditation requirements and standards It further outlines that on an annual basis the Credentialing

35 of 43

Department reassesses the delegatersquos performance through an onsite audit of their program documentation credentialing and recredentailing files Upon completion of the audit the Plan sends a copy to the delegate of the audited items including the scoring process and if areas of improvement are identified a description of the Corrective Action Plan (CAP) process request

Policy and Procedure Number CR-006 Credentialing Verification Process states that the Credentialing Department verifies from primary sources credentialing and re-credentialing submitted by practitionersproviders to ensure all the information received is complete and meets the established criteria and complies with standards

The Plan delegated credentialing and re-credentialing functions to its delegated entities However the Plan remains responsible for the delegated credentialing oversight activities The Plan did not fully adhere to its internal policies and procedures regarding delegated credentialing protocols The Plan did conduct oversight audits of the delegatesrsquo credentialing processes to identify deficiencies and required necessary corrective action plans however the Plan did not have an adequate monitoring system in place for credentialing oversight For example the Plan included in the Provider Network rendering providers who were not properly reviewed for credentialing by the Credentialing Department

RECOMMENDATION

531 Adhere to the Planrsquos policies and procedures for adequate delegated credentialing monitoring and oversight

36 of 43

LA Care Health Plan

Contract Number 03-75799 State Supported Services

Audit Period July 1 2014 Through

June 30 2015

TABLE OF CONTENTS I INTRODUCTION 1 II COMPLIANCE AUDIT FINDINGS 2

INTRODUCTION

The audit report presents findings of the LA Care Health Planrsquos compliance to its contract and its implementation of the State Supported Services Contract Number 03-75799 with the State of California The State Supported Services contract covers abortion services for LA Care Health Plan (the Plan) The on-site audit was conducted from July 20 2015 through July 31 2015 The audit covered the review period from July 1 2014 through June 30 2015 and consisted of review of documents supplied by the Plan and interviews conducted on-site An Exit Conference was held on March 4 2016 with the Plan There were no deficiencies found for the review period of the Planrsquos State Supported Services

COMPLIANCE AUDIT FINDINGS (CAF) PLAN LA Care Health Plan

AUDIT PERIOD July 1 2014 through June 30 2015

DATE OF AUDIT July 20 2015 through July 31 2015

STATE SUPPORTED SERVICES CONTRACT REQUIREMENTS Abortion Contractor agrees to provide or arrange to provide to eligible Members the following State Supported Services Current Procedural Coding System Codes 59840 through 59857 HCFA Common Procedure Coding System Codes X1516 X1518 X7724 X7726 Z0336 These codes are subject to change upon the Department of Health Servicesrsquo (DHSrsquo) implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) electronic transaction and code sets provisions Such changes shall not require an amendment to this Contract State Supported Services Contract Exhibit A1 SUMMARY OF FINDINGS

Abortion is a sensitive service covered by the Medi-Cal program without prior authorization for out-patient abortions however for in-patient abortions prior authorization is required The Plan must provide members pregnancy termination procedures from in-or-out of network providers for out-patient abortions The Planrsquos policies and procedures inform providers that members can obtain sensitive services without prior authorization through any qualified provider in-or-out of network Members are informed about their rights to access family planning services which include sensitive services such as abortions through the Member Handbook member updates and educational sessions and materials Although the billing codes are not included in the Planrsquos policies the billing codes are included in the Claims Department processing instructions and billing system During the audit period July 1 2014 through June 30 2015 the Planrsquos billing system included the updated claim payment codes as follow Current Procedural Terminology (CPT) Codes 59840 through 59857 Healthcare Common Procedure Coding System (HCPCS) Codes A4649 with Modifier U1 andor U2 ICD-9-CM Diagnosis Codes 632 63400 ndash 63492 63500 ndash 63592 V617 HCPCS S0199 (Medical Abortion) S0190 (Mifepristone [RU-486]) and S0191 (Misoprostol) as billable codes for abortion services

The Plan provides or arranges to provide to eligible members the required State Supported Services listed above Based on the review no deficiencies were found

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


24 INITIAL HEALTH ASSESSMENT

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS

33 TELEPHONE PROCEDURES AFTER HOURS CALLS

SUMMARY OF FINDINGS

RECOMMENDATIONS


Contractor shall arrange for the provision of seldom used or unusual specialty services from specialists outside the network if unavailable within Contractorrsquos network when determined Medically Necessary

SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS


Types of Linguistic Services

SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

sss passed checkpdf

STATE SUPPORTED SERVICES CONTRACT REQUIREMENTS

TABLE OF CONTENTS

I INTRODUCTION 1

II EXECUTIVE SUMMARY 2

III SCOPEAUDIT PROCEDURES 5

IV COMPLIANCE AUDIT FINDINGS Category 1 ndash Utilization Management7 Category 2 ndash Case Management and Coordination of Care 16 Category 3 ndash Access and Availability of Care 19 Category 4 ndash Memberrsquos Rights 30 Category 5 ndash Quality Management 40 Category 6 ndash Administrative and Organizational CapacityNA

I INTRODUCTION

1 of 43

2 of 43

3 of 43

4 of 43

PROCEDURES

5 of 43

6 of 43

SUMMARY OF FINDINGS

7 of 43

RECOMMENDATIONS

SUMMARY OF FINDINGS

8 of 43

9 of 43

10 of 43

RECOMMENDATIONS

11 of 43

SUMMARY OF FINDINGS

12 of 43

13 of 43

14 of 43

RECOMMENDATIONS

SUMMARY OF FINDINGS

15 of 43

16 of 43

RECOMMENDATIONS

17 of 43

SUMMARY OF FINDINGS

18 of 43

RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

24 of 43

RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

26 of 43

27 of 43

RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

sss passed checkpdf


I INTRODUCTION

1 of 43

2 of 43

3 of 43

4 of 43

PROCEDURES

5 of 43

6 of 43

SUMMARY OF FINDINGS

7 of 43

RECOMMENDATIONS

SUMMARY OF FINDINGS

8 of 43

9 of 43

10 of 43

RECOMMENDATIONS

11 of 43

SUMMARY OF FINDINGS

12 of 43

13 of 43

14 of 43

RECOMMENDATIONS

SUMMARY OF FINDINGS

15 of 43

16 of 43

RECOMMENDATIONS

17 of 43

SUMMARY OF FINDINGS

18 of 43

RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

24 of 43

RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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33 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

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LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



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SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

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2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

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RECOMMENDATIONS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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33 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

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LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

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2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

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RECOMMENDATIONS

2-Plan Contract A65

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SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

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RECOMMENDATIONS

2-Plan Contract A65

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

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RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

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2-Plan Contract A65

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

SUMMARY OF FINDINGS

18 of 43

RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

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RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

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18 of 43

RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

SUMMARY OF FINDINGS

18 of 43

RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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27 of 43

RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

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32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

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RECOMMENDATIONS

SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

SUMMARY OF FINDINGS

18 of 43

RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

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32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

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14 of 43

RECOMMENDATIONS

SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

SUMMARY OF FINDINGS

18 of 43

RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

24 of 43

RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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27 of 43

RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

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32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

SUMMARY OF FINDINGS

18 of 43

RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

24 of 43

RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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27 of 43

RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

SUMMARY OF FINDINGS

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RECOMMENDATIONS

17 of 43

SUMMARY OF FINDINGS

18 of 43

RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

24 of 43

RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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27 of 43

RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

SUMMARY OF FINDINGS

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16 of 43

RECOMMENDATIONS

17 of 43

SUMMARY OF FINDINGS

18 of 43

RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

24 of 43

RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

26 of 43

27 of 43

RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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SUMMARY OF FINDINGS

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2-Plan Contract A65

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SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

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LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

17 of 43

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RECOMMENDATIONS

2-Plan Contract A65

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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RECOMMENDATIONS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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RECOMMENDATIONS

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SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan Contract A65

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

24 of 43

RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

2-Plan Contract A65

19 of 43

SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

24 of 43

RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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27 of 43

RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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2-Plan Contract A65

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SUMMARY OF FINDINGS

20 of 43

RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

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RECOMMENDATIONS

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2-Plan Contract G3H

SUMMARY OF FINDINGS

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32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

2-Plan A132A

SUMMARY OF FINDINGS

21 of 43

RECOMMENDATIONS

22 of 43

SUMMARY OF FINDINGS

RECOMMENDATION

23 of 43

SUMMARY OF FINDINGS

24 of 43

RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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2-Plan A132A

SUMMARY OF FINDINGS

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RECOMMENDATIONS

22 of 43

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RECOMMENDATION

23 of 43

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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27 of 43

RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATION

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41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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27 of 43

RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

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RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATION

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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SUMMARY OF FINDINGS

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RECOMMENDATIONS

41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

25 of 43

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

28 of 43

SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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SUMMARY OF FINDINGS

29 of 43

RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

30 of 43

2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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2-Plan Contract G3H

SUMMARY OF FINDINGS

31 of 43

32 of 43

RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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RECOMMENDATIONS

33 of 43

SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

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SUMMARY OF FINDINGS

34 of 43

RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

sss passed checkpdf


RECOMMENDATIONS

2-Plan Contract A46

SUMMARY OF FINDINGS

35 of 43

RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

sss passed checkpdf


RECOMMENDATION

36 of 43

LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

sss passed checkpdf


LA Care Health Plan

June 30 2015

INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

sss passed checkpdf


INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

sss passed checkpdf


INTRODUCTION

RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

sss passed checkpdf


RECOMMENDATION

Not Applicable


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATION


SUMMARY OF FINDINGS

RECOMMENDATIONS


41 GRIEVANCE SYSTEM

SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATIONS



SUMMARY OF FINDINGS

RECOMMENDATIONS


SUMMARY OF FINDINGS

RECOMMENDATION

sss passed checkpdf
