transactions, to two (2) decimal divided by the places. total draft or payment transactions. Claims Standards 95% of all claims are Measured by the 3.00% of fees if adjudicated within 10 State's performance is Processing Time business days; and 98% independent less than of all claims are auditor as part of standard. adjudicated within 20 the annual claims business days. audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal places. Provision of claims Delivery of agreed-upon Date-stamp of 0.05% for each and eligibility data claims and eligibility receipt by the calendar day the to party data to third party third-party vendor data is not vendors. vendors in the format and verification of received or is and frequency required completeness of incomplete. by the applicable required vendor(s). documentation. Annual Hospital Conduct hospital Provide quarterly 3.00% of fees if Records Claims records (including reporting of the performance is Audit clinical and billing number of audits less than issues) audits for every conducted, the standards. admission with paid amount of claims in excess of recoveries to the $25,000, subject to a SLEOLA Plan. minimum of 2% of all hospital claims. Audits are to be conducted to ensure accuracy of billed charges in relation to the clinical services delivered. SLEOLA Member Satisfactory or better Survey results. 1.00% of fees if Satisfaction results from an annual less than 90% of State-conducted members indicate Participant satisfaction satisfied or very survey. 90% of satisfied. members indicate satisfied or very satisfied.
transactions, divided by the total draft or payment transactions. to two (2) decimal places. Claims Standards Processing Time 95% of all claims are adjudicated within 10 business days; and 98% of all claims are adjudicated within 20 business days. Measured by the State's independent auditor as part of the annual claims audit. Criteria as defined by the State's independent auditor. Measured to two (2) decimal places. 3.00% of fees if performance is less than standard. Provision of claims and eligibility data to party vendors. Delivery of agreed-upon claims and eligibility data to third party vendors in the format and frequency required by the applicable vendor(s). Date-stamp of receipt by the third-party vendor and verification of completeness of required documentation. 0.05% for each calendar day the data is not received or is incomplete. Annual Hospital Records Claims Audit Conduct hospital records (including clinical and billing issues) audits for every admission with paid claims in excess of $25,000, subject to a minimum of 2% of all hospital claims. Audits are to be conducted to ensure accuracy of billed charges in relation to the clinical services delivered. Provide quarterly reporting of the number of audits conducted, the amount of recoveries to the SLEOLA Plan. 3.00% of fees if performance is less than standards. SLEOLA Member Satisfaction Satisfactory or better results from an annual State-conducted Participant satisfaction survey. 90% of members indicate satisfied or very satisfied. Survey results. 1.00% of fees if less than 90% of members indicate satisfied or very satisfied.