assumptions utilized to develop the projected costs. Disclosure of supporting data used in the calculations, including monthly paid claims and enrollment, large claims analysis, trend analysis, demographic analysis, etc. Substantiation of any proposed increase in fixed costs via a thorough analysis of activities and costs covered by those fees. Explanations for any unusual trend results (high relative to the market, low relative to the market). Claims Standards: 99% of claim dollars Measured by the 2.00% of fees if Financial Accuracy processed accurately. State's below 99% but at Measures the independent least 97%. 4.00% gross dollars paid auditor as part of of fees if less than incorrectly the annual claims 97%. (overpayments) audit. Criteria as plus defined by the underpayments) State's subtracted from independent total paid claim auditor. Measured dollars, divided by to two (2) decimal total paid claim places. dollars within the audit sample Claims Standards: 97% of claims w/ Measured by the 2.00% of fees if Payment Accuracy benefit payments are State's below 97% but at Measures the processed accurately. independent least 95%. 4.00% number of auditor as part of of fees if less than incorrect drafts of the annual claims 95%. payments made audit. Criteria as on behalf of the defined by the State, subtracted State's from the total independent draft or payments auditor. Measured transactions, to two (2) decimal
assumptions utilized to develop the projected costs. Disclosure of supporting data used in the calculations, including monthly paid claims and enrollment, large claims analysis, trend analysis, demographic analysis, etc. Substantiation of any proposed increase in fixed costs via a thorough analysis of activities and costs covered by those fees. Explanations for any unusual trend results (high relative to the market, low relative to the market). Claims Standards: Financial Accuracy Measures the gross dollars paid incorrectly (overpayments) plus underpayments) subtracted from total paid claim dollars, divided by total paid claim dollars within the audit sample 99% of claim dollars processed accurately. 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. 2.00% of fees if below 99% but at least 97%. 4.00% of fees if less than 97%. Claims Standards: Payment Accuracy Measures the number of incorrect drafts of payments made on behalf of the State, subtracted from the total draft or payments transactions, 97% of claims w/ benefit payments are processed accurately. 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 2.00% of fees if below 97% but at least 95%. 4.00% of fees if less than 95%.
F10B3400022-AttachmentS-PPO-SF.docx