divided by the places. total draft or payment transactions. Claims Standards: 95% of all claims are Measured by the 3.00% of fees if Processing Time adjudicated within 10 State's performance is business days; and 98% independent less than of all claims are auditor as part of standards. 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 One-half of a Unit and eligibility data claims and eligibility receipt by the Point for each to third party data to third party third-party vendor calendar day the vendors. vendors in the format and verification of data is not and frequency required completeness of received or is by the applicable required incomplete. 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 State. 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. Employee Satisfactory or better Survey results 1% of fees if Satisfaction – results from an annual performance is Frequency of Satisfactory State-conducted less than report: Annually Participant satisfaction standards survey. Time over which standard is measured: Annual 90% of members
divided by the total draft or payment transactions. 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 standards. Provision of claims and eligibility data to third 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. One-half of a Unit Point 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 State. 3.00% of fees if performance is less than standards. Employee Satisfaction – Satisfactory Satisfactory or better results from an annual State-conducted Participant satisfaction survey. Time over which standard is measured: Annual 90% of members Survey results Frequency of report: Annually 1% of fees if performance is less than standards
F10B3400022-AttachmentS-PPO-SF.docx