DRAFT Suggested Example Performance Measures for NC Medicaid Administration Shading Indicates PED Suggestion

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1 DRAFT Suggested Performance s for NC Medicaid Administration 1 2 Expectation Potentially Eligible Population Eligibility Determinations Made Performance (Not Exclusive) and percentage distribution of categories of individuals estimated as potentially eligible and percentage of individuals with eligibility made by type including application, transfer or redetermination Eligibility Determinations Made Individuals Determined Eligible *Data Driven Eligibility Determinations *Share of Eligibility Determinations Made with Little or No Time Elapsed of individuals with eligibility as a percentage of estimated potentiallly eligible population by category (annual) compared to of individuals determined eligible by type including application, transfer or redetermination and percentage of eligibility completed without the need for the submission of documentation by the applicant 6 7 Individuals Ineligible for Eligibility Reasons Individuals Ineligible for Procedural Reasons of individuals denied for failing to meet eligibility criteria (by reason) within the of individuals denied for failing to meet procedural criteria (by reason) within the 8 Rate of Timely Eligibility Determination and percentage of eligibility made within the that were completed within 5 days, 10 days, 30 days High degree of customer satisfaction with application and enrollment experience Average Time to Process (# of days from application receipt date to eligibility determination date for applications with eligibility made within the divided by applications with eligibility made within the ) Total Enrollment Total Disenrollment Individuals Disenrolled for Procedural Reasons Individuals Disenrolled for Eligibility Reasons Internal Churn Rate Beneficiary Application and Enrollment Satisfaction Rate Average time to determine eligibility, by type of application (including transfers) of individuals eligible on the 1st of the of individuals with eligibility ending within the, by reason (including, e.g., at time of redetermination) and percentage of individuals disenrolled for failing to meet procedural criteria by reason, including transfer by and percentage of individuals disenrolled for failing to meet eligibility criteria by reason, including transfer by of disenrolled beneficiaries reenrolling within 6 s Percentage of individuals surveyed rating their application and enrollment experience very good compared to and percentage of eligibility decisions ed (mediated and unmediated) Page 1 of 4

2 DRAFT Suggested Performance s for NC Medicaid Administration Expectation Performance (Not Exclusive) and percentage of mediated s *resolved *impasse *no show *withdrawn Average cost per mediated 19 and percentage of eligibility decision unmediated s (handled by Office of Hearings) 20 and percentage of unmediated s decided for State compared to 21 Average cost per unmediated Accurate Transfer Rate Average cost per mediated as percentage of cost per unmediated Percentage of individuals transferred to Medicaid, CHIP, or the Exchange, as applicable, who are determined eligible by that agency 24 Cost effective application and enrollment processes Cost per Application Average administrative cost per application 25 2-Defining the scope of covered benefits Assurance of legislative intent Periodic review of State plan covered benefits Date of last annual review of total scope of covered benefits including stakeholder input and recommendations to Governor and General Assembly Setting provider and plan payment rates Assurance of cost effectiveness Periodic review of provider and State plan payment rates New Provider Applications New Providers Enrolled Average Provider Application Time Processing Average Provider Application Time Processing Date of latest annual review of plan payment rates including stakeholder input and including recommendations to Governor and General Assembly of provider applications received within the and percentage of provider applications received within the whose application for enrollment was accepted Average processing time for provider applications ( of days from receipt of provider application to application adjudication for all applications adjudicated within the divided by the number of applications adjudicated within the ) Average processing time for provider applications Providers Terminated Enrolled Providers Billing Providers of who were terminated from participation within the (by reason) of with at least one day of enrollment in the program during the and percentage of with one paid claim in the Page 2 of 4

3 DRAFT Suggested Performance s for NC Medicaid Administration 34 Expectation Inactive Providers Performance (Not Exclusive) Percentage of who are inactive ( of eligible to bill with no paid claims in the last 12 s divided by the number of eligible to bill with at least one day of enrollment in the program during the ) Average Days to Pay Claims Average Days to Pay 90 percent of Claims Average Days to Pay 99 percent of Claims Accounts Payable Aging of Accounts Payable Timely Payment of Public Provider Claims Settlements Pending Audit Average number of days to pay ( of days from receipt of clean claims adjudicated divided by the number of claims adjudicated) Average number of days to achieve adjudication of 90% of clean claims (excluding the 10% of claims with the largest number of days to adjudicate, number of days from receipt of clean claims adjudicated divided by the number of clean claims adjudicated) Average number of days to achieve adjudication of 99% of clean claims (excluding the 1% of claims with the largest number of days to adjudicate, number of days from receipt of clean claims adjudicated divided by number of clean claims adjudicated) Dollar value of provider accounts payable (GAAP basis) by and as of June 30 Dollar value of provider accounts payable (GAAP basis) by and as of June 30 representing payables overdue by 60, 90, 120, and over 120 days Dollar value of provider accounts subject to claims settlement (10% withheld pending DMA audit) categorized by Fiscal Year that claims were made High degree of customer satisfaction with enrollment and claims payment experience Accurate payment to Accurate payment to Cost effective claims processing Improved of care Provider Enrollment and Claims Payment Satisfaction Rate First Pass Resolve Rate Denial Rate cost per claim Improvement in of care for children based on core child indicators Percentage of satisfied with enrollment and claims payment experience (annual) compared to ( of rating their experience very good divided by number of surveyed) Percentage of claims adjudicated on the provider s first submission ( of claims adjudicated on the first submission divided by number of claims adjudicated) Percentage of clean claims denied (number of claims denied divided by number of clean claims adjudicated) Average administrative cost per claim (administrative cost divided by number of claims processed) and percentage of eligible children receiving core child service procedures at the recommended frequency (e.g.screens, vaccinations) Page 3 of 4

4 DRAFT Suggested Performance s for NC Medicaid Administration Expectation Improved of care Improved of care Improvement in of care for adults based on core adult indicators Reduction in health disparities based on key disparity indicators Investigations initiated Amount collected Performance (Not Exclusive) and percentage of adult recipients receiving core services and procedures at the reommended frequency (e.g. screens, vaccinations) and percentage of recipients who did not receive or delayed getting medical care due to cost in the past 12 s of investigations opened per Total amount collected through program Integrity or Third Party vendors and as a percentage of amount originally owed Investigations closure rate Recovery rate Providers suspension rate Closure rate of investigations ( of investigations initiatiated divided by number of investigations completed) Amount recovered per closed investigation and as percentage of amount originally owed of referred or suspended per 53 8-Processing s Timely hearings and s Hearings and s made Percentage of Medicaid recipients or requesting hearing or Notifications made Percentage of notifications of hearings 54 8-Processing s Timely hearings and s and s made within 10 days Final administrative action made Percentage of hearings with final 55 8-Processing s Timely hearings and s administrative action within 90 days Corrective action taken Percentage of cases requiring agency to 56 8-Processing s Timely corrective action take corrective action of required reports to State and 57 Timely and accurate reporting of required reports federal government Timely and accurate reporting Timely reports Timely and accurate reporting Accurate reports and percentage of required reports submitted by date required and percentage of required reports requiring resubmission for deficiencies Page 4 of 4

5 Suggested Performance s for Medicaid Administration Sorted by of

6 DRAFT Suggested Performance s for NC Medicaid Administration 2 Expectation Eligibility Determinations Made Performance (Not Exclusive) and percentage of individuals with eligibility made by type including application, transfer or redetermination 4 Individuals Determined Eligible of individuals determined eligible by type including application, transfer or redetermination 6 Individuals Ineligible for Eligibility Reasons of individuals denied for failing to meet eligibility criteria (by reason) within the 7 Individuals Ineligible for Procedural Reasons of individuals denied for failing to meet procedural criteria (by reason) within the 12 Individuals Disenrolled for Procedural Reasons and percentage of individuals disenrolled for failing to meet procedural criteria by reason, including transfer by 13 Individuals Disenrolled for Eligibility Reasons and percentage of individuals disenrolled for failing to meet eligibility criteria by reason, including transfer by 16 and percentage of eligibility decisions ed (mediated and unmediated) 17 and percentage of mediated s *resolved *impasse *no show *withdrawn 19 and percentage of eligibility decision unmediated s (handled by Office of Hearings) 25 2-Defining the scope of covered benefits Assurance of legislative intent Periodic review of State plan covered benefits Date of last annual review of total scope of covered benefits including stakeholder input and recommendations to Governor and General Assembly 26 3-Setting provider and plan payment rates Assurance of cost effectiveness Periodic review of provider and State plan payment rates Date of latest annual review of plan payment rates including stakeholder input and including recommendations to Governor and General Assembly 27 New Provider Applications of provider applications received within the 28 New Providers Enrolled and percentage of provider applications received within the whose application for enrollment was accepted 31 Providers Terminated of who were terminated from participation within the (by reason) Page 1 of 5

7 DRAFT Suggested Performance s for NC Medicaid Administration Expectation Billing Providers Performance (Not Exclusive) and percentage of with one paid claim in the Investigations initiated of investigations opened per Providers suspension rate of referred or suspended per 8-Processing s Timely hearings and s Hearings and s made requesting hearing or 53 Percentage of Medicaid recipients or 57 Timely and accurate reporting of required reports of required reports to State and federal government 3 Eligibility Determinations Made of individuals with eligibility as a percentage of estimated potentiallly eligible population by category (annual) compared to 5 *Data Driven Eligibility Determinations *Share of Eligibility Determinations Made with Little or No Time Elapsed and percentage of eligibility completed without the need for the submission of documentation by the applicant 8 Rate of Timely Eligibility Determination and percentage of eligibility made within the that were completed within 5 days, 10 days, 30 days 15 High degree of customer satisfaction with application and enrollment experience Beneficiary Application and Enrollment Satisfaction Rate Percentage of individuals surveyed rating their application and enrollment experience very good compared to 20 and percentage of unmediated s decided for State compared to 23 Accurate Transfer Rate Percentage of individuals transferred to Medicaid, CHIP, or the Exchange, as applicable, who are determined eligible by that agency 39 Aging of Accounts Payable Dollar value of provider accounts payable (GAAP basis) by and as of June 30 representing payables overdue by 60, 90, 120, and over 120 days 41 High degree of customer satisfaction with enrollment and claims payment experience Provider Enrollment and Claims Payment Satisfaction Rate Percentage of satisfied with enrollment and claims payment experience (annual) compared to ( of rating their experience very good divided by number of surveyed) Page 2 of 5

8 DRAFT Suggested Performance s for NC Medicaid Administration 45 Expectation Improved of care Improvement in of care for children based on core child indicators Performance (Not Exclusive) and percentage of eligible children receiving core child service procedures at the recommended frequency (e.g.screens, vaccinations) 46 Improved of care Improvement in of care for adults based on core adult indicators and percentage of adult recipients receiving core services and procedures at the reommended frequency (e.g. screens, vaccinations) 47 Improved of care Reduction in health disparities based on key disparity indicators and percentage of recipients who did not receive or delayed getting medical care due to cost in the past 12 s 49 Amount collected Total amount collected through program Integrity or Third Party vendors and as a percentage of amount originally owed 51 Recovery rate Amount recovered per closed investigation and as percentage of amount originally owed 56 8-Processing s Timely corrective action Corrective action taken Percentage of cases requiring agency to take corrective action 58 Timely and accurate reporting Timely reports and percentage of required reports submitted by date required 59 Timely and accurate reporting Accurate reports and percentage of required reports requiring resubmission for deficiencies 1 Potentially Eligible Population and percentage distribution of categories of individuals estimated as potentially eligible Total Enrollment Total Disenrollment of individuals eligible on the 1st of the of individuals with eligibility ending within the, by reason (including, e.g., at time of redetermination) 32 Enrolled Providers of with at least one day of enrollment in the program during the 34 Inactive Providers Percentage of who are inactive ( of eligible to bill with no paid claims in the last 12 s divided by the number of eligible to bill with at least one day of enrollment in the program during the ) 38 Accounts Payable Dollar value of provider accounts payable (GAAP basis) by and as of June 30 Page 3 of 5

9 DRAFT Suggested Performance s for NC Medicaid Administration 43 Expectation Accurate payment to Denial Rate Performance (Not Exclusive) Percentage of clean claims denied (number of claims denied divided by number of clean claims adjudicated) 9 Average Time to Process (# of days from application receipt date to eligibility determination date for applications with eligibility made within the divided by applications with eligibility made within the ) Average time to determine eligibility, by type of application (including transfers) 14 Internal Churn Rate of disenrolled beneficiaries reenrolling within 6 s 18 Average cost per mediated 21 Average cost per unmediated 22 Average cost per mediated as percentage of cost per unmediated 24 Cost effective application and enrollment processes Cost per Application Average administrative cost per application 29 Average Provider Application Time Processing Average processing time for provider applications ( of days from receipt of provider application to application adjudication for all applications adjudicated within the divided by the number of applications adjudicated within the ) 30 Average Provider Application Time Processing Average processing time for provider applications 35 Average Days to Pay Claims Average number of days to pay ( of days from receipt of clean claims adjudicated divided by the number of claims adjudicated) 36 Average Days to Pay 90 percent of Claims Average number of days to achieve adjudication of 90% of clean claims (excluding the 10% of claims with the largest number of days to adjudicate, number of days from receipt of clean claims adjudicated divided by the number of clean claims adjudicated) Page 4 of 5

10 DRAFT Suggested Performance s for NC Medicaid Administration 37 Expectation Average Days to Pay 99 percent of Claims Performance (Not Exclusive) Average number of days to achieve adjudication of 99% of clean claims (excluding the 1% of claims with the largest number of days to adjudicate, number of days from receipt of clean claims adjudicated divided by number of clean claims adjudicated) 40 Timely Payment of Public Provider Claims Settlements Pending Audit Dollar value of provider accounts subject to claims settlement (10% withheld pending DMA audit) categorized by Fiscal Year that claims were made 42 Accurate payment to First Pass Resolve Rate Percentage of claims adjudicated on the provider s first submission ( of claims adjudicated on the first submission divided by number of claims adjudicated) 44 Cost effective claims processing cost per claim Average administrative cost per claim (administrative cost divided by number of claims processed) 50 Investigations closure rate Closure rate of investigations ( of investigations initiatiated divided by number of investigations completed) 54 8-Processing s Timely hearings and s Notifications made and s made within 10 days Percentage of notifications of hearings 55 8-Processing s Timely hearings and s Final administrative action made Percentage of hearings with final administrative action within 90 days Page 5 of 5