Care Management Program
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Care Coordination | Grievances and Appeals | Health Services Management - Standard Medicaid | HEDIS Acute and Chronic Care Measures | HEDIS Preventive Care Measures | Member Experience of Care - Adults | Member Experience of Care - Children | Member Services | Network Adequacy | Non-Emergent Medical Transportation (NEMT) | Provider Services▲ Back to top
Care Coordination
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Grievances and Appeals
- Grievance Dispositions Made Within 45 Calendar Days
- Member Appeals Received
- Member Grievances Received
- Resolution of All Appeals within 45 Calendar Days
- Resolution of Appeals by Disposition Type
- Resolution of Expedited Appeals within 72 Hours
- Resolution of Extended Standard Appeals within 44 Calendar Days
- Resolution of Provider Appeals within 30 Calendar Days
- Resolution of Standard Appeals within 30 Calendar Days
- Services Authorized within 72 Hours Following a Reversed Appeal
- Timely Processing of All Grievances, By Grievance Type
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Health Services Management - Standard Medicaid
- Medical Service, Equipment and Supply Post-Delivery Service Authorization Timely Determination Rate
- Medical Service, Equipment and Supply Service Authorization Timely Determination Rate: New Routine Requests
- Medical Service, Equipment and Supply Service Authorization Timely Determination Rate: Urgent Requests
- Pharmacy Service Authorization Timely Determination Rate
- Service Authorization Denials for Waiver & Non-HCBC Waiver Populations
- Service Authorizations: Physical, Occupational & Speech Therapy Service Authorization Denials by Waiver & Non-HCBC Waiver Populations
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HEDIS Acute and Chronic Care Measures
- Comprehensive Diabetes Care (CDC, Hybrid Specification): Blood Pressure Controlled <140/90 mm Hg
- Comprehensive Diabetes Care (CDC, Hybrid Specification): Medical Attention for Nephropathy
- Lead Screening
- Medication Management for People With Asthma (MMA): Medication Compliance 50%
- Medication Management for People With Asthma (MMA): Medication Compliance 75%
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HEDIS Preventive Care Measures
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Member Experience of Care - Adults
- Adult CAHPS®: Aware Can Make a Complaint To Health Plan About Care or Services Received or Decisions Made
- Adult CAHPS®: Customer Service Provided Information or Help: Usually or Always
- Adult CAHPS®: Customer Service Treated Member with Courtesy and Respect: Usually or Always
- Adult CAHPS®: Days to Get Appointment For Check-up or Routine Care
- Adult CAHPS®: Days to Get Appointment When Care Needed Right Away
- Adult CAHPS®: Doctor or Other Health Provider Talked About What Member Thought was Best for Themselves When Discussing Medicine
- Adult CAHPS®: Doctor or Other Health Provider Talked with Member About Reasons Member Might Not Want to Take a Medicine
- Adult CAHPS®: Doctor or Other Health Provider Talked With Member About Reasons Member Might Want to Take a Medicine
- Adult CAHPS®: Doctor or Other Health Provider Talked with Member about Specific Things the Member Could do to Prevent Illness
- Adult CAHPS®: Ease In Getting Care, Tests, and Treatment: Usually or Always
- Adult CAHPS®: Ease in Getting Special Medical Equipment: Usually or Always
- Adult CAHPS®: Ease in Getting Treatment or Counseling: Usually or Always
- Adult CAHPS®: Feel Comfortable Speaking To Doctor or Other Health Provider About Personal or Family Problems with Alcohol or Other Drugs
- Adult CAHPS®: Flu Vaccinations for Adults Ages 18 - 64 (FVA)
- Adult CAHPS®: Getting Appointment to See Specialist as Soon as Needed: Usually or Always
- Adult CAHPS®: Getting Needed Care from a Doctor's Office or Clinic During Evenings, Weekends, or Holidays - Usually or Always
- Adult CAHPS®: Getting Needed Care Right Away - Usually or Always
- Adult CAHPS®: Getting Routine or Check-up Appointments as Soon as They Were Needed: Usually or Always
- Adult CAHPS®: Heath Plan Forms Easy to Fill Out: Usually or Always
- Adult CAHPS®: In The Last 6 Months, Needed Treatment or Counseling For An Alcohol or Drug Problem But Didn’t Get It
- Adult CAHPS®: Member Got Care from a Doctor or Other Health Provider Besides Their Personal Doctor
- Adult CAHPS®: Member Rating of Overall Health - Very Good or Excellent
- Adult CAHPS®: Member Rating of Overall Mental or Emotional Health - Very Good or Excellent
- Adult CAHPS®: Members Reporting a Condition or Problem Lasting at Least 3 months for which They Received Health Care 3 or More Times in the Last 6 Months.
- Adult CAHPS®: Number of Specialists Seen
- Adult CAHPS®: Number of Visits to Personal Doctor
- Adult CAHPS®: Percent of Adults Reporting a Condition or Problem Lasting at Least 3 months for which They Need or Take Medicine Prescribed by a Doctor.
- Adult CAHPS®: Percent of Adults Reporting Now Needing or Taking Medicine Prescribed by a Doctor
- Adult CAHPS®: Personal Doctor Asked About Feeling Sad, Empty, or Depressed
- Adult CAHPS®: Personal Doctor Explained Things in a Way That Was Easy to Understand: Usually or Always
- Adult CAHPS®: Personal Doctor Listened Carefully: Usually or Always
- Adult CAHPS®: Personal Doctor Provided Help Needed to Manage Care Among Different Providers and Services - Usually or Always
- Adult CAHPS®: Personal Doctor Showed Respect: Usually or Always
- Adult CAHPS®: Personal Doctor Spent Enough time with Member: Usually or Always
- Adult CAHPS®: Personal Doctor Up-to-Date about Care from other Doctors or Health Providers: Usually or Always
- Adult CAHPS®: Provider had Medical Records About Care - Usually or Always
- Adult CAHPS®: Rating of Health Care - 8, 9 or 10
- Adult CAHPS®: Rating of Health Plan: 8, 9, or 10
- Adult CAHPS®: Rating of Personal Doctor - 8, 9 or 10
- Adult CAHPS®: Rating of Specialist Seen Most Often - 8, 9 or 10
- Adult CAHPS®: Reason Why Did Not Get the Treatment or Counseling for an Alcohol or Drug Problem Needed
- Adult CAHPS®: Written Materials or Internet Provide Information Needed about How Health Plan Works: Usually or Always
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Member Experience of Care - Children
- Child CAHPS®: Care Coordination for More than One Kind of Health Care Provider or Service
- Child CAHPS®: Caregiver Aware of Health Plan Complaint Process
- Child CAHPS®: Child Able to Talk with Doctors about His or Her Health Care
- Child CAHPS®: Child Got Care from a Doctor or Other Health Provider Besides Their Personal Doctor
- Child CAHPS®: Child has Emotional, Developmental, or Behavioral Problem for which they Need/Get Treatment or Counseling
- Child CAHPS®: Child Limited or Prevented in Ability to do Things Most Children of Same Age Can Do
- Child CAHPS®: Child Needs/Gets Special Therapy (e.g., Physical, Occupational, or Speech)
- Child CAHPS®: Child Needs/Uses More Health Care than Usual for Children of Same Age
- Child CAHPS®: Child Needs/Uses Prescribed Medicine Due Health Condition
- Child CAHPS®: Child's Health Plan, Doctor's Office, or Clinic Helped Get Prescription Medicines for Child
- Child CAHPS®: Child's Health Plan, Doctor's Office, or Clinic Helped Get Special Medical Equipment or Devices for Child
- Child CAHPS®: Child's Health Plan, Doctor's Office, or Clinic Helped Get Special Therapy for Child
- Child CAHPS®: Child's Health Plan, Doctor's Office, or Clinic Helped Get Treatment or Counseling for Child
- Child CAHPS®: Child's Personal Doctor Understands How Health Conditions Affect Child's Day-to-Day Life
- Child CAHPS®: Child's Personal Doctor Understands How Health Conditions Affect Child's Family's Day-to-Day Life
- Child CAHPS®: Customer Service Provided Information or Help: Usually or Always
- Child CAHPS®: Customer Service Treated Caregiver with Courtesy and Respect: Usually or Always
- Child CAHPS®: Days to Get Appointment For Check-up or Routine Care
- Child CAHPS®: Days to Get Appointment When Care Needed Right Away
- Child CAHPS®: Doctor/Other Health Provider Talked About What Caregiver Thought was Best for Child When Discussing Medicine
- Child CAHPS®: Doctor/Other Health Provider Talked with Caregiver About Reasons Caregiver Might Not Want Child to Take Medicine
- Child CAHPS®: Doctor/Other Health Provider Talked With Caregiver About Reasons Caregiver Might Want Child to Take Medicine
- Child CAHPS®: Doctor/Other Health Provider Talked with Caregiver about Specific Things Caregiver Could do to Prevent Illness for Child
- Child CAHPS®: Ease In Getting Care, Tests, and Treatment- Usually or Always
- Child CAHPS®: Ease in Getting Prescription Medicines for Child - Usually or Always
- Child CAHPS®: Ease in Getting Special Medical Equipment or Devices for their Child - Usually or Always
- Child CAHPS®: Ease in Getting Special Therapy for their Child - Usually or Always
- Child CAHPS®: Ease in Getting Treatment or Counseling for their Child - Usually or Always
- Child CAHPS®: Getting Appointment to See Specialist as Soon as Needed: Usually or Always
- Child CAHPS®: Getting Needed Care from a Doctor's Office or Clinic During Evenings, Weekends, or Holidays - Usually or Always
- Child CAHPS®: Getting Needed Care Right Away - Usually or Always
- Child CAHPS®: Getting Questions Answered by Child's Doctors or Other Health Providers - Usually or Always
- Child CAHPS®: Getting Routine or Check-up Appointments as Soon as They Were Needed: Usually or Always
- Child CAHPS®: Got Help Needed From Child's Doctors or Other Health Providers to Contact Child's School or Daycare
- Child CAHPS®: Heath Plan Forms Easy to Fill Out: Usually or Always
- Child CAHPS®: Member Rating of Overall Health - Very Good or Excellent
- Child CAHPS®: Member Rating of Overall Mental or Emotional Health - Very Good or Excellent
- Child CAHPS®: Needed Child's Doctors or Other Health Providers to Contact Child's School or Daycare
- Child CAHPS®: Number of Specialists Seen
- Child CAHPS®: Number of Visits to Personal Doctor
- Child CAHPS®: Personal Doctor Explained Things in a Way That Was Easy for Child to Understand: Usually or Always
- Child CAHPS®: Personal Doctor Explained Things in a Way That Was Easy to Understand: Usually or Always
- Child CAHPS®: Personal Doctor Had Medical Records or Other Information About Child's Care - Usually or Always
- Child CAHPS®: Personal Doctor Listened Carefully: Usually or Always
- Child CAHPS®: Personal Doctor Showed Respect: Usually or Always
- Child CAHPS®: Personal Doctor Spent Enough time with Child: Usually or Always
- Child CAHPS®: Personal Doctor Talked with Caregiver about How Child is Feeling, Growing, or Behaving
- Child CAHPS®: Personal Doctor Up-to-Date about Child's Care from other Doctors or Health Providers: Usually or Always
- Child CAHPS®: Rating of Health Care - 8, 9 or 10
- Child CAHPS®: Rating of Health Plan: 8, 9, or 10
- Child CAHPS®: Rating of Personal Doctor - 8, 9 or 10
- Child CAHPS®: Rating of Specialist Seen Most Often - 8, 9 or 10
- Child CAHPS®: Satisfaction with Help Received to Coordinate Child's Care - Satisfied or Very Satisfied
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Member Services
- Family and Friends Program NEMT Rides
- Member Communications: Calls Abandoned
- Member Communications: Calls Returned by the Next Business Day
- Member Communications: Reasons for Telephone Inquiries
- Member Communications: Speed to Answer Within 30 Seconds
- NEMT Request Authorization Approvals by Mode of Transportation
- NEMT Requests Delivered by Mode of Transportation
- NEMT Requests Delivered by Type of Medical Service
- New Member Health Needs Assessment – Best Effort to Conduct a Health Needs Assessment
- New Member Health Needs Assessment - MCO Successfully Completed HNA
- Non-Emergent Medical Transportation Contracted Transportation & Wheelchair Van Provider Scheduled Trip Member Cancellations by Reason for Member Cancellation for Contracted Providers
- Requests for Assistance Accessing MCO Designated Primary Care Providers by County
- Requests for Assistance Accessing Physician/APRN Specialists (non-MCO Designated) by County
- Results of Scheduled NEMT Trips by Outcome
- Timeliness of Scheduled and Delivered NEMT Trips
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Network Adequacy
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Non-Emergent Medical Transportation (NEMT)
- Family and Friends Program NEMT Rides
- NEMT Request Authorization Approvals by Mode of Transportation
- NEMT Requests Delivered by Mode of Transportation
- NEMT Requests Delivered by Type of Medical Service
- Results of Scheduled NEMT Trips by Outcome
- Timeliness of Scheduled and Delivered NEMT Trips
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Provider Services
- Average Pharmacy Claim Processing Time
- Claims Quality Assurance: Claims Financial Accuracy
- Claims Quality Assurance: Claims Payment Accuracy
- Claims Quality Assurance: Claims Processing Accuracy
- Interest Paid on Late Paid Claims
- Non-Emergent Medical Transportation Claims Quality Assurance: Claims Processing Accuracy
- Non-Emergent Medical Transportation Timely Claims Processing
- Professional and Facility Medical Claim Processing Results
- Provider Communications: Calls Abandoned
- Provider Communications: Calls Returned by Next Business Day
- Provider Communications: Reasons for Telephone Inquiries
- Provider Communications: Speed to Answer within 30 Seconds
- Timely Processing of All Clean Provider Claims: Ninety Days of Receipt
- Timely Processing of All Clean Provider Claims: Thirty Days of Receipt
- Timely Processing of Electronic Provider Claims: Fifteen Days of Receipt
- Timely Processing of Non-Electronic Provider Claims: Thirty Days of Receipt
- Timely Professional and Facility Medical Claim Processing
- Timely Professional and Facility Medical Claim Processing: Sixty Days of Receipt