Care Management Program
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Care Coordination | Grievances and Appeals | Health Services Management - Standard Medicaid | HEDIS Acute and Chronic Care Measures | HEDIS Behavioral Health Care Measures | HEDIS Preventive Care Measures | Member Services | Network Adequacy | Provider Services▲ Back to top
Care Coordination
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Grievances and Appeals
- Appeals by Reason Type
- Appeals Elevated to State Fair Hearing
- Grievance Dispositions Made Within 45 Calendar Days
- 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 Standard Appeals Within 30 Calendar Days
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Health Services Management - Standard Medicaid
- Complex Diagnostic Radiology Authorization Timely (2 Day) Determination Rate: Routine Requests
- Medical Service, Equipment and Supply Post Delivery Service Authorization Timely (30 Day) Determination Rate
- Medical Service, Equipment and Supply Service Authorization Timely (14 Day) Determination Rate: New Routine Requests
- Medical Service, Equipment and Supply Service Authorization Timely Determination Rate: Continued/Extended Urgent Services
- Medical Service, Equipment and Supply Service Authorization Timely Determination Rate: Urgent Requests
- Pharmacy Prior Authorizations Requests By Behavioral Health and Non-Behavioral Health Therapeutic Drug Classes
- Pharmacy Service Authorization Timely Determination Rate
- Timeliness of Notice Delivery: Expedited Process
- Timeliness of Notice Delivery: Standard Service Authorization Denial
- Timeliness of Notice Delivery: Standard Service Authorization Denial With Extension
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HEDIS Acute and Chronic Care Measures
- Adults’ Access to Preventive/Ambulatory Health Services (AAP)
- Annual Monitoring for Patients on Persistent Medications (MPM): ACE Inhibitors or ARBs
- Annual Monitoring for Patients on Persistent Medications (MPM): Digoxin
- Annual Monitoring for Patients on Persistent Medications (MPM): Diuretics
- Appropriate Testing for Children With Pharyngitis (CWP)
- Appropriate Treatment for Children With Upper Respiratory Infection (URI)
- Asthma Medication Ratio (AMR)
- Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (AAB)
- Children and Adolescents’ Access to Primary Care Practitioners (CAP): Age 12-19 Years
- Children and Adolescents’ Access to Primary Care Practitioners (CAP): Age 12-24 Months
- Children and Adolescents’ Access to Primary Care Practitioners (CAP): Age 25 Months - 6 Years
- Children and Adolescents’ Access to Primary Care Practitioners (CAP): Age 7-11 Years
- Comprehensive Diabetes Care (CDC, Hybrid Specification): Blood Pressure Controlled <140/90 mm Hg
- Comprehensive Diabetes Care (CDC, Hybrid Specification): Eye Exam
- Comprehensive Diabetes Care (CDC, Hybrid Specification): HbA1c Control (<7.0%) for a Selected Population
- Comprehensive Diabetes Care (CDC, Hybrid Specification): HbA1c Control (<8.0%)
- Comprehensive Diabetes Care (CDC, Hybrid Specification): HbA1c Poor Control (>9.0%)
- Comprehensive Diabetes Care (CDC, Hybrid Specification): HbA1c Testing
- Comprehensive Diabetes Care (CDC, Hybrid Specification): Medical Attention for Nephropathy
- Controlling High Blood Pressure (CBP)
- Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART)
- Persistence of Beta-Blocker Treatment After a Heart Attack (PBH)
- Pharmacotherapy Management of COPD Exacerbation (PCE): Bronchodilator
- Pharmacotherapy Management of COPD Exacerbation (PCE): Systemic Corticosteroid
- Use of Imaging Studies for Low Back Pain (LBP)
- Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)
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HEDIS Behavioral Health Care Measures
- Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)
- Antidepressant Medication Management (AMM): Effective Acute Phase Treatment
- Antidepressant Medication Management (AMM): Effective Continuation Phase Treatment
- Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC)
- Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD)
- Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD)
- Follow-Up After Hospitalization for Mental Illness (FUH): 30-Day Follow-Up
- Follow-Up After Hospitalization for Mental Illness (FUH): 7-Day Follow-Up
- Follow-Up Care for Children Prescribed ADHD Medication (ADD): Continuation and Maintenance Phase
- Follow-Up Care for Children Prescribed ADHD Medication (ADD): Initiation Phase
- Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM)
- Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)
- Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)
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HEDIS Preventive Care Measures
- Adolescent Well-Care Visits (AWC, Hybrid Specification)
- Adult BMI Assessment (ABA, Administrative Specification)
- Adult BMI Assessment (ABA, Hybrid Specification)
- Cervical Cancer Screening (CCS, Hybrid Specification)
- Childhood Immunization Status (CIS, Hybrid Specification): Combination 10
- Childhood Immunization Status (CIS, Hybrid Specification): Combination 2
- Childhood Immunization Status (CIS, Hybrid Specification): DTaP
- Childhood Immunization Status (CIS, Hybrid Specification): Hepatitis A
- Childhood Immunization Status (CIS, Hybrid Specification): Hepatitis B
- Childhood Immunization Status (CIS, Hybrid Specification): HiB
- Childhood Immunization Status (CIS, Hybrid Specification): Influenza
- Childhood Immunization Status (CIS, Hybrid Specification): IPV
- Childhood Immunization Status (CIS, Hybrid Specification): MMR
- Childhood Immunization Status (CIS, Hybrid Specification): PCV
- Childhood Immunization Status (CIS, Hybrid Specification): Rotavirus
- Childhood Immunization Status (CIS, Hybrid Specification): VZV
- Chlamydia Screening in Women (CHL, Administrative Specification)
- Frequency of Ongoing Prenatal Care (FPC, Hybrid Specification): 81+ Percent
- Immunizations for Adolescents (IMA, Hybrid Specification): Combination 1
- Immunizations for Adolescents (IMA, Hybrid Specification): Meningococcal Vaccine
- Immunizations for Adolescents (IMA, Hybrid Specification): Tdap/Td Vaccine
- Medication Management for People With Asthma (MMA): Medication Compliance 50%
- Medication Management for People With Asthma (MMA): Medication Compliance 75%
- Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS)
- Prenatal and Postpartum Care (PPC, Hybrid Specification): Postpartum Care
- Prenatal and Postpartum Care (PPC, Hybrid Specification): Timeliness of Prenatal Care
- Statin Therapy for Patients With Cardiovascular Disease (SPC): Received Statin Therapy
- Statin Therapy for Patients With Cardiovascular Disease (SPC): Statin Adherence 80%
- Statin Therapy for Patients With Diabetes Disease (SPD): Received Statin Therapy
- Statin Therapy for Patients With Diabetes Disease (SPD): Statin Adherence 80%
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC, Hybrid Specification): Counseling for Nutrition
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC, Hybrid Specification): Counseling for Physical Activity
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC, Hybrid Specification): Evidence of BMI Percentile Documentation
- Well-Child Visits in the First 15 Months of Life (W15, Hybrid Specification): 6 or More Visits
- Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34, Hybrid Specification)
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Member Services
- Health Risk Assessment Completion for Higher Risk Populations
- Health Risk Assessment Completion Percentage
- Health Risk Assessment Quarterly Completions
- Member Communications: Calls Abandoned
- Member Communications: New Members Who Had a Successfully Completed New Member Welcome Call or Received at Least Three Welcome Call Attempts
- Member Communications: New Member Welcome Calls
- Member Communications: Reasons for Telephone Inquiries
- Member Communications: Speed to Answer Within 30 Seconds
- Member Communications: Voice Mails Returned by Next Business Day
- Member Communications: Warm Transfers to NH DHHS
- Member Requests for Assistance Accessing MCO Designated Primary Care Providers per Average Members by County
- Member Requests for Assistance Accessing MCO Designated Primary Care Providers per Average Members by Geographic Region - Excluding NHHPP Members
- Member Requests for Assistance Accessing Other Providers (non-Physician/APRN) per Average Members by County
- Member Requests for Assistance Accessing Other Providers (non-Physician/APRN) per Average Members by Geographic Region - Excluding NHHPP Members
- Member Requests for Assistance Accessing Physician/APRN Specialists (non-MCO Designated Primary Care) Providers per Average Members by County
- Member Requests for Assistance Accessing Physician/APRN Specialists (non-MCO Designated Primary Care) Providers per Average Members by Geographic Region - Excluding NHHPP Members
- New Member Health Needs Assessment – Best Effort to Conduct a Health Needs Assessment
- New Member Health Needs Assessment - MCO Successfully Completed HNA
- Non-Emergent Transportation Contracted Transportation & Wheelchair Van Provider Scheduled Trip Member Cancellations by Reason for Member Cancellation for Contracted Providers
- Non-Emergent Transportation Contracted Transportation & Wheelchair Van Provider Scheduled Trip Results by Outcome
- Non-Emergent Transportation Contracted Transportation & Wheelchair Van Provider Scheduled Trip Results by Outcome - Excluding NHHPP Members
- Non-Emergent Transportation Request Authorization Approval Rate by Mode of Transportation
- Non-Emergent Transportation Requests Delivered by Mode of Transportation
- Non-Emergent Transportation Requests Delivered by Type of Medical Service
- Quality Assessment: Referral to Case Management for All Newborns With a Diagnosis of Neonatal Abstinence Syndrome
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Network Adequacy
- Member Requests for Assistance Accessing MCO Designated Primary Care Providers per Average Members by County
- Member Requests for Assistance Accessing MCO Designated Primary Care Providers per Average Members by Geographic Region - Excluding NHHPP Members
- Member Requests for Assistance Accessing Other Providers (non-Physician/APRN) per Average Members by County
- Member Requests for Assistance Accessing Other Providers (non-Physician/APRN) per Average Members by Geographic Region - Excluding NHHPP Members
- Member Requests for Assistance Accessing Physician/APRN Specialists (non-MCO Designated Primary Care) Providers per Average Members by County
- Member Requests for Assistance Accessing Physician/APRN Specialists (non-MCO Designated Primary Care) Providers per Average Members by Geographic Region - Excluding NHHPP Members
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Provider Services
- Average Pharmacy Claim Processing Time
- Claims Quality Assurance: Claims Processing Accuracy
- Interest Paid on Late Paid Claims
- NEMT Timely Claims Processing
- Professional and Facility Medical Claim Processing Results
- Provider Communications: Calls Abandoned
- Provider Communications: Mean Call Time
- Provider Communications: Reasons for Telephone Inquiries
- Provider Communications: Speed to Answer Within 30 Seconds
- Provider Communications: Voice Mails Returned by Next Business Day
- Timely Pharmacy Claim Processing
- Timely Professional and Facility Medical Claim Processing
- Timely Professional and Facility Medical Claim Processing: Sixty Days of Receipt