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 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
- Appeals by Reason Type
- Appeals Elevated to State Fair Hearing
- 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 Standard Appeals within 30 Calendar Days
- Services Authorized within 72 Hours Following a Reversed Appeal
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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 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 Prior Authorizations Requests By Behavioral Health and Non-Behavioral Health Therapeutic Drug Classes
- Pharmacy Service Authorization Timely Determination Rate
- Timely Member Notification of the Termination, Suspension or Reduction of Services
- Timely Notification of Adverse Standard/Routine Service Authorization Decisions
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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): 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): A. Age 12-24 Months
- Children and Adolescents’ Access to Primary Care Practitioners (CAP): B. Age 25 Months - 6 Years
- Children and Adolescents’ Access to Primary Care Practitioners (CAP): C. Age 7-11 Years
- Children and Adolescents’ Access to Primary Care Practitioners (CAP): D. Age 12-19 Years
- Comprehensive Diabetes Care (CDC): Blood Pressure Control (<140/90 mm Hg)
- Comprehensive Diabetes Care (CDC): Eye Exam
- Comprehensive Diabetes Care (CDC): HbA1c Control (<8.0%)
- Comprehensive Diabetes Care (CDC): HbA1c Poor Control (>9.0%)
- Comprehensive Diabetes Care (CDC): HbA1c Testing
- Comprehensive Diabetes Care (CDC, Hybrid Specification): Blood Pressure Controlled <140/90 mm Hg
- Comprehensive Diabetes Care (CDC, Hybrid Specification): Medical Attention for Nephropathy
- Comprehensive Diabetes Care (CDC): Medical Attention for Nephropathy
- Controlling High Blood Pressure (CBP)
- Disease-Modifying Anti-Rheumatic Drug Therapy in 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 Emergency Department Visit for Alcohol and Other Drug Dependence (FUA) Within 07 days
- Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA) within 30 days
- Follow-up After Emergency Department Visit for Mental Illness (FUM) Within 07 days
- Follow-up After Emergency Department Visit for Mental Illness (FUM) Within 30 days
- Follow-Up After Hospitalization for Mental Illness (FUH) Within 07 Days
- Follow-Up After Hospitalization for Mental Illness (FUH) Within 30 Days
- 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)
- Adult BMI Assessment (ABA)
- Breast Cancer Screening (BCS)
- Cervical Cancer Screening (CCS)
- Childhood Immunization Status (CIS): Combination 10
- Childhood Immunization Status (CIS): Combination 2
- Childhood Immunization Status (CIS): Combination 3
- Childhood Immunization Status (CIS): Combination 4
- Childhood Immunization Status (CIS): Combination 5
- Childhood Immunization Status (CIS): Combination 6
- Childhood Immunization Status (CIS): Combination 7
- Childhood Immunization Status (CIS): Combination 8
- Childhood Immunization Status (CIS): Combination 9
- Chlamydia Screening in Women (CHL)
- Frequency of Ongoing Prenatal Care (FPC, Hybrid Specification): 81+ Percent
- Human Papillomavirus Vaccine for Adolescents (HPV)
- Immunizations for Adolescents (IMA): Combination 1
- Immunizations for Adolescents (IMA): Combination 2
- Immunizations for Adolescents (IMA): Meningococcal Vaccine
- Immunizations for Adolescents (IMA): 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): Postpartum Care
- Prenatal and Postpartum Care (PPC): 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 (SPD): Received Statin Therapy
- Statin Therapy for Patients With Diabetes (SPD): Statin Adherence 80%
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC): Counseling for Nutrition
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC): Counseling for Physical Activity
- Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC): Evidence of BMI Percentile Documentation
- Well-Child Visits in the First 15 Months of Life (W15): 6 or More Visits
- Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)
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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 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
- 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 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 Other Providers (non-Physician/APRN) per Average Members by County
- 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
- Quality Assessment: Referral to Case Management for All Newborns With a Diagnosis of Neonatal Abstinence Syndrome
- 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
- Member Requests for Assistance Accessing Other Providers (non-Physician/APRN) per Average Members by County
- Requests for Assistance Accessing MCO Designated Primary Care Providers by County
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Non-Emergent Medical Transportation (NEMT)
- NEMT Request Authorization Approvals by Mode of Transportation
- NEMT Requests Delivered by Mode of Transportation
- NEMT Requests Delivered by Type of Medical Service
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Provider Services
- Average Pharmacy Claim Processing Time
- 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: 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 Professional and Facility Medical Claim Processing
- Timely Professional and Facility Medical Claim Processing: Sixty Days of Receipt