Md. Code Regs. 10.67.04.15

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.04.15 - Data Collection and Reporting

A. An MCO shall notify the Department immediately when it has knowledge of an enrollee's death.

B. Encounter Data.

(1) An MCO shall submit encounter data reflecting 100 percent of provider-enrollee encounters, in CMS1500 and UB04 format or an alternative format previously approved by the Department.

(2) An MCO may use alternative formats including:

(a) ASC X12N 837 and NCPDP formats; and

(b) ASC X12N 835 format, as appropriate.

(3) An MCO shall submit encounter data that identifies the provider who delivers any items or services to enrollees at a frequency and level of detail to be specified by CMS and the Department, including, at a minimum:

(a) Enrollee and provider identifying information;

(b) Service, procedure, and diagnoses codes;

(c) Allowed, paid, enrollee responsibility, and third-party liability amounts; and

(d) Service, claims submission, adjudication, and payment dates.

(4) An MCO shall report encounter data within 60 calendar days after receipt of the claim from the provider.

(5) An MCO shall submit encounter data utilizing a secure on-line data transfer system.

C. Monthly Reports.

(1) An MCO shall submit to the Department monthly a report detailing which primary care provider panels are accepting new patients to new enrollees.

(2) An MCO shall provide an updated list of the PCP's assigned enrollees to each PCP at least on a monthly basis.

D. Quarterly Reports. An MCO shall submit to the Department:

(1) Within 30 calendar days of the close of each calendar quarter, quality assurance reports including, but not limited to:

(a) Quality assurance committee meeting minutes reflecting major quality assurance corrective action plans, initiatives, and activities; and

(b) An analysis of recipient appeal and grievance logs including significant trends or anomalies, what caused the trend or anomaly, and any actions taken to address the trend or anomaly;

(2) Within 30 calendar days after the close of each calendar quarter, in the format specified by the Department, a list of all pre-service denials or reduction of services or benefits issued by the MCO or MCO subcontractors during the preceding quarter.

(3) Within 30 calendar days of the close of each calendar quarter, third-party liability collection activities as described in Regulation .18D of this chapter.

(4) In a format specified by the Department, amounts the MCO has cost-avoided and recovered and the number of cases the MCO has handled in each case area during the quarter.

(5) Not later than 45 days after the end of each quarterly rebate period, drug utilization data necessary for the Department to bill manufacturers for rebates in accordance with § 1927(b)(1) (A) of the Social Security Act, that:

(a) Include, at a minimum, the following information by National Drug Code of each covered outpatient drug dispensed or covered by the MCO:

(i) Total number of units of each dosage form;

(ii) Total number of units of each dosage strength; and

(iii) Total number of units of each dosage package size; and

(b) Distinguish utilization data for covered outpatient drugs that are subject to discounts under the 340B drug pricing program.

(6) Within 10 calendar days after the close of each calendar quarter, in the format specified by the Department, a list of all State fair hearing outcomes during the preceding quarter.

E. Annual Reports. Except as provided in §E(5) of this regulation, an MCO shall submit to the Department annually, within 90 days after the end of the calendar year:

(1) A summary of the information contained in §D(1)(b) of this regulation;

(2) A report of the MCO's consumer advisory board outlining the board's activities and recommendations;

(3) A copy of the MCO's drug formulary;

(4) Any revisions to the MCO's quality assurance, utilization management, and case management plans;

(5) HealthChoice Financial Monitoring Reports (HFMRs), including any supplemental schedules required by the Department:

(a) In the format required by the Department;

(b) Prepared according to:

(i) The criteria, set forth in Regulation .19-5 of this chapter, for allocating MCO costs to HFMR expense categories; and

(ii) Reporting instructions provided by the Department for the HFMR form and any required supplemental schedules; and

(c) Submitted according to the following schedule:

(i) Services incurred from January 1 through December 31 of the prior year, reported through March 31 of the current year - due on May 15 of the current year; and

(ii) Services incurred January 1 through December 31 of the prior year, reported through June 30 of the current year - due on September 1 of the current year; and

(6) A detailed description of its drug utilization program activities.

F. Unless the MCO is exempt for good cause, an MCO shall submit to the Department when requested the following reports for its enrollee/member services and provider/authorization/preauthorization lines:

(1) Caller abandonment rates;

(2) Caller service level rates; and

(3) Caller average hold time.

G. If the MCO exits the Health Choice Program for any reason, including those listed in COMAR 10.67.63.06A(1)(e) and (f):

(1) The MCO shall provide the Department with a list of enrollees and the name of each enrollee's PCP, at least 30 days before exiting the program; and

(2) On receiving the list provided by the MCO, the Department shall provide the list to:

(a) The health benefits exchange to assist and provide outreach to participants in selecting an MCO; and

(b) If permitted by State and federal law, the remaining MCOs for linking participants with a PCP.

H. Jurisdictional Reporting to Local Health Departments. The Department shall:

(1) Aggregate by jurisdiction the encounter data it receives from MCOs; and

(2) Provide to local health departments jurisdiction-specific information based on aggregated encounter data for public health monitoring and assessment.

I. For the purposes of Maryland Medicaid Managed Care Program administration or monitoring MCO performance pursuant to this chapter, the MCO shall supply other information as the Department may from time to time request, given a reasonable period of notice.

J. For the purposes of Maryland Medicaid Managed Care Program administration or monitoring MCO performance pursuant to this chapter, the MCO shall supply other information as the Department may from time to time request, given a reasonable period of notice.

J. Reporting to Local Departments of Social Services. An MCO shall provide, or ensure that its providers provide, the notice required by Regulations .11-1 and .11-2 of this chapter.

K. Upon request, an MCO whose member has disenrolled shall transfer historical utilization data to the member's new MCO in the timeframe and format specified by the Department.

Md. Code Regs. 10.67.04.15

Regulations .15 recodified from 10.09.65.15 effective 46:22 Md. R. 976, eff. 11/1/2019; amended effective 47:10 Md. R. 515, eff. 5/18/2020; amended effective 51:12 Md. R. 620, eff. 6/24/2024.