Calendar of Required PPG Submissions

Provider Type

Participating Physician Groups (PPG)

Documents to be Submitted	Due Date
Financial Statements (Annually Audited)	150 days after close of fiscal year
Financial Statements (Quarterly Updates)	45 days after close of quarter
Monthly Encounter Data Submission	Within 30 days of end of month of service

Delegated Service		LOB Detail	Report Description	Frequency	Due Date
UM		Complex Case Management (COM, MCL, MCR)	Complex Case Management Report	Quarterly	15th of the month following the end of the quarter
UM		Cal MediConnect (H3237)	CA 3.2 CMC Care Coordinator Training	Annually	January 15, 2023
UM		Cal MediConnect (H3237)	Core 5.1 CMC Care Coordinator to Member Ratio	Annually	January 15, 2023
UM		Cal MediConnect (H3237)	MMP Standard and Expedited Service Authorization Requests (M_SAR)	Monthly	15th calendar day of the following month
UM		Commercial	UM Authorization Source Data - COMM	Monthly	15th calendar day of the following month
UM		Commercial	Specialty Referral Access Timeliness - COMM	Quarterly	15th of the month following the end of the quarter
UM		Special Needs Plan - Dual & Chronic	Special Needs Plan MOC Report - Case Management	Monthly	15th calendar day of the following month
UM		Medi-Cal, Medi-Cal CalViva and Medi-Cal Molina	UM Authorization Source Data - MCAL, MOLN, CALV	Monthly	15th calendar day of the following month
UM		Medi-Cal, Medi-Cal CalViva and Medi-Cal Molina	Specialty Referral Access Timeliness - MCAL, MOLN, CALV	Quarterly	15th of the month following the end of the quarter
UM		Medicare (HMO-H0562, SAP-H3561)	Standard and Expedited Organization Determinations (OD)	Monthly	15th calendar day of the following month
UM		Medicare (HMO-H0562, SAP-H3561, Cal MediConnect (H3237)	UM Reopens	Quarterly	15th of the month following the end of the quarter
UM		Medicare (HMO-H0562, SAP-H3561), Cal MediConnect, Commercial, Medi-Cal, Medi-Cal CalViva and Medi-Cal Molina	UM Work Plan	Annually Semi-annual Quarterly	All LOB Initial - Annual: February 15 MCR & COMM - Semi-annual: August 15and February 15 Cal MediConnect, Medi-Cal, Medi-Cal Molina and CalViva - Quarterly: Last day of the month following the end of the quarter
UM		Cal MediConnect (H3237)	CMC Case Management Report	Monthly	15th calendar day of the following month
Claims	Medicare (HMO-H0562, SAP-H3561)		Provider Dispute Organization Determinations - MCR	Monthly		15th calendar day of the following month
Claims	Medicare (HMO-H0562, SAP-H3561)		Organization Determinations Claims - MCR	Monthly		15th calendar day of the following month
Claims	Cal MediConnect (H3237)		Organization Determinations Claims- SARAG	Monthly		15th calendar day of the following month
Claims	Medicare (HMO-H0562, SAP-H3561,Cal MediConnect (H3237)		Claims Reopens	Quarterly		15th of the month following the end of the quarter
Claims	Commercial		AB72 IDRP Delegated Contact List	Annually		31-Oct-22
Claims	Commercial		Claims Organization Determinations- COMM	Monthly		15th calendar day of the following month
Claims	Commercial		Provider Disputes Organization Determinations - COMM	Monthly		15th calendar day of the following month
Claims	Commercial		Federal Employee Health Benefit Program (FEHBP) Claim Reports	Semi-annual		Semi-annual - April 1 and October 1
Claims	Commercial		Provider Dispute Summary Report - COMM	Quarterly		15th of the month following the end of the quarter
Claims	Commercial		Claims Settlement Practice Report - COMM	Quarterly		15th of the month following the end of the quarter
Claims	Commercial		Timeliness Summary Reports - COMM	Quarterly		15th calendar day of the following month after each quarter end.
Claims	Medi-Cal, Medi-Cal_CalViva, Medi-Cal_Molina		Claims Organization Determinations - MCAL, CALV, MOLN	Monthly		15th calendar day of the following month
Claims	Medi-Cal, Medi-Cal_CalViva, Medi-Cal_Molina		Provider Disputes Organization Determinations - MCAL, CALV, MOLN	Monthly		15th calendar day of the following month
Claims	Medi-Cal		Provider Dispute Summary Report - MCAL	Quarterly		30th of the month following the end of the quarter
Claims	Medi-Cal		Claims Settlement Practice Report - MCAL	Quarterly		30th of the month following the end of the quarter
Claims	Medi-Cal		Timeliness Summary Reports - MCAL	Quarterly		30th calendar day of the following month after each quarter end.
Claims	Medi-Cal CalViva		Claims Settlement Practice Report - CALV	Quarterly		30th of the month following the end of the quarter
Claims	Medi-Cal CalViva		Provider Dispute Summary Report - CALV	Quarterly		30th of the month following the end of the quarter
Claims	Medi-Cal CalViva		Timeliness Summary Reports - CALV	Quarterly		30th calendar day of the following month after each quarter end.
Claims	Medi-Cal Molina		Claims Settlement Practice Report - MOLN	Quarterly		30th of the month following the end of the quarter
Claims	Medi-Cal Molina		Provider Dispute Summary Report - MOLN	Quarterly		30th of the month following the end of the quarter
Claims	Medi-Cal Molina		Timeliness Summary Reports - MOLN	Quarterly		30th calendar day of the following month after each quarter end.
Claims	ALL LOBs		Notification - Change of Principal Officer	As applicable		Immediate upon change of officer
Credentialing	Medi-Cal		Credentialing Report	Quarterly		15th of the month following the end of the quarter.
Credentialing	Commercial Medicare		Credentialing Report	Semi-annual		February 15 August 15

Organization Determinations

If a participating physician groups (PPGs) or hospitals is delegated for Utilization Management (UM) they must submit monthly to the plan (delegation oversight team) the complete Organization Determination (OD) template provided by the plan, for each line of business, that includes all authorizations that a determination was completed in the previous month.

If a PPGs or hospitals is delegated for Claim processing they must submit monthly to the plan (delegation oversight team) the complete OD template and for each line of business that includes all claims (received and claims in addition where a determination was made in the previous month. Additionally, quarterly a summary report should be submitted for processed claims and disputes using the MTR, PDR & STML form posted on the Industry Collaborative Effort (ICE).

For UM & Claims the Plan is required to submit to Centers for Medicare and Medicaid Services (CMS) aggregates quarterly and annually from all delegated entities. Additionally for claims data is submitted quarterly and annually to Department of Managed Health Care (DMHC).

Reporting Elements & Submission

All reporting elements including instruction, data dictionary and template are included in the template workbook provided by the plan.

All reports should be submitted through the SFTP access granted to the PPG users responsible for reporting.

The plan does delegate responsibility for complex case management to those providers with a dual-risk contract who meet the requirement as delineated by the National Committee for Quality Assurance (NCQA). Although the plan does not delegate responsibility for QI functions, all PPGs are required to participate in and cooperate with QI activities, including Healthcare Effectiveness Data and Information Set (HEDIS^®), access surveys, disease management, and other quality initiatives.

To access the current year UM/QI report templates, workplans and instruction, visit the Industry Collaboration Effort (ICE).