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		Dental General Anesthesia	Quarterly		15th of the month following the end of the quarter
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		15th of the month following the end of the quarter
Claims		Medi-Cal	Claims Settlement Practice Report - MCAL		Quarterly		15th of the month following the end of the quarter
Claims		Medi-Cal	Timeliness Summary Reports - MCAL		Quarterly		15th calendar day of the following month after each quarter end.
Claims		Medi-Cal CalViva	Claims Settlement Practice Report - CALV		Quarterly		15th of the month following the end of the quarter
Claims		Medi-Cal CalViva	Provider Dispute Summary Report - CALV		Quarterly		15th of the month following the end of the quarter
Claims		Medi-Cal CalViva	Timeliness Summary Reports - CALV		Quarterly		15th calendar day of the following month after each quarter end.
Claims		Medi-Cal Molina	Claims Settlement Practice Report - MOLN		Quarterly		15th of the month following the end of the quarter
Claims		Medi-Cal Molina	Provider Dispute Summary Report - MOLN		Quarterly		15th of the month following the end of the quarter
Claims		Medi-Cal Molina	Timeliness Summary Reports - MOLN		Quarterly		15th 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).