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Organizational Determinations Reporting Requirement

Provider Type

  • Participating Physician Groups (PPG)

Participating physician groups (PPGs) and hospitals must submit data to the plan on a quarterly basis regarding total number of organization determination made in reporting time period, number of organization determinations processed timely, favorable, partial and adverse organizational determinations withdrawn organization determinations, reopened decisions for all Medicare members. Variance explanations are required. The plan is required to submit an aggregate report of data from all delegated entities to the Centers for Medicare and Medicaid Services (CMS) on a quarterly basis.

The recommended Excel file template, ICE Standardized ICE Reporting Document, Medicare Advantage Part C Reporting UM Determination spreadsheet, can be obtained from the Industry Collaborative Effort (ICE) website at www.iceforhealth.org/library.asp > APPROVED ICE DOCUMENTS > QI / UM Team - Main > Part C Reporting Documents.

Reporting Elements

Providers must include all total number of organization determination made in reporting time period, number of organization determinations processed timely, fully favorable, partially favorable, denied organizational determinations, withdrawn determinations, and any reopens not related to post-service claim determinations. This includes determinations based on medical necessity and benefit determinations, as well as eligibility denials. Include data for only the members being reported.

Reports may be sent in monthly; however, one aggregated report must be sent in quarterly.

Clinical Data Information

The Standardized Reporting spreadsheet provides instructions for completing specific elements of the report. Refer to the worksheet or tab labeled Instructions for field parameters and explanations. In general:

  • The plan recommends all reports be submitted using the excel workbook titled Standardized Reporting spreadsheet
  • Each month's data reporting is for decisions made during that month
  • Report only member' data
  • Provide monthly totals for each of the three months within the quarter (for example, January, February and March) for the number of decisions made regarding requests for services, in the following categories:
    • Total number of organization determination made in reporting time period
    • Number of organization determinations processed timely
    • Fully favorable determinations
    • Partially favorable determinations
    • Adverse (denials) determinations
    • Withdrawals
    • Reopens
  • Do not submit line-item details, only total numbers for each month or quarter, based on date of decision for approval or denial of services.
  • Report all reopen cases on a separate tab of the spreadsheet titled Reopen Data

Deadline for Submission

Providers must submit reports at the beginning of each new quarter; Health Net must receive reports no later than the 15th day of the month following the close of each quarter. This enables the plan to process utilization management (UM) decisions data for all delegated PPGs and submit an aggregate report to CMS. Reporting for each month is based on the date of the decision for approval or denial of services.

On an annual basis, the reporting submission deadlines are as follows:

Quarters

Provider Submission Deadline to Health Net

Health Net Submission to CMS

First

April 15

May 31

Second

July 15

August 31

Third

October 15

November 30

Fourth

January 15

February 28

Submit the Excel file to the Delegation Oversight Department via email at provider.oversight@healthnet.com.

Last Updated: 11/19/2019