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

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, Medi-Cal Community Health Plan of Imperial Valley 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, Medi-Cal Community Health Plan of Imperial Valley 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, 

UM Reopens

Quarterly

15th of the month following the end of the quarter

UM

Medicare (HMO-H0562, SAP-H3561),  Commercial, Medi-Cal, Medi-Cal CalViva, Medi-Cal Community Health Plan of Imperial Valley and Medi-Cal Molina

UM Work Plan

Annually
Semi-annual
Quarterly

All LOB Initial - Annual: February 15
MCR & COMM - Semi-annual:  August 15 Medi-Cal, Medi-Cal Molina and CalViva  - Quarterly: Last day of the month following the end of the quarter

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

Medicare (HMO-H0562, SAP-H3561

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 Community Health Plan of Imperial Valley and 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 Community Health Plan of Imperial Valley and 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).