Calendar of Required PPG Submissions
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 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, | 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 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_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).