State of New Jersey Department of Banking and Insurance

Transcription

1 I. MEMBER COMPLAINTS (As defined at N.J.A.C. 11:24-3.7) Instructions For purposes of the Annual Supplement, a "complaint" is defined as an expression of dissatisfaction with any aspect of the HMO's health care services, including, but not limited to, quality of care, provider choice and accessibility and network adequacy. Report the number of written and verbal complaints received from commercial members during the year in Table I (a). specific to behavioral health and substance abuse treatment should be reported separately. Follow the instructions below in completing the table: *Include complaints reported directly to an Organized Delivery System (ODS) if the ODS has responsibility for member complaints. * Do NOT include general inquires * Do NOT include utilization management appeals. The Department has included a column to capture complaints that initially appeared to be resolvable by Services but later determined to involve a question of medical necessity and subsequently forwarded to the UM appeal process. * Report a complaint only ONCE COMMERCIAL MEMBER COMPLAINTS Unresolved in Progress at Start of TABLE I (a) New During the * Resolved During the Percentage of Resolved within 30 days Unresolved at End of Forwarded to UM Appeal Process (except behavioral health & substance abuse treatment) % 29 0 Behavioral Health % 0 0 Substance Abuse Treatment % 0 0 * The number of complaints resolved should be the same in Table I (a) as in Tables I (b) and 1 (c). 28

2 I. MEMBER COMPLAINTS BY CATEGORY Report the number of commercial member complaints resolved during the year, by category. In completing Tables 1 (b) and (c), select the one category that most accurately reflects the nature of each resolved complaint, even when more than one category could be considered applicable. Number of Commercial Percentage of Commercial TABLE I (b) CATEGORIES OF MEMBER COMPLAINTS Categories of Appointment Availability - PCP Appointment Availability - Specialist Appointment Availability - Other Type of Provider Waiting Time Too Long at Office - PCP Waiting Time Too Long at Office - Specialist Dissatisfaction with Quality of Medical Care - PCP Dissatisfaction with Quality of Medical Care - Specialist Dissatisfaction with Quality of Medical Care - Hospital Dissatisfaction with Quality of Medical Care - Other Type of Provider Difficulty in Obtaining Access to a Health Care Professional After Hours Difficulty Related to Obtaining Emergency Services 1 0.2% Dissatisfaction with Dental Services 3 0.5% Dissatisfaction with Vision Services 5 0.8% Dissatisfaction with Ancillary Services (Home Health, DME, Therapy, etc.) 5 0.8% Dissatisfaction with Plan Benefit Design Dissatisfaction with Provider Office Administration % Dissatisfaction with Marketing, Services, Handbook, etc % Dissatisfaction with Utilization Management Process Denial of Clinical Treatment for Covered Service 6 0.9% Dissatisfaction with Provider Network Difficulty in Obtaining Referrals to Network Specialist of 's Choice Difficulty in Obtaining Referrals for Ancillary Services (Home Health, DME, etc.) Difficulty in Obtaining Referrals for Covered Services - Eye Care Difficulty in Obtaining Referrals for Covered Services - Dental Services Difficulty with Plan Policies Regarding Specialty Referrals 1 0.2% Laboratory Issues % Pharmacy/Formulary Issues % Reimbursement Problems/Unpaid Claims % Referral or Authorization Not Obtained 2 0.3% Not Covered at Time of Service 4 0.6% Service Not Covered % Timeliness of Notification to HMO % Other (Administrative Billing) % Total number of commercial member complaints resolved during the year* *The number of complaints resolved should be the same in Table I (a) and (b). 29

3 I. MEMBER COMPLAINTS BY CATEGORY BEHAVIORAL HEALTH AND SUBSTANCE ABUSE TREATMENT Report the number of commercial member complaints concerning behavioral health and substance abuse treatment services resolved during the year by category. In completing the Table, select the one category that most accurately reflects the nature of each resolved complaint, even if more than one category could be considered applicable. TABLE I (c) CATEGORIES OF BEHAVIORAL HEALTH & SUBSTANCE ABUSE TREATMENT SERVICES COMPLAINTS Commercial Behavioral Health Commercial Substance Abuse Treatment Categories of Number Percent Number Percent Appointment Availability - Psychologist Appointment Availability - Psychiatrist % Appointment Availability - Other Type of Provider Waiting Time Too Long at Office 1 7.7% 0 N/A Dissatisfaction with Quality of Medical Care - Inpatient % Dissatisfaction with Quality of Medical Care - Other Type of Provider Difficulty in Obtaining Access to a Health Care Professional After Hours Difficulty Related to Obtaining Emergency Services 1 7.7% Dissatisfaction with Plan Benefit Design Dissatisfaction with Provider Office Administration Dissatisfaction with Marketing, Services or Handbook Dissatisfaction with Utilization Management Appeal Process Dissatisfaction with Provider Network 1 7.7% Difficulty in Obtaining Referral to Network Specialist of 's Choice Difficulty in Obtaining Referral for Covered Services Difficulty with Plan Policies Regarding Specialty Referrals Pharmacy/Formulary Issues % Reimbursement Problems/Unpaid Claims Administrative Denials % Referral or Authorization Not Obtained Not Covered at Time of Service 1 7.7% Service Not Covered Timeliness of Notification to HMO % Other (Define) % 1 *Total number of commercial member complaints resolved during 100% the year * The number of complaints resolved should be the same as reported in Table I (a) and (c). 30

4 J. PROVIDER COMPLAINTS (As defined at N.J.A.C. 11:24-3.7) Complete the following tables for all written and verbal complaints received from HMO providers. 1. Report the number of provider complaints in the table below: Unresolved in Progress at Start of NUMBER OF PROVIDER COMPLAINTS New During the * Resolved During the Unresolved at End of Report the number of complaints resolved during the year by category in the table below: CATEGORIES OF PROVIDER COMPLAINTS Percentage of Categories of % Claim issues (reimbursement, timeliness, resubmission) - PCP 1.5% Claim issues (reimbursement, timeliness, resubmission) - Specialist 8.8% Claim issues (reimbursement, timeliness, resubmission) - Hospital 29.4% Claim issues (reimbursement, timeliness, resubmission) - Other Provider 2.0% Complexity of Administrative Process Difficulty Obtaining Prompt Authorization for Needed Medical Services 0.5% Credentialing/Recredentialing Termination Dissatisfaction with Provider Manual Dissatisfaction with Responsiveness of Provider Services 1.0% Dissatisfaction with UM Appeal Process/Medical Mgmt. Guidelines 5.4% Dissatisfaction with Provider Network Coordination of Benefits Other (Define) Out-of-network provider not satisfied with reimbursement rate 33.3% offered for single case agreement 100% *Total number of complaints resolved during the year *The number of complaints resolved should be the same in both tables. 31

5 State of New Jersey M. (i) UTILIZATION OF INPATIENT SERVICES BY MEMBERSHIP Type of Inpatient Admission* To Facility** Total Inpatient Admissions To Non- Facility Total Admissions To Facility** To Non- Facility Total Admissions Denied In Facility (a) In Non- Facility (b) Total Days (a) +(b) Per 1,000 s Per Average Length of Stay In Facility (c) In Non- Facility (d) 1. Hospital A. Medical/Surgical 1, , , , B. Obstetrical (Maternity) , , C. Newborns*** , , D. Behavioral Health Excluding Substance Abuse , E. Substance Abuse F. Comprehensive Rehab G. All Other (Define) Other Facilities A. Skilled Nursing Facility B. Comprehensive Rehab C. Psychiatric Hospitals D. Residential/Substance Abuse E. All Other (Define) Total 2, , ,342 2,104 13, Note: Days hospitalized should be total days before coordination of benefits. Commercial Table Total Inpatient Admissions Denied ** A contracting facility is one that has a written contract with the HMO to provide services for a specified fee or capitation. *** Newborn days should be reported separately from the mother's days, regardless of hospital billing procedure. Total Inpatient Days Note: Report only HMO and HMO POS members. * Primary discharge diagnosis only. If more than one health condition is treated during the hospital stay, the plan should determine the one condition considered to be primary with respect to the hospitalization and report the case accordingly. Total Inpatient Days Denied Total Days Denied (c) +(d) 33

6 N. INTERNAL UTILIZATION MANAGEMENT APPEAL PROCESS - (as defined at N.J.A.C. 11:24-8) 1. Submit a description of the two-stage internal Utilization Management Appeal Process followed by the HMO and any subcontractors responsible for appeals. Additionally, submit a copy of the denial letters issued by the HMO and subcontractor after a Stage I and Stage II denial. The following tables are to be used for reporting denials or limitations of any covered service appealed through the internal utilization management appeals process by commercial members or providers acting on behalf of the member with the member's consent. Separate tables have been provided for reporting appeals of formulary, behavioral health and substance abuse (BH/SA) treatment denials. TABLE I NUMBER OF STAGE I AND STAGE II COMMERCIAL APPEALS (Exclude formulary and BH/SA appeals) in Progress at Start of in Progress at Start of New Stage I During the the in Progress at End of New Stage II During the the in Progress at End of Report the resolution of all completed Stage I and Stage II appeals below: TABLE II: RESOLUTION OF STAGE I AND II COMMERCIAL APPEALS Stage I Stage I Forwarded to Stage II % 0 Stage II % 35

7 State of New Jersey N. INTERNAL UTILIZATION MANAGEMENT APPEALS BY CATEGORY Report the number of completed Stage I and Stage II appeals, by category, below: Stage I % TABLE III: CATEGORIES OF STAGE I AND ll COMMERCIAL APPEALS Stage II % Categories of % Denial of inpatient admissions % % Denial of inpatient hospital days % 2 5.6% Reduction of acuity level (inpatient) % Denial of surgical procedure Denial of emergency services % % Denial of outpatient medical treatment/diagnostic testing 6 1.6% % Denial of outpatient rehabilitation therapy (PT, OT, Speech, Cardiac, etc.) Denial of home health care Denial of hospice care 1 0.3% Denial of skilled nursing facility % % Denial of medical equipment (DME) and/or supplies 1 0.3% Denial of referral to out of network specialist 8 2.2% % Denial of a covered medication 6 1.6% 1 2.8% Service not a covered benefit Service considered experimental/investigational Service considered cosmetic, not medically necessary 7 1.9% 3 8.3% Service considered dental, not medically necessary % 2 5.6% Other (Define): Laboratory; Patient Education; Transportation % % Total Resolved 36

8 OXFORD HEALTH PLANS (NJ), Inc. N. UTILIZATION MANAGEMENT APPEAL PROCESS Report the number of Stage I and Stage II formulary appeals filed by commercial members or by providers acting on behalf of commercial members with the member's consent below: STAGE I AND II COMMERCIAL FORMULARY APPEALS New Stage I During the in Progress at Start of in Progress at Start of TABLE I the In Progress at End of New Stage II During the the In Progress at End of TABLE II: RESOLUTION OF STAGE 1 AND STAGE II FORMULARY APPEALS Stage I Formulary % 0 Stage II Formulary % TABLE III Forwarded to Stage II NUMBER OF EXTERNAL APPEALS Cases Under Review by IURO at Start of IURO Decisions Received by Plan During the Cases Remaining Under Review by IURO at End of RESOLUTION OF EXTERNAL APPEALS IURO DECISION* Denial Upheld Denial Reversed Denial Modified

9 N. INTERNAL UTILIZATION MANAGEMENT APPEAL PROCESS 1. Report the number of Stage I and Stage II appeals of behavioral health services filed by commercial members or by providers acting on behalf of commercial members with the member's consent in the table below: NUMBER OF COMMERCIAL BEHAVIORAL HEALTH APPEALS New Stage I During the in Progress at Start of in Progress at Start of TABLE I the In Progress at End of New Stage II During the the In Progress at End of Report the outcome of all Stage I and Stage II appeals completed during the year in the table below: TABLE II RESOLUTION OF COMMERCIAL BEHAVIORAL HEALTH APPEALS Stage I % 3 Stage II % Forwarded to Stage II 3. If the two-stage internal Utilization Management Appeal Process is in any way different than the Utilization Management appeal process described earlier, attach a description of the process and a copy of the denial letters issued after a Stage I and Stage II denial. Please identify any stage of the appeal process delegated to a subcontractor. 38

10 N. INTERNAL UTILIZATION MANAGEMENT APPEALS PROCESS Report the number of Stage I and Stage II appeals of substance abuse treatment services filed by commercial members or by providers acting on behalf of commercial members with the member's consent in the table below: TABLE I NUMBER OF SUBSTANCE ABUSE TREATMENT SERVICES APPEALS New in Stage I In Progress at Start of During the Progress at End of the New Stage II During the in Progress at Start of the In Progress at End of TABLE II RESOLUTION OF SUBSTANCE ABUSE TREATMENT APPEALS Stage I % 1 Stage II % Forwarded to Stage II 39

11 State of New Jersey Department of Health and Senior Services N. INTERNAL UTILIZATION MANAGEMENT APPEALS BY CATEGORY Behavioral Health and Substance Abuse Treatment Report the number of Completed Stage I and Stage II appeals, by category, in the table below: Behavioral Health Stage I Behavioral Health Stage II Substance Abuse Stage I TABLE III Substance Abuse Stage II Number % Number % Number % Number % Categories of Behavioral Health and Substance Abuse Treatment Services % % Denial of inpatient admissions % % Denial of inpatient hospital days % % % % Reduction of acuity level Denial of emergency services % % Denial of referral to out-of-network specialist Service not a covered benefit % Other (Define): % 3 100% 8 100% 1 100% Total Resolved 40

12 O. EXTERNAL UTILIZATION MANAGEMENT APPEAL PROCESS Complete the following tables for all external appeals reviewed by the IURO: TABLE I Cases Under Review by IURO at Start of NUMBER OF EXTERNAL APPEALS IURO Decisions Received by Plan During the Cases Remaining Under Review by IURO at End of RESOLUTION OF EXTERNAL APPEALS IURO DECISION* Denial Upheld Denial Reversed Denial Modified TABLE II CATEGORIES OF EXTERNAL APPEALS % Categories of 16.7% Denial of inpatient admissions Denial of inpatient hospital days Reduction of acuity level 8.3% Denial of surgical procedure Denial of emergency services 25.0% Denial of outpatient medical treatment/diagnostic testing Denial of outpatient rehabilitation therapy (PT, OT, Cardiac, Speech, etc.) Denial of home health care Denial of hospice care Denial of skilled nursing facility Denial of medical equipment (DME) and/or supplies Denial of referral to out of network specialist Denial of a covered medication 16.7% Service not a covered benefit Service considered experimental/investigational Service considered cosmetic, not medically necessary 8.3% Service considered dental, not medically necessary 25.0% Other (MH/SA) 100% * Total Received * Number should be the same as Table I 41