113 SECTION Q – CLAIMS MANAGEMENT

113 SECTION Q – CLAIMS MANAGEMENT

114 Q.1

Part Two: Technical Proposal

Section Q: Claims Management

Section Q: Claims Management (Section §17 of RFP)

Q.1 Describe the capabilities of your claims management systems as it relates to each of the requirements as specified in Electronic Claims Management Functionality Section and the Adherence to Key Claims Management Standards Section. In your response explain whether and how your systems meet (or exceed) each of these requirements. Cite at least three examples from similar contracts.

For over 25 years, Aetna Better Health®’s affiliates have used their expansive expertise in the development and implementation of an IT infrastructure to improve the accessibility and quality of healthcare services for its covered populations, while controlling the program’s rate of cost increase. We benefit, in this endeavor, from the strategic alignment of IT resources with Aetna Medicaid, an Aetna Company (Aetna Medicaid). For example, while Aetna Better Health benefits – on one hand – from the backing of Aetna Medicaid’s considerable resources in hardware and network infrastructure support, we also count ourselves fortunate – on the other – for the unwavering support of Aetna Medicaid’s expertise in application support and configuration management. When combined, these systems bring Aetna Better Health every advantage one could expect from an IT infrastructure that is reliable, flexible, expandable, and designed to interface seamlessly with other systems. In this section, the systems and applications that support the major functional areas of Aetna Better Health are detailed, starting with the guiding principles that form the foundation of our IT infrastructure:

• Privacy and Security: To secure members’ Protected Health Information (PHI), a layered approach to security includes clearly delineated policies and procedures, employee training, comprehensive communications, hardening of physical systems, adherence to federal laws such as HIPAA and Louisiana specific requirements that are more stringent.

• Business Integration: Aetna Better Health’s IT systems have the ability to integrate and map data from disparate systems, inside and outside the company, and to utilize data mining tools to analyze and report Key Performance Indicators (KPI) to improve the quality of services.

• People: Aetna Better Health shares with Aetna Medicaid the mission of providing “value, integrity and compassion in healthcare management” through recruiting and retaining the most skilled and experienced IT personnel available and continuously training them on the most up-to-date technologies.

• Business Continuity: Even the best applications and systems are ineffectual if they are not available. To address this, Aetna Better Health has built redundancy into the IT infrastructure, communication services and environmental support systems. We have a 99.9% system availability record for our computer systems and applications.

• Scalability: Aetna Better Health will meet DHH’s changing needs by managing the network infrastructure, load-balancing server clusters and communications systems with the ability to grow rapidly without sacrificing availability.

This IT system will support our expansion from GSA A –to GSA B – to GSA C. The depth, reliability, scalability and flexibility of our IT system mean that Aetna Better Health will be able to accept and manage additional membership and providers without interruption or disruption to

Response to RFP No. 305PUR-DHHRFP-CCN-P-MVA for Geographic Service Areas A, B and C Section Q – Requirement §17

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our current members and providers. The Aetna Better Health management team and Aetna Medicaid IT team will work together to see that that our expansion activities are seamless and in accordance with our history of excellence in working with Medicaid programs across the nation.

Provider Payment Support Aetna Better Health and our affiliates paid 17,761,200 claims nationwide during calendar year 2010. This volume is possible because of our efficient systems, tools and processes.

Aetna Better Health offers our network providers a choice between receiving payment via Electronic Fund Transfer (EFT) or physical checks. The payment method is set to physical check by default, but any network provider wishing to activate EFT need only do the following:

• A network provider submits an EFT enrollment form to Aetna Better Health, indicating the desired bank routing and account numbers

• That information is then loaded into QNXT™, Aetna Better Health’s claims payment system, designating that applicant as an EFT network provider

• A test document, called a prenote, is then sent to the network provider’s bank to see that the routing and account numbers are accurate and functioning properly

• Upon notification of a successful test transaction, the network provider’s account is configured accordingly and EFT enabled

• When the network provider has a payment generated during the check run process, the payment is included in a secure electronic file that is then “held” for submission to the various banks and clearing houses for processing

• Upon approval of the check run by Aetna Better Health, physical checks are released for printing and mailing, while the EFT file is released to the designated financial institutions for processing

• Network providers receiving EFT receive a hard copy remittance via mail detailing the claims processed in a particular payment run, as well as a paper copy of what would have been a check indicating the EFT Check # and total dollars, thereby allowing them to post the payment accordingly

Any network provider wishing to discontinue EFT payments and return to payment by physical check need only contact the health plan in writing and claims personnel will discontinue EFT functionality on the indicated accounts accordingly.

Claims Adjudication At the heart of Aetna Better Health’s claims adjudication process lies QNXT™, a client/server based managed care information system with unmatched claims processing capabilities. Operating in a Microsoft Windows NT™ and SQL Server environment, this rules-based system – with its graphical user interface and relational database – allows users immediate access to real-time claims information. Since QNXT™ is based on a common operating system and database platform, a multitude of tools can be used to display, print and analyze information. Moreover, this information can be presented in both textual and graphical formats to enhance readability and review. The following paragraphs detail Aetna Better Health’s claims adjudication processes, our claims inventory and workflow management practices and the monitoring tools and audit trails in place to provide for the timely, accurate adjudication of claims.


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Manual and Automated Claims Processing Functions Electronic Claims Acquisition (Electronic Data Interface) To assist us in processing and paying claims efficiently, accurately and timely; and to best leverage QNXT™’s automated claims processing capabilities, Aetna Better Health encourages network providers to submit claims electronically. To facilitate electronic claims submission, we have developed business relationships with ten major clearinghouses, including Gateway EDI, Emdeon and SSI, among others. We receive EDI claims directly from these clearinghouses, process them through pre-import edits to see to the validity of the data, HIPAA compliance and member enrollment and then upload them into QNXT™ each business day. Within 24 hours of file receipt, we provide production reports and control totals to all trading partners to validate successful transactions and identify errors for correction and resubmission. Our Arizona affiliate, Mercy Care Plan (MCP) has received (from February 2010 and February 2011) 70.4 percent of total claims submissions via EDI. At the same time MCP’s EFT transactions rose to over 65 percent and that exceeded the minimum standard for Medicaid health plans in the state.

Manual Claims Acquisition (Paper) Network providers unable to submit claims via EDI can submit paper claims to Aetna Better Health’s designated post office box. Each business day, our imaging contractor, FutureVision, retrieves, opens and sorts the mail using our pre-defined criteria for either imaging and scanning or distribution directly to Aetna Better Health. FutureVision assigns each claim a unique reference number based on the date received and use it to track the claim throughout the entire adjudication process. FutureVision then converts the imaged data into an EDI ready format within 24 to 48 hours of receipt and forwards it to Aetna Better Health. Each business day, Aetna Better Health’s claims processing personnel upload that data into QNXT™ via EDI processing, where it is accessible to users with approved, secure access to claims information.

Importantly, FutureVision is unable to scan certain documents, including non-claim submissions (e.g., returned member/network provider mail, explanations of benefits, checks, medical records documentation) and certain paper claims (e.g., illegible claims or poor quality printed claims). FutureVision forwards these documents to Aetna Better Health’s Claims Administration Department, where they are sorted and distributed to the appropriate department(s). When claims-related, each document is immediately assigned a unique reference number, scanned, indexed for ready retrieval and keyed into QNXT™. Upon successful validation within both Aetna Better Health’s imaging system and QNXT™, the hard copy is shredded and disposed of in accordance with policy.

Claims Adjudication Processes Auto Adjudication Aetna Better Health’s IT Department runs batch processes on a daily basis against a comprehensive set of edits that we individually configure based on contractual and regulatory requirements. In 2010, our Arizona affiliate, Mercy Care Plan, auto adjudicated over 75 percent of claims without manual intervention. This rules-based system [QNXT™] allows for setting multiple edits to test claim validity and to determine if claims are paid or denied appropriately. These edits include, but are not limited to:

• Member eligibility

• Covered/non-covered services


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• Required documentation

• Services within the scope of the network provider’s practice

• Duplication of services

• Prior authorization

• Invalid procedure codes

• Services in excess of benefit limitations

• Services in excess of lifetime benefits

Based on these and other system edits, claims are systematically processed to either a pay, deny or pend status. Those marked “pay” or “deny” are processed in the course of Aetna Better Health’s weekly financial cycle, wherein we generate, print and mail payments and corresponding remittance advices to the submitting provider(s), including the minimum required data elements and HIPAA compliant remit comments. Remittance data is also available via AboveHealth®, Aetna Better Health’s secure provider Web portal and, by request, in HIPAA 835 format. In some instances, we also provide electronic remittance advices to providers that include all fields required for compliance with the HIPAA 835 format.

Ideally, all claims are “clean claims” and can be processed without the need for additional investigation or information from the service provider or third party. In those instances when a claim cannot be adjudicated as a result of insufficient information, the claim is marked “deny,” and returned to the submitting provider with an appropriate remit comment. When the claim is resubmitted with the required information, the original claim is then adjusted for payment per our adjudication rules.

Manual Adjudication of Pended Claims Aetna Better Health assigns a “pend” status to any claim requiring internal attention, such as provider verification, authorization, medical review and/or COB. These pended claims are sent to the appropriate department for research and resolution. For example, should a claim require review for outlier consideration, claims analysts will send the claim to the Medical Management Department, which will then make a determination as to whether the claim will be paid or denied. Once a determination is made, the claim is then sent back to Claims Administration for processing. Should a pended claim assigned to a department other than Claims remain unresolved beyond the required timeframe, the Claims Supervisor will contact the respective department to determine the cause.

In some instances, as in the case of a claim with an Explanation of Benefits attached, pended claims become the responsibility of our own claims analysts, who then manually adjudicate them using a comprehensive set of documented desktop procedures. Regardless of the department assigned, tracking tools and reports provide Claims Supervisors the means to monitor and control the process.

Claims Inventory and Workflow Management Aetna Better Health is committed to achieving the highest level of timeliness in the claims adjudication and payment process. This is accomplished through focused claims inventory and workflow management practices, data monitoring and analysis and management oversight.


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As mentioned above, we utilize a suite of tools, scheduled and ad hoc reports to monitor claim receipts, automated claims processing, manual claims adjudication and check and remittance advice production/distribution on a daily, weekly and monthly basis to provide timely claim payment. These tools and reports include, but are not limited to:

• Pended Claims Tool and Reports – Claims and other departments use the pended claims tool to track and manage claims that edit out of the auto adjudication process for manual review. Populated hourly, the tool presents claims counts and billed dollars by pend reason and claim age, with drill down capabilities to detailed information on each claim. The tool can sort and filter the data by claim age, claim type, claim form, network provider, and contract. Additionally, daily reports of pended claims inventory are generated for managerial or historical review.

• Unfinished Claims Tool and Reports – Claims and other departments use the unfinished claims tool to track and manage all claims that are in process, whether a system batch process or pended for manual review and adjudication. Populated hourly, the tool presents claims counts by process status and claim age, with drill down capabilities to detailed information on each claim. Reports can sort and filter by claim age, claim type, claim form, network provider, and contract. Additionally, daily reports of pended claims inventory are generated for managerial or historical review.

• Claims Payment Processing Reports – Finance and Information Technology Departments generate and monitor several process control reports to achieve timely and accurate network provider check and remittance advice production and distribution, whether by mail or electronic funds transfer/electronic remittance advice file. The reports reconcile, through each major process step, the claim counts and amounts from claims waiting payment to payment and remittance advice distribution.

• Claims Awaiting Payment Forecast – The Claims Department uses the claims awaiting payment forecast report to predict claims payment turnaround times based on current inventory and future check dates, initiating additional actions as necessary to achieve our claim payment timeliness regulatory requirements.

Monitored daily, Aetna Better Health’s Claims Management uses these and other tools and reports to proactively manage the claim workflow and our comprehensively trained personnel to achieve our claims timeliness requirements. If our reports reflect a less than favorable trend, such as during a period of unusual high claim receipts, Claims and other departments work aggressively to address our inventories. We immediately develop and implement action plans, which may include one or more of the following: staff overtime, workload balancing with other Aetna Better Health Medicaid managed care plans and Aetna Medicaid operations personnel, temporary personnel, or increase utilization of overflow vendors to assist with the reduction of claim inventories. Additionally, if claim receipt trends and forecasts indicate, Aetna Better Health’s Claims Department will hire and train additional claims personnel in anticipation of increased claim receipts.

On a daily, weekly and monthly basis, we utilize a suite of tools, scheduled and ad hoc reports, claims processing and results data and claims payment feedback from network providers to further support timely claim payment. These tools and reports include, but are not limited to:


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• Deny Analysis – The Claims Department uses the deny claims analysis tool to evaluate all deny status claims that are currently awaiting payment, identifying and investigating abnormal denial patterns. The tool presents claims counts for all claims in a deny status by network provider and denial reason, with drill down capabilities to detailed information on each claim.

• Denial Diagnostics – Claims and other departments use the denied claims analysis tool to evaluate denied claims, trending and evaluating the claims with their corresponding denial reason, investigating abnormal fluctuations or high levels of denied claims. The tool presents denied claims counts and billed amounts with denial reasons by network provider, contract and QNXT™ adjudication edit, with drill down capabilities to detailed information on each claim.

• Network Provider Inquiry Tracking – Claims and other departments use the network provider inquiry tracking tool to monitor, manage, and trend network providers claim inquiries, requests and complaints. The tool presents network provider call counts by network provider, reason, and age, with drill down capabilities to detailed information regarding the call and, when provided, the claim number.

Aetna Better Health’s Claims Department and other departments use these tools and reports to proactively manage and to improve our claims payments. If our reports indicate a claims payment issue, our Claims Department investigates and corrects the claim payment, either prior to the initial payment or post-payment. If the issue requires a systemic solution beyond the immediate actions of the Claims Department, an interim solution permitting claims payment is implemented whenever possible until the systemic issue is resolved.

Claims Adjudication Audit and Quality Review: Aetna Better Health adheres to the following standards with regard to claims accuracy:

• Procedural: 95 percent accuracy (determined by the number of claims processed correctly divided by the total number of claims)

• Payment: 98 percent accuracy (determined by the total number of claims paid without dollar errors divided by the total number of claims paid)

• Financial: 99 percent accuracy (determined by total claim dollars paid correctly divided by the total paid claim dollars)

To support these high standards, a random two percent of all adjudicated claims are reviewed on a daily basis. The Quality Review (QR) Unit within the Claims Department conducts all claim audits, using desktop procedures (desktop procedures are detailed instructions for the claims analyst) as their guide.

To further minimize the impact of inaccurate data, daily focused audits are conducted on all claims with billed charges equal to or greater than $50,000. Non-finalized claims with errors are pended for correction prior to the finance payment process. Finalized claim with identified errors are adjusted retrospectively.

New claims analysts have an increased amount of claim audits conducted over the course of their first month following training, starting at 100 percent and decreasing to the standard two percent if they meet the claims accuracy standards defined above.


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Aetna Better Health performs internal reviews of check payments on a weekly basis. A statistically valid sample of claims are selected and reviewed against the applicable network provider contract. In addition, Aetna Better Health performs a review of all high dollar claims and performs an audit for appropriate billing prior to the payment of the claims.

Overpayment and Underpayment of Claims Overpayment and underpayment of claims is identified through QNXT™ system edits; audit activities; and information received from network providers and members. When an overpaid/underpaid claim is identified, the claim is reversed or, reversed and reprocessed. The reversed or reprocessed claim is listed on the network provider’s remittance advice with a remark indicating that the claim (and the check) has been adjusted and the reason for the adjustment. Recouped amounts, if necessary, are credited to the specific claim in the network provider’s claim history; underpaid amounts are reimbursed to the network provider either via check or future remittance advice.

Remediation Process for Manual Adjudication Any claims analyst that fails to meet any of the accuracy levels (payment, procedural or financial) for a given month, receives a documented verbal coaching from the Supervisor. The employee is informed that their quality percentage has dropped below the acceptable rate and is given one month to show improvement. At the end of the month following notification, if there is no noticeable improvement, the employee is provided with a written quality improvement plan. This process can involve additional training and increased audit activity to see that the claims analyst is meeting the required accuracy standards. Failure of any claims analyst to improve substandard accuracy results in further disciplinary action, up to termination.

Remediation Process for Auto Adjudication System Issue Identification Forms (IIF) are submitted to the Business Application Management (BAM) Department for investigation of any suspected system issue. This department conducts a root cause analysis by performing the necessary research, validating the contract or source document against the current system configuration. If a setup issue is discovered, corrections are made and any incorrectly processed claims are identified via a query and forwarded back to the Claims Department for adjustment activities. If appropriate, BAM Department leadership will provide staff coaching and additional training, update the BAM training program, improve configuration methodologies and testing procedures and/or submit product enhancement requests to the TriZetto Group, designer of the QNXT™ application platform.

Management Oversight Aetna Better Health senior leadership reviews claim performance, on a regular basis, addressing any outstanding claim issues or trends as needed. This monitoring includes a weekly CFO review of claims awaiting payment and a monthly CEO review of the claims key indicator reports. Additionally, our operations management team meets weekly. This cross functional team includes Representatives from several disciplines, including network provider services, network provider information management, information technology, finance, claims, business application management and medical management. This meeting includes a standing agenda item for the review of claims inventories, claim payment forecasts, and action planning, when necessary, to achieve timely payment of claims. We have reviewed the claims timeliness standards for DHH and anticipate no problem meeting these requirements.


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Claims Performance Measures Aetna Better Health does not differentiate between in-network and out-of-network providers with regard to timeliness of claims payment requirements, holding us to the same performance standards for both. In- and out-of-network providers alike, we measure several claim key indicators, reporting our performance to DHH as required. This key indicator, as well as our respective performance with regard to each over the past 12 months has been stellar.

This outstanding performance speaks to the excellent service which DHH and Aetna Better Health members receive from Aetna Better Health and our operations personnel.

Related Claims Processing and Management Information System Functions Aetna Better Health maintains claims processing activities that include the application of comprehensive clinical and data related edits supporting the efficient, effective adjudication of claims. QNXT™, our core claims adjudication application, has data related edits configured within its software and is supplemented by two clinical claims editing solutions. The first of the two clinical claims editing solutions, iHealth Technologies’ (iHT) Integrated Claims Management Services (ICM Services), applies select payment policies from one of the industry’s most comprehensive correct coding and medical policy content libraries. The second, McKesson’s ClaimCheck®, expands upon those capabilities by enabling our claims management team to define and combine specific claims data criteria, such as provider or diagnosis, to set up unique edits that deliver enhanced auditing power.

The three applications utilize historic and “new day” claims information to detect questionable billing practices, such as new patient billing codes submitted by the same provider for the same member within a six month period. These applications also assist in identifying fraudulent and abusive billing patterns by generating reports that indicate trending and outliers of provider billing behavior. Inbound claims are initially checked for items such as member eligibility, covered services, excessive or unusual services for gender or age (e.g. “medically unlikely”), duplication of services, prior authorization, invalid procedure codes, and duplicate claims. Claims billed in excess of $50,000 are automatically pended for review, as are any requiring additional documentation (e.g. medical records) in order to determine the appropriateness of the service provided. Professional claims that reach an adjudicated status of “Pay” are automatically reviewed against nationally recognized standards such as the Correct Coding Initiative (CCI), medical policy requirements [e.g., American Medical Association (AMA)], and maximum unit requirements supplied by DHH, with recommendations applied during an automatic re-adjudication process. Other methodologies utilized throughout the auto-adjudication process include, but are not limited to, Multiple Surgical Reductions and Global Day E & M Bundling.

QNXT™ Data Edits QNXT™ has over 400 business rules that Aetna Better Health configures to support enforcement of our claims Policies and Procedures (P&Ps). The application of specific conditions, restrictions, and validation criteria promote the accuracy of claim processing against DHH standards. The edits can result in claims pending or denying depending on the editing logic. For example, if the member is not eligible on the date of service, QNXT™will automatically deny the claim. In the event that the category of service of the provider of record does not match the procedure code billed the claim will pend for manual review to validate accuracy of provider set-up.


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Examples of data edits specific to QNXT™ include the following:

Benefits Package Variations QNXT™ automatically analyzes CPT, REV, and HCPC codes to determine whether specific services are covered under the contract or benefit rules. If services are not covered, the system will automatically deny the respective claim line. The claim line will deny with the appropriate HIPAA remittance remark on the EOB.

Data Accuracy QNXT™ is continually updated based on the most current code sets available (HCPCS, REV, CPT codes) by year. As new codes are added, terminated, or changed, we update the codes in QNXT™ so the system is always in compliance with HIPAA standards. If a network provider bills a code that has been terminated, QNXT™ will deny the claim line and advise the provider the code is invalid via remittance advice.

Adherence to Prior Authorization Requirements QNXT™ is configured to enforce the supporting documentation requirements of certain services. In addition, QNXT™ has the ability to configure Prior Authorization (PA) by code, provider type, and place of service. QNXT™ is configured to automatically identify certain types of authorizations for medical director review. Claim edit rules are set to validate the claim against the network provider, member, dates of service, services rendered, and units authorized.

Provider Qualifications QNXT™ provider files are configured by specialty and category of service. This allows for the enforcement of categories of service and provider type on claims validation. Certain procedures can only be performed by select network provider types. For example, QNXT™ will not permit the processing of a claim for in-office heart surgery by a podiatrist. iHealth lends additional support in this regard, reviewing any claim line set to “Pay” for billing appropriateness by specialty. QNXT™ checks other provider-specific items as well, verifying, for example, that each provider has obtained the requisite National Provider Identifier (NPI) or its equivalent and included the identifier on all claims submissions.

Member Eligibility and Enrollment QNXT™ validates the date of service against the member’s enrollment segment to determine if the member was eligible on the date of service. If the member was not eligible on the date of service, the system will automatically deny the claim using the appropriate HIPAA approved remittance comment.

Duplicate Billing Logic QNXT™ uses a robust set of edits to determine duplication of services. Examples are same member, same date, same network provider, same service, or any combination of these criteria. In addition, claim lines set to “Pay” are subjected to iHealth’s duplicate logic. This logic protects against Aetna Better Health paying for services rendered by the same physician or other physicians within the same provider group

ClaimCheck® Edits ClaimCheck® is a comprehensive code auditing solution that supports QNXT™ by applying expert industry edits from a provider recognized knowledge base to analyze claims for accuracy


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and consistency with Aetna Better Health’s P&Ps. ClaimCheck® clinical editing software identifies coding errors in the following categories:

• Procedure unbundling

• Mutually exclusive procedures

• Incidental procedures

• Medical visits, same date of service

• Bilateral and duplicate procedures

• Pre and Post-operative care

• Assistant Surgeon

• Modifier Auditing

• Medically Unlikely

Aetna Better Health offers network providers access to Clear Claim Connection®, a provider reference tool that helps providers optimize their claims submission accuracy. Currently there are 2300 provider groups registered to use this web-based tool that providers can use to understand Aetna Better Health’s clinical editing logic. This allows them to better understand the rules and clinical rationale affecting adjudication. Providers access Clear Claim Connection® through Aetna Better Health’s web portal via secure login. Various coding combinations can then be entered to determine why, for example, a particular coding combination resulted in a denial. The provider may also review coding combinations prior to claim submission, to determine if applicable auditing rules and clinical rationale will deny the claim before it is submitted.

iHealth Edits iHealth clinically edits claims to assist Aetna Better Health to promote the proper and fair payment of professional DME and outpatient claims.

Coding Accuracy If the services are up-coded, or unbundled, iHealth will alert the Claims Department to deny the claim line along with the specific clinical editing policy justification for the denial. The claim line will deny with the appropriate HIPAA remittance remark on the Explanation of Benefits (EOB).

Duplicate Billing Logic In addition, claim lines set to “Pay” are subjected to iHealth’s duplicate logic. This logic protects against Aetna Better Health paying for services rendered by the same physician or other physicians within the same provider group

Durable Medical Equipment (DME) Editing iHealth Technologies’ (iHT) performs edits related to select DME payment policies that align with ALTCS covered service policies. These DME edits include but are not limited to; DME rentals, oxygen and oxygen systems, hospital beds and accessories, external infusion pumps and anatomic/functional modifiers required for DME services.


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Procedure Code Guidelines - iHealth Aetna Better Health follows the AMA CPT-4 Book and CMS HCPCS Book, which both provide instructions regarding code usage. iHT has developed these guidelines into edits. For example, if a vaccine administration code is billed without the correct vaccine/toxoid codes, Aetna Better Health would then deny the code as inappropriate coding based on industry standards. According to the AMA CPT Book, this vaccination must be reported in addition to the vaccine and toxoid code(s).

Procedure Code Definition Policies - iHealth iHT supports correct coding based on the definition or nature of a procedure code or combination of procedure codes. These editing policies will either bundle or re-code procedures based on the appropriateness of the code selection. For example, if a provider attempts to unbundle procedures, iHT will apply editing logic that will bundle all of the procedures billed into the most appropriate code. For example, if a provider bills an office visit and also bills separately for heart monitoring with a stethoscope at the same visit, iHT will rebundle the service into the appropriate E&M or office code.

Fraud & Abuse Aetna Better Health’s Fraud and Abuse Department, under the direction of the VP of Health Plan Operations, utilizes claims payment tracking and trending reports, claims edits, audits and provider billing patterns as indicators of potential fraud and abuse. The Fraud and Abuse Department uses this information to detect aberrant provider billing behavior, prompting additional analysis and investigation. Aetna Better Health fraud and abuse personnel work in conjunction with Aetna Better Health’s Provider Services and Compliance Departments to address the questionable behavior(s) through provider education and outreach. If Aetna Better Health becomes aware that an incident of potential/suspected fraud and abuse has occurred, internal P&Ps mandate that we report the incident to DHH within 10 business days of discovery by completing and submitting the confidential DHH Referral for Preliminary Investigation form.

Claims Education Aetna Better Health’s Provider Claims Educator works to educate contracted and non-contracted providers on appropriate claims submission requirements, coding updates and available resources, such as provider manuals, websites, fee schedules, etc. In addition, the Provider Claims Educator will participate in any DHH workgroup tasked with developing uniform guidelines for standardizing hospital outpatient and outpatient provider claim requirements, sharing information with providers accordingly.

Claims Editing Results In calendar year 2010, due to our robust and comprehensive claims editing programs, Aetna Better Health cost avoided/recovered in excess of seventeen million dollars related to the ALTCS program.

Use of iHealth Technologies to Detect Questionable Billing Practices QNXT™ is supplemented by an Integrated Claims Management Services (ICM Services) powered by iHealth Technologies (iHT). This software is seamless to the network provider and allows consistent and accurate administration of claims adjudication policies. Professional claims that reach an adjudicated status of “pay” are automatically reviewed against nationally


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recognized standards such as the Correct Coding Initiative (CCI) and recommendations applied during an automatic re-adjudication process.

The QNXT™ and Integrated Claims Management applications utilize historical claims information to detect and correct questionable billing practices and assist in identifying fraudulent and abusive patterns. Professional claims that reach an adjudicated status of “pay” receive a Correct Coding Initiative (CCI) control edit. These edits include, but are not limited to:

Member Eligibility The QNXT™ adjudication system validates the date of service against the member’s enrollment segment to determine if the member was eligible on the date of service. If the member was not eligible on the date of service, the system will automatically deny the claim using the appropriate HIPAA approved remittance comment.

Covered/Non-Covered Services The QNXT™ system automatically determines if specific services using the CPT, REV or HCPC codes are covered under the contract or benefit rules of the DHH plan. If services are not covered, the system will automatically deny that claim line. If the services are up-coded, or unbundled, iHealth will send a recommendation back to deny the claim line along with the specific reason why. The claim line will deny with the appropriate HIPAA remittance remark on the EOB.

Required Documentation The QNXT™ system is configured, for certain services, to require additional documentation before the claim can be adjudicated. For example, a signed consent form is required documentation for sterilization procedures.

Services within the Scope of the Network Provider’s Practice The QNXT™ system is configured by specialty to allow certain procedures to only be performed by selected network provider types. For example, the system does not permit a claim for heart surgery performed in-office by a podiatrist to be processed. In addition to the QNXT™ system, iHealth also reviews claim lines which are set to pay for network provider billing appropriateness by specialty.

Duplication of Services The QNXT™ system has a very robust set of edits to determine duplication of services. Examples are same member, same date, same network provider, same service or any combination of these criteria. In addition, claim lines set to pay will go through the iHealth duplicate logic which will review services rendered by any other physician within the group affiliation for duplicate billings.

Prior Authorization The QNXT™ system has a separate configuration for prior authorization (PA) templates and associated service groups for PA. This allows for flexibility when creating authorizations, which can be accomplished at the code level if needed. The system is organized to automatically identify certain types of authorizations for medical director review. Claim edit rules are set to validate the claim against the network provider, member, dates of service, services rendered and units authorized.


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Invalid Procedure Codes QNXT™ reference files are configured by year and procedure code. As new codes are added, terminated or changed, we update the codes in the system so that the system is always in compliance with HIPAA standards. If a network provider bills a code that has terminated, the system will deny the claim line and advise the network provider the code is invalid.

Liability Management Practices Aetna Better Health utilizes generally accepted actuarial practices to estimate its unpaid claim liability. Each month, a query is run to extract paid claims by month of service, month of payment, and category of expense. The paid claims extract is reconciled against the check register and is compared to the previous month's extract to validate the data. Then, for each category a completion factor is calculated for each month of service and is applied to the claims paid to date to develop the estimate of ultimate incurred claims for that month. Results are then aggregated across all months of service and all categories of expense. Adjustments for any known liabilities are added as appropriate (for example, a long hospital stay that is known but for which a bill has not yet been received). A margin is added, and the final result is the estimate of Incurred But Not Paid Claims.

Estimated liabilities for Received But Unadjudicated Claims are determined by applying historical factors to the billed charges for these claims. If the estimated liability is high enough to warrant an adjustment to the unpaid claim liability, such an adjustment is made. Incurred But Not Reported Claims are simply the difference between Incurred But Not Paid Claims and Received But Unadjudicated Claims.

Aetna Better Health’s corporate valuation actuary makes an independent estimate of Incurred But Not Paid Claims each month. This estimate is compared to Aetna Better Health's estimate, and consensus is reached on the appropriate value to use.

Retrieval and Integration of Enrollment/Eligibility Data: Aetna Better Health has over 10 years’ experience successfully managing plan membership, as well as a comprehensive system in place that enables us to efficiently resolve discrepancies in membership data. The purpose of reconciling the member file is to maintain correct member eligibility information at all times and pay only for services provided to eligible members. With the eligibility file kept current, capitated network providers are neither overpaid nor underpaid and the eligibility information transferred to subcontractors is correct. Maintaining accurate membership files allows Aetna Better Health to easily reconcile monthly premium payments from the State to the information in QNXT™. It is important that all eligibility segments be recorded in QNXT™ correctly so that medical services are paid only when appropriate.

QNXT™, Aetna Better Health’s client/server-based managed care information system, serves as the backbone of our ECM functionality. QNXT™ is used to synthesize the online, phone-based, EFT and ACH capabilities that provide our network providers a comprehensive, cohesive and automated means of claims submission, monitoring and payment. We focus here on those services made available to our network providers by our Claims Inquiry Claims Research (CICR) Line and AboveHealth®, Aetna Better Health’s HIPAA-compliant secure Web portal for providers.


13



Aetna Better Health’s Claims Department maintains a Claims Inquiry Claims Research (CICR) Line, a toll-free number that network providers are free to call between the hours of 6:00 a.m. and 5:00 p.m. to speak with claims research line personnel.

CICR Representatives are specifically designated to answer provider phone inquiries regarding claims status, track those inquiries within QNXT™’s Call Tracking functionality and provide status and/or process adjustments to previously processed claims accordingly. If a single inquiry results in more than three adjustments, the issue is call tracked, by way of QNXT™, to a research and adjustment analyst for processing so that CICR Representatives can remain available to answer provider calls. For every non-status call (requires further action/research) received, a call tracking issue must be opened.

Whenever possible, CICR Representatives resolve provider inquiries in the course of a call. However, in those rare instances when this is not possible, the issue is resolved within seven calendar days. CICR Representatives and Supervisors monitor Call Tracking reports daily to maintain resolution time standards.

With regard to online claims status capabilities, AboveHealth® supports communication between Aetna Better Health and our network providers in a multitude of ways, among them extensive online support of the claim status function. As the screenshots that follow demonstrate, network providers can, at any time, login to AboveHealth®, navigate to the Claim Status Search page, search on multiple criteria, then view and print their search results.

AboveHealth® Network Provider Claim Status Search Page


14



Claims Status Search Results (by Network Provider)

Claims Detail


15



Claims Status Detail Report (Printable)


16



Provider Training and Education For those network providers wishing to take advantage of AboveHealth®’s online claims status inquiry capabilities, Aetna Better Health offers a variety of training opportunities, including, but not limited to the following:

• Orientation sessions

• Distribution of written materials through mailings and on our Website

• Training during scheduled site visits

• Regularly scheduled provider training forums and meetings

• In-person training sessions at provider offices.


17

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

De

lawar

e Fl

orid

a Ma

rylan

d Re

quire

men

t Me

ets o

r Exc

eeds

Req

uire

men

t Ex

plan

atio

n

17 C

laim

s Man

agem

ent

17.1

Elec

troni

c Clai

ms M

gmt F

unct

iona

lity

17.1.

1 The

Coo

rdina

ted C

are N

etwor

k (CC

N) sh

all

annu

ally c

omply

with

DHH

’s El

ectro

nic C

laims

Da

ta Int

erch

ange

polic

ies fo

r cer

tifica

tion o

f ele

ctron

ically

subm

itted c

laims

.

Meets

Me

ets

Meets

Tw

o app

licati

ons p

rovid

e for

Aetn

a Bett

er H

ealth

’s co

ntinu

ed

comp

lianc

e with

contr

actin

g stat

es’ E

lectro

nic C

laims

Data

Int

erch

ange

polic

ies fo

r cer

tifica

tion o

f elec

tronic

ally s

ubmi

tted

claim

s: 1)

Micr

osoft

BizT

alk w

ith H

IPAA

Acc

elera

tor™

is a

data

trans

forma

tion a

pplic

ation

that

trans

lates

data

to an

d fro

m the

full

spec

trum

of HI

PAA

trans

actio

ns se

ts in

a high

ly cu

stomi

zable

, fle

xible,

and r

obus

t ser

ver-b

ased

envir

onme

nt. 2)

Was

hingto

n Pu

blish

ing C

ompa

ny (W

PC) I

mplem

entat

ion G

uide s

chem

as fo

r ea

ch H

IPAA

ANS

I X12

tran

sacti

on ar

e emb

edde

d dire

ctly w

ithin

the ap

plica

tion e

ngine

, inclu

ding a

facil

ity to

upda

te the

se

sche

mas a

utoma

ticall

y as t

he tr

ansa

ction

sets

are u

pdate

d ove

r tim

e. Ad

dition

ally,

Fore

sight’

s HIP

AA V

alida

tor™

, InSt

ream

™, is

a ful

ly fun

ction

al HI

PAA

editin

g and

valid

ation

appli

catio

n. It v

alida

tes

HIPA

A tra

nsac

tions

thro

ugh a

ll sev

en le

vels

of ed

its as

defin

ed

by th

e Wor

kgro

up fo

r Elec

tronic

Data

Inter

chan

ge an

d Stra

tegic

Natio

nal Im

pleme

ntatio

n Pro

cess

(WED

I/SNI

P), h

as al

l stan

dard

HI

PAA

code

sets

embe

dded

, and

supp

orts

custo

m, tr

ading

-pa

rtner

-spec

ific co

mpan

ion gu

ides a

nd va

lidati

on re

quire

ments

. Ae

tna B

etter

Hea

lth fo

llows

the S

trateg

ic Na

tiona

l Imple

menta

tion

Proje

ct (S

NIP)

reco

mmen

datio

ns fo

r tes

ting c

reate

d by t

he

Wor

kgro

up fo

r Elec

tronic

Data

Inter

chan

ge (W

EDI),

furth

er

prom

oting

syste

m co

mplia

nce w

ith fe

dera

l IT m

anda

tes.

17.1.

2 To t

he ex

tent th

at the

CCN

comp

ensa

tes

prov

iders

on a

fee-fo

r-ser

vice o

r othe

r bas

is re

quirin

g the

subm

ission

of cl

aims a

s a co

nditio

n of

Meets

Me

ets

Meets

QN

XT™

, Aetn

a Bett

er H

ealth

's co

re tr

ansa

ction

proc

essin

g sy

stem,

comp

rises

28 in

tegra

ted m

odule

s tha

t main

tain t

he


18

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

paym

ent, t

he C

CN sh

all pr

oces

s the

prov

ider’s

cla

ims f

or co

vere

d ser

vices

prov

ided t

o mem

bers,

co

nsist

ent w

ith ap

plica

ble C

CN po

licies

and

proc

edur

es an

d the

term

s of th

e Con

tract

and t

he

Syste

ms G

uide,

includ

ing, b

ut no

t limi

ted to

, time

ly fili

ng, a

nd co

mplia

nce w

ith al

l app

licab

le sta

te an

d fed

eral

laws,

rules

and r

egula

tions

.

follow

ing:

● Cl

aims d

ata, in

cludin

g ass

ociat

ed ad

judica

tion,

COB

and

TPL p

roce

sses

●

Demo

grap

hic, e

ligibi

lity an

d enr

ollme

nt da

ta, in

cludin

g prio

r co

vera

ge

● Pr

ovide

r con

tract

confi

gura

tion,

includ

ing ne

twor

k and

se

rvice

s ●

EDI p

roce

sses

●

QM/U

M inc

luding

, but

not li

mited

to P

rior A

uthor

izatio

ns an

d co

ncur

rent

revie

ws

Unde

r the

dire

ction

of th

e Dire

ctor o

f Bus

iness

App

licati

on

Mana

geme

nt (B

AM),

Aetna

Bett

er H

ealth

's BA

M De

partm

ent is

re

spon

sible

for:

● De

signin

g and

docu

menti

ng th

e ove

rall c

onfig

urati

on an

d ru

les ne

eded

for t

he Q

NXT™

build

. ●

Load

ing th

e rule

s and

requ

ireme

nts of

any n

ew he

alth p

lan,

prod

uct o

r bus

iness

func

tion i

nto Q

NXT™

, inclu

ding e

ligibi

lity

file la

yout,

prov

ider c

ontra

cts, fe

e sch

edule

s and

mem

ber

bene

fits an

d prio

r auth

oriza

tion r

equir

emen

ts. T

his w

ill all

ow

for th

e cap

ture,

proc

essin

g and

stor

age o

f all d

ata el

emen

ts re

quire

d by D

HH fo

r enc

ounte

r data

subm

ission

as st

ipulat

ed

in thi

s Sec

tion o

f the R

FP an

d the

Sys

tems G

uide.

● Va

lidati

ng th

e ove

rall q

uality

, time

lines

s and

accu

racy

of th

e QN

XT™

buil

d. ●

Partic

ipatin

g in t

he cl

aims p

roce

ssing

syste

m un

it tes

ting w

ith

our O

pera

tions

Pro

cess

and K

nowl

edge

Man

agem

ent


19

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

(OPK

M) D

epar

tmen

t and

wor

king t

o res

olve a

ny is

sues

. ●

Partic

ipatin

g in e

nd to

end t

estin

g with

end u

sers;

reso

lving

an

y iss

ues d

uring

imple

menta

tions

and m

ajor s

ystem

up

grad

es.

QNXT

™, in

conju

nctio

n with

the d

ocum

ent s

cann

ing an

d OCR

fun

ction

ality

affor

ded b

y Futu

reVi

sion,

our d

ocum

ent

mana

geme

nt so

lution

vend

or, p

rovid

es fo

r the

subm

ission

and

proc

essin

g of n

on-e

lectro

nic an

d elec

tronic

claim

s by c

ontra

cted

prov

iders.

QN

XT's™

inter

faces

with

Abo

veHe

atlh,

our s

ecur

e web

porta

l, in

addit

ion to

our A

vaya

phon

e sys

tem, p

ermi

t pro

vider

s on-

line a

nd

phon

e-ba

sed a

cces

s to c

laim

proc

essin

g stat

us in

forma

tion.

17.1.

3 The

CCN

shall

main

tain a

n elec

tronic

cla

ims m

anag

emen

t sys

tem th

at wi

ll: Me

ets

Meets

Me

ets

See b

elow:

17.1.

3.1 U

nique

ly ide

ntify

the at

tendin

g and

billin

g pr

ovide

r of e

ach s

ervic

e; Me

ets

Meets

Me

ets

QNXT

™, A

etna B

etter

Hea

lth’s

claim

s pro

cess

ing sy

stem,

utiliz

es

prov

ider s

electi

on lo

gic pr

ovidi

ng fo

r the

uniqu

e ide

ntific

ation

of

the at

tendin

g and

billin

g pro

vider

for e

ach s

ervic

e.

17.1.

3.2 Id

entify

the d

ate of

rece

ipt of

the c

laim

(the d

ate th

e CCN

rece

ives t

he cl

aim an

d en

coun

ter in

forma

tion)

;

Exce

eds

Exce

eds

Exce

eds

QNXT

’s™ c

ore f

uncti

onali

ty re

cord

s the

date

any c

laim

or

enco

unter

infor

matio

n is r

eceiv

ed.

17.1.

3.3 Id

entify

real-

time a

ccur

ate hi

story

with

dates

of ad

judica

tion r

esult

s of e

ach c

laim

such

as

paid,

denie

d, su

spen

ded,

appe

aled,

etc., a

nd

follow

up in

forma

tion o

n app

eals;

Exce

eds

Exce

eds

Exce

eds

Data

histor

y is n

ot pu

rged

in su

ppor

t of r

etriev

al/re

view

of ac

cura

te an

d com

preh

ensiv

e clai

m his

tory p

rofile

s, e.g

. hist

orica

l da

ta of

paid,

denie

d, an

d sus

pend

ed cl

aims.

(Note

that

appe

aled

claim

data

is no

t stor

ed in

the c

laim’

s sys

tem an

d ins

tead i

s sto

red i

n the

appe

als da

tabas

e). T

he ge

nera

l and

admi

nistra

tive

datab

ase t

rack

s clai

m his

tory a

nd re

lated

adjud

icatio

n res

ults,

thus p

rovid

ing an

adde

d mec

hanis

m for

claim

s hist

ory r

eview

. If

claim

is ad

justed

as th

e res

ult of

an ap

peal,

the a

djustm

ent is


20

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

docu

mente

d in t

he C

laims

proc

essin

g sys

tem, a

nd th

at his

tory i

s ma

intain

ed an

d retr

ievab

le.

17.1.

3.4 Id

entify

the d

ate of

paym

ent, t

he da

te &

numb

er of

the c

heck

or ot

her f

orm

of pa

ymen

t su

ch as

elec

tronic

fund

s tra

nsfer

(EFT

);

Exce

eds

Exce

eds

Exce

eds

The c

laims

syste

m is

capa

ble of

trac

king a

nd m

aintai

ning e

ach o

f the

se el

emen

ts, an

d inc

ludes

the a

bility

for p

erso

nnel

to qu

ery

the da

tabas

e for

thes

e spe

cific

eleme

nts.

17.1.

3.5 Id

entify

all d

ata el

emen

ts as

requ

ired b

y DH

H for

enco

unter

data

subm

ission

as st

ipulat

ed

in thi

s Sec

tion o

f the R

FP an

d the

Sys

tems G

uide;

and

Meets

Me

ets

Meets

Ou

r pro

priet

ary E

ncou

nter M

anag

emen

t Sys

tem (E

MS) p

rovid

es

for th

e acc

urate

, time

ly an

d com

plete

subm

ission

of en

coun

ter

data

–inclu

ding a

ll bille

d, pa

id an

d den

ied un

its an

d cha

rges

, as

well a

s the

Nati

onal

Prov

ider I

denti

fier (

NPI)

– to D

HH in

HIP

AA

comp

liant

837(

I/P) f

orma

t. Dev

elope

d with

the f

uncti

onali

ty to

mana

ge en

coun

ter da

ta ac

ross

the e

ncou

nter s

ubmi

ssion

co

ntinu

um –

includ

ing pr

epar

ation

, rev

iew, v

erific

ation

, ce

rtifica

tion,

subm

ission

, and

repo

rting –

the s

ystem

cons

olida

tes

requ

ired c

laims

data

from

multip

le so

urce

s (e.g

. QNX

T™ an

d our

de

legate

d visi

on se

rvice

s pro

vider

) for

all s

ervic

es (in

cludin

g tho

se in

the p

rior p

eriod

) for

whic

h Aetn

a Bett

er H

ealth

incu

rred a

fin

ancia

l liab

ility,

as w

ell as

claim

s for

servi

ces e

ligibl

e for

pr

oces

sing w

here

no fin

ancia

l liab

ility w

as in

curre

d. Co

mpre

hens

ive, c

oord

inated

edits

and w

orkfl

ow m

anag

emen

t too

ls ide

ntify

and a

ddre

ss po

tentia

l data

issu

es at

the e

arlie

st op

portu

nity.

EMS

is co

nfigu

red t

o extr

act th

e clai

m va

lues

nece

ssar

y to p

opula

te a v

alid a

nd ac

cura

te en

coun

ter. T

his

proc

ess w

ill be

deve

loped

using

DHH

’s sp

ecific

codin

g ins

tructi

ons a

nd te

sted f

or ac

cura

cy an

d com

pleten

ess.

Our

enco

unter

syste

m is

custo

m bu

ilt for

the r

equir

emen

ts of

each

sta

te. W

e con

sisten

tly co

llabo

rate

with

the M

edica

id ag

encie

s tha

t con

tract

with

us to

prov

ide m

anag

ed ca

re se

rvice

s. A

s an

exam

ple, th

is co

llabo

ratio

n, ou

r affil

iate i

n Ariz

ona,

Mercy

Car

e Pl

an, w

orkin

g with

the S

tate’s

Med

icaid

agen

cy’s

enco

unter


21

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

proc

essin

g unit

, con

tribute

d to t

he su

cces

sful a

ccep

tance

of ov

er

99 pe

rcent

of all

subm

itted e

ncou

nters

in ca

lenda

r yea

r 201

0.

17.1.

3.6 A

llow

subm

ission

of no

n-ele

ctron

ic an

d ele

ctron

ic cla

ims b

y con

tracte

d pro

vider

s. Ex

ceed

s Ex

ceed

s Ex

ceed

s

17.1.

4 The

CCN

shall

see t

hat a

n elec

tronic

claim

s ma

nage

ment

(ECM

) cap

abilit

y tha

t acc

epts

and

proc

esse

s clai

ms su

bmitte

d elec

tronic

ally i

s in

place

.

Meets

Me

ets

Meets

Aetna

Bett

er H

ealth

’s cla

ims m

anag

emen

t sys

tem, Q

NXT™

, pr

ovide

s for

the s

ubmi

ssion

and p

roce

ssing

of el

ectro

nic cl

aims

by co

ntrac

ted pr

ovide

rs via

mult

iple c

learin

ghou

ses.

Prov

iders

may a

lso su

bmit p

aper

claim

s to p

lan-sp

ecific

post

office

boxe

s ad

jacen

t to F

uture

Visio

n, Ae

tna B

etter

Hea

lth’s

docu

ment

imag

ing ve

ndor

, pro

viding

for t

heir p

romp

t con

versi

on to

ele

ctron

ic for

mat a

nd up

load t

o QNX

T™, s

hould

any s

uppo

rting

docu

menta

tion b

e atta

ched

(e.g.

EOB

), the

ir sec

ure d

elive

ry to

the ap

prop

riate

Aetna

Bett

er H

ealth

depa

rtmen

t.

17.1.

5 The

CCN

shall

see t

hat th

e ECM

syste

m fun

ction

s in a

ccor

danc

e with

infor

matio

n exc

hang

e an

d data

man

agem

ent r

equir

emen

ts as

spec

ified

in thi

s Sec

tion o

f the R

FP an

d the

Sys

tems G

uide.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth is

able

to co

mply

with

the in

forma

tion

exch

ange

and d

ata m

anag

emen

t req

uirem

ents

spec

ified i

n this

RF

P an

d the

Sys

tems G

uide.

17.1.

6 The

CCN

shall

see t

hat, a

s par

t of th

e ECM

fun

ction

, it ca

n pro

vide o

n-lin

e and

phon

e-ba

sed

capa

bilitie

s to o

btain

proc

essin

g stat

us in

forma

tion.

Meets

Me

ets

Meets

On

line c

apab

ilities

will

be pr

ovide

d via

Abov

eHea

lth® .

Abov

eHea

lth® i

s a se

cure

HIP

AA-co

mplia

nt we

b por

tal fo

r Aetn

a Be

tter H

ealth

’s me

mber

s and

prov

iders.

Des

igned

to fo

ster o

pen

comm

unica

tion a

nd fa

cilita

te ac

cess

to a

varie

ty of

data

in a

multit

ude o

f way

s, thi

s sec

ure,

ASP-

base

d app

licati

on

sync

hron

izes d

ata on

a da

ily ba

sis w

ith Q

NXT™

thro

ugh d

ata

extra

ct an

d loa

d pro

cess

es, a

llowi

ng pr

ovide

rs to

chec

k elig

ibility

sta

tus, r

eview

bene

fits, e

ncou

nters

and p

rior a

uthor

izatio

n stat

us,

and s

end s

ecur

e ema

ils to

Aetn

a Bett

er H

ealth

.. Ph

one-

base

d ca

pabil

ities f

or cl

aim st

atus a

nd ot

her p

roce

ssing

infor

matio

n will

be av

ailab

le via

our C

ICR.

CIC

R pe

rsonn

el wi

ll be a

vaila

ble fr

om

7 am

to 7 p

m, C

entra

l Tim

e, Mo

nday

thro

ugh F

riday

for p

rovid

er

inquir

ies.


22

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.1.

7 The

CCN

shall

supp

ort a

n auto

mated

cle

aring

hous

e (AC

H) m

echa

nism

that a

llows

pr

ovide

rs to

requ

est a

nd re

ceive

elec

tronic

fund

s tra

nsfer

(EFT

) of c

laims

paym

ents.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth af

fords

prov

iders

the op

portu

nity t

o rec

eive

paym

ent v

ia dir

ect d

epos

it, or

elec

tronic

fund

tran

sfer (

EFT)

. The

pr

oces

s is a

s foll

ows:

1)

Prov

iders

comp

lete a

n EFT

enro

llmen

t form

(ava

ilable

on

line)

, pro

viding

their

bank

routi

ng an

d acc

ount

numb

ers.

The c

omple

ted fr

om is

faxe

d to o

ur E

DI D

epar

tmen

t. 2)

Ae

tna B

etter

Hea

lth pe

rsonn

el en

ter ea

ch pr

ovide

r’s ro

uting

an

d acc

ount

infor

matio

n into

QNX

T™ an

d des

ignate

them

as

an E

FT pr

ovide

r. 3)

A

test d

ocum

ent c

alled

a “p

re-n

ote” is

sent

to the

prov

ider’s

ba

nk to

see t

hat th

e rou

ting n

umbe

r and

acco

unt n

umbe

r are

ac

cura

te an

d fun

ction

prop

erly.

4)

Up

on ap

prov

al of

the “p

re-n

ote” b

y the

prov

ider’s

bank

, EFT

ca

pabil

ities a

re en

abled

with

in the

resp

ectiv

e Aetn

a Bett

er

Healt

h acc

ounts

. 5)

As

prov

ider p

ayme

nts ar

e gen

erate

d dur

ing th

e che

ck ru

n pr

oces

s, pa

ymen

t infor

matio

n is c

ompil

ed w

ithin

a file

and

queu

ed fo

r sch

edule

d dist

ributi

on to

the a

ssoc

iated

bank

s an

d Auto

mated

Clea

ring H

ouse

s (AC

Hs) f

or pr

oces

sing.

Upon

appr

oval

of the

chec

k run

by th

e hea

lth pl

an, c

heck

s ar

e rele

ased

for p

rintin

g and

mail

ing an

d the

EFT

file i

s re

lease

d to t

he re

spec

tive f

inanc

ial in

stitut

ions.

6)

Prov

iders

rece

ive a

hard

copy

remi

ttanc

e in t

he m

ail de

tailin

g the

claim

s pro

cess

ed in

a pa

rticula

r pay

ment

cycle

and a

pa

per c

opy o

f wha

t wou

ld ha

ve be

en a

chec

k ind

icatin

g the

EF

T ch

eck n

umbe

r and

total

dolla

rs, th

ereb

y allo

wing

them

to

post

paym

ents

appr

opria

tely.


23

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

Any p

rovid

er ca

n cho

ose t

o stop

EFT

paym

ents

at an

y tim

e and

re

turn t

o pay

ment

by ph

ysica

l che

ck by

conta

cting

the h

ealth

plan

in

writin

g.

17.1.

8 The

CCN

shall

not d

erive

finan

cial g

ain fr

om

a pro

vider

’s us

e of e

lectro

nic cl

aims f

iling

functi

onali

ty an

d/or s

ervic

es of

fered

by th

e CCN

or

a thir

d par

ty. H

owev

er, th

is pr

ovisi

on sh

all no

t be

cons

trued

to im

ply th

at pr

ovide

rs ma

y not

be

resp

onsib

le for

paym

ent o

f app

licab

le tra

nsac

tion

fees a

nd/or

char

ges.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth ac

know

ledge

s and

will

comp

ly. It

has n

ever

be

en A

etna B

etter

Hea

lth’s

busin

ess p

racti

ce to

asse

ss a

fee fo

r su

ch se

rvice

s and

we a

re co

nfide

nt tha

t futur

e bus

iness

prac

tices

wi

ll con

tinue

to su

ppor

t our

prov

iders

in the

ir ado

ption

of E

DI

capa

bilitie

s.

17.1.

9 The

CCN

shall

requ

ire th

at the

ir pro

vider

s co

mply

at all

times

with

stan

dard

ized b

illing

form

s an

d for

mats,

and a

ll futu

re up

dates

for

Profe

ssion

al cla

ims (

CMS

1500

) and

Insti

tution

al cla

ims (

UB 04

).

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth's

Claim

s Edu

cator

prov

ides i

n-ne

twor

k and

ou

t-of-n

etwor

k pro

vider

s (i.e

., pro

fessio

nal a

nd in

stitut

ional)

in-

depth

educ

ation

rega

rding

appr

opria

te cla

ims s

ubmi

ssion

re

quire

ments

, cod

ing up

dates

, elec

tronic

claim

s tra

nsac

tions

and

electr

onic

fund t

rans

fer, a

nd av

ailab

le he

alth p

lan re

sour

ces s

uch

as pr

ovide

r man

uals,

web

sites

, fee s

ched

ules,

and s

o for

th.

Prov

ider c

ontra

cts, in

conju

nctio

n with

initia

l and

ongo

ing pr

ovide

r ed

ucati

on an

d tra

ining

relat

ed to

claim

s req

uirem

ents,

supp

ort

prov

iders'

comp

lianc

e with

rega

rd to

claim

s sub

miss

ion

requ

ireme

nts. P

repr

oces

sing e

dits e

nforce

this

requ

ireme

nt an

d de

ny an

y clai

m su

bmitte

d in a

nons

tanda

rd fo

rmat.


24

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.1.

10 T

he C

CN m

ust c

omply

with

requ

ireme

nts

of Se

ction

6507

of th

e Pati

ent P

rotec

tion a

nd

Affor

dable

Car

e Act

of 20

10, r

egar

ding “

Mand

atory

State

Use

of N

ation

al Co

rrect

Codin

g Init

iative

s,”

includ

ing al

l app

licab

le ru

les, r

egula

tions

, and

me

thodo

logies

imple

mente

d as a

resu

lt of th

is ini

tiativ

e.

Meets

Me

ets

Meets

QN

XT's™

data

relat

ed ed

its ar

e sup

pleme

nted b

y two

clini

cal

claim

s edit

ing so

lution

s. Th

e firs

t, iHe

alth,

appli

es se

lect p

ayme

nt po

licies

from

one o

f the i

ndus

try’s

most

comp

rehe

nsive

corre

ct co

ding a

nd M

edica

l Poli

cy co

ntent

libra

ries.

The s

econ

d, Mc

Kess

on’s

Claim

Chec

k®, e

xpan

ds up

on th

ose c

apab

ilities

by

enab

ling o

ur cl

aims m

anag

emen

t team

to de

fine a

nd co

mbine

sp

ecific

claim

s data

crite

ria, s

uch a

s pro

vider

or di

agno

sis, to

set

up un

ique e

dits t

hat d

elive

r enh

ance

d aud

iting p

ower

. Pr

ofess

ional

claim

s (CM

S 15

00s)

that r

each

an ad

judica

ted

status

of “P

ay” a

re au

tomati

cally

revie

wed a

gains

t nati

onall

y re

cogn

ized s

tanda

rds s

uch N

ation

al Co

rrect

Codin

g Init

iative

(N

CCI),

med

ical p

olicy

requ

ireme

nts [e

.g., A

meric

an M

edica

l As

socia

tion (

AMA)

], and

can m

eet m

axim

um un

it req

uirem

ents

supp

lied b

y DHH

, with

reco

mmen

datio

ns ap

plied

durin

g an

autom

atic r

e-ad

judica

tion p

roce

ss.

The u

se of

thes

e two

syste

ms co

mbine

d, alo

ng w

ith su

ppor

tive

modu

les an

d stat

ed re

sour

ces,

prov

ide fo

r com

plian

ce w

ith C

CI

rules

, reg

ulatio

ns an

d rela

ted m

ethod

ologie

s.

17.1.

11 T

he C

CN ag

rees

that

at su

ch tim

e tha

t DH

H pr

esen

ts re

comm

enda

tions

conc

ernin

g cla

ims b

illing

and p

roce

ssing

that

are c

onsis

tent

with

indus

try no

rms,

the C

CN sh

all co

mply

with

said

reco

mmen

datio

ns w

ithin

ninety

(90)

calen

dar

days

from

notic

e by D

HH.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth ac

know

ledge

s and

will

comp

ly.

17.1.

12 T

he C

CN sh

all ha

ve pr

oced

ures

appr

oved

by

DHH

, ava

ilable

to pr

ovide

rs in

writte

n and

web

for

m for

the a

ccep

tance

of cl

aim su

bmiss

ions

which

inclu

de:

Meets

Me

ets

Meets

Th

e clea

n date

(actu

al re

ceipt

date)

of no

n-ele

ctron

ic cla

ims

(pap

er) is

deriv

ed fr

om F

uture

Visio

n, Ae

tna B

etter

Hea

lth's

docu

ment

imag

ing ve

ndor

. This

date

is a t

rue r

epre

senta

tion o

f wh

en th

e clai

ms w

ere a

ctuall

y rec

eived

and p

roce

ssed

by th

e im

age v

endo

r and

is em

bedd

ed w

ithin

the da

ta file

of th

e clai

ms


25

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.1.

12.1

The p

roce

ss fo

r doc

umen

ting t

he da

te of

actua

l rece

ipt of

non-

electr

onic

claim

s and

date

and t

ime o

f elec

tronic

claim

s;

Meets

Me

ets

Meets

17.1.

12.2

The p

roce

ss fo

r rev

iewing

claim

s for

ac

cura

cy an

d acc

eptab

ility;

Meets

Me

ets

Meets

17.1.

12.3

The p

roce

ss fo

r pre

venti

on of

loss

of

such

claim

s, an

d Me

ets

Meets

Me

ets

17.1.

12.4

The p

roce

ss fo

r rev

iewing

claim

s for

de

termi

natio

n as t

o whe

ther c

laims

are a

ccep

ted

as cl

ean c

laims

.

Meets

Me

ets

Meets

trans

mitte

d to u

s by o

ur im

age v

ende

r. Th

is da

te wi

ll also

ma

tches

Alch

emy (

our c

laim

imag

e retr

ieval

appli

catio

n) cl

aim

numb

er (J

ulian

date)

that

is sta

mped

on th

e ima

ges o

f the e

ach

claim

. Th

e ima

ge ve

ndor

scan

s (via

OCR

tech

nolog

y) the

claim

and

assig

ns a

Docu

ment

Contr

ol Nu

mber

(DCN

) to e

ach c

laim

for

track

ing an

d rec

oncil

iation

purp

oses

. The

se im

age f

iles a

re

forwa

rded

to ou

r IT

Oper

ation

s Dep

artm

ent, u

pload

ed to

Alch

emy

and l

inked

to th

e ass

ociat

ed el

ectro

nic cl

aim vi

a DCN

. FV

Tech

pick

s up c

laims

from

the d

esign

ated P

O Bo

x in t

he

morn

ing, s

cans

and u

pload

s the

imag

es, a

nd w

ithin

24 to

26

hour

s of th

eir pi

ck up

time a

t the U

nited

Stat

es P

ostal

Ser

vice,

the im

ages

are s

ent to

Aetn

a Bett

er H

ealth

, with

an im

age f

ile

simult

aneo

usly

loade

d into

Alch

emy.

ED

I clai

ms ar

e typ

ically

rece

ived f

rom

multip

le Cl

earin

ghou

ses,

with

each

Clea

ringh

ouse

boun

d by t

heir s

pecif

ic co

ntrac

tual

agre

emen

t with

a Pr

ovide

r. O

nce E

DI cl

aims a

re re

ceive

d, the

y ar

e pro

cess

ed vi

a Ins

tream

and L

evel

1 & 2

HIPA

A ed

its ar

e ap

plied

. Reje

cts ar

e the

n sub

mitte

d to A

etna E

DI G

atewa

y whic

h cre

ates t

he 27

7 for

the C

learin

ghou

se. I

t is th

e Clea

ringh

ouse

' ag

reem

ent w

ith th

e Pro

vider

that

deter

mine

s data

elem

ents

of re

jects.

Cl

aims t

hat a

re ac

cepte

d are

mas

s adju

dicate

d and

plac

ed in

a Pa

y, De

ny or

Pen

d stat

us. P

end &

Den

y stat

us w

ould

indica

te an

un

clean

claim

.


26

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.1.

13 T

he C

CN sh

all ha

ve a

proc

edur

e app

rove

d by

DHH

avail

able

to pr

ovide

rs in

writte

n and

web

for

m for

notify

ing pr

ovide

rs of

batch

rejec

tions

. The

re

port,

at a

minim

um, s

hould

conta

in the

follo

wing

inf

orma

tion:

Meets

Me

ets

Meets

17.1.

13.1

Date

batch

was

rece

ived b

y the

CCN

; Me

ets

Meets

Me

ets

17.1.

13.2

Date

of re

jectio

n rep

ort;

Meets

Me

ets

Meets

17

.1.13

.3 Na

me or

iden

tifica

tion n

umbe

r of C

CN

issuin

g batc

h reje

ction

repo

rt;

Meets

Me

ets

Meets

17.1.

13.4

Batch

subm

itters

name

or id

entifi

catio

n nu

mber

; and

Me

ets

Meets

Me

ets

17.1.

13.5

Reas

on ba

tch is

rejec

ted.

Meets

Me

ets

Meets

Batch

rejec

tions

occu

r at th

e Clea

ringh

ouse

and d

ata el

emen

ts co

ntaine

d in t

he re

ports

are d

eterm

ined b

y the

Clea

ringh

ouse

s co

ntrac

tual a

gree

ment.

If a

batch

is re

ceive

d by A

etna B

etter

He

alth's

Clai

ms D

epar

tmen

t and

rejec

ted he

re, w

e sub

mit a

re

port

to the

Aetn

a EDI

Gate

way w

hich i

n tur

n cre

ates t

he 27

7 for

the

Clea

ringh

ouse

. Aga

in, it

is the

Clea

ringh

ouse

's ag

reem

ent

with

the P

rovid

er th

at de

termi

nes d

ata el

emen

ts of

rejec

ts.

17.1.

14 T

he C

CN sh

all as

sume

all c

osts

asso

ciated

with

claim

proc

essin

g, inc

luding

the

cost

of re

proc

essin

g/res

ubmi

ssion

, due

to

proc

essin

g erro

rs ca

used

by th

e CCN

or to

the

desig

n of s

ystem

s with

in the

CCN

’s sp

an of

co

ntrol.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth ac

know

ledge

s and

will

comp

ly.

17.1.

15 T

he C

CN sh

all no

t emp

loy of

f-sys

tem or

gr

oss a

djustm

ents

when

proc

essin

g cor

recti

on to

pa

ymen

t erro

r, un

less i

t req

uests

and r

eceiv

es

prior

writt

en au

thoriz

ation

from

DHH

.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth ac

know

ledge

s and

will

comp

ly.


27

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.1.

16 F

or pu

rpos

es of

netw

ork m

anag

emen

t, the

CC

N sh

all no

tify al

l con

tracte

d pro

vider

s to f

ile

claim

s ass

ociat

ed w

ith co

vere

d ser

vices

dire

ctly

with

the C

CN, o

r its c

ontra

ctors,

on be

half o

f Lo

uisian

a Med

icaid

memb

ers.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth's

Claim

s Edu

cator

prov

ides i

n-ne

twor

k and

ou

t-of-n

etwor

k pro

vider

s (i.e

., pro

fessio

nal a

nd in

stitut

ional)

in-

depth

educ

ation

rega

rding

appr

opria

te cla

ims s

ubmi

ssion

re

quire

ments

. Lan

guag

e with

in ou

r pro

vider

contr

acts

instru

cts

prov

iders

to file

all c

laims

dire

ctly w

ith A

etna B

etter

Hea

lth. C

laim

subm

ission

instr

uctio

ns ar

e also

inclu

ded i

n the

Pro

vider

Ha

ndbo

ok, th

e pro

vider

page

s of o

ur w

ebsit

e and

claim

s rela

ted

news

letter

s and

bulle

tins.

The r

equir

emen

t is re

itera

ted du

ring

prov

iders'

initia

l orie

ntatio

n and

ongo

ing ed

ucati

on by

Pro

vider

Se

rvice

Rep

rese

ntativ

es.

17.1.

17 A

t a m

inimu

m, th

e CCN

shall

run o

ne (1

) pr

ovide

r pay

ment

cycle

per w

eek,

on th

e sam

e day

ea

ch w

eek,

as de

termi

ned b

y the

CCN

and

appr

oved

by D

HH.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth ru

ns on

e (1)

prov

ider p

ayme

nt cy

cle pe

r we

ek.

17.2

Claim

s Pro

cess

ing

Meth

odol

ogy R

equi

rem

ents

Th

e CCN

shall

per

form

syst

em ed

its, in

cludi

ng, b

ut n

ot lim

ited

to:

17.2.

1 Con

firming

eligi

bility

on ea

ch m

embe

r as

claim

s are

subm

itted o

n the

basis

of th

e elig

ibility

inf

orma

tion p

rovid

ed by

DHH

and t

he E

nroll

ment

Brok

er th

at ap

plies

to th

e per

iod du

ring w

hich t

he

char

ges w

ere i

ncur

red;

Meets

Me

ets

Meets

Inb

ound

claim

s are

uploa

ded t

o QNX

T™, o

ur cl

aims p

roce

ssing

sy

stem,

whe

re th

ey ar

e sub

jected

to m

ultipl

e hea

der a

nd lin

e ite

m ed

its. A

mong

thes

e are

edits

that

comp

are s

ervic

e data

to

eligib

ility i

nform

ation

prov

ided b

y DHH

and t

he E

nroll

ment

Brok

er

in or

der t

o con

firm m

embe

rs' el

igibil

ity du

ring t

he pe

riod t

o whic

h ch

arge

s wer

e inc

urre

d.

17.2.

2 A re

view

of the

entire

claim

with

in fiv

e (5)

wo

rking

days

of re

ceipt

of an

elec

tronic

claim

, to

deter

mine

that

the cl

aim is

not a

clea

n clai

m an

d iss

ue an

exce

ption

repo

rt to

the pr

ovide

r indic

ating

all

defec

ts or

reas

ons k

nown

at th

at tim

e tha

t the

claim

is no

t a cl

ean c

laim.

The

exce

ption

repo

rt sh

all co

ntain

at a m

inimu

m the

follo

wing

Meets

Me

ets

Meets

Le

vel I

and I

I edit

s occ

ur at

the c

learin

ghou

se an

d han

dled w

ithin

5 wor

king d

ays.

The

clea

ringh

ouse

bear

s res

pons

ibility

for

prov

iding

exce

ption

repo

rts to

the p

rovid

ers.


28

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

infor

matio

n:

17.2.

2.1 M

embe

r nam

e; Me

ets

Meets

Me

ets

17.2.

2.2 P

rovid

er cl

aim nu

mber

, pati

ent a

ccou

nt nu

mber

, or u

nique

mem

ber id

entifi

catio

n num

ber;

Meets

Me

ets

Meets

17.2.

2.3 D

ate of

servi

ce;

Meets

Me

ets

Meets

17

.2.2.4

Tota

l bille

d cha

rges

; Me

ets

Meets

Me

ets

17.2.

2.5 C

CN’s

name

; and

Me

ets

Meets

Me

ets

17.2.

2.6 T

he da

te the

repo

rt wa

s gen

erate

d. Me

ets

Meets

Me

ets

17.2.

3 Med

ical n

eces

sity;

Meets

Me

ets

Meets

Cl

inica

l edit

s are

capa

ble of

verify

ing w

hen a

proc

edur

e is f

or

certa

in ge

nder

or an

age,

e.g.,

the cl

aim ed

its w

ill be

able

to de

tect if

preg

nanc

y-rela

ted se

rvice

s are

inad

verte

ntly b

eing

assig

ned t

o a m

ale m

embe

r. Re

fer to

17.2.

4 app

lies e

dits

acco

rding

ly.

17.2.

4 Prio

r App

rova

l – T

he sy

stem

shall

de

termi

ne w

hethe

r a co

vere

d ser

vice r

equir

ed pr

ior

appr

oval

and i

f so,

wheth

er th

e CCN

gran

ted su

ch

appr

oval;

Meets

Me

ets

Meets

17.2.

5 Dup

licate

Clai

ms –

The s

ystem

shall

in an

au

tomate

d man

ner,

flag a

claim

as be

ing ex

actly

the

same

as a

prev

iously

subm

itted c

laim

or a

poss

ible d

uplic

ate an

d eith

er de

ny or

pend

the

claim

as ne

eded

;

Meets

Me

ets

Meets

Aetna

Bett

er H

ealth

's Bu

sines

s App

licati

on M

anag

emen

t (BA

M)

Depa

rtmen

t is re

spon

sible

for th

e acc

urate

and e

fficien

t co

nfigu

ratio

n of fu

nctio

nal b

usine

ss re

quire

ments

and r

ules w

ithin

QNXT

™ n

eces

sary

for ad

minis

trativ

e ser

vices

to oc

cur.

This

inc

ludes

mee

ting c

laims

proc

essin

g stan

dard

s and

auto-

adjud

icatio

n tar

gets.

The

objec

tives

of th

e buil

d are

to:

● An

alyze

busin

ess r

equir

emen

ts to

desig

n and

confi

gure

an

optim

al an

d effic

ient s

ystem

build

that

will m

inimi

ze th

e nee

d for

man

ual p

roce

ssing

.


29

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.2.

6 Cov

ered

Ser

vices

- Se

e tha

t the s

ystem

ve

rify th

at a s

ervic

e is a

cove

red s

ervic

e and

is

eligib

le for

paym

ent;

Meets

Me

ets

Meets

17.2.

7 Pro

vider

Vali

datio

n - S

ee th

at the

syste

m sh

all ap

prov

e for

paym

ent o

nly th

ose c

laims

re

ceive

d fro

m pr

ovide

rs eli

gible

to re

nder

servi

ce

for w

hich t

he cl

aim w

as su

bmitte

d;

Meets

Me

ets

Meets

17.2.

8 Qua

ntity

of Se

rvice

- Se

e tha

t the s

ystem

sh

all ev

aluate

claim

s for

servi

ces p

rovid

ed to

me

mber

s to s

ee th

at an

y app

licab

le be

nefit

limits

ar

e app

lied;

Meets

Me

ets

Meets

17.2.

9 Per

form

syste

m ed

its fo

r vali

d date

s of

servi

ce, a

nd as

sure

that

dates

of se

rvice

s are

valid

da

tes su

ch as

not in

the f

uture

or ou

tside

of a

memb

er’s

Medic

aid el

igibil

ity sp

an;

Meets

Me

ets

Meets

● Lo

ad th

e rule

s and

requ

ireme

nts of

a ne

w he

alth p

lan,

prod

uct o

r bus

iness

func

tion i

n the

claim

s pro

cess

ing

syste

m, in

cludin

g elig

ibility

file l

ayou

t, pro

vider

contr

acts,

fee

sche

dules

and m

embe

r ben

efits

and p

rior a

uthor

izatio

n re

quire

ments

. ●

Comp

lete c

onfig

urati

on do

cume

ntatio

n whil

e ente

ring t

he

build

infor

matio

n. ●

Audit

and v

alida

te the

build

base

d on t

he ru

les an

d re

quire

ments

state

d by t

he he

alth p

lan an

d the

im

pleme

ntatio

n tea

m.

● Jo

intly

perfo

rm un

it tes

ting w

ith th

e Ope

ratio

ns P

roce

ss

Know

ledge

Man

agem

ent (

OPKM

) Tes

ting t

eam

to va

lidate

tha

t the s

ystem

is op

erati

onal

and m

eets

busin

ess

requ

ireme

nts.

● Pa

rticipa

te in

end-

to-en

d tes

ting w

ith al

l impa

cted

depa

rtmen

ts to

see t

hat th

e sys

tem is

oper

ating

as ex

pecte

d.

17.2.

10 P

erfor

m po

st-pa

ymen

t rev

iew on

a sa

mple

of cla

ims t

o see

that

servi

ces p

rovid

ed w

ere

medic

ally n

eces

sary;

and

Meets

Me

ets

Meets

17.2.

11 H

ave a

staff

of qu

alifie

d, me

dicall

y tra

ined

and a

ppro

priat

ely lic

ense

d per

sonn

el, co

nsist

ent

with

NCQA

accre

ditati

on st

anda

rds,

whos

e prim

ary

dutie

s are

to as

sist in

evalu

ating

claim

s for

med

ical

nece

ssity

.

Meets

Me

ets

Meets

Aetna

Bett

er H

ealth

main

tains

an in

depe

nden

t (i.e

. doe

s not

repo

rt to

claim

s lea

dersh

ip) po

st-pa

ymen

t Aud

it Dep

artm

ent

resp

onsib

le for

draw

ing st

ratifi

ed ra

ndom

samp

les an

d co

nduc

ting f

ocus

ed au

dits o

f paid

and d

enied

claim

s. Th

e pu

rpos

e of th

ese a

ctivit

ies is

to au

dit co

mplia

nce o

f clai

ms

adjud

icatio

n with

DHH

regu

lator

y req

uirem

ents

and p

rovid

er

contr

acts.

Aud

it find

ings a

re sh

ared

with

Clai

ms m

anag

emen

t for

root

caus

e ana

lysis

and c

orre

ctive

actio

n.


30

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.3

Expl

anat

ion

of B

enef

its (E

OBs)

17

.3.1 T

he C

CN sh

all w

ithin

forty-

five (

45) d

ays o

f pa

ymen

t of c

laims

, pro

vide i

ndivi

dual

notic

es to

a sa

mple

grou

p of th

e mem

bers

who r

eceiv

ed

servi

ces.

The r

equir

ed no

tice m

ust s

pecif

y:

17.3.

1.1.1

The s

ervic

e fur

nishe

d;

17.3.

1.1.2

The n

ame o

f the p

rovid

er fu

rnish

ing th

e se

rvice

;

17.3.

1.1.3

The d

ate on

whic

h the

servi

ce w

as

furnis

hed;

and

17.3.

1.1.4

The a

moun

t of th

e pay

ment

made

for

the se

rvice

.

17.3.

2 The

CCN

shall

also

:

17.3.

2.1 In

clude

in th

e sam

ple, c

laims

for s

ervic

es

with

hard

bene

fit lim

its, d

enied

claim

s with

mem

ber

resp

onsib

ility,

and p

aid cl

aims (

exclu

ding a

ncilla

ry an

d ane

sthes

ia se

rvice

s).

17.3.

2.2 S

tratify

paid

claim

s sam

ple to

see t

hat a

ll pr

ovide

r typ

es (o

r spe

cialtie

s) ar

e rep

rese

nted i

n the

pool

of ge

nera

ted E

OBs.

To th

e exte

nt tha

t the

CCN

cons

iders

a par

ticula

r spe

cialty

(or p

rovid

er)

to wa

rrant

close

r scru

tiny,

the C

CN m

ay ov

er

samp

le the

grou

p. Th

e paid

claim

s sam

ple sh

ould

be a

minim

um of

two h

undr

ed (2

00) t

o two

hu

ndre

d-fift

y (25

0) cl

aims p

er ye

ar.

See e

xplan

ation

Ae

tna B

etter

Hea

lth ac

know

ledge

s and

will

comp

ly. A

ll elem

ents

requ

ired i

n the

Exp

lanati

on of

Ben

efits

will b

e inc

luded

in th

e EO

B pr

ovide

d to C

CN m

embe

rs. A

s new

EOB

requ

ireme

nts an

d ele

ments

are u

pdate

d, Ae

tna B

etter

Hea

lth w

ill co

mply

and a

s su

ch, m

ake n

eces

sary

modif

icatio

ns to

exist

ing E

OB re

porte

d fie

lds as

requ

ired.


31

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.3.

3 The

CCN

shall

trac

k any

comp

laints

re

ceive

d fro

m me

mber

s and

reso

lve th

e co

mplai

nts ac

cord

ing to

its es

tablis

hed p

olicie

s an

d pro

cedu

res.

The r

esolu

tion m

ay be

mem

ber

educ

ation

, pro

vider

educ

ation

, or r

eferra

l to D

HH.

The C

CN sh

all us

e the

feed

back

rece

ived t

o mo

dify o

r enh

ance

the E

OB sa

mplin

g me

thodo

logy.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth m

aintai

ns an

inter

nal, p

ropr

ietar

y app

licati

on

that s

uppo

rts th

e Grie

vanc

e and

App

eals

proc

ess b

y tra

cking

me

mber

and p

rovid

er is

sues

from

ince

ption

to re

solut

ion. T

his

affor

ds us

the m

eans

to ad

dres

s not

only

issue

s affe

cting

ind

ividu

al me

mber

and p

rovid

er sa

tisfac

tion,

but p

otenti

al tre

nds

in the

deliv

ery s

ystem

as a

whole

, per

mittin

g hea

lth pl

an

perso

nnel

to tak

e pro

mpt, c

orre

ctive

step

s to m

inimi

zing r

isks t

o pe

rform

ance

stan

dard

s. F

eedb

ack r

eceiv

ed du

ring t

his pr

oces

s or

feed

back

rece

ived t

hrou

gh ot

her m

eans

, will

be sh

ared

with

the

appr

opria

te pe

rsonn

el wi

thin t

he C

laims

unit f

or fu

ture

hand

ling a

nd m

odific

ation

s in c

once

rt wi

th the

IT D

epar

tmen

t. Ae

tna B

etter

Hea

lth w

ill us

e the

feed

back

rece

ived v

ia the

me

mber

comp

liant

syste

m to

impr

ove o

ur E

OB sa

mplin

g me

thodo

logy.

Resu

lts of

mem

ber f

eedb

ack w

ill be

revie

wed b

y ou

r Ser

vice I

mpro

veme

nt Co

mmitte

e (SI

C) an

d res

ults f

orwa

rded

to

QM/U

M Co

mmitte

e for

revie

w an

d rec

omme

ndati

ons

deve

loped

.

17.4

Rem

ittan

ce A

dvice

s In

conj

unct

ion

with

its p

aym

ent c

ycles

, the

CCN

shall

pro

vide:

17

.4.1 E

ach r

emitta

nce a

dvice

gene

rated

by th

e CC

N to

a pro

vider

shall

, if kn

own a

t that

time,

clear

ly ide

ntify

for ea

ch cl

aim, th

e foll

owing

inf

orma

tion:

Meets

Me

ets

Meets

17.4.

1.1 T

he na

me of

the m

embe

r; Me

ets

Meets

Me

ets

17.4.

1.2 U

nique

mem

ber id

entifi

catio

n num

ber;

Meets

Me

ets

Meets

17.4.

1.3 P

atien

t clai

m nu

mber

or pa

tient

acco

unt

numb

er;

Meets

Me

ets

Meets

QNXT

™, A

etna B

etter

Hea

lth's

core

tran

sacti

on pr

oces

sing

syste

m, ge

nera

tes pa

per R

emitta

nce A

dvice

s (RA

s) for

our

prov

iders.

In ad

dition

, pro

vider

s tak

ing ad

vanta

ge of

our

Elec

tronic

Fun

d Tra

nsfer

(EFT

) cap

abilit

y hav

e the

optio

n of

rece

iving

Elec

tronic

Rem

ittanc

e Adv

ices (

ERAs

). Bu

sines

s Ap

plica

tion M

anag

emen

t (BA

M) pe

rsonn

el co

nfigu

re Q

NXT™

to

gene

rate

RAs f

orma

tted s

uch t

hat r

equir

ed da

ta ele

ments

are

read

ily id

entifi

able.


32

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.4.

1.4 D

ate of

servi

ce;

Meets

Me

ets

Meets

17

.4.1.5

Tota

l pro

vider

char

ges;

Meets

Me

ets

Meets

17.4.

1.6 M

embe

r liab

ility,

spec

ifying

any c

o-ins

uran

ce, d

educ

tible,

co-p

ayme

nt, or

non-

cove

red

amou

nt;

Meets

Me

ets

Meets

17.4.

1.7 A

moun

t paid

by th

e CCN

; Me

ets

Meets

Me

ets

17.4.

1.8 A

moun

t den

ied an

d the

reas

on fo

r den

ial;

and

Meets

Me

ets

Meets

The f

ollow

ing st

ateme

nt sh

all be

inclu

ded o

n eac

h re

mitta

nce a

dvice

sent

to pr

ovide

rs: “I

unde

rstan

d tha

t pay

ment

and s

atisfa

ction

of th

is cla

im w

ill be

fro

m fed

eral

and s

tate f

unds

, and

that

any f

alse

claim

s, sta

temen

ts, do

cume

nts, o

r con

cealm

ent o

f a m

ateria

l fact,

may

be pr

osec

uted u

nder

ap

plica

ble fe

dera

l and

/or st

ate la

ws.”

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth’s

exist

ing re

mitta

nce a

dvice

can b

e co

nfigu

red t

o mee

t this

requ

ireme

nt.

17.5

Adhe

renc

e to

Key C

laim

s Man

agem

ent S

tand

ards

17.5.

1 Pro

mpt

Pay

men

t to

Prov

ider

s 17

.5.1.1

The

CCN

shall

see t

hat n

inety

perce

nt (9

0%) o

f all c

lean c

laims

for p

ayme

nt of

servi

ces

deliv

ered

to a

memb

er ar

e paid

by th

e CCN

to th

e pr

ovide

r with

in fift

een (

15) b

usine

ss da

ys of

the

rece

ipt of

such

claim

s.

See e

xplan

ation

17.5.

1.2 T

he C

CN sh

all pr

oces

s and

, if

appr

opria

te, pa

y with

in thi

rty (3

0) ca

lenda

r day

s, nin

ety-n

ine pe

rcent

(99%

) of a

ll clea

n clai

ms to

pr

ovide

rs for

cove

red s

ervic

es de

liver

ed to

a

See e

xplan

ation

Aetna

Bett

er H

ealth

pres

ently

man

ages

its cl

aims p

ayme

nt pr

oces

s suc

h tha

t Stat

e man

dated

paym

ent ti

mefra

mes a

re ei

ther

met o

r exc

eede

d by t

he C

laim’

s Unit

. For

exam

ple, in

Flor

ida,

Aetna

Bett

er H

ealth

man

ages

the c

laim

proc

ess s

uch t

hat th

e en

tire cl

aims p

roce

ss is

comp

leted

with

12 da

ys on

aver

age,

with

an ad

ded 7

days

tagg

ed on

to th

e pro

cess

to ac

coun

t for c

heck

iss

uanc

e pur

pose

s, so

that

the to

tal tim

e to p

roce

ss, o

n ave

rage

is

20 bu

sines

s day

s (the

requ

ireme

nt is

20 da

ys),

thus t

he cl

aim

paym

ent ti

me ex

ceed

s the

man

dator

y tim

efram

e in F

lorida

. Ae

tna B

etter

Hea

lth an

ticipa

tes al

so ex

ceed

ing th

e exp

ectat

ions


33

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

memb

er.

of the

Louis

iana D

epar

tmen

t of H

ealth

’s wh

ich pr

ovide

for

paym

ent o

f 90%

of cl

ean c

laims

with

in fift

een d

ays a

nd 99

%

paym

ent w

ithin

the al

lotted

thirty

calen

dar d

ay tim

efram

e.

17.5.

1.3 If

a clea

n clai

m is

denie

d on t

he ba

sis th

e pr

ovide

r did

not s

ubmi

t req

uired

infor

matio

n or

docu

menta

tion w

ith th

e clai

m, th

en th

e rem

ittanc

e ad

vice s

hall s

pecif

ically

iden

tify al

l suc

h inf

orma

tion a

nd do

cume

ntatio

n. Re

subm

ission

of a

claim

with

furth

er in

forma

tion a

nd/or

do

cume

ntatio

n sha

ll not

cons

titute

a new

claim

for

purp

oses

of es

tablis

hing t

he tim

efram

e for

timely

fili

ng.

Meets

Me

ets

Meets

W

hen a

n othe

rwise

claim

denie

s spe

cifica

lly on

the b

asis

of lac

k of

docu

menta

tion r

equir

ed to

proc

ess t

he cl

aim, th

e rem

ittanc

e ad

vice i

denti

fies w

ith sp

ecific

ity th

e rea

son f

or th

e den

ial.

Prov

iders

are i

nstru

cted t

o res

ubmi

t the c

laim,

alon

g with

the

requ

ired d

ocum

ent a

nd to

notat

e tha

t the c

laim

is a r

esub

miss

ion.

As su

ch, th

ose c

laims

with

the “

resu

bmiss

ion” n

otatio

n rec

eive

are a

djudic

ated f

or tim

ely fil

ing us

ing th

e orig

inal s

ubmi

ssion

date

of the

claim

.

17.5.

1.4 T

o the

exten

t that

the pr

ovide

r con

tract

requ

ires c

ompe

nsati

on of

a pr

ovide

r on a

ca

pitati

on ba

sis or

on an

y othe

r bas

is tha

t doe

s not

requ

ire th

e sub

miss

ion of

a cla

im as

a co

nditio

n to

paym

ent, s

uch p

ayme

nt sh

all be

mad

e to t

he

prov

ider b

y no l

ater t

han:

● Th

e tim

e per

iod sp

ecifie

d in t

he pr

ovide

r co

ntrac

t betw

een t

he pr

ovide

r and

the C

CN, o

r if a

time p

eriod

is no

t spe

cified

in th

e con

tract:

−

The t

enth

(10th

) day

of th

e cale

ndar

mon

th if

the pa

ymen

t is to

be m

ade b

y a co

ntrac

tor,

or

− If t

he C

CN is

requ

ired t

o com

pens

ate th

e pr

ovide

r dire

ctly,

withi

n five

(5) c

alend

ar da

ys

after

rece

ipt of

the c

apita

ted pa

ymen

t and

su

ppor

ting m

embe

r ros

ter in

forma

tion f

rom

DHH.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth ca

pitate

d con

tracts

prov

ide fo

r pay

ment

by

the 15

th cale

ndar

day o

f the m

onth.

Netw

ork p

rovid

ers i

ndica

te the

ir agr

eeme

nt wi

th thi

s tim

efram

e as e

viden

ced b

y the

ir sign

ing

the ag

reem

ent a

nd th

e spe

cific

prov

ider r

ate at

tachm

ent.


34

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.5.

1.5 T

he C

CN sh

all no

t den

y pro

vider

claim

s on

the b

asis

of un

timely

filing

in si

tuatio

ns

rega

rding

coor

dinati

on of

servi

ces o

r sub

roga

tion,

in wh

ich ca

se th

e pro

vider

is pu

rsuing

paym

ent

from

a thir

d par

ty. In

situa

tions

of th

ird pa

rty

bene

fits, th

e tim

efram

es fo

r filin

g a cl

aim sh

all

begin

on th

e date

that

the th

ird pa

rty co

mplet

es

reso

lution

of th

e clai

m.

Meets

Me

ets

Meets

Ae

tna B

etter

Hea

lth ac

know

ledge

s and

will

comp

ly. A

etna B

etter

He

alth a

ckno

wled

ges D

HH’s

timely

failin

g rela

ted to

subr

ogate

d or

COB

claim

s and

will

comp

ly wi

th sa

id re

quire

ments

. It is

Ae

tna B

etter

Hea

lth’s

stand

ard o

pera

ting p

roce

dure

to ac

cept

claim

s tha

t are

with

in the

statu

torily

allot

ted tim

ely fil

ing lim

its,

and t

hose

timefr

ames

and o

ther c

onsid

erati

ons a

pplic

able

to su

brog

ated c

laims

or co

ordin

ation

of be

nefits

17.5.

1.6 T

he C

CN sh

all no

t pay

any c

laim

subm

itted b

y a pr

ovide

r who

is ex

clude

d fro

m pa

rticipa

tion i

n Med

icare

, Med

icaid,

or C

HIP

prog

ram

pursu

ant to

Sec

tion 1

128 o

r 115

6 of th

e So

cial S

ecur

ity A

ct or

is ot

herw

ise no

t in go

od

stand

ing w

ith D

HH.

Meets

Me

ets

Meets

As

part

of ou

r cre

denti

aling

proc

ess,

Aetna

Bett

er H

ealth

quer

ies

the lis

ting o

f exc

luded

indiv

iduals

, pur

suan

t to th

e req

uirem

ents

of se

ction

1128

or 11

56 of

the S

ocial

Sec

urity

Act,

and s

ees t

hat

those

prov

iders

treati

ng m

embe

rs co

vere

d und

er th

e agr

eeme

nt be

twee

n Aetn

a Bett

er H

ealth

and t

he D

HH, a

re in

good

stan

ding

with

DHH

prior

to co

mplet

ing th

e con

tracti

ng an

d cre

denti

aling

pr

oces

s. A

t rec

rede

ntiali

ng, th

e pro

cedu

res a

re fo

llowe

d to m

ake

certa

in go

od st

andin

g with

DHH

and l

ack o

f exc

lusion

or

restr

iction

for p

artic

ipatio

n in a

Med

icaid,

Med

icare

or ot

her

gove

rnme

nt he

althc

are p

rogr

am. A

etna B

etter

Hea

lth, th

roug

h its

vend

or P

DS, a

lso co

nduc

ts qu

eries

of no

n-ne

twor

k pro

vider

s, on

a p

eriod

ic an

d ran

dom

basis

, to su

pplem

ent it

s exis

ting q

uery

proc

esse

s rela

ted to

the c

ontra

cted n

etwor

k.

17.5.

2 Clai

ms D

isput

e Man

agem

ent

17.5.

2.1 T

he C

CN sh

all ha

ve an

inter

nal c

laims

dis

pute

proc

edur

e tha

t sha

ll be s

ubmi

tted t

o DHH

wi

thin t

hirty

(30)

days

of th

e date

the C

ontra

ct is

signe

d by t

he C

CN, w

hich w

ill be

revie

wed a

nd

appr

oved

by D

HH.

Meets

Me

ets

Meets

17.5.

2.2 T

he C

CN sh

all co

ntrac

t with

inde

pend

ent

revie

wers

to re

view

dispu

ted cl

aims.

Meets

Me

ets

Meets

Aetna

Bett

er H

ealth

’s Cl

aims A

dmini

strati

on D

epar

tmen

t emp

loys

full-ti

me cl

aims i

nquir

y and

Res

earch

Rep

rese

ntativ

es to

resp

ond

to pr

ovide

r que

stion

s, sta

tus in

quirie

s and

claim

s pay

ment

dispu

tes vi

a the

claim

s inq

uiry l

ine fr

om 8:

00 a.

m. to

5:00

p.m.

, Mo

nday

thro

ugh F

riday

. An a

utoma

ted te

lepho

ne sy

stem

allow

s ca

llers

to sp

eak d

irectl

y with

a Re

pres

entat

ive or

leav

e a de

tailed

me

ssag

e reg

ardin

g the

ir inq

uiry.


35

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.5.

2.3 T

he C

CN sh

all sy

stema

ticall

y cap

ture t

he

status

and r

esolu

tion o

f all c

laim

dispu

tes as

well

as

all a

ssoc

iated

docu

menta

tion.

Meets

Me

ets

Meets

W

hene

ver p

ossib

le, th

e pro

vider

inqu

iry w

ill be

reso

lved w

hile t

he

prov

ider is

on th

e pho

ne. I

f the p

rovid

er’s

inquir

y can

not b

e re

solve

d whil

e the

prov

ider is

on th

e pho

ne an

d the

prov

ider’s

inq

uiry r

equir

es ad

dition

al re

sear

ch to

reac

h res

olutio

n, the

n a

call t

rack

ing ca

se w

ill be

open

for t

he pr

ovide

r’s is

sue.

It is

the

depa

rtmen

t’s go

al to

rese

arch

and r

espo

nd to

the p

rovid

er’s

issue

s with

in fiv

e to t

en bu

sines

s day

s. W

hen i

t is no

t pos

sible

to re

solve

the i

ssue

with

in thi

s tim

e fra

me, th

en th

e iss

ue w

ill be

call

track

ed to

the a

ppro

priat

e dep

artm

ent, a

nd th

erea

fter f

ollow

ed by

an

inde

pend

ent r

eview

er. C

laim

dispu

tes m

ay es

calat

e, at

the

requ

est o

f the p

rovid

er, to

the G

rieva

nce a

nd A

ppea

ls pr

oces

s.

As su

ch tim

e, es

tablis

hed G

rieva

nce a

nd A

ppea

ls pr

oced

ures

are

follow

ed an

d app

lied t

o the

prov

ider’s

claim

disp

ute.

Aetna

Bett

er H

ealth

ackn

owled

ges a

nd w

ill co

mply

with

the

requ

ireme

nt to

subm

it its

spec

ific cl

aims d

ispute

polic

ies to

the

DHH

withi

n 30 d

ays o

f con

tract

awar

d. Cl

aim di

spute

data

is ca

pture

d by A

etna B

etter

Hea

lth in

its

syste

ms an

d fur

ther d

ocum

ented

thro

ugh t

he G

rieva

nce a

nd

Appe

als pr

oces

s, as

appli

cable

.


36

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

17.5.

3 Clai

ms P

aym

ent A

ccur

acy R

epor

t 17

.5.3.1

On a

mon

thly b

asis,

the C

CN sh

all su

bmit

a clai

ms pa

ymen

t acc

urac

y per

centa

ge re

port

to DH

H. T

he re

port

shall

be ba

sed o

n an a

udit

cond

ucted

by th

e CCN

. The

audit

shall

be

cond

ucted

by an

entity

or pe

rsonn

el ind

epen

dent

of cla

ims m

anag

emen

t as s

pecif

ied in

this

Secti

on

of the

RFP

, and

shall

utiliz

e a ra

ndom

ly se

lected

sa

mple

of all

proc

esse

d and

paid

claim

s upo

n ini

tial s

ubmi

ssion

in ea

ch m

onth.

A m

inimu

m sa

mple

cons

isting

of tw

o hun

dred

(200

) to t

wo

hund

red-

fifty (

250)

claim

s per

year

, bas

ed on

fin

ancia

l stra

tifica

tion,

shall

be se

lected

from

the

entire

popu

lation

of el

ectro

nic an

d pap

er cl

aims

proc

esse

d or p

aid up

on in

itial s

ubmi

ssion

.

Exce

eds

Exce

eds

Exce

eds

Aetna

Bett

er H

ealth

main

tains

a Cl

aims Q

uality

Rev

iew T

eam

to mo

nitor

quali

ty sta

ndar

ds fo

r all c

laims

proc

esse

s. Un

der t

he

direc

tion o

f the d

irecto

r of O

pera

tions

Pro

cess

and K

nowl

edge

Ma

nage

ment

(OPK

M), Q

uality

Rev

iew A

nalys

ts co

nduc

t ran

dom

and f

ocus

ed re

views

of pr

oces

sed c

laims

for p

ayme

nt, fin

ancia

l an

d pro

cedu

ral a

ccur

acy a

nd pr

ovide

r inqu

iry ca

lls, w

hich f

ocus

on

both

accu

racy

and c

ustom

er se

rvice

skills

. Per

forma

nce i

s me

asur

ed ag

ainst

estab

lishe

d dep

artm

ent g

uideli

nes.

More

over

, the C

laims

Qua

lity R

eview

Tea

m ful

ly au

dits t

he w

ork

of all

new

claim

s ana

lysts

for at

leas

t one

mon

th su

bseq

uent

to the

ir orie

ntatio

n and

train

ing. T

he au

dit st

arts

at 10

0 per

cent

of the

ir wor

k pro

duct

and d

ecre

ases

to a

stand

ard t

wo pe

rcent

by

the fif

th we

ek, p

rovid

ed th

e new

claim

s ana

lyst c

ontin

ues t

o mee

t cla

ims a

ccur

acy s

tanda

rds.

Finall

y, we

revie

w 16

prov

ider c

alls

per C

laims

Inqu

iry R

epre

senta

tive p

er m

onth,

asse

ssing

the

quali

ty of

servi

ce in

terac

tion a

nd ac

cura

cy of

infor

matio

n pr

ovide

d. Ind

ividu

al qu

ality

repo

rts ar

e pre

sente

d to t

he

Repr

esen

tative

and t

heir S

uper

visor

for c

orre

ctive

actio

n (e.g

., liv

e call

mon

itorin

g) if

appr

opria

te.

Quali

ty Re

view

Analy

sts co

nduc

t a se

ries o

f pre

-pay

ment

audit

s inc

luding

:

1)

A on

e per

cent

rand

om sa

mple

of sy

stem-

adjud

icated

cla

ims,

2)

A

two p

erce

nt ra

ndom

samp

le of

all an

alyst-

adjud

icated

cla

ims,

3)

A

daily

rand

om sa

mple

of bil

led cl

aims u

p to $

49,99

9.99,

and


37

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

4)

100 p

erce

nt of

all cl

aims w

ith bi

lled c

harg

es ov

er $5

0,000

. W

e will

have

one f

ull tim

e Aud

itor a

ssign

ed an

d we w

ill pu

ll a to

tal

of 4 a

udits

per m

onth;

two U

B (fa

cility

) file

s and

two 1

500

(phy

sician

) file

s bas

ed on

a tw

o wee

k paid

date/

chec

k cyc

le. O

ur

samp

le siz

e is 9

5/2/2

(95%

confi

denc

e; the

erro

r rate

is 2%

; with

a d

esire

d pre

cision

of +

/- 2%

) whic

h is a

n ave

rage

of 18

0+ cl

aims

revie

wed e

ach w

eek.

Eac

h file

prov

ides A

etna B

etter

Hea

lth w

ith

Paym

ent a

nd F

inanc

ial A

ccur

acy f

inding

s for

the p

eriod

audit

ed

and e

ach f

ile is

distr

ibuted

for r

eview

and r

espo

nse t

o all

appli

cable

depa

rtmen

ts.

17.5.

3.2 T

he m

inimu

m att

ribute

s to b

e tes

ted fo

r ea

ch cl

aim se

lected

shall

inclu

de:

● Cl

aim da

ta co

rrectl

y ente

red i

nto th

e clai

ms

proc

essin

g sys

tem;

● Cl

aim is

asso

ciated

with

the c

orre

ct pr

ovide

r; ●

Prop

er au

thoriz

ation

was

obtai

ned f

or th

e se

rvice

; ●

Memb

er el

igibil

ity at

proc

essin

g date

corre

ctly

appli

ed;

● Al

lowed

paym

ent a

moun

t agr

ees w

ith

contr

acted

rate;

●

Dupli

cate

paym

ent o

f the s

ame c

laim

has n

ot oc

curre

d; ●

Denia

l reas

on ap

plied

appr

opria

tely;

● Co

-pay

ment

appli

catio

n con

sider

ed an

d

Exce

eds

Exce

eds

Exce

eds

Post-

paym

ent a

udits

revie

w, at

a mi

nimum

, inclu

de au

dit fo

r the

att

ribute

s list

ed in

requ

ireme

nt 17

.5.3.2

., and

also

prov

ide fo

r re

view

of:

● Va

lid C

oding

, e.g.

prop

er us

e of c

odes

and m

odifie

r cod

es;

● Me

mber

eligi

bility

; ●

Data

entry

into

the sy

stems

is ac

cura

te;

● Tim

ely F

iling;

● Cl

aim is

asso

ciated

with

the c

orre

ct tre

ating

prov

ider;

● Pr

ior A

uthor

izatio

n req

uirem

ents;

●

Denia

l reas

ons a

pplie

d cor

rectl

y; ●

Bene

fit ap

plica

tion (

includ

ing lim

itatio

ns an

d exc

lusion

s);

● Co

ordin

ation

of B

enefi

ts ap

plica

tion;

●

Claim

s hist

ory r

eview

for d

uplic

ate cl

aim;

● Ma

nual

Prici

ng ap

plica

tion;


38

Par

t Tw

o: T

echn

ical

Pro

posa

l

Sec

tion

Q: C

laim

s M

anag

emen

t

Delaw

are

Flor

ida

Mary

land

Requ

irem

ent

Meet

s or E

xcee

ds R

equi

rem

ent

Expl

anat

ion

appli

ed, if

appli

cable

; ●

Effec

t of m

odifie

r cod

es co

rrectl

y app

lied;

and

● Pr

oper

codin

g.

● Co

ntrac

ted P

rovid

er an

d Spe

cial P

rovid

er ag

reem

ents,

such

as

one-

time c

ase a

gree

ments

and f

or bo

th en

surin

g pay

ment

amou

nt ag

rees

with

contr

acted

rate;

●

Modif

ier D

iscou

nts; a

nd

● Cl

aims b

undli

ng/un

bund

ling.

17.5.

3.3 T

he re

sults

of te

sting

at a

minim

um

shou

ld be

docu

mente

d to i

nclud

e: ●

Resu

lts fo

r eac

h attr

ibute

tested

for e

ach c

laim

selec

ted;

● Am

ount

of ov

erpa

ymen

t or u

nder

paym

ent fo

r ea

ch cl

aim pr

oces

sed o

r paid

in er

ror;

● Ex

plana

tion o

f the e

rrone

ous p

roce

ssing

for

each

claim

proc

esse

d or p

aid in

erro

r; ●

Dete

rmina

tion i

f the e

rror is

the r

esult

of a

keyin

g erro

r or t

he re

sult o

f erro

r in th

e co

nfigu

ratio

n or t

able

maint

enan

ce of

the

claim

s pro

cess

ing sy

stem;

and

● Cl

aims p

roce

ssed

or pa

id in

erro

r hav

e bee

n co

rrecte

d.

Exce

eds

Exce

eds

Exce

eds

Audit

docu

menta

tion c

ompr

ises,

at a m

inimu

m, do

cume

ntatio

n of

findin

gs by

attrib

ute, th

e amo

unt o

f the a

ssoc

iated

un

der/o

verp

ayme

nt, th

e roo

t cau

se an

d res

olutio

n stat

us. A

udit

files r

emain

'ope

n' un

til all

iden

tified

issu

es ha

ve be

en re

solve

d an

d cor

recti

ons/a

djustm

ents

imple

mente

d acc

ordin

gly.

17.5.

3.4 If

the C

CN co

ntrac

ted fo

r the

prov

ision

of

any c

over

ed se

rvice

s, an

d the

CCN

’s co

ntrac

tor is

re

spon

sible

for pr

oces

sing c

laims

, then

the C

CN

shall

subm

it a cl

aims p

ayme

nt ac

cura

cy

perce

ntage

repo

rt for

the c

laims

proc

esse

d by t

he

contr

actor

.

Exce

eds

Exce

eds

Exce

eds

Deleg

ated v

endo

rs ar

e req

uired

to m

atch A

etna B

etter

Hea

lth’s

Claim

s aud

iting p

roce

dure

s. T

o mon

itor c

ompli

ance

with

this

contr

actua

l requ

ireme

nt, A

etna B

etter

Hea

lth co

nduc

ts a s

emi-

annu

al an

d ann

ual e

valua

tion o

f dele

gated

vend

or cl

aims

audit

ing pr

oces

ses,

and w

e will

includ

e a re

view

of DH

H sp

ecific

au

dit re

quire

ments

as pa

rt of

our d

elega

tion o

versi

ght p

roce

ss.


39

115 Q.2



Q.2 Describe your methodology for ensuring that claims payment accuracy standards will be achieved per, Adherence to Key Claims Management Standards Section. At a minimum address the following in your response:

● The process for auditing a sample of claims as described in Key Claims Management Standards Section;

● The sampling methodology itself;

● Documentation of the results of these audits; and

● The processes for implementing any necessary corrective actions resulting from an audit.

Methodology for Claims Payment Accuracy Standards Claims Accuracy Standards Introduction Aetna Better Health takes pride in our claims performance, nationally – for all Aetna Better Health affiliates, we adjudicate over 80 percent of clean claims within 10 days of receipt and over 95 percent within 30 days of receipt. We also continuously evaluate methods to improve our payment processes and streamline payment. Our processing goal is to adjudicate 90 percent of all Louisiana clean claims within 15 business days of receipt and 99 percent within 30 business days of receipt. When a claim reaches either a pay, deny or reverse status, it is ready for final processing. We process claims in a pay status through weekly finance payment runs.

Our claims processing system determines the timeliness of claims adjudication. We use the claim’s receipt/clean date to calculate the submission window. Discounts are calculated at the time of the check run based on the receipt date of the claim. Within 48 hours of receiving a “pay status” claim, Aetna’s Automated Business Fulfillment (ABF) generates, prints and mails payments and corresponding remittance advice to providers, including the minimum required information elements as well as HIPAA compliant remit comments. We also provide electronic remittance advices to providers that include all fields required for compliance with the HIPAA 835 format.

For those clean claims which are denied due to lack of required or additional information necessary to review the claim, then the remittance advice will indicate the denial reason, with specificity, so that the provider is able to take the necessary action in support of claim resubmission. Additionally, Aetna Better Health providers are instructed to indicate that a claim is a “resubmission” and as such, allows the provider claim to be adjudicated using the same timely filing date as the original claim.

Key Claims Management Standards 1) Requirement - On a monthly basis, the Coordinated Care Network (CCN) shall submit a

claims payment accuracy percentage report to DHH. The report shall be based on an audit conducted by the CCN. The audit shall be conducted by an entity or staff independent of claims management as specified in this Section of the RFP, and shall utilize a randomly selected sample of all processed and paid claims upon initial submission in each month. A minimum sample consisting of two hundred (200) to two hundred-fifty (250) claims per year,


40



based on financial stratification, shall be selected from the entire population of electronic and paper claims processed or paid upon initial submission.

Response: Aetna Better Health's Claims Audit Department conducts an average of 48 post-payment audits a year; performing approximately two CMS1500 and two UB04 audits each month, thus exceeding the DHH’s requirements. Auditors review on average 187 Paid/Denied claims per health plan per week, depending on claim volume. The unit operates independent of our Claims Department and bears responsibility for submission of the monthly Claims Accuracy Percentage Report to DHH.

2) Requirement - The CCN shall process and, if appropriate, pay within thirty (30) calendar days, ninety-nine percent (99%) of all clean claims to providers for covered services delivered to a member.

Response: Aetna Better Health presently manages its claims payment process such that State mandated payment timeframes are either met or exceeded by the Claim’s Unit. For example, in Florida, Aetna Better Health manages the claim process such that the entire claims process is completed with 12 days on average, with an added 7 days tagged on to the process to account for check issuance purposes, so that the total time to process, on average is 20 business days (the requirement is 20 days), thus the claim payment time exceeds the mandatory timeframe in Florida. Aetna Better Health anticipates also exceeding the requirements of the Louisiana DHH, which provide for payment of 90% of clean claims within fifteen days and 99% payment within the allotted thirty calendar day timeframe.

3) Requirement - If a clean claim is denied on the basis the provider did not submit required information or documentation with the claim, and then the remittance advice shall specifically identify all such information and documentation. Resubmission of a claim with further information and/or documentation shall not constitute a new claim for purposes of establishing the timeframe for timely filing.

Response: When an otherwise clean claim denies specifically on the basis of lack of documentation required to process the claim, the remittance advice identifies with specificity the reason for the denial. Providers are instructed to resubmit the claim, along with the required document and to notate that the claim is a resubmission. As such, those claims with the “resubmission” notation receive are adjudicated for timely filing using the original submission date of the claim.

4) Requirement - To the extent that the provider contract requires compensation of a provider on a capitation basis or on any other basis that does not require the submission of a claim as a condition to payment, such payment shall be made to the provider by no later than:

The time period specified in the provider contract between the provider and the CCN, or if a time period is not specified in the contract:

- The tenth (10th) day of the calendar month if the payment is to be made by a contractor, or


41



- If the CCN is required to compensate the provider directly, within five (5) calendar days after receipt of the capitated payment and supporting member roster information from DHH.

Response: Aetna Better Health capitated contracts provide for payment by the 15th calendar day of the month. Network providers indicate their agreement with this timeframe as evidenced by their signing the agreement and the specific provider rate attachment.

5) The CCN shall not deny provider claims on the basis of untimely filing in situations regarding coordination of services or subrogation, in which case the provider is pursuing payment from a third party. In situations of third party benefits, the timeframes for filing a claim shall begin on the date that the third party completes resolution of the claim.

Response: Aetna Better Health acknowledges DHH’s timely failing related to subrogated or COB claims and will comply with said requirements. It is Aetna Better Health’s standard operating procedure to accept claims that are within the statutorily allotted timely filing limits, and those timeframes and other considerations applicable to subrogated claims or coordination of benefits.

6) Requirement - The CCN shall not pay any claim submitted by a provider who is excluded from participation in Medicare, Medicaid, or CHIP program pursuant to Section 1128 or 1156 of the Social Security Act or is otherwise not in good standing with DHH.

Response: As part of our credentialing process, Aetna Better Health queries the listing of excluded individuals, pursuant to the requirements of section 1128 or 1156 of the Social Security Act, and sees that, through the same process, those providers treating members covered under the agreement between Aetna Better Health and the DHH, are in good standing with DHH prior to completing the contracting and credentialing process. At re-credentialing, the procedures are followed to make certain good standing with DHH and lack of exclusion or restriction for participation in a Medicaid, Medicare or other government healthcare program. Aetna Better Health, through its vendor PDS, also conducts queries of non-network providers, on a periodic and random basis, to supplement its existing query processes related to the contracted network.

7) Requirement - Post-payment audits review, at a minimum,

• Results for each attribute tested for each claim selected;

• Amount of overpayment or underpayment for each claim processed or paid in error;

• Explanation of the erroneous processing for each claim processed or paid in error;

• Determination if the error is the result of a keying error or the result of error in the configuration or table maintenance of the claims processing system; and

• Claims processed or paid in error have been corrected.

Response: Aetna Better Health’s auditing processes exceed the DHH’s mandated audit elements and also include documentation of findings by attribute, the amount of


42



the associated under/overpayment, the root cause and resolution status. Audit files remain 'open' until all identified issues have been resolved and corrections/adjustments implemented accordingly.

8) Requirement: If the CCN contracted for the provision of any covered services, and the CCN’s contractor is responsible for processing claims, then the CCN shall submit a claims payment accuracy percentage report for the claims processed by the contractor.

Response: Delegated vendors are required to match Aetna Better Health’s Claims auditing procedures. To monitor compliance with this contractual requirement, Aetna Better Health conducts a semi-annual and annual evaluation of delegated vendor claims auditing processes, and we will include a review of DHH specific audit requirements as part of our delegation oversight process.

Claims Auditing Process Aetna Better Health maintains a Claims Quality Review Team to monitor quality standards for all claims processes. Under the direction of the director of Operations Process and Knowledge Management (OPKM), Quality Review Analysts conduct random and focused reviews of processed claims for payment, financial and procedural accuracy and provider inquiry calls, which focus on both accuracy and customer service skills. Performance is measured against established department guidelines.

Moreover, the Claims Quality Review Team fully audits the work of all new claims analysts for at least one month subsequent to their orientation and training. The audit starts at 100 percent of their work product and decreases to a standard two percent by the fifth week, provided the new claims analyst continues to meet claims accuracy standards. Finally, we review 16 provider calls per Claims Inquiry Representative per month, assessing the quality of service interaction and accuracy of information provided. Individual quality reports are presented to the Representative and their Supervisor for corrective action (e.g., live call monitoring) if appropriate.

Quality Review Analysts conduct a series of pre-payment audits including:

1) A one percent random sample of system-adjudicated claims,

2) A two percent random sample of all analyst-adjudicated claims,

3) A daily random sample of billed claims up to $49,999.99, and

4) 100 percent of all claims with billed charges over $50,000.

Aetna Better Health will have one full-time auditor assigned and we will pull a total of four audits per month: two UB (facility) files and two 1500 (physician) files based on a two week paid date/check cycle. Our sample size is 95/2/2 (95% confidence; the error rate is 2%; with a desired precision of +/- 2%) which is an average of 180+ claims reviewed each week. Each file provides Aetna Better Health with Payment and Financial Accuracy findings for the period audited and each file is distributed for review and response to all applicable departments. Below is a summary of the claim audit process utilized by an auditor:

Random Statistically Valid (RSV) process: Standard audit sample sizes are determined using a statistically valid sample, based on the total population size. The Claims Audit RSV table uses


43



an algorithm to determine the level of confidence, expected error rate and the desired precision required, as validated by Aetna Better Health and its affiliate Actuarial Department. The RSV size and total population is documented on each audit file. An automated program is utilized to extract the random claims sample with a proportion of paid or denied claims consistent with the total population.

Payment Accuracy– Reflects the percent of accurate claims. Calculation: The total number of audited claims correctly paid, divided by the total number of claims audited.

Financial Accuracy – Reflects the percent of dollars paid appropriately. Calculation: (Total $ Paid - $ Overpaid) + $ Underpaid = Total Correct Paid then (Total Correct Paid - Total $ Incorrect) / Total Correct Paid.

Claim Audit Process: In this step, contractual appropriateness of the provider attachment to the contract, e.g., fee schedules in accordance to the contract, is validated.

• Provider Validation: All contracted providers have a signed contract on file that is accessible for use by the Claims Department and the designated auditor(s). The auditor validates the contractual appropriateness of the provider attachment to the source documentation and reports any discrepancies, and simultaneously notifies the Network Development Department of the discrepancy and track on the audit file.

• Contract Validation: All provider network contracts should be accessible for use by the Audit Department. Validate the contract system configuration for appropriateness to the source documentation and report any discrepancies, and notify the Business Applications Management Department and track on the audit file. Each claim line is analyzed for appropriateness of contract term selection during the audit process.

• Benefit Validation: Benefits are validated by referring to the listing of Medicaid/DHH covered services, which should be accessible for use by the Audit Department. Validate the benefit system configuration for appropriateness to the source documentation and report any discrepancies, including reporting to the Business Applications Management Department and track on the audit file. Each claim line is analyzed for appropriateness of the benefit term selection during the audit process.

• Claim Validation: Data field validation for each claim can be verified either through viewing the paper claim submitted via Alchemy or viewing the EDI data submitted. All claims are subjected to analysis that involves but is not limited to the following:

− Valid Coding, e.g. proper use of codes and modifier codes;

− Member eligibility;

− Data entry into the systems is accurate;

− Timely Filing;

− Claim is associated with the correct treating provider;

− Prior Authorization requirements;

− Denial reasons applied correctly;

− Benefit application (including limitations and exclusions);


44



Coordination of Benefits application;

Claims history review for duplicate claims;

Manual pricing application;

Contracted Provider and Special Provider agreements, such as one-time case agreements and for both ensuring payment amount agrees with contracted rate;

Modifier discounts; and

Claims bundling/unbundling. Claims Payment Accuracy Percentage Report and Audit On average, Aetna Better Health's Claims Audit Department conducts an average of 48 randomized, post-payment audits a year; performing approximately two CMS1500 and two UB04 each month of both paper and electronically processed or paid claims. Auditors review on average 187 Paid/Denied claims per health plan per week, depending on claim volume, as such; we exceed the DHH’s mandate to sample up to 250 claims per year. Additional, the audit unit operates independently of our Claims Department and bears responsibility for submission of the monthly Claims Accuracy Percentage Report to DHH.

Sampling Frame

Random audit of billed claims, up to $49,999.99, on a daily basis

Quality standard maintained at 95% for external procedural (98% for Pennsylvania)

Quality standard maintained at 98% for payment

Quality standard maintained at 99% for financial accuracy

16 calls randomly audited for each CICR analyst on a monthly basis

Quality standard maintained at 95%

100% daily audit of billed claims, $50,000 and greater, on a daily basis




New employees audited at descending rate starting at 100% post training




Random audit of 1% of claims that have been systematically adjudicated

Quality standard maintained at 95% for external procedural



Three closed PCR audited per day, per eligible PDA

Quality standard maintained at 98% accuracy


45



Edits Utilized in Support of Claim Adjudication and Accuracy Standards Aetna Better Health maintains claims processing activities that include the application of comprehensive clinical and data related edits supporting the efficient, accurate, effective adjudication of claims. QNXT™, our core claims adjudication application has data related edits configured within its software and is supplemented by two clinical claims editing solutions. The first of the two clinical claims editing solutions, iHealth Technologies’ (iHT) Integrated Claims Management Services (ICM Services), applies select payment policies from one of the industry’s most comprehensive correct coding and Medical Policy content libraries. The second, McKesson’s ClaimCheck®, expands upon those capabilities by enabling our claims management team to define and combine specific claims data criteria, such as eligibility, provider or diagnosis, duplicate claims and other unique edits we set up to deliver enhanced auditing power.

The three applications utilize historic and “new day” claims information to detect questionable billing practices, such as new patient billing codes submitted by the same provider for the same member within a six month period or other improper or invalid coding schematics. These applications also assist in identifying fraudulent and abusive billing patterns by generating reports that indicate trending and outliers of provider billing behavior. Inbound claims are initially checked for items such as member eligibility, covered services, excessive or unusual services for gender or age (e.g. “medically unlikely”), duplication of services, prior authorization, invalid procedure codes, and duplicate claims. Claims billed in excess of $50,000 are automatically pended for review, as are any requiring additional documentation (e.g. medical records) in order to determine the appropriateness of the service provided. Professional claims that reach an adjudicated status of “Pay” are automatically reviewed against nationally recognized standards such as the Correct Coding Initiative (CCI), medical policy requirements [e.g., American Medical Association (AMA)], and other requirements.

QNXT™ Data Edits QNXT™ has over 400 business rules that MCP configures to support enforcement of our claims Policies and Procedures (P&Ps). The application of specific conditions, restrictions, and validation criteria promote the accuracy of claim processing against AHCCCS standards. The edits can result in claims pending or denying depending on the editing logic. For example, if the member is not eligible on the date of service, QNXT™ will automatically deny the claim. In the event that the category of service of the provider of record does not match the procedure code billed the claim will pend for manual review to validate accuracy of provider set-up.



Data Accuracy QNXT™ is continually updated based on the most current code sets available (HCPCS, REV, CPT codes) by year. As new codes are added, terminated, or changed, we update the codes in QNXT™ so the system is always in compliance with HIPAA standards. If a network provider


46



bills a code that has been terminated, QNXT™ will deny the claim line and advise the provider the code is invalid via remittance advice.


Provider Qualifications QNXT™ provider files are configured by specialty and category of service. This allows for the enforcement of categories of service and provider type on claims validation. Certain procedures can only be performed by select network provider types. For example, QNXT™ will not permit the processing of a claim for in-office heart surgery by a podiatrist. iHealth lends additional support in this regard, reviewing any claim line set to “Pay” for billing appropriateness by specialty.

QNXT™ checks other provider-specific items as well, verifying, for example, that each provider has obtained the requisite National Provider Identifier (NPI) or its equivalent and included the identifier on all claims submissions.

Duplicate Billing Logic QNXT™ uses a robust set of edits to determine duplication of services. Examples are same member, same date, same network provider, same service, or any combination of these criteria. In addition, claim lines set to “Pay” are subjected to iHealth’s duplicate logic. This logic protects against MCP paying for services rendered by the same physician or other physicians within the same provider group

ClaimCheck® Edits ClaimCheck® is a comprehensive code auditing solution that supports QNXT™ by applying expert industry edits from a provider recognized knowledge base to analyze claims for accuracy and consistency with Aetna Better Health policies and procedures. ClaimCheck® clinical editing software identifies coding errors in the following categories:









• Medically Unlikely

Network providers do received access to Clear Claim Connection®, a provider reference tool that helps providers optimize their claims submission accuracy. Currently there are 2300


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provider groups have registered to use this web-based tool that providers can use to understand clinical editing logic utilized by Aetna Better Health. This allows them to better understand the rules and clinical rationale affecting adjudication. Providers access Clear Claim Connection® through Aetna Better Health’s internet web portal via secure login.

Various coding combinations can then be entered to determine why, for example, a particular coding combination resulted in a denial. The provider may also review coding combinations prior to claim submission, to determine if applicable auditing rules and clinical rationale will deny the claim before it is submitted.

iHealth Edits iHealth clinically edits claims to assist Aetna Better Health to promote the proper and fair payment of professional DME and outpatient claims.

Coding Accuracy If the services are up-coded, or unbundled, iHealth will alert the Claims Department to deny the claim line along with the specific clinical editing policy justification for the denial. The claim line will deny with the appropriate HIPAA remittance remark on the Explanation of Benefits (EOB).

Duplicate Billing Logic In addition, claim lines set to “Pay” are subjected to iHealth’s duplicate logic. This logic protects against Aetna Better Health paying for services rendered by the same physician or other physicians within the same provider group

Durable Medical Equipment (DME) Editing iHealth Technologies’ (iHT) performs edits related to select DME payment policies that align with Medicaid covered service policies. These DME edits include but are not limited to; DME rentals, oxygen and oxygen systems, hospital beds and accessories, external infusion pumps and anatomic/functional modifiers required for DME services.

Procedure Code Guidelines - iHealth Aetna Better Health follows the AMA CPT-4 Book and CMS HCPCS Book, which both provide instructions regarding code usage. iHT has developed these guidelines into edits. For example, if a vaccine administration code is billed without the correct vaccine/toxoid codes, Aetna Better Health would then deny the code as inappropriate coding based on industry standards. According to the AMA CPT Book, this vaccination must be reported in addition to the vaccine and toxoid code(s).

Procedure Code Definition Policies - iHealth iHT supports correct coding based on the definition or nature of a procedure code or combination of procedure codes. These editing policies will either bundle or re-code procedures based on the appropriateness of the code selection. For example, if a provider attempts to unbundle procedures, iHT will apply editing logic that will bundle all of the procedures billed into the most appropriate code. For example, if a provider bills an office visit and also bills separately for heart monitoring with a stethoscope at the same visit, iHT will rebundle the service into the appropriate evaluation and management or office code.


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Fraud & Abuse Aetna Better Health’s Fraud and Abuse Department, under the direction of the VP of Health Plan Operations, utilizes claims payment tracking and trending reports, claims edits, audits and provider billing patterns as indicators of potential fraud and abuse. The Fraud and Abuse Department uses this information to detect aberrant provider billing behavior, prompting additional analysis and investigation. Aetna Better Health’s fraud and abuse personnel work in conjunction with Aetna Better Health’s Provider Services and Compliance Departments to address the questionable behavior(s) through provider education and outreach. If MCP discovers, or becomes aware, that an incident of potential/suspected fraud and abuse has occurred, internal P&Ps mandate that we report the incident to AHCCCS within 10 business days of discovery by completing and submitting the confidential AHCCCS Referral for Preliminary Investigation form.

Claims Audit and Ongoing Accuracy Monitoring – Supportive Tools Aetna Better Health facilitates inter-departmental exchange of information and the external exchange of information between these departments and our providers through reporting and other educational interactions. We then inform providers of, among other things, any issue(s) potentially impacting claim adjudication or any opportunities for provider education. We utilize a suite of tools, including but not limited to, scheduled and ad hoc reports to monitor claim receipts, automated claims processing, manual claims adjudication, and check and remittance advice production/distribution. These tools and reports include, but are not limited to:

Pended Claims and Aging Report – the pended and aging claim reports allow management to effectively intervene when and where necessary to improve accurate and timely adjudication of claims. Populated hourly and reviewed daily, the tool presents claims counts and billed dollars by pend reason and claim age, with drill down capabilities to gather for review detailed claims information.

In-Process Claim Reports – In-process claims report allow management to effectively track and manage all claims in process so that needed interventions may be applied to improve the accuracy and timeliness of claim adjudication.

Claims Payment Processing Reports – This is a set of retrospective claims adjudication reports that are produced and reviewed weekly to provide claims, health plan operations and finance units with data to support reconciliation of claim volume and adjudicated dollars including information to support the reinsurance process.

Monthly Claims Dashboard –This management tool can be used to identify trends related to critical claims metrics. The claims dashboard is reviewed monthly by compliance, encounters, health plan operations, and finance personnel to identify appropriate action plans.

These reports are also utilized to proactively manage claims workflow so that timeliness is addressed before it becomes an issue. For example, based on such analysis, the Claim Department can take proactive action to address any trends that indicate a potential issue such as turnaround times or inventory levels for aging claims. It is our standard operating procedure to immediately determine a root cause and develop and implement the appropriate action plan. In the past, these plans have included one or more of the following:

1) System reconfiguration;


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2) Staff overtime;

3) Workload balancing;

4) Training of personnel and providers; and

5) Hiring and training temporary workers to assist with the reduction of claim inventories.

Based on our claims volume, we adjust hiring to accommodate any increased trends. Additional information on our claims monitoring and resolution of deficiencies process can be found in an illustration following our response.

Corrective Actions Process and Resolution of Deficiencies When pre-payment errors are discovered during the above referenced audits, claims are pended for analysis and adjusted as required for final adjudication. If an error in adjudication of the claim indicates a system configuration problem, the issue is routed to our Business Application Management (BAM) Department for further review, analysis, testing, and correction. If adjudication errors are identified relative to manually adjudicated claims, we review/update pertinent policies and procedures and institute additional training accordingly. If our audit identifies a provider billing issue, the information is forwarded to provider services personnel for provider outreach and education as necessary.

To further support quality reviews of claims processing accuracy, a post-payment audit occurs outside the Claims Department, where stratified random samples and focused audits of paid and denied claims are overseen. The purpose of these activities is to audit compliance of claims adjudication with state regulatory requirements and provider contracts. Audit results are shared with Claims management in order to identify training and/or coaching opportunities, qualify merit-based compensation and implement corrective action as necessary.

It is our standard operating procedure to continuously monitor the adequacy of our claims adjudication process to determine its effectiveness. Aetna Better Health uses the Plan-Do-Study-Act (PDSA) model to assess our claims administration, adjudication and management processes. Our PDSA approach involves the network development and provider services units and leadership from Aetna Better Health’s entire organization. The PDSA model for continuous improvement provides the framework for our approach to developing and implementing network interventions through the following steps:

1. Plan. Recognize an opportunity and plan a change. 2. Do. Test the change. Carry out a small-scale study. 3. Study. Review the test, analyze the results and identify what

we’ve learned. 4. Act. Take action based on what we learned in the study step: If

the change was ineffective, repeat cycle with a different plan. We incorporate successful interventions into our network development/management approach, using what we learned to plan new improvements, beginning the cycle again.


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The leadership from Aetna Better Health’s entire organization participates in the PDSA process. Supporting this process is our Service Improvement Committee, the QM/UM Committee and QMOC. Each of these committees includes cross functional and multidisciplinary leadership from across our operations. This means that member services, quality management, utilization management, grievance and appeals, and operations (e.g., claims, etc) are aware of and contribute to our claims administration planning and performance improvement activities. This organizational commitment to meeting the needs of our providers is a hallmark of Aetna Better Health success.


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116 Q.3



Q.3 Describe your methodology for ensuring that the requirements for claims processing, including adherence to all service authorization procedures, are met.

Introduction to Aetna Better Health’s Claim System Aetna Better Health along with its affiliates claims processing activities include the application of comprehensive clinical and data related edits that support the efficient, effective adjudication of claims. QNXT™, our core claims adjudication system, has data-related edits configured within its software and is supplemented by two clinical claims editing solutions. The first of the two clinical claims editing solutions, iHealth Technologies’ (iHT) Integrated Claims Management Services (ICM Services), applies select payment policies from one of the industry’s most comprehensive correct coding and Medical Policy content libraries. The second, McKesson’s ClaimCheck®, expands upon those capabilities by enabling our claims management team to define and combine specific claims data criteria, such as provider or diagnosis, to set up unique edits that deliver enhanced auditing power.

Inbound claims are initially checked for items such as member eligibility, covered services, excessive or unusual services for gender or age (e.g. “medically unlikely”), duplication of services, prior authorization compliance, invalid procedure codes, and duplicate claims. Claims billed in excess of $50,000 are automatically pended for review, as are any requiring additional documentation (e.g. medical records) in order to determine the appropriateness of the service provided. Aetna Better Health maintains a staff of qualified, medically trained and appropriately licensed personnel – consistent with NCQA accreditation standards – whose primary duty is to assist in the determination of medical necessity. Professional claims (CMS1500s) that reach an adjudicated status of “Pay” are automatically reviewed against nationally recognized standards such as the Correct Coding Initiative (CCI), medical policy requirements (e.g., American Medical Association (AMA)), and maximum unit requirements supplied by state agencies, with recommendations applied during an automatic re-adjudication process. Other methodologies utilized throughout the auto-adjudication process include, but are not limited to, Multiple Surgical Reductions and Global Day E & M Bundling.

Claims Management System Aetna Better Health uses the QNXT™ management information system, a product of Trizetto Inc., to process Medicaid member health claims. This rules-based system allows us to set multiple edits to test claims validity, allows us to customize the edits, and to otherwise pay or deny claims in accordance with the Louisiana Department of Health and Hospitals’ claims adjudication requirements. The QNXT™ edits include, but are not limited to,

• Verification of member eligibility

• Verification of covered services

• Determining whether services are within the scope of a provider’s specialty

• Valid prior authorization

• Submission of required documentation

• Excessive or unusual services based on the member’s age or gender


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• Duplication of services

• Invalid procedure codes

• Duplicate claims

Based on one or more of these edits, unusual items result in the claim being denied or pended for further review. The system also automatically pends for further review any claims over a certain dollar amount and requires that certain codes be accompanied with supporting medical records to determine the appropriateness of the service provided.

QNXT™ Data Edits in Support of Meeting Claims Processing Requirements QNXT™ has over 400 business rules that Aetna Better Health’s Business Application Management (BAM) Department configures to enforce claims-related Policies and Procedures (P&Ps). The application of specific conditions, restrictions, and validation criteria promotes the accuracy of claim processing against relevant and established state standards. The edits can result in claims pending or denying depending on the editing logic. For example, if the member is not eligible on the date of service, QNXT™ will automatically deny the claim. In the event that the category of service on the provider of record does not match the procedure code billed, the claim will pend for manual review to validate accuracy of provider set-up.



Data Accuracy QNXT™ is continually updated based on the most current code sets available (HCPCS, REV, CPT codes) by year. As new codes are added, terminated, or changed, we update the codes in QNXT™ so the system is always in compliance with HIPAA standards. If a network provider bills a code that has been terminated, QNXT™ will deny the claim line and advise the provider the code is invalid via remittance advice.


Provider Qualifications QNXT™ provider files are configured by specialty and category of service. This allows for the enforcement of categories of service and provider type on claims validation. Certain procedures can only be performed by select network provider types. For example, QNXT™ will not permit the processing of a claim for in-office heart surgery by a podiatrist. iHealth lends additional support in this regard, reviewing any claim line set to “Pay” for billing appropriateness by specialty. QNXT™ checks other provider-specific items as well, verifying, for example, that each


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provider has obtained the requisite National Provider Identifier (NPI) or its equivalent and included the identifier on all claims submissions.

Member Eligibility and Enrollment QNXTTM validates the date of service against the member’s enrollment segment to determine if the member was eligible on the date of service. If the member was not eligible on the date of service, the system will automatically deny the claim using the appropriate HIPAA approved remittance comment.

Duplicate Billing Logic QNXT™ uses a robust set of edits to determine duplication of services. Examples are same member, same date, same network provider, same service, or any combination of these criteria. In addition, claim lines set to “Pay” are subjected to iHealth’s duplicate logic. This logic protects against payment for services rendered by the same physician or other physicians within the same provider group

Other Claims Processing Edits and Tools Utilized to Ensure Accuracy Throughout Adjudication Process

ClaimCheck® Edits ClaimCheck® is a comprehensive code auditing solution that supports QNXTTM by applying expert industry edits from a provider recognized knowledge base to analyze claims for accuracy and consistency with relevant P&Ps. ClaimCheck® clinical editing software identifies coding errors in the following categories:









• Medically Unlikely Services iHealth Edits Aetna Better Health also uses Integrated Claims Management Services (ICM Services), powered by iHealth Technologies, to enhance QNXT™ edit functionality for professional claims that reach an adjudicated status of “pay”. Aetna Better Health has developed algorithms with iHealth to detect potential claims upcoding, with follow-up procedures for chart audits as appropriate. iHealth clinically edits claims to assist state agencies in promoting proper and fair payment of claims. Examples of applied edits include:

Coding Accuracy If services are up-coded or unbundled, iHealth will alert the Claims Department to deny the claim line along with the specific clinical editing policy justification for the denial. The claim


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line will deny with the appropriate HIPAA remittance remark on the Explanation of Benefits (EOB).

Duplicate Billing Logic In addition, claim lines set to “Pay” are subjected to iHealth’s duplicate logic. This logic protects against payment for services rendered by the same physician or other physicians within the same provider group

Durable Medical Equipment (DME) Editing iHealth Technologies’ (iHT) performs edits related to select DME payment policies that align with state agencies’ respective covered service policies. These edits include but are not limited to, DME rentals, oxygen and oxygen systems, hospital beds and accessories, external infusion pumps and anatomic/functional modifiers required for DME services.

Procedure Code Guidelines Aetna Better Health follows the AMA CPT-4 Book and CMS HCPCS Book, which provide instructions regarding code usage. iHT has developed these guidelines into edits. For example, if a vaccine administration code is billed without the correct vaccine/toxoid codes, we will deny the code as inappropriate coding based on industry standards. According to the AMA CPT Book, this vaccination must be reported in addition to the vaccine and toxoid code(s).

Procedure Code Definition Policies iHT supports correct coding based on the definition or nature of a procedure code or combination of procedure codes. The ability to code in this manner supports prior authorization requirements during claim adjudication. Furthermore, these editing policies will either bundle or re-code procedures based on the appropriateness of the code selection. For example, if a provider attempts to unbundle procedures, iHT will apply editing logic that will bundle all of the procedures billed into the most appropriate code. For example, if a provider bills an office visit and also bills separately for heart monitoring with a stethoscope at the same visit, iHT will rebundle the service into the appropriate E&M or office code.

Claims Development Aetna Better Health has existing policies and procedures whereby we 'develop' claims requiring additional information from a service provider or third party. Non-clean claims are pended and a letter sent to the provider indicating, at a minimum, the nature of the problem, instructions on its remedy (e.g. submission of missing documentation) and the following:

• Member name

• Provider claim number

• Patient account number or unique member identification number

• Date of service

• Total billed charges

• Coordinated Care Network’s (CCN’s) name; and

• The date the report was generated

Claims analysts will attempt to follow up three times within the allotted time; if a response from the provider has not been received within the allotted time, the claim is denied.


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Ensuring Adherance to Claims Processing Requirements Claims Monitoring Process Aetna Better Health uses a suite of regularly scheduled and ad hoc reports to monitor claim receipts, production, payment, proper applicability of State mandates and quality activity on a daily, weekly and monthly basis. Sample reports include, but are not limited to, the following:

• Mail Counts and Reconciliation Reports: Used to trend receipts, plan resource allocation and verify that all claims received are accounted for in the system.

• Pended Claims Audit by Provider or Age: Includes all claims that fail auto adjudication or are suspended for manual review.

• Unfinished Claims Report: Identifies all claims by age and processing status category (e.g., open, pay, deny, pend, reverse).

• Denial Analysis: Trends denied claims with corresponding reason for the denial.

• Claims Production: Monitors daily, weekly and monthly manual and auto adjudication production.

• Claims Performance Reporting: Monitors turnaround time for clean claims over selected time periods.

• Quality Review Statistics: Reports by individual and plan as well as error frequency.

Aetna Better Health’s Claims Department uses these and other reports to track specific claims and monitor workflow to see that we meet our processing standards and are compliant with DHH’s standards. In addition, senior management regularly reviews claims key indicators, including claims awaiting payment and a Claims Dashboard Report. Aetna Better Health employs workflow management and comprehensive personnel training to keep claims backlogs to a minimum. Claims Supervisors also monitor daily mail receipt volumes and staffing to monitor whether we are devoting adequate resources to meet processing standards. If our reports reflect a less than favorable trend, we immediately develop and implement appropriate corrective action plans. For example, we might apply additional staffing to clear up a backlog of aged claims through a combination of overtime hours, temporary labor and workload balancing.

Pre and Post-Payment Review Aetna Better Health maintains a Claims Quality Review team to monitor quality standards for all claims processes. Under the direction of the director of Operations Process and Knowledge Management (OPKM), Quality Review Analysts conduct random and focused reviews of processed claims for payment, financial and procedural accuracy. Performance is measured against established department guidelines.

Quality Review Analysts conduct a series of pre-payment audits including: 1) a one percent random sample of system-adjudicated claims, 2) a two percent random sample of all analyst-adjudicated claims, 3) a daily random sample of billed claims up to $49,999.99, and 4) 100 percent of all claims with billed charges over $50,000. When pre-payment errors are discovered during these audits, claims are pended for analysis and adjusted as required for final adjudication. If an error in adjudication of the claim indicates a system configuration problem, the issue is routed to our Business Application Management (BAM) Department for further review, analysis, testing, and correction. If adjudication errors are identified relative to manually


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adjudicated claims, we review/update pertinent policies and procedures and institute additional training accordingly. If our audit identifies a provider billing issue, the information is forwarded to provider services personnel for provider outreach and education as necessary.

To further support quality reviews of claims processing accuracy, an independent (does not report to claims leadership) post-payment Audit Department is responsible for conducting stratified random samples and focused audits of paid and denied claims. The purpose of these activities is to audit compliance of claims adjudication with state regulatory requirements and provider contracts. Audit results are shared with claims management in order to identify training and/or coaching opportunities, qualify merit-based compensation and implement corrective action as necessary.

Electronic Data Interface (EDI) To assist us in processing and paying claims efficiently, accurately and timely, Aetna Better Health encourages providers to submit claims electronically. To facilitate electronic claims submissions, we have developed business relationships with ten major clearinghouses, including RelayHealth, Emdeon, MedAvant, among others. We receive EDI claims directly from these clearinghouses, process them through pre-import edits to see to the validity of the data, HIPAA compliance and member enrollment and then upload them into QNXT™ each business day. Within 24 hours of file receipt, we provide production reports and control totals to all trading partners to validate successful transactions and identify errors for correction and resubmission.

Manual Claims Acquisition (Paper) Providers can submit paper claims to Aetna Better Health’s designated post office box. Each business day, our imaging vendor, FutureVision, retrieves, opens and sorts the mail using our pre-defined criteria for either imaging and scanning or distribution directly to Aetna Better Health. They assign each claim a unique reference number based on the date received and use it to track the claim throughout the entire adjudication process. FutureVision then converts the imaged data into an EDI ready format within 24 to 48 hours of initial receipt and forwards it to Aetna Better Health. Each business day, our IT processing personnel upload the data into QNXT™ via EDI processing. Only users with approved, secured access to claims information can view this information.

If FutureVision, for whatever reason, is unable to scan certain documents, including non-claim submissions (e.g., returned member/provider mail, explanations of benefits, checks, medical records documentation) and certain paper claims (e.g., illegible claims or poor quality printed claims), FutureVision forwards these paper documents to our Claims Administration Department, where we sort and distribute them to the appropriate department(s). We assign each claim document a unique identifying number within 24 hours of receipt and electronic store the document. We then shred the paper claims and store the electronic document in a locked and secure location prior to entering the data into QNXT™, which occurs within 2 days of receipt of the document(s) from FutureVision.

Clear Claim Connection® Aetna Better Health offers network providers access to Clear Claim Connection®, a web-based, code-auditing reference tool designed to mirror how code combinations are evaluated during the auditing of professional claims. Clear Claim Connection® enables Aetna Better Health to disclose its claim auditing rules to providers, along with the clinical rationale inherent to the


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system. Currently, there are approximately 2300 provider groups registered through Aetna Better Health to use this web-based tool. Providers access Clear Claim Connection® through Aetna Better Health’s web portal via secure login. Various coding combinations and claim scenarios can then be entered by the provider (or his/her designated staff) to determine why, for example, a particular coding combination may result (or did result) in a denial. The provider may also review coding combinations prior to claim submission, to determine if applicable auditing rules and clinical rationale will deny the claim before it is submitted or if other supportive information is necessary on the provider’s behalf, in order to promote a clean claim submission. Clear Claim Connection® databases and logic are updated regularly by Aetna Better Health for consistency with claim handling requirements, new procedure codes, current healthcare trends, and/or medical and technological advances.

The table that follows provides a mapping of claims processing methodology requirements to an explanation of Aetna Better Health’s handling or policies in support of compliance.

Requirement Meets or Exceeds

Requirement Explanation

17.2.1 Confirming eligibility on each member as claims are submitted on the basis of the eligibility information provided by DHH and the Enrollment Broker that applies to the period during which the charges were incurred;

Meets Inbound claims are uploaded to QNXT™, our claims processing system, where they are subjected to multiple header and line item edits. Among these are edits that compare service data to eligibility information provided by DHH and the Enrollment Broker in order to confirm members' eligibility during the period to which charges were incurred.

17.2.2 A review of the entire claim within five (5) working days of receipt of an electronic claim, to determine that the claim is not a clean claim and issue an exception report to the provider indicating all defects or reasons known at that time that the claim is not a clean claim. The exception report shall contain at a minimum the following information:

Meets

17.2.2.1 Member name; Meets

17.2.2.2 Provider claim number, patient account number, or unique member identification number;

Meets

17.2.2.3 Date of service; Meets 17.2.2.4 Total billed charges; Meets

17.2.2.5 CCN’s name; and

Meets

Level I and II edits occur at the clearinghouse and handled within 5 working days. The clearinghouse bears responsibility for providing exception reports to the providers.


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17.2.2.6 The date the report was generated.

Meets

17.2.3 Medical necessity; Meets Clinical edits are capable of verifying when a procedure is for certain gender or an age, e.g., the claim edits will be able to detect if pregnancy-related services are inadvertently being assigned to a male member. Refer to 17.2.4 applies edits accordingly.

17.2.4 Prior Approval – The system shall determine whether a covered service required prior approval and if so, whether the CCN granted such approval;

Meets

17.2.5 Duplicate Claims – The system shall in an automated manner, flag a claim as being exactly the same as a previously submitted claim or a possible duplicate and either deny or pend the claim as needed;

Meets

17.2.6 Covered Services - See that the system verifies that a service is a covered service and is eligible for payment;

Meets

17.2.7 Provider Validation - See that the system shall approve for payment only those claims received from providers eligible to render service for which the claim was submitted;

Meets

17.2.8 Quantity of Service - See that the system shall evaluate claims for services provided to members to see that any applicable benefit limits are applied;

Meets

17.2.9 Perform system edits for valid dates of service, and assure that dates of services are valid dates such as not in the future or outside of a member’s Medicaid eligibility span;

Meets

Aetna Better Health's Business Application Management (BAM) Department is responsible for the accurate and efficient configuration of functional business requirements and rules within QNXT™ necessary for administrative services to occur. This includes meeting claims processing standards and auto-adjudication targets. The objectives of the build are to:

• Analyze business requirements to design and configure an optimal and efficient system build that will minimize the need for manual processing.

• Load the rules and requirements of a new health plan, product or business function in the claims processing system, including eligibility file layout, provider contracts, fee schedules and member benefits and prior authorization requirements.

• Complete configuration documentation while entering the build information.

• Audit and validate the build based on the rules and requirements stated by the health plan and the implementation team.

• Jointly perform unit testing with the Operations Process Knowledge Management (OPKM) Testing team to validate that the system is operational and meets business requirements.

• Participate in end-to-end testing with all impacted departments to see that the system is operating as expected.


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17.2.10 Perform post-payment review on a sample of claims to see that services provided were medically necessary; and

Meets

17.2.11 Have a staff of qualified, medically trained and appropriately licensed personnel, consistent with NCQA accreditation standards, whose primary duties are to assist in evaluating claims for medical necessity.

Meets

Aetna Better Health maintains an independent (i.e. does not report to claims leadership) post-payment Audit Department responsible for drawing stratified random samples and conducting focused audits of paid and denied claims. The purpose of these activities is to audit compliance of claims adjudication with DHH regulatory requirements and provider contracts. Audit findings are shared with Claims management for root cause analysis and corrective action.

17.3 Explanation of Benefits (EOBs) 17.3.1 The CCN shall within forty-five (45) days of payment of claims, provide individual notices to a sample group of the members who received services. The required notice must specify: 17.3.1.1.1 The service furnished;

17.3.1.1.2 The name of the provider furnishing the service; 17.3.1.1.3 The date on which the service was furnished; and 17.3.1.1.4 The amount of the payment made for the service. 17.3.2 The CCN shall also:

17.3.2.1 Include in the sample, claims for services with hard benefit limits, denied claims with member responsibility, and paid claims (excluding ancillary and anesthesia services). 17.3.2.2 Stratify paid claims sample to see that all provider types (or specialties) are represented in the pool of generated EOBs. To the extent that the CCN considers a particular specialty (or provider) to warrant closer scrutiny, the CCN may over sample the group. The paid claims sample should be a minimum of two hundred (200) to two hundred-fifty (250) claims per year.

Aetna Better Health acknowledges and will comply. All elements required in the Explanation of Benefits will be included in the EOB provided to CCN members. As new EOB requirements and elements are updated, Aetna Better Health will comply and as such, make necessary modifications to existing EOB reported fields as required.


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17.3.3 The CCN shall track any complaints received from members and resolve the complaints according to its established policies and procedures. The resolution may be member education, provider education, or referral to DHH. The CCN shall use the feedback received to modify or enhance the EOB sampling methodology.

Meets Aetna Better Health maintains an internal, proprietary application that supports the Grievance and Appeals process by tracking member and provider issues from inception to resolution. This affords us the means to address not only issues affecting individual member and provider satisfaction, but potential trends in the delivery system as a whole, permitting health plan personnel to take prompt, corrective steps to minimizing risks to performance standards. Feedback received during this process or feedback received through other means, will be shared with the appropriate personnel within the Claims unit for future handling and modifications in concert with the IT Department.

17.4.1 Each remittance advice generated by the CCN to a provider shall, if known at that time, clearly identify for each claim, the following information:

Meets

17.4.1.1 The name of the member; Meets

17.4.1.2 Unique member identification number;

Meets

17.4.1.3 Patient claim number or patient account number;

Meets

17.4.1.4 Date of service; Meets

17.4.1.5 Total provider charges; Meets

17.4.1.6 Member liability, specifying any co-insurance, deductible, co-payment, or non-covered amount;

Meets

17.4.1.7 Amount paid by the CCN; Meets

17.4.1.8 Amount denied and the reason for denial; and

Meets

QNXT™, Aetna Better Health's core transaction processing system, generates paper Remittance Advices (RAs) for our providers. In addition, providers taking advantage of our Electronic Fund Transfer (EFT) capability have the option of receiving Electronic Remittance Advices (ERAs). Business Application Management (BAM) personnel configure QNXT™ to generate RAs formatted such that required data elements are readily identifiable.

The following statement shall be included on each remittance advice sent to providers: “I understand that payment and satisfaction of this claim will be from federal and state funds, and that any false claims, statements, documents, or concealment of a material fact, may be prosecuted under

Meets Aetna Better Health’s existing remittance advice can be configured to meet this requirement.


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applicable federal and/or state laws.”

17.5.1.1 The CCN shall see that ninety percent (90%) of all clean claims for payment of services delivered to a member are paid by the CCN to the provider within fifteen (15) business days of the receipt of such claims. 17.5.1.2 The CCN shall process and, if appropriate, pay within thirty (30) calendar days, ninety-nine percent (99%) of all clean claims to providers for covered services delivered to a member.

Aetna Better Health presently manages its claims payment process such that State mandated payment timeframes are either met or exceeded by the Claim’s Unit. For example, in Florida, Aetna Better Health manages the claim process such that the entire claims process is completed with 12 days on average, with an added 7 days tagged on to the process to account for check issuance purposes, so that the total time to process, on average is 20 business days (the requirement is 20 days), thus the claim payment time exceeds the mandatory timeframe in Florida. Aetna Better Health anticipates also exceeding the expectations of the Louisiana Department of Health and Hospitals, which provide for payment of 90% of clean claims within fifteen days and 99% payment within the allotted thirty calendar day timeframe.

17.5.1.3 If a clean claim is denied on the basis the provider did not submit required information or documentation with the claim, then the remittance advice shall specifically identify all such information and documentation. Resubmission of a claim with further information and/or documentation shall not constitute a new claim for purposes of establishing the timeframe for timely filing.

Meets When an otherwise claim denies specifically on the basis of lack of documentation required to process the claim, the remittance advice identifies with specificity the reason for the denial. Providers are instructed to resubmit the claim, along with the required document and to notate that the claim is a resubmission. As such, those claims with the “resubmission” notation receive are adjudicated for timely filing using the original submission date of the claim.


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17.5.1.4 To the extent that the provider contract requires compensation of a provider on a capitation basis or on any other basis that does not require the submission of a claim as a condition to payment, such payment shall be made to the provider by no later than: ● The time period specified in the provider

contract between the provider and the CCN, or if a time period is not specified in the contract:

− The tenth (10th) day of the calendar month if the payment is to be made by a contractor, or

− If the CCN is required to compensate the provider directly, within five (5) calendar days after receipt of the capitated payment and supporting member roster information from DHH.

Meets Aetna Better Health capitated contracts provide for payment by the 15th calendar day of the month. Network providers indicate their agreement with this timeframe as evidenced by their signing the agreement and the specific provider rate attachment.

17.5.1.5 The CCN shall not deny provider claims on the basis of untimely filing in situations regarding coordination of services or subrogation, in which case the provider is pursuing payment from a third party. In situations of third party benefits, the timeframes for filing a claim shall begin on the date that the third party completes resolution of the claim.

Meets Aetna Better Health acknowledges and will comply. Aetna Better Health acknowledges DHH’s timely failing related to subrogated or COB claims and will comply with said requirements. It is Aetna Better Health’s standard operating procedure to accept claims that are within the statutorily allotted timely filing limits, and those timeframes and other considerations applicable to subrogated claims or coordination of benefits

17.5.1.6 The CCN shall not pay any claim submitted by a provider who is excluded from participation in Medicare, Medicaid, or CHIP program pursuant to Section 1128 or 1156 of the Social Security Act or is otherwise not in good standing with DHH.

Meets As part of our credentialing process, Aetna Better Health queries the listing of excluded individuals, pursuant to the requirements of section 1128 or 1156 of the Social Security Act, and sees that those providers treating members covered under the agreement between Aetna Better Health and the DHH, are in good standing with DHH prior to completing the contracting and credentialing process. At recredentialing, the procedures are followed to make certain good standing with DHH and lack of exclusion or restriction for participation in a Medicaid, Medicare or other government healthcare program. Aetna Better Health, through


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its vendor PDS, also conducts queries of non-network providers, on a periodic and random basis, to supplement its existing query processes related to the contracted network.

17.5.2 Claims Dispute Management 17.5.2.1 The CCN shall have an internal claims dispute procedure that shall be submitted to DHH within thirty (30) days of the date the Contract is signed by the CCN, which will be reviewed and approved by DHH.

Meets

17.5.2.2 The CCN shall contract with independent reviewers to review disputed claims.

Meets

17.5.2.3 The CCN shall systematically capture the status and resolution of all claim disputes as well as all associated documentation.

Meets

Aetna Better Health’s Claims Administration Department employs full-time claims inquiry and Research Representatives to respond to provider questions, status inquiries and claims payment disputes via the claims inquiry line from 8:00 a.m. to 5:00 p.m., Monday through Friday. An automated telephone system allows callers to speak directly with a Representative or leave a detailed message regarding their inquiry. Whenever possible, the provider inquiry will be resolved while the provider is on the phone. If the provider’s inquiry cannot be resolved while the provider is on the phone and the provider’s inquiry requires additional research to reach resolution, then a call tracking case will be open for the provider’s issue. It is the department’s goal to research and respond to the provider’s issues within five to ten business days. When it is not possible to resolve the issue within this time frame, then the issue will be call tracked to the appropriate department, and thereafter followed by an independent reviewer. Claim disputes may escalate, at the request of the provider, to the Grievance and Appeals process. As such time, established Grievance and Appeals procedures are followed and applied to the provider’s claim dispute. Aetna Better Health acknowledges and will comply with the requirement to submit its specific claims dispute policies to the DHH within 30 days of contract award. Claim dispute data is captured by Aetna Better Health in its systems and further documented through the Grievance and Appeals process, as applicable.


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17.5.3 Claims Payment Accuracy Report 17.5.3.1 On a monthly basis, the CCN shall submit a claims payment accuracy percentage report to DHH. The report shall be based on an audit conducted by the CCN. The audit shall be conducted by an entity or staff independent of claims management as specified in this Section of the RFP, and shall utilize a randomly selected sample of all processed and paid claims upon initial submission in each month. A minimum sample consisting of two hundred (200) to two hundred-fifty (250) claims per year, based on financial stratification, shall be selected from the entire population of electronic and paper claims processed or paid upon initial submission.

Exceeds Aetna Better Health maintains a Claims Quality Review Team to monitor quality standards for all claims processes. Under the direction of the director of Operations Process and Knowledge Management (OPKM), Quality Review Analysts conduct random and focused reviews of processed claims for payment, financial and procedural accuracy and provider inquiry calls, which focus on both accuracy and customer service skills. Performance is measured against established department guidelines. Moreover, the Claims Quality Review Team fully audits the work of all new claims analysts for at least one month subsequent to their orientation and training. The audit starts at 100 percent of their work product and decreases to a standard two percent by the fifth week, provided the new claims analyst continues to meet claims accuracy standards. Finally, we review 16 provider calls per Claims Inquiry Representative per month, assessing the quality of service interaction and accuracy of information provided. Individual quality reports are presented to the Representative and their Supervisor for corrective action (e.g., live call monitoring) if appropriate. Quality Review Analysts conduct a series of pre-payment audits including: 1) A one percent random sample of system-adjudicated claims, 2) A two percent random sample of all analyst-adjudicated claims, 3) A daily random sample of billed claims up to $49,999.99, and 4) 100 percent of all claims with billed charges over $50,000. We will have one full time Auditor assigned and we will pull a total of 4 audits per month; two UB (facility) files and two 1500 (physician) files based on a two week paid date/check cycle. Our sample size is 95/2/2 (95% confidence; the error rate is


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2%; with a desired precision of +/- 2%) which is an average of 180+ claims reviewed each week. Each file provides Aetna Better Health with Payment and Financial Accuracy findings for the period audited and each file is distributed for review and response to all applicable departments.

17.5.3.2 The minimum attributes to be tested for each claim selected shall include: ● Claim data correctly entered into the

claims processing system; ● Claim is associated with the correct

provider; ● Proper authorization was obtained for

the service; ● Member eligibility at processing date

correctly applied; ● Allowed payment amount agrees with

contracted rate; ● Duplicate payment of the same claim

has not occurred; ● Denial reason applied appropriately; ● Co-payment application considered and

applied, if applicable; ● Effect of modifier codes correctly

applied; and ● Proper coding.

Exceeds Post-payment audits review, at a minimum, include audit for the attributes listed in requirement 17.5.3.2., and also provide for review of: ● Coding, e.g. proper use of codes and modifier

codes; ● Member eligibility; ● Data entry into the systems is accurate; ● Timely Filing; ● Claim is associated with the correct treating

provider; ● Prior Authorization requirements; ● Denial reasons applied correctly; ● Benefit application (including limitations and

exclusions); ● Coordination of Benefits application; ● Claims history review for duplicate claim; ● Manual Pricing application; ● Contracted Provider and Special Provider

agreements, such as one-time case agreements and for both ensuring payment amount agrees with contracted rate;

● Modifier Discounts; and ● Claims bundling/unbundling. ● Contracted Provider and Special Provider

agreements, such as one-time case agreements and for both ensuring payment amount agrees


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with contracted rate; ● Modifier Discounts; and ● Claims bundling/unbundling

17.5.3.3 The results of testing at a minimum should be documented to include: ● Results for each attribute tested for each

claim selected; ● Amount of overpayment or

underpayment for each claim processed or paid in error;

● Explanation of the erroneous processing for each claim processed or paid in error;

● Determination if the error is the result of a keying error or the result of error in the configuration or table maintenance of the claims processing system; and

● Claims processed or paid in error have been corrected.

Exceeds Audit documentation comprises, at a minimum, documentation of findings by attribute, the amount of the associated under/overpayment, the root cause and resolution status. Audit files remain 'open' until all identified issues have been resolved and corrections/adjustments implemented accordingly.

17.5.3.4 If the CCN contracted for the provision of any covered services, and the CCN’s contractor is responsible for processing claims, then the CCN shall submit a claims payment accuracy percentage report for the claims processed by the contractor.

Exceeds Delegated vendors are required to match Aetna Better Health’s Claims auditing procedures. To monitor compliance with this contractual requirement, Aetna Better Health conducts a semi-annual and annual evaluation of delegated vendor claims auditing processes, and we will include a review of DHH specific audit requirements as part of our delegation oversight process.

17.5.5 Claims Summary Report 17.5.5.1 The CCN must submit quarterly, Claims Summary Reports to DHH by GSA and by claim type.

Meets Aetna Better Health acknowledges and will comply.


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113 SECTION Q – CLAIMS MANAGEMENT

Documents