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Contract Section      Report

2                            Managed Care Question and Answer Grid  
3.7       Manual Maternity Kicker  
3.18 Call Center Performance  
4.2 Autism Prior Authorization                                                                   new/updated
4.2 Autism Claims Payment                                                                      new/updated
4.2 PRTF Prior Authorization                                                                     new/updated
4.2 PRTF Claims Payment Accuracy                                                       new/updated
4.3 Additional Services Form  
4.8 Member Incentive Form  
5.4 Care Management  
6.3 Provider Network                                                                                     new/updated
7.3 PCMH  
7.4 FQHC RHC Wrap Detail Data                                                                 new/updated
7.4 FQHC/RHC Wrap Summary Data  
9.1 Member Appeal Log  
9.1 Member Grievance Log  
9.2 Provider Dispute Log  
10.9 TPL Cost Avoidance  
10.9 TPL COB Savings  
10.9 TPL Recoveries                                                                        new/updated
10.9 TPL Casualty Cases                                                                   new/updated
11.1 PI Fraud and Abuse Definitions  
11.1 PI Monthly Fraud and Abuse Report  
11.1 PI Monthly Fraud and Abuse Report Instructions                           new/updated
11.1 PI Quarterly Fraud and Abuse  
11.1 PI Quarterly Fraud and Abuse Report Instructions                               new/updated
11.1 PI Termination for Cause  
11.1 PI Rules for Share Point Suspension Termination Exclusion           new/updated
11.1 PI Instructions-Use of SharePoint Suspension Termination Exclusion new/updated
11.1 PI Annual Strategic Plan Format for MCOs                                           new/updated
11.2 PI Compliance Plan - DHHS                                                                 new/updated
11.2 PI Compliance Plan - MCO  
11.10 Pharmacy Lock In Member Letter  
11.10 Pharmacy Lock In Member Instructions  
11.10 Pharmacy Lock In Member Removal Letter   
11.10 Pharmacy Lock In Pharmacy Letter   
13.1 Claims Payment Accuracy  
13.1 GME Report  
14.5 Encounter Submission Summary  
14.10 Encounter Quality Initiative (EQI)  
15.5 Alternative Payment Models                                                              new/updated

 

Additional Resources

       Health Plan Data Request Methodology Document 

       MLR Calculation Document

       HIPAA 5010 834 Transaction Layout

       Encounter Errors Mapping to 277CA

       Encounter Edit Code List

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