Exhibit C-Reporting Documents and Schedules for MCOs (1).pdf
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- Attached to
- MEDICAID MANAGED CARE RATE SETTING/PROGRAM ADMIN
- Solicitation number
- CRFP 0511 BMS2700000001 3
- Issued by
- Kanawha County, West Virginia
About this file
This is an Exhibit C document outlining the comprehensive reporting requirements for Managed Care Organizations (MCOs) administering the Medicaid Health Transitions (MHT) and Medicaid Health Plan (MHP) programs in West Virginia, under the oversight of the Bureau for Medical Services (BMS). The document establishes mandatory reporting obligations across multiple categories, including quality reporting, provider reporting, financial reporting, federal reporting, and state-required reporting, with specific timeframes and due dates for each submission. Quality-related submissions include quarterly MHT/MHP reporting templates due within 45 calendar days of quarter-end, Performance Improvement Plans (PIPs) with results due by July 15th, HEDIS audited reports due by June 15th, and Quality and Patient Safety Initiative (QAPI) annual evaluation reports also due by June 15th. Provider reporting requirements mandate monthly electronic provider directory submissions to BMS's Enrollment Broker, annual full network adequacy reports due by October 31st, quarterly specialty network change reports due 45 days after quarter-end, PCP changes reported within 14 days, and hospital changes reported immediately. Encounter data submissions are required within 30 days of month-end, with annual core quality measures due by September 1st.
Financial reporting obligations include annual financial statements due by June 1st and quarterly reports to the Office of the Insurance Commissioner concurrent with Department of Insurance (DOI) submissions. MCOs must submit Medical Loss Ratio (MLR) reports and calculations eight months after the state fiscal year ends and recovery of overpayments reports by the 15th of each month. Additional mandatory submissions include Business Continuity and Disaster Recovery Plans within 10 business days of BMS request, attestations for hysterectomies, sterilizations, and communicable diseases by October 1st, MCO Annual Reports by April 1st, organization charts by October 1st, marketing plans by October 1st, and Data Accuracy and Completeness Plans by October 1st. Mental health-specific reporting includes mental health service access reports with approval, denial, and wait time data as defined in Section 10.1, and substance use disorder utilization and finance reports due by the 10th of the following month. Disclosure of ownership reporting is required annually by July 1st, upon request within 35 calendar days, or upon any change in ownership within 35 calendar days. All MCO reports must reflect MHT and MHP program-related data only unless otherwise requested by BMS.
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Text version
EXHIBIT C: SUMMARY OF MHT AND MHP MCO REPORTING
REQUIREMENTS
All MCO reports submitted under this Contract must reflect MHT and MHP program-related data only unless otherwise requested by BMS.
Reporting Requirement Timeframe
Monthly Quarterly Annually Other Due Date
Quarterly Reporting
MHT/MHP Quarterly Reporting
Template
X
Within forty-five (45) calendar days of end of quarter (by the 15th day of the second month following the end of the reporting period)
Quality Reporting
Written Description of PIPs and Results X On or before July 15th
PIP Progress Report X
Within one-hundred twenty
(120) days of end of quarter
HEDIS
X
On or before June 15th
(audited)
QAPI Annual Evaluation Report
Including Status and Results X On or before June 15th
QAPI CAP X
Within thirty (30) days of identification of systemic problem
CAHPS Enrollee Survey Analysis, Action Plan and Evaluation X
Annual analysis is due on or before August 15th.
Accreditation Review Report X Upon completion or change in status
Encounter Data X Within thirty (30) days of end of month
Adult and Child Core Quality Measures X On or before September 1st
Provider Reporting
Provider Network Data X
Electronic provider directories to be submitted to
BMS’ Enrollment Broker monthly
Reporting Requirement Timeframe
Monthly Quarterly Annually Other Due Date
Provider Network Adequacy X X X
• Full network - Annually by October 31st
• All Network changes by specialty – Quarterly, 45 days after end of the quarter
• PCP changes –fourteen
(14) days after the change
• Hospital changes – immediately
• Material changes of other providers affecting service delivery- fourteen (14) days after the change
Provider Satisfaction Survey X By June 30th of each contract year.
Suspension and Adverse Enrollment
Action Report (formerly the CAF
Suspension and PDC reports)
X By the 15th of the following month
Financial Reporting
Annual Financial Statements X On or before June 1st
Offices of the Insurance Commissioner
Reports – Quarterly and Annually X X
Concurrent with DOI submission
Third Party Liability Cases Not Pursued X
The 15th of each month (to include all events from the prior month)
Provider-Preventable Conditions X July 15th
PCP Payment Methodology X Upon request from BMS
Directed Payments Report X
45 days after each quarter, providing payment has been received from BMS.
MHT and MHP MLR Reports and
Calculations X
Eight (8) months after the end of the SFY
Recovery of All Overpayments Report
(included in the FWA Report) X By the 15th of the month
IMD Report X Submit on the 15th and 30th of each month
Hospital Paid Claims Report X 45 days after each quarter to
OAMR
Federal Reporting
Hysterectomies and Sterilizations X Submit attestation by
October 1st
EPSDT Services and Reporting X 45 days after each quarter
Other State Required Reporting
Business Continuity Plan X Within ten (10) business days of BMS written request
Disaster Recovery Plan X Within ten (10) business days of BMS written request
Information Security Plan X Within ten (10) business days of BMS written request
System Quality Assurance Plan X Within ten (10) business days of BMS written request
Sexually Transmitted Diseases X Submit attestation by
October 1st
Tuberculosis X Submit attestation by
October 1st
Communicable Diseases X Submit attestation by
October 1st
MCO Annual Report X On or before April 1st
Organization Chart X On or before October 1st
Marketing Plan X On or before October 1st
Subcontractor Monitoring Plan X Within ten (10) business days of BMS written request
Data Accuracy and Completeness Plan X On or before October 1st
Activities Summary, Analyses, and
Results of Provider/Beneficiary
Utilization to Detect FWA
X On or before June 15th
HB 4217 Report X On March 30th of each year
Alternative Payment Model Report X August 15th
FWA Reporting X By the 15th of the following month
Disclosure of Ownership Reporting X X
• Annually, on or before
July 1st;
• Upon request, within thirty-five (35) calendar days; or
• Upon change in ownership, within thirty-five (35) calendar days
FWA Internal Compliance Plan X On or before October 1st
Parity in Mental Health and Substance
Use Disorder (SUD) Benefits
Compliance Plan
X On or before June 30th
Claims Aging Report X By the 15th of the following month
Mental Health Services Access Report X
As defined in Section 10.1, the MCO shall provide a mental health service utilization report that provides data on the mental health services approved and denied by the MCO, as well as the average wait time between referral to mental health appointment.
SUD Utilization/Finance Report X By the 10th of the following month
PRTF and Children’s Residential
Services and Demographic Report X
By the 15th day of the following month
Monthly Member Status Report X By the 15th day of the following month
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