Provider Complaint Spreadsheet Issue Descriptors

1. Provider Services Representatives who will resolve provider issues, including, but not limited to, problems with claims payment, prior authorizations (PA) and referrals.

2. Claims Adjudication. The MCP must have the capacity to electronically accept and adjudicate all claims to final status (payment or denial). Information on claims submission procedures must be provided to non-contracting providers within 30 days of a request.

3. The MCP must notify providers who have submitted claims of claims status paid, denied, pended (suspended)] within one month of receipt by the MCP or its designee.

4. The MCP is prohibited from recovering back or adjusting any payments that are beyond two years from the date of payment of the claim due to the MCP member’s retroactive termination of coverage from the MCP, unless the MCP is directed to do so by CMS, ODM, or applicable state or federal law and regulation.

5. The MCP must have policies providing that, upon discovery of claims payment systemic errors that resulted in incorrectly underpaying or denying claims, the MCP is required to reprocess and correctly pay such claims, from the date of identification of the error retroactively through the period specified in the contract between the MCP and the provider for claims payment corrective activity.

6. The MCP must load rate changes into applicable systems within 30 days of being notified by ODM of the change.

7. The MCP is prohibited from engaging in practices that unfairly or unnecessarily delay the processing or payment of any claim for MCP members.

8. The MCP is required to give a 30-calendar day advance notice to providers of any new edits or system changes related to claims adjudication or payments processing.

9. MCPs must pay 90% of all submitted clean claims within 30 days of the date of receipt and 99% of such claims within 90 days of the date of receipt, unless the MCP and its contracted provider(s) have established an alternative payment schedule that is mutually agreed upon and described in their contract. The clean pharmacy and non-pharmacy claims will be separately measured against the 30 and 90 day prompt pay standards. The prompt pay requirement applies to the processing of both electronic and paper claims for contracting and non-contracting providers by the MCP and delegated claims processing entities.