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Medicaid Care Management Grievance and Appeals Prepared by the Office of Quality Assurance and Improvement NH Department of Health and Human Services 1 4/9/2018 Member Grievances per 10,000 Member Months 5 4 Rate per 10,000 member months 3

  1. Medicaid Care Management Grievance and Appeals Prepared by the Office of Quality Assurance and Improvement NH Department of Health and Human Services 1 4/9/2018

  2. Member Grievances per 10,000 Member Months 5 4 Rate per 10,000 member months 3 1.9 2 1.5 1.3 1.2 1.1 0.8 0.8 0.6 1 0 Q1-2016 Q2-2016 Q3-2016 Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017 2 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  3. Grievances by Grievance Category* 100 11.1 1.9 3.1 3.3 3.3 1.9 6.7 8.3 11.5 6.7 5.8 9.4 9.9 4.4 90 9.1 6.3 5.0 3.8 9.6 2.1 8.9 5.5 9.4 80 12.1 16.7 13.5 15.4 23.1 22.9 70 15.2 60 Percent 50 40 80.0 78.1 68.3 67.3 65.9 61.5 30 60.4 57.6 20 10 0 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3 2017-Q4 Customer Service Billing & Financial Coverage Benefits Quality of Care Access Website System or Material Attitude and Services * Categories are determined by the National Committee for Quality Assurance of Health Plans 3 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  4. Grievance Count by Provider Type* 70 60 49 50 40 Number of Grievances 35 29 30 23 22 21 20 20 19 18 18 20 15 15 11 10 10 8 8 8 10 4 4 3 3 0 0 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3 2017-Q4 Health Plan Provider Sub-contractor *Provider type indicates who the grievance is filed against. 4 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  5. Grievance Dispositions Made Within 45 Calendar Days 5 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  6. Member Appeals Filed per 10,000 Member Months 12 10.4 Pharmacy Non-Pharmacy 10 Rate per 10,000 member months 8 5.9 6.4 6 5.1 3.9 3.7 4 3.1 3.3 4.1 4.0 3.4 3.2 2.5 2 2.6 2.5 2.3 0 Q1-2016 Q2-2016 Q3-2016 Q4-2016 Q1-2017 Q2-2017 Q3-2017 Q4-2017 6 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  7. Count of Appeals Filed: Pharmacy and Non-Pharmacy 500 428 400 Pharmacy Non-Pharmacy 300 258 Appeals 240 205 200 170 161 156 149 138 123 131 131 100 99 104 98 92 0 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3 2017-Q4 7 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  8. Appeal Processing Time: Resolution of Standard Appeals Within 30 Calendar Days 8 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  9. Appeals Processing Time: Resolution of Expedited Appeals Within 72 Hours 9 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  10. Resolution of Appeals by Disposition Type Note: 2016 data may include over reporting for member abandoned appeals 10 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  11. Count of Appeals Elevated to State Fair Hearings 10 8 Fair Hearings 6 5 5 4 4 3 2 2 0 0 0 2016-Q1 2016-Q2 2016-Q3 2016-Q4 2017-Q1 2017-Q2 2017-Q3 11 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  12. Count of Fair Hearing Requests by Disposition Type (1/1/2016 – 12/31/2017) Upheld 0 Resolved by Settlement 3 Fair Hearings Dismissed 2 Reversed by Withdrawn 4 Plan 13 12 Source Data: Medicaid Quality Information System Retrieved on 3/26/2018

  13. MCM Grievance and Appeals Data Measure ID Measure Name GRIEVANCE.01 Grievance Dispositions Made Within 45 Calendar Days GRIEVANCE.02 Grievance Log Including State Plan / 1915B Waiver Flag GRIEVANCE.03 Member Grievances Received APPEALS.01 Resolution of Standard Appeals Within 30 Calendar Days APPEALS.02 Resolution of Extended Standard Appeals Within 44 Calendar Days APPEALS.03 Resolution of Expedited Appeals Within 72 Hours APPEALS.04 Resolution of All Appeals Within 45 Calendar Days APPEALS.05 Resolution of Appeals by Disposition Type APPEALS.09 Appeals by Reason Type APPEALS.10 Fair Hearings by Disposition Type Appeals by Type of Resolution and Category of Service by State Plan, APPEALS.16 1915B Waiver, and Total Population Pharmacy Appeals by Type of Resolution and Therapeutic Drug Class by APPEALS.17 State Plan, 1915B Waiver, and Total Population APPEALS.18 Services Authorized within 72 Hours Following A Reversed Appeal APPEALS.19 Member Appeals Received Data Available at: https://medicaidquality.nh.gov/ 13

  14. 14

  15. Contact Information • Patrick McGowan, MS, CPHQ – Administrator, Bureau of Quality Management patrick.mcgowan@dhhs.nh.gov http://medicaidquality.nh.gov/ 15

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