Report (Vertical) · Web view2019/01/01 · PHP Financial Reporting ManualNorth Carolina DHHS PHP...

North Carolina

Prepaid Health Plan

Financial Reporting Manual

DRAFT version 1.0

Issued January 2019

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PHP Financial Reporting Manual North Carolina DHHS

Contents1. Introduction and General Instructions..........................................................................1

1.01 Introduction....................................................................................................1 1.02 Reporting Time Frames.................................................................................1 1.03 General Instructions.......................................................................................3 1.04 Format and Delivery.......................................................................................4 1.05 Certification Statement...................................................................................4 1.07 Medicaid Monitoring Metrics..........................................................................5 1.08 Maintenance of Records................................................................................5

2. Monthly Reporting Requirements.................................................................................6 2.01 Schedule A: Balance Sheet...........................................................................6 2.02 Schedule B: Medicaid Income Statement....................................................10 2.03 Schedule B1: Other Income Statement........................................................16 2.04 Schedule C: Financial Statement Footnotes................................................16 2.05 Schedule D: HCQI and Administrative Expenses........................................16 2.06 Schedule E1: Total Profitability....................................................................19 2.07 Profitability Schedules E2: Region 1 through E7: Region 6.........................19 2.08 Lag Schedules F1: Inpatient through F5: Other...........................................20 2.09 Schedule G: Encounter Inputs.....................................................................23 2.10 Schedule H: Comparison.............................................................................23 2.11 Schedule I: In Lieu of Services.....................................................................23 2.12 Schedule J: MLR..........................................................................................24 2.13 Schedule K: Outpatient Pharmacy...............................................................28 2.14 Schedule L: Additional Provider Payments..................................................31 2.15 Schedule M: FQHC/RHC Payments............................................................31 2.15 Schedule N: TCOC Report...........................................................................32 2.16 Schedule O: Supplemental Working Area....................................................33

3. Quarterly Reporting Requirements............................................................................34 3.01 Schedule P: Value-Added Services.............................................................34 3.02 Schedule Q: Medicaid Claim Aging..............................................................34 3.03 Schedule R: Medicaid Claim Processing.....................................................34 3.04 Schedule S: Medicaid Coordination of Benefits and Third Party Liability....35 3.05 Schedule T: Medicaid Fraud and Abuse Tracking.......................................36 3.06 Schedule U1: Total Utilization......................................................................36 3.07 Utilization Schedules U2: Utilization Region 1 through

U7: Utilization Region 6........................................................................................36 3.08 Schedule V: Cost Avoidance........................................................................36 3.09 Schedule W: VBP Methods..........................................................................37 3.10 Schedule X: Contributions to Health-Related Resources............................37 3.11 Schedule Y and Y1: Out of Network............................................................37

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4. Annual Reporting Requirements................................................................................39 4.01 Schedule Z: Annual Narrative......................................................................39 4.02 Schedule AA: Audited Financial Statements................................................39

5. Appendix A: Scenarios for Updating Schedule R: Medicaid Claim Processing.........40 Scenarios.............................................................................................................40 Historical Reporting..............................................................................................43 Zero Dollar Claims...............................................................................................45

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1. Introduction and General Instructions1.01 IntroductionThe provisions and requirements of the Financial Reporting Manual (Manual) are effective November 2019. The purpose of this Manual is to set forth reporting requirements for the Prepaid Health Plans (PHPs) contracted with the State of North Carolina (State) Department of Health and Human Services (DHHS). This manual and the accompanying financial reporting templates are one of many data submissions and reporting requirements of the PHPs.

All reports shall be submitted as outlined in the general and report-specific instructions. The financial reports submitted based on the Manual will be used to monitor PHP operations and may be used as a data source in capitation rate setting. There must be segregation of reporting between revenue, expenditures, and balance sheet-related items associated with PHP funding sources, and other state-only or other non-Medicaid funding sources.

All terms and conditions of the PHP contract apply to the template. The Manual and template may be revised as deemed necessary by DHHS. Sanctions may be enforced for untimely or inaccurate template filings.

The reporting periods contained within the template relate to the DHHS fiscal year and may not correspond with PHP fiscal year end. As a result, PHPs may be required to obtain a report of findings from an independent auditor based on specific, agreed upon procedures performed when populating the template. Agreed upon procedures may be prescribed by DHHS in future reporting guides.

1.02 Reporting Time FramesAmendments and/or updates to this Manual may be issued by the State as deemed necessary.

The annual reporting period is defined as July 1 through June 30, corresponding to the State fiscal year.

The following table depicts reporting requirements and scheduling. Due dates are based on calendar days. Schedules submitted earlier than the due dates may be accepted. Monthly reports are reported 20 days after the month end, quarterly reports are due 45 days after the quarter end and should include the corresponding monthly schedules. For example, utilization reports for 2020 Q1 are due on May 15, 2020 and all of the monthly reports should be included with data through March 31, 2020. The monthly figures may be updated for run out through the time of the quarterly submission. Similarly, annual reports are due 60 days after the reporting year end (June 30) and should be submitted along with the quarterly and monthly schedules for the entire fiscal year. Figures within the quarterly and monthly reports may be updated for run out through the date of the annual submission. The annual submission, submitted 60 days after year end (June 30), should match the annual audited financial reports and include all of the monthly and quarterly reports within the reporting template.

Schedule Report name Frequency Due date1 FormatA Balance Sheet Monthly 20 days after

month endPredetermined

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Schedule Report name Frequency Due date FormatB Medicaid Income Statement Monthly 20 days after

month endPredetermined

B1 Other Income Statement Monthly 20 days after month end

Predetermined

C Financial Statement Footnotes Monthly 20 days after month end

Predetermined

D HCQI and DHH Administrative Expenses

Monthly 20 days after month end

Predetermined

E1 Total Profitability Summary Report (All Regions)


Predetermined

E2 though E7

Total Profitability for Region 1 through Region 6


Predetermined

F1 through F5

Inpatient through Other Services Lag Reports


Predetermined

G Encounter Inputs Monthly 20 days after month end

Predetermined

H Financial and Encounter Comparison


Predetermined

I In Lieu of Services Monthly 20 days after month end

Predetermined

J Medical Loss Ratio (MLR) Monthly and Supplemental

20 days after month end

Predetermined

K Outpatient Pharmacy Monthly 20 days after month end

Predetermined

L Additional Payments Monthly 20 days after month end

Predetermined

M Federally Qualified Health Center/Rural Health Center (FQHC/RHC) Payments


Predetermined

N Total Cost of Care (TCOC) Report


Predetermined

O Supplemental Working Area Monthly 20 days after month end

Narrative

P Value-Added Services Quarterly 45 days after quarter end

Predetermined

Q Medicaid Claim Aging Quarterly 45 days afterquarter end

Predetermined

R Medicaid Claim Processing Quarterly 45 days afterquarter end

Predetermined

S Medicaid Coordination Of Benefits And Third-Party Liability (COB and TPL)

Quarterly 45 days afterquarter end

Predetermined

T Medicaid Fraud And Abuse Tracking


Predetermined

U1 Total Utilization Summary Report (All Regions)


Predetermined

U2 through U7

Utilization Region 1 though Utilization Region 6


Predetermined

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Schedule Report name Frequency Due date FormatV Cost Avoidance Quarterly 45 days after

quarter endPredetermined

W Value-Based Purchasing (VBP) Methods


Predetermined

X Contributions to Health-Related Resources

Quarterly 45 days after quarter end

Predetermined

Y and Y1 Out Of Network Quarterly 45 days after quarter end

Predetermined

Z Annual Narrative Annually and Supplemental

60 days after year end

Narrative

AA Audited Financial Statement Annually and Supplemental

60 days after year end

PDF embedded documents

1.03 General InstructionsGenerally accepted accounting principles are to be observed in the preparation of these reports. All revenues and expenses must be reported using the full accrual basis method of accounting.

All monthly, quarterly, and annual reports must be completed and submitted to DHHS by the due dates outlined above. DHHS may extend a report deadline if a request for an extension is communicated in writing and is received at least five business days prior to the report due date. Any request for extension must include the reason for delay and the date by which the report will be filed.

Most line and column descriptions within each report are self-explanatory and do not necessitate instructions. However, specific instructions are provided in instances when interpretation may vary. Any entry for which no specific instruction is provided should be made in accordance with sound accounting principles and in a manner consistent with related items for which instruction is provided.

Categories of service (COS) descriptions are included in the Rate Book. Always use predefined categories or classifications before reporting an amount as “Other.” For any material amount included as “Other”, the PHP is required to provide a detailed explanation on Schedule O: Supplemental Working Area. For this purpose, material is defined as comprising an amount greater than or equal to 5% of the total for each section. For example, if “Other Income” reported is less than 5% of Total Revenue, no disclosure is necessary. However, if “Other Income” were reported with a value that is greater than or equal to 5% of Total Revenue, a disclosure would be necessary. Such disclosure is to be documented on Schedule O: Supplemental Working Area.

Unanswered questions and blank lines or schedules will not be considered properly completed and may result in a resubmission request and potentially a sanction for non-completion. Any resubmission must be clearly identified as such. If no answers or entries are to be made, write “None”, not applicable (N/A), or “-0-”, in the space provided.

Select schedules may require information to be entered by provider. In an effort to standardize responses, please use the provider name and National Provider Identifier, per the National Plan & Provider Enumeration System (NPPES) database at https://npiregistry.cms.hhs.gov/ .

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https://npiregistry.cms.hhs.gov/


Input areas for the spreadsheet are shown with red font.

1.04 Format and DeliveryThe PHPs will submit these reports using Microsoft® Excel spreadsheets in the format and in the template specified in this Manual without alteration. Please submit the completed reports and required supplemental materials, such as narrative support for “Other” categories that are considered material in nature, using the general reporting procedures defined by DHHS.

1.05 Certification StatementThe purpose of the certification statement is to attest the information submitted in the reports is current, complete, and accurate. The statement should include the PHP’s name, period ended, preparer information, and signature. In addition, the PHP must enter the appropriate reporting month of the fiscal year from the drop down menu. The months correspond to DHHS’ fiscal year and may not be the same as PHP’s fiscal year. This value is critical to ensure the calculations on the “Medicaid Monitoring” tab are calculated accurately.

The certification statement must be signed by the PHP’s CFO or CEO and submitted using the general reporting procedures defined by the DHHS.

1.06 Financial Statement Instructions and Check Figures In addition to the schedules that must be completed by the PHPs, the template includes an “Instructions and Check Figures” worksheet that evaluates the consistency of the values entered by the PHPs. The Financial Statement Instructions reporting template and Check Figures tab lists the instructions for completing the spreadsheet, as well as checks figures that identify any differences within specific schedules. The check figures must match prior to the submission of the monthly and annual financial statements. If the check figures do not match, the cells will highlight in red. If the audit check figures do not match, data should be corrected or an explanation should be provided in writing and submitted with the financial statement-reporting package.

1.07 Medicaid Monitoring MetricsThe template includes a “Medicaid Metrics” worksheet that evaluates information contained within the reports and highlights key metrics monitored by DHHS. The data fields are automatically calculated within this tab.

1.08 Maintenance of RecordsThe PHPs must maintain and make available to DHHS, and others determined necessary by DHHS, upon request, the data used to complete any reports contained within this Manual.

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2. Monthly Reporting RequirementsMonthly reports are due 20 days after the end of the month. The report shall include the schedules listed below.

2.01 Schedule A: Balance SheetCurrent assets are assets that are expected to be converted into cash, used, or consumed within one year from the date of the balance sheet. Statutory deposits, restricted assets for the general risk reserves, etc., are not to be included as current assets.

The PHP is required to separate Medicaid, State, and other assets and liabilities. The methodology for such separation must be submitted to DHHS.

Specification Inclusion ExclusionCash and Cash Equivalents

Cash and cash equivalents available for current use. Cash equivalents are investments maturing 90 days or less from the date of purchase.

Restricted cash (and equivalents) and any investments pledged by the PHP to satisfy minimum net worth requirements.

Short-Term Investments Investments that are readily marketable and are expected to be redeemed or sold within one year of the balance sheet date.

Investments maturing 90 days or less than one year from the date of purchase and restricted securities.

Medicaid Capitation Receivable

Capitation payments earned, but not yet received from DHHS.

Other receivables from DHHS.

Investment Income Receivable

Income earned, but not yet received from cash equivalents, investments, performance bonds or short- and long-term investments.

Reinsurance Receivable Accrued reinsurance receivable amounts due to contractual agreements with reinsurance contractors.

Withhold Receivable Current Year

Revenue expected to be received from withhold on capitation revenue for the current reporting year.

Withhold receivables from prior years.

Withhold Receivable Prior Years

Revenue expected to be received from withhold on capitation revenue from prior reporting years.

Withhold receivables from the current year.

Quality Incentive Receivables

Revenue expected to be received from earned quality incentives.

VBP Receivables Receivables for shared-savings or risk-sharing from providers in VBP arrangements with providers.

Due from Affiliates (Current)

Receivables from related-party organizations expected to be received within one year.

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Specification Inclusion ExclusionOther Current Assets The total current portion of other assets,

which will include all other assets not accounted for elsewhere on the balance sheet. Any receivables from providers due to overpayments should be accounted for in this line item.

Other assets are assets that are expected to be held for greater than one year of the balance sheet date.

Specification Inclusion ExclusionStatutory Deposits Amounts deposited under the

North Carolina Department of Insurance (DOI) regulations that require the PHP to maintain a minimum level of tangible net equity, if applicable.

Restricted Cash and Other Assets

Cash, securities, receivables, etc., whose use is restricted, including performance bonds (if applicable).

Cash and/or investments pledged by the PHP to satisfy DOI or DHHS statutory deposit requirements.

Due from Affiliates (Non-Current)

Receivables from related-party organizations not expected to be received within one year.

Long-Term Investments Investments maturing 90 days or less than one year from the date of purchase and restricted securities.

Investments that are readily marketable and that are expected to be redeemed or sold within one year of the balance sheet date.

Other Non-Current Assets Include all other non-current assets not accounted for elsewhere on the balance sheet. Any receivables from providers should be accounted for in this line item.

Property and equipment consists of fixed assets, including land, buildings, leasehold improvements, furniture, equipment, etc.

Specification Inclusion ExclusionLand Real estate owned by the PHP.Buildings Buildings owned by the PHP, including

buildings under a capital lease and improvements to buildings owned by the PHP.

Improvements made to leased or rented buildings or offices.

Leasehold Improvements Capitalized improvements to facilities not owned by the PHP.

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Specification Inclusion ExclusionFurniture and Equipment Medical equipment, office equipment, data

processing hardware, software (where permitted), and furniture owned by the PHP, as well as similar assets held under capital leases.

Other — Property and Equipment

All other fixed assets not falling under one of the other specific asset categories.

Accumulated Depreciation/Amortization

The total of all depreciation and amortization accounts relating to the various fixed asset accounts.

Current liabilities are obligations whose liquidation is reasonably expected to occur within one year from the balance sheet date.

Specification Inclusion ExclusionAccounts Payable Amounts due to creditors for the

acquisition of goods and services on a credit basis.

Claims payable from providers.

Accrued Administrative Expenses

Accrued expenses, management fees, and any other amounts estimated as of the balance sheet date (e.g., payroll, taxes). Also, include accrued interest payable on debts.

Subcapitation Payable Net amounts owed to providers for monthly capitation.

Capitation amounts payable to DHHS as a result of overpayment. (This amount should be reported in the ‘Other Current Liabilities’ line.)

Claims Payable Adjudicated but unpaid claims. Pended claims or claims received but not adjudicated.

Incurred But Not Reported (IBNR)

The respective IBNR amounts calculated on an accrual basis estimating the remaining liability of IBNR claims.

VBP Payable Payables for shared-savings or risk-sharing from providers in VBP arrangements with providers.

Other Services Payable Medical services payable that are not part of the IBNR claims payable amount.

Due to Affiliates (Current) Payables owed to a related-party organizations expected to be paid within one year.

Current Portion Long-Term Debt

The total current portion of long-term debt, which will include the principal amount on loans, notes and capital lease obligations due within one year of the balance sheet date.

Long-term portion of and accrued interest on loans, notes and capital lease obligations.

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Specification Inclusion ExclusionMLR Payable to State Accrued MLR rebate amounts and

non-risk amounts payable to DHHS as a result of overpayment from current year activity.

MLR accruals owed to DHHS for prior years.

HIPF Payable Accrued amount related to the HIPF. HIPF for non-current time periods.

Premium Tax Payable to State

Accrued amount related to premium taxes for the current time period.

Premium tax for non-current time periods.

Other Current Liabilities The total current portion of other liabilities, which will include those current liabilities not specifically identified elsewhere.

Other liabilities are those obligations whose liquidation is not reasonably expected to occur within one year of the date of the balance sheet.

Specification Inclusion ExclusionNon-Current Portion — Long-Term Debt

The total non-current portion of long-term debt, which will include the long-term portion of principal on loans, notes, and capital lease obligations.

Current portion of and accrued interest on loans, notes and capital lease obligations.

MLR Payable (Non-Current)

Accrued MLR rebate amounts and non-risk amounts payable to DHHS as a result of overpayment from prior year activity.

HIPF Payable(Non-Current)

Accrued amount related to the HIPF for non-current time periods.

Current time periods.

Premium Tax Payable to State(Non-Current)

Accrued amount related to premium taxes for non-current time period.

Current time periods.

Due to Affiliates (Non-Current)

Payables owed to a related-party organizations not expected to be paid within one year.

Other Non-Current Liabilities

The total non-current portion of liabilities not specifically identified elsewhere.

Equity or Net Assets include contributed capital, retained earnings, unrealized long-term gains, and are net of any dividends or distributions.

Specification Inclusion ExclusionPreferred Stock/ Restricted Funds

Should equal the par value or, in the case of no-par shares, the stated or liquidation value per share multiplied by the number of issued shares for for-profit entities; or the sum of fund balances with restricted use for nonprofit entities.

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Specification Inclusion ExclusionCommon Stock/ Unrestricted Funds

Should equal the par value or, in the case of no-par shares, the stated value, per share multiplied by the number of issued shares for for-profit entities; or the sum of fund balances without restrictions on use for nonprofit entities.

Treasury Stock Include the amount of treasury stock reported using the par value or cost method.

Unrealized Gain on Long-Term Investments

Include unrealized gain on long-term investments as described in Financial Accounting Statement 115.

Additional Paid-In Capital Amounts paid and contributed in excess of the par or stated value of shares issued.

Contributed Capital Include capital donated to the PHP. Describe the nature of the donation as well as any restrictions on this capital in the footnote disclosures in Schedule C: Financial Statement Footnotes.

Retained Earnings Prior Years

Excess of revenues over expenses from prior years. Excess of expenses over revenues from prior years would be shown as a negative amount. Any amounts redirected to other funds should be described in detail in Schedule L: Additional Payments.

Current year earnings/loss amounts.

Increase (Decrease) Year to Date (YTD)

Excess of revenues over expenses from current year. Excess of expenses over revenues from current year would be shown as a negative amount. Any amounts redirected to other funds should be described in detail in Schedule L: Additional Payments.

Prior year earnings/loss amounts.

2.02 Schedule B: Medicaid Income StatementThe PHP shall report revenues and expenses using the full accrual method. The Medicaid Income Statement reflects Medicaid revenues and expenses only on a fiscal year basis. Please include all prior months within a reporting year when completing this schedule.

For example, the monthly report for December should reflect revenues and expenses that relate to December along with any prior month covered by the contract, as the figures in this template are not included on a cumulative YTD basis.

The report is completed in total across all rating groups. In addition, the report includes a YTD total for the prior year. This will be input based upon prior fiscal year data. For example, if this report is being completed for the first six months YTD of the fiscal year, the PHP should include the prior year’s first six months YTD information in the prior year to date column. Please note that all quarters relate to the fiscal year and correspond to September 30, December 31,

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March 31 and June 30. The reporting year end is the State’s fiscal year end June 30. The date field for the appropriate month must be updated with each monthly report submission.

NOTE: First year rates may not be in effect a full year.

Specification Inclusion ExclusionTotal Member Months (MMs)

An MM is equivalent to one member for whom the PHP has received and/or accrued at-risk capitation-based revenue.

Total Deliveries Report the number of maternity event payments received and/or accrued from DHHS.

Medicaid Prospective PMPM Capitation

Revenue received and accrued on a prepaid basis for the provision of covered services. Revenue entered here should assume full payment and release all withhold amounts. These amounts should reflect the full capitation rates for the PHP; i.e., do not incorporate any adjustment for the withhold provisions.

Medicaid Maternity Event Payments

Revenue received and accrued for all maternity event payments.

Medicaid Other Capitation Revenue

Revenue received and accrued from DHHS to address payment arrangements, not applicable to an individual member and outside and separate from the prospective PMPM capitation and maternity event payments.

Unearned Withholds - Current Year(enter as negative)

Unearned revenue related to the withhold program, as outlined in the contract, which should be entered as a negative number if the PHP determines it is unlikely to receive such revenue.

Unearned Withholds - Prior Year

Unearned revenue related to the withhold program from a prior year the PHP does not expect to receive.

Investment Income Income received and/or accrued from cash equivalents, investments, performance bonds or short- and long-term investments.

Health Insurance Provider Fee (HIPF) Received for Premiums Written in the Prior Year

HIPF revenue received and accrued in the current year pertaining to prior year premiums.

HIPF Adjustments for Non-Current Periods

HIPF revenue received and accrued pertaining to adjustments to HIPF for non-current periods, such as due to state, federal or audit activities.

Other Income/Revenue Revenue from sources not identified in the other revenue categories.

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Medical expenses and recoveries must be reported net of third party reimbursement and COBs (e.g., Medicare and other commercial insurance) and in correspondence to the identified COS as identified in the Rate Book. Expenses should be reported as paid claims only and report changes in IBNR in the appropriately described lines, corresponding to the detail provided in the lag tables from Schedules F1: Inpatient through F5: Other.

Expenses should align with COS descriptions included in the Rate Book. The Rate Book breaks out service expenses in the categories (as should be reported within this schedule).

Funding for provider care management is included within the medical component of the PMPM capitation rate and is reported within the medical expense section of the income statement and total profitability statements. Please do not include expenditures related to provider care management within the HCQI section.

Provider care management reflects the following categories of service: Care Coordination for Children (CC4C) Local Health Department (LHD) Payments Obstetric Care Management (OBCM) LHD Payments Advanced Medical Home (AMH) Payments – Tiers 1 and 2 AMH Payments – Tiers 3 and 4 (Base) AMH Payments – Tier 3 and Tier 4 (Enhanced)

Care management that does not relate to the activities listed above should be included as HCQI within Schedule D – HCQI and Administrative report.

Specification Inclusion ExclusionInpatient – Physical Health (PH)

As defined in the Rate Book.

Inpatient – Behavioral Health (BH)


Inpatient Payments Outside of PMPM Capitation Rate

Include additional utilization-based payments made to hospitals for inpatient services.

Other Contractual Inpatient Requirements

Other contractually required payments for services delivered in an Inpatient setting.

Inpatient Change in IBNR Difference between the current period and prior period IBNR balance for inpatient services.

Outpatient Hospital As defined in the Rate Book.

Emergency Room (ER) – PH


ER – BH As defined in the Rate Book.

Outpatient Payments Outside of PMPM Capitation Rate

Include additional utilization-based payments to hospitals for outpatient services.

Outpatient Change in IBNR Difference between the current period and prior period IBNR balance for

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Specification Inclusion Exclusionoutpatient services.

Physician – Primary Care As defined in the Rate Book.

Physician – Specialty Care As defined in the Rate Book.

FQHC/RHC As defined in the Rate Book.

Other Clinic As defined in the Rate Book.

Family Planning Services As defined in the Rate Book.

Other Professional – PH As defined in the Rate Book.

Other Professional – BH As defined in the Rate Book.

Therapies – Physical Therapy/Occupational Therapy/Speech Therapy


Professional Payments Outside of PMPM Capitation Rate

Include additional utilization-based payments made to hospitals for physician services and payments to local health departments.

Other Contractual Professional Requirements

Pay for performance, professional provider incentives, and other contractually-required payments not in an inpatient setting.

Professional Change in IBNR

Difference between the current period and prior period IBNR balance for professional services.

Prescribed Drugs As defined in the Rate Book.

Prescribed Drugs Change in IBNR

Difference between the current period and prior period IBNR balance for prescription drugs.

Long-Term Services and Supports (LTSS) Services


Durable Medical Equipment (DME)


Limited Dental Services As defined in the Rate Book.

Optical As defined in the Rate Book.

Lab and X-Ray As defined in the Rate Book.

Other Services — PH As defined in the Rate Book.

Other Services — BH As defined in the Rate Book.

Emergency Transportation As defined in the Rate Book.

Non-Emergency Medical Transportation (NEMT)


Other Payments Outside of PMPM Capitation Rate

Include additional utilization-based payments to public ambulance providers.

Other Contractual Requirements

Contracted payments not listed elsewhere.

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Specification Inclusion ExclusionOther Change in IBNR Difference between the current period

and prior period IBNR balance for other services not captured elsewhere.

Care Coordination for Children (CC4C) Local Health Department (LHD) Payments

As defined in the Rate Book. Medical service costs related to CC4C should not be reported in this section

Obstetric Care Management (OBCM) LHD Payments As defined in the Rate Book.

Medical service costs related to OBCM should not be reported in this section.

Advanced Medical Home (AMH) Payments – Tiers 1 and 2

See AMH payments section of the contract as well as the AMH provider manual.https://files.nc.gov/ncdhhs/30-19029-DHB-1.pdf

https://files.nc.gov/ncdma/documents/Providers/Programs_Services/amh/AMH_Provider-Manual_08272018.pdf

Medical service costs related to AMH should not be reported in this section.

Advanced Medical Home (AMH) Payments – Tiers 1 and 2 (Incentives)




AMH Payments – Tiers 3 and 4 (Base)

Expenses relate to the AMH PMPM payments.




AMH Payments – Tier 3 and Tier 4 (Enhanced)

See AMH payments section of the contract as well as the AMH provider manual.https://files.nc.gov/ncdhhs/30-19029-DHB-1.pdf https://files.nc.gov/ncdma/documents/Providers/Programs_Services/amh/AMH_Provider-Manual_08272018.pdf


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https://files.nc.gov/ncdhhs/30-19029-DHB-1.pdf


















Specification Inclusion ExclusionValue-Added Services Expenses for value-added services

provided in addition to the contracted benefit package.

Recoveries reported in the claim system should be netted against the claim payment and be reported in the appropriate COS as identified previously. Adjustments reflecting recoveries not recognized within the claims system should be reported using the categories and descriptions listed in the subsequent table. These items should be used only in instances in which the recovery is not reported in the claim system. The adjustments will be used to determine the net medical costs of the PHPs.

Specification Inclusion ExclusionReinsurance Premiums Reinsurance premium payments to

contracted reinsurance entities.Reinsurance Recoveries Reinsurance recoveries, billed and

unbilled, expected to be recovered from contracted reinsurance entities.

COB/TPL Recoveries Cost recoveries subsequent to the payment of a claim that has not been adjusted to the original claim for recoveries associated with third-party resources.

Do not include COB payments that are deducted from payments to providers in the normal course of claims processing.

Fraud and Abuse Recoveries

Payments to the PHP as a result of state, PHP, or Provider-sponsored recovery efforts.

Other Recoveries Other recoveries of medical claims previously paid not included in a category above.

Administrative Expenses Administrative expenses are divided into activities that improve health care quality and those that are other, general, and operational, to perform necessary business functions. Use the guidance below in Section 2.05 for reporting administrative activities that meet the criteria for improving health care quality.

Additional non-operating items are required to be reported within Schedule A: Balance Sheet. These items are described below:

Specification InclusionNon-Operating Income/Loss

Any amounts relating to the non-operating revenues and expenses.

Income Taxes Income tax expense paid or accrued for the period.Premium Tax Assessments

Premium taxes paid or accrued for the period.

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Specification InclusionHIPF Assessments Paid Based on Premiums for Prior Years

Internal Revenue Service-assessed HIPF paid in the current year based on premiums written in prior years. This amount should reflect the difference between amounts accrued in the prior year and the amount paid in the current year.

HIPF Adjustments for Prior Years

Adjustments to HIPF receivable from prior years.

Other Any other income/loss not included elsewhere in the Income Statement including, but not limited to, MLR rebate accruals.Note: Amounts should be disclosed and fully explained in Schedule O: Supplemental Working Area.

2.03 Schedule B1: Other Income StatementThis schedule is used to report financial activity for non-Medicaid business. DHHS monitors activity other than Medicaid that may affect the financial health of the PHP. COS logic should follow the hierarchy described in the Rate Book and may be summarized at the major COS level, as shown in Schedule B: Medicaid Income Statement.

2.04 Schedule C: Financial Statement FootnotesThe financial statement footnotes are designed to present information regarding organizational structures and changes to reimbursement methodologies, as well as an area to explain other amounts not specified in the reporting package. The list is not exclusive of explanations that may be useful to DHHS. The footnote requirements are generally accepted accounting principle-oriented but have also been tailored to notify DHHS of fluctuations to revenues, expenses, and incurred but not paid (IBNP). Please include a separate document within Schedule O – Supplemental Working Area describing the methodology used to allocate figures included in the template.

2.05 Schedule D: HCQI and Administrative ExpensesThis schedule is for reporting detailed expenses related to HCQI activities, as defined in 45 CFR § 150.158. The PHP must separate HCQI expenses from general administrative costs. To qualify as HCQI, the activity must:

Improve health quality. Increase the likelihood of desired health outcomes in ways that are capable of being

objectively measured and of producing verifiable results and achievements. Be directed toward Medicaid members or incurred for the benefit of Medicaid members or

provide health improvements to the population beyond Medicaid as no additional costs due to the non-Medicaid members.

Be grounded in evidence-based medicine, widely accepted best clinical practice, or criteria issued by recognized professional medical associations, accreditation bodies, government agencies, or other nationally recognized health care quality organizations.

The PHP should report all health care quality improvement expenses and should use the following guidance for reporting HCQI activities. These expenses should only include expenses associated with the administration of the Medicaid program.

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Specification Inclusion ExclusionHealth Outcome Improvement

Care management, case management, care coordination, chronic disease management, medication and care compliance through the use of medical homes.

Utilization management or activities designed to control or contain costs.

Provider care management, as outlined in the Medical Expense section (lines 53 through 57).

Hospital Readmission Prevention

Comprehensive discharge planning, patient-centered education and counseling, personalized post-discharge counseling.

Patient Safety Improvement and Medical Error Reduction

Identification of best clinical practices to avoid harm and evidenced-based medicine to reduce clinical errors. Activities to reduce facility-acquired infections and performing prospective drug utilization reviews.

Wellness and Health Promotion

Wellness assessments, health coaching.

Health Information Technology (HIT) Expenses for Health Quality Improvement

HIT costs for any of the aforementioned HCQI activities.

Other HCQI Expenses Please describe in the Supplemental Working Area.

This schedule should report all administrative expenses and should use the following guidance for reporting administrative activities. These expenses should only include expenses associated with the administration of the Medicaid program. Please exclude provider care management, as it relates to activities outlined in lines 53-57 of the income statement.

Specification Inclusion ExclusionUtilization Management and Concurrent Review

Utilization management activities that manage medically-necessary covered services, as well as prospective and concurrent utilization review.

Network Development and Credentialing Costs

Contracting, provider credentialing, and provider education.

Marketing Sales and marketing expenditures.Member Services Member service/support and grievance

and appeals, including member enrollment.

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Specification Inclusion ExclusionFraud Reduction Fraud reduction activities. Fraud recoveries shall be

reported in the medical expense section.

Fraud prevention does not currently qualify as HCQI and should be included in General and Operational administrative expenses.

General and Operational Senior operational management and general administrative support (e.g., administrative assistants, public relations to the extent it does not relate to marketing or member/enrollment services as described below, receptionist, etc.).

Claims and Referral/Authorization Processing

Processing of Provider Payments — Expenditures related to the processing and authorizing of provider payments.

Informational Systems Costs of information systems and communications, including telephones and telecommunication equipment.

Pharmacy Benefit Management (PBM)

Component of pharmacy paid to the PBM NOT for payment to providers.

Administrative Services Only (ASO) Cost

Expenditures for the processing of provider payments for other organizations.

Other Direct Costs Other costs directly related to administering the contract with Medicaid: Administrative Business Expenditures — rent, utilities, office supplies, printing and copier expenses, marketing materials, training and education, recruiting, relocation, travel, depreciation and amortization, and other miscellaneous administrative expenses. Payments to incent providers to submit encounter forms.

Indirect Costs Management fees and other allocations of corporate expenses based on some methodology (e.g., PMPM, percent of revenue, percent of head counts and/or full time equivalents, etc.).

Facility Costs Costs for rent, mortgage interest, utilities, and insurance associated where the PHP performs contracted activities.

Lobbying Costs Contributions to political parties, candidates or lobbying groups.

Charitable Contributions Donations to non-profits and other 501(c)(3) charities.

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Specification Inclusion ExclusionTravel and Entertainment Expense

Expenses for traveling and entertainment including, but not limited to, airfare, hotel, car rental, mileage, meals and event tickets.

Sanctions, Penalties, and Late Payment Interest

Expense incurred resulting from federal or state sanctions, penalties, and interest incurred for the late payment of claims.

Interest Expense All other forms of interest expense. Excluding mortgage interest and interest incurred for the late payment of claims.

Other Administrative Costs Those administrative expenses not specifically identified elsewhere. If greater than 5% of total administrative costs, please describe in the Schedule O: Supplemental Working Area.

Other administrative expenses indicated elsewhere.

2.06 Schedule E1: Total ProfitabilityThis report is meant to collect detailed information on revenues and expenses for all regions and categories of aid (COA) by rate cells. The columns of Schedule E1: Total Profitability are automatically calculated from the Medicaid Regional Profitability Schedules E2: Region 1 through E7: Region 6. This schedule is a cumulative summarization of the profit/loss for the current fiscal year. Provide detail for each region and rate cell using the COS logic described in Section 2.02 and in the Rate Book.

2.07 Profitability Schedules E2: Region 1 through E7: Region 6Schedules E2 through E7 reports the results of operations by Medicaid eligibility category and are a cumulative summarization of the profit/loss for the current fiscal year by region. The table below lists the population categories and procedure codes that help define each group for reporting purposes.

COA Identifier

Aged, Blind and Disabled [Placeholder for identifiers from 820/834 files]

Temporary Assistance for Needy Families (TANF) and Other Related Children (<1)

TANF and Other Related Children (1-20)

TANF and Other Related Adults (21+)

Maternity Event, all agesReference the Maternity Event Criteria detail in the Rate Book.

The definitions associated with the specific revenue and expense lines detailed in Schedule B: Medicaid Income Statement and in the Rate Book are applicable for this schedule as well.

Schedules E2: Region 1 through E7: Region 6 should be completed for the respective region. Each schedule should only include the revenues and expenses that are associated with the

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membership assigned to the specific region for which the schedule is being completed (e.g., E2: Region 1 should only include revenues and expenses for beneficiaries residing in Region 1 and E3: Region 2 should only include revenues and expenses for beneficiaries residing in Region 2, and so forth.)

2.08 Lag Schedules F1: Inpatient through F5: OtherSchedules F1: Inpatient through F5: Other list the payments by month of payment and month of service, and the remaining estimated IBNR by service month. The table is arranged with the month of service horizontally and the month of payment vertically. Therefore, payments made during the current month for services rendered during the current month would be reported in line 1, column C, while payments made during the current month for services rendered in prior months would be reported on line 1, columns D through AM. Lines 1 through 3 contain data for payments made in the current month. Earlier data on lines 4 through 37 shall match data on appropriate lines on the prior period’s submission. If lines 4 through 37 change from the prior period’s submission, an explanation is required. The current month is the last month of the period that is being reported.

Analyzing the accuracy of historical medical claims liability estimates is of the utmost importance in assessing the adequacy of current liabilities. This schedule provides the necessary information to make this analysis.

Service costs must be reported net of COB/TPL. Claims liabilities should not include the administrative portion of claim settlement expenses. Any liability for future claim settlement expense must be disclosed separately in a footnote from the unpaid claim liability.

Line 39 – Global/Subcapitation and Other Non-Claim Payments: Global/subcapitation payments should be reported on this line by month of payment, and should not be included in any lines above line 39. Include other payment(s) for medical expenses not paid through the claims system. All amounts reported on line 39 should be documented on Schedule O: Supplemental Working Area. Global/Subcapitation payments include:

Global capitation payments: Payments made to fully delegated risk entities contracted with the PHP. These types of payments are expected to be broken out between the appropriate COS.

Subcapitation payments: Those services paid through a normal provider capitation agreement. Examples would include PMPM payments for a specified list of services.

Line 40 – Settlements: For prescription drugs, use line 40. For all other lag tables, the PHP should report payments/recoupment on lines 1 through 37 to the extent possible. If the PHP makes a settlement or other payment that cannot be reported on lines 1 through 37 due to lack of data, the amount must be reported on line 40 with the payment month used as a substitute for the service month. The PHP may use an alternative method of reporting settlements that restates prior period amounts to reflect an actual settlement for that month. For all amounts reported on line 40, include a footnote explanation on Schedule O: Supplemental Working Area. Do not include adjustments to IBNR amounts on this line.

Settlements should include payments to or refunds from providers that cannot be linked to a specific claim adjudicated through the payment system. For instance, fraud abuse recoupments, incentive payments, and inaccurate payment settlement agreements with a

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provider that have not been captured through the claims payment system should be included.

Line 41 – Claims Paid Outside the Claims System: The PHP should report payments/recoupment on lines 1 through 37 to the extent possible. If the PHP makes a claim payment outside the claim system that is not a result of a settlement, the amount must be reported in this line with the payment month used as a substitute for the service month. All amounts reported on line 41 should be documented on Schedule O: Supplemental Working Area. Do not include adjustments to IBNR amounts on this line.

Line 42 – Total Amount Paid to Date: The total amount paid to date (including subcapitation) for services rendered and should equal the sum of lines 38 through 41. This line will calculate automatically.

Line 43 – Current Estimate of Remaining Medical Expense Liability (IBNR): Amounts on this line represent the current estimates for unpaid claims by month of service for the past 36 months, and the aggregate amount for all prior months. The PHP must determine a new IBNR amount for each service month and include this amount on line 43. The development of each IBNR should be based on the most recent paid claims data. The remaining estimate of IBNR includes services incurred for which PHP has not yet received the claim; claims the PHP has received, but have not yet processed; and claims the PHP has received and processed, but for which the PHP has not mailed the check.

Line 44 – Total Incurred Claims: Total incurred claims is the sum of line 42 (amounts paid to date) and line 43 (IBNR). These amounts represent current estimated amounts ultimately to be paid for medical services by month of service for the past 36 months, and for all months prior to the 36th month. Each amount represents the medical expense for a particular month, not including adjustments to prior month IBNR claims estimates. This amount is comprised of claims for the incurred month known to be paid by the end of the reporting period, plus claims for the incurred month estimated to be unpaid at the end of the reporting period.

Line 45 – Prior Period IBNR Adjustments Recorded in General Ledger: At any point in time, the PHP may review its prior period IBNR estimates and determine if it has over-/under-accrued medical expenses for a prior period. To the extent an adjustment is recorded in the general ledger during the current reporting period, that amount must be entered in this column. This is needed to ensure the total services per the general ledger agree to this report for a given reporting period. This adjustment is only applicable for the current reporting period.

Line 46 – Total Service Expense per the General Ledger: This row calculates automatically and is only applicable for the current reporting period.

Line 47 – Original Estimate of Total Incurred Claims for Service Month: This row provides the original estimate of total medical service expense for a service month. It is used to evaluate how well the PHP estimates its total final incurred in the initial month of estimation. This amount will not change over time as adjustments to IBNR and paid claims run out. To evaluate how well the PHP is estimating its total incurred medical expenses, compare this line to line 44 over time. If line 44 is greater than line 47 on a consistent basis, the PHP is underestimating IBNR; if line 44 is less than line 47 it is overestimating IBNR. For example, in the illustration, if line 44 for the service month of April as of April is $1,600,000, line 47 for the service month of April is $1,600,000. If, in May, the plan determines line 44 for April should only have been $900,000, line 43 will reflect the change in remaining IBNR and line 44 will show $900,000, but line 47 will remain at $1,600,000 for the month of April.

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Line 48 – Completion Percentage: Line 48 calculates the ratio of paid expenses to incurred expenses.

The lag tables from Schedules F1: Inpatient through F5: Other must provide data for the period beginning with the first month the PHP is responsible for providing medical benefits to recipients and ending with the current month.

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Ties to line 44

Does not change

Adjusted in May


Schedules F1: Inpatient through F5: Other should be completed for the respective claim type lag report. Each report should only include the historical claims liability information as outlined above that are associated with the specific claim type for which the lag report is being completed (e.g., Schedules F1: Inpatient should only include claim information for Inpatient claims, Schedule F2: Outpatient should only include claim information for Outpatient claims, and so forth.)

2.09 Schedule G: Encounter InputsThis schedule is designed to collect the reported paid amounts of encounter data to measure the completeness and accuracy of encounter data as compared to reported paid claims in the lag tables. Categorize encounter data by date of service, claim type, and report submitted paid amounts by incurred month. Column A lists the reporting quarter. Column C lists the claim type. Include dental, vision, lab and radiology, transportation and DME in Other.

Report the paid amount of encounters accepted by DHHS’ Encounter Processing System in column D if the encounter is submitted directly by the PHP. If the service is subcapitated (e.g., vision or dental), enter paid amounts in column F. If the encounter is rejected, record the paid amount in column E if submitted directly by the PHP and column G if it is subcapitated. Rejected claims that are resubmitted and accepted should not be counted.

2.10 Schedule H: ComparisonNo data entry is required for this tab. The purpose of this schedule is to estimate the completeness of encounter data when compared to incurred paid claims in the lag tables. Amounts in column D are pulled from the lag tables in Schedules F1: Inpatient through F5: Other. Paid amounts from column E are pulled from Schedule G: Encounter Inputs.

2.11 Schedule I: In Lieu of ServicesSchedule I: In Lieu of Services is designed to inform DHHS of costs associated with approved alternative, or “in lieu of” services. Alternative or “In Lieu of” services approved by DHHS should be tracked and reported on a YTD basis. Enter each approved service on a separate line. Use column B to identify the service description as it was approved by DHHS. Use column C to record the applicable procedure codes and modifiers. Enter a method for identifying the service in the encounters in column D, the affected line in Schedule B: Medicaid Income Statement in column E, and the description for the service replaced in column F. The implementation date listed in column G should not precede the approval date of the alternative service by DHHS. If members are currently using the service, enter “Yes” in column H and calculate the rate paid to providers for the service in column I. If rates vary, use additional lines. Enter a unit description in column J. If more than one unit description exists, add a new row for each type. Enter the total number of units provided in column K. Column L will calculate the total amount paid by multiplying column J with column H.

2.12 Schedule J: MLR In adherence to the contract, the MLR analysis schedule tracks medical expenses as a percentage of revenue less any tax and fee considerations and with and without consideration of HCQI activities. The report automatically links to several areas of the workbook for ease of

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use. The report also includes line items to record any adjustments to the MLR for specific line items not captured elsewhere.

Amounts entered in cells with red fonts should be cumulative back to the first month of the reporting period. For example, if the first month of the reporting period is July, data entered into the column for September should include the sum of amounts for July, August, and September.

This schedule is intended to be a proxy for the annual MLR report, which is a separate report. The proxy uses the current revenue levels reported within the total profitability statement along with DHHS-established MLR by rate cell to estimate the annual minimum MLR threshold.

The Numerator:Reported Claims Line 1.1 – Reported claims, not including unpaid claim liabilities for the MLR reporting year:

Note this amount should be net of all fraud recoveries, including what is reported in or out of the claims system.

Line 1.2 – IBNR for claims incurred in the period expected to be paid in months after the known runout.

Line 1.3 – Amount of incentive and bonus payments made, or expected to be made, to network providers not included in lines 1.1 or 1.2.

Line 1.4 – Changes in other claims-related reserves. Line 1.5 – Reserves for contingent benefits and the medical claim portion of lawsuits. Line 1.6 – Net payment or receipts related to state-mandated solvency funds. Line 1.7 – Community investment (approved as part of the quality strategy). Line 1.8a – Amount spent on fraud reduction. As of the date of this manual, fraud

prevention activities do not qualify as HCQI and should be reported as general administrative costs.

Line 1.8b – Amount of claims payments recovered through fraud reduction: Note that line 1.1 should be net of all fraud recoveries, including what is reported in and out of the claims system. That same recoveries amount is then reported here as a positive amount.

Line 1.9 – Claims that are recoverable for anticipated COB/TPL or subrogation. Line 1.10 – Overpayment recoveries received from network providers. DHHS expects this to

include any anticipated settlements for claims incurred during the MLR reporting year, including those outside the claims system.

Activities that Improve Health Care QualityLine 2.1 is for HCQI activities, as defined in 42 CFR § 438.8 (e)(3). HCQI consists of expenses designed to: Improve health outcomes

Care coordination HIT to support care coordination Accreditation fees directly related to quality of care Chronic disease management

This section includes costs related to medication compliance and care compliance initiatives (including the use of medical homes) and quality reporting and documentation of care in non-electronic format).

Activities to prevent hospital readmissions

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HIT to support hospital readmissions Comprehensive discharge planning Patient-centered education and counseling Personalized post-discharge reinforcement and counseling by an appropriate health

care professional Improve patient safety and reduce medical errors

Prospective prescription drug utilization review aimed at identifying adverse drug interactions

HIT to support patient safety and reduced medical errors This section includes costs to ensure appropriate identification and use of best clinical

practices to avoid harm. Wellness & Health promotion activities

Public Health education campaigns that are performed in conjunction with state or local health departments

Actual rewards, incentives, bonuses, reductions in copayment that are not already reflected in premiums or claims should be allowed as quality improvement activities

Health information technology to support wellness and health promotion activities Wellness assessments Coaching programs designed to educate individuals on clinically-effective methods for

dealing with a specific chronic disease or condition Coaching or education programs and health promotion activities designed to change

member behavior and conditions Other HCQI activities

Activities designed to enhance the use of data to improve quality, transparency, and outcomes

Describe any other activities in Schedule R: Medicaid Claim Processing

Line 2.2 – PHP activity related to any external quality review (EQR)-related activity as described in §§ 438.358(b) and 438.358(c)

A PHP activity related to any EQR-related activity as described in § 438.358(b) and (c)

§ 438.358 – Activities related to external quality review(a) Mandatory activities.

(1) For each PHP the following EQR-related activities must be performed:(i) Validation of performance improvement projects required in accordance with

§ 438.330(b)(1) that were underway during the preceding 12 months.(ii) Validation of PHP performance measures required in accordance with

§ 438.330(b)(2) or PHP performance measures calculated by the State during the preceding 12 months.

(iii) A review, conducted within the previous 3-year period, to determine the PHP's, PIHP's, or PAHP's compliance with the standards set forth in subpart D of this part and the quality assessment and performance improvement requirements described in § 438.330.

(iv) Validation of PHP network adequacy during the preceding 12 months to comply with requirements set forth in § 438.68 and, if the State enrolls Indians in the PHP, PIHP, or PAHP, § 438.14(b)(1).

(2) For each PCCM entity (described in § 438.310(c)(2)), the EQR-related activities in paragraphs (b)(1)(ii) and (iii) of this section must be performed.

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(b) Optional activities. For each PHP, PIHP, PAHP, and PCCM entity (described in § 438.310(c)(2)), the following activities may be performed by using information derived during the preceding 12 months:(1) Validation of encounter data reported by a PHP, PIHP, PAHP, or PCCM entity

(described in § 438.310(c)(2)).(2) Administration or validation of consumer or provider surveys of quality of care.(3) Calculation of performance measures in addition to those reported by a PHP,

PIHP, PAHP, or PCCM entity (described in § 438.310(c)(2)) and validated by an EQRO in accordance with (b)(2) of this section.

(4) Conduct of performance improvement projects in addition to those conducted by a PHP, PIHP, PAHP, or PCCM entity (described in § 438.310(c)(2)) and validated by an EQRO in accordance with (b)(1) of this section.

(5) Conduct of studies on quality that focus on a particular aspect of clinical or nonclinical services at a point in time.

(6) Assist with the quality rating of PHPs, PIHPs, and PAHPs consistent with § 438.334.

Line 2.3 – PHP expenditure that is related to HIT and meaningful use: See § 438.8(e)(3)(iii)Any PHP expenditure that is related to Health Information Technology and meaningful use, meets the requirements placed on issuers found in 45 CFR 158.151, and is not considered incurred claims, as defined in paragraph (e)(2) of this section.

45 CFR § 158.151(a) General requirements. An issuer may include as activities that improve health care

quality such Health Information Technology (HIT) expenses as are required to accomplish the activities allowed in § 158.150 of this subpart and that are designed for use by health plans, health care providers, or enrollees for the electronic creation, maintenance, access, or exchange of health information, as well as those consistent with Medicare and/or Medicaid meaningful use requirements, and which may in whole or in part improve quality of care, or provide the technological infrastructure to enhance current quality improvement or make new quality improvement initiatives possible by doing one or more of the following:(1) Making incentive payments to health care providers for the adoption of certified

electronic health record technologies and their “meaningful use” as defined by HHS to the extent such payments are not included in reimbursement for clinical services as defined in § 158.140 of this subpart;

(2) Implementing systems to track and verify the adoption and meaningful use of certified electronic health records technologies by health care providers, including those not eligible for Medicare and Medicaid incentive payments;

(3) Providing technical assistance to support adoption and meaningful use of certified electronic health records technologies;

(4) Monitoring, measuring, or reporting clinical effectiveness including reporting and analysis of costs related to maintaining accreditation by nationally recognized accrediting organizations such as NCQA or URAC, or costs for public reporting of quality of care, including costs specifically required to make accurate determinations of defined measures (for example, CAHPS surveys or chart review of HEDIS measures and costs for public reporting mandated or encouraged by law.

(5) Tracking whether a specific class of medical interventions or a bundle of related services leads to better patient outcomes.

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(6) Advancing the ability of enrollees, providers, issuers or other systems to communicate patient centered clinical or medical information rapidly, accurately and efficiently to determine patient status, avoid harmful drug interactions or direct appropriate care, which may include electronic Health Records accessible by enrollees and appropriate providers to monitor and document an individual patient's medical history and to support care management.

(7) Reformatting, transmitting or reporting data to national or international government-based health organizations for the purposes of identifying or treating specific conditions or controlling the spread of disease.

(8) Provision of electronic health records, patient portals, and tools to facilitate patient self-management.

Excluded CostsExcluded costs are identified to ensure they are not included in the calculation of MLR. Line 3.1 – Amounts paid to third party vendors for secondary network savings, network

development, admin fees, claims processing, and utilization management. Line 3.2 – Amounts paid to a provider for professional or administrative services outside of

providing services to enrollees. Line 3.3 – Fines and penalties assessed by regulatory authorities. Line 3.4 – Amounts in Stabilization Reserve Line 3.5 – Amounts related to prior period MLR remittance.

The DenominatorPremium Revenue Line 4.1 – State capitation payments, including adjustments, and including directed

payments. This line should include Service revenue, Administrative revenue, and Risk Reserve revenue.

Line 4.2 – Earned premium withholds approved under § 438.6(b)(3). Line 4.3 – Unpaid cost-sharing amount that the health plan could have collected from

enrollees under the contract: See § 438.8(f)(2)(iv). Unpaid cost-sharing amounts the PHP could have collected from enrollees under the

contract, except those amounts the PHP can show it made a reasonable, but unsuccessful, effort to collect.

Line 4.4 – All changes to unearned premium reserves. Line 4.5a – Profit Sharing remittances to DHHS (report a negative value). Line 4.5b – Other net payments/receipts related to risk sharing mechanisms.

Federal, State, and Local Taxes Line 5.1 – Statutory assessments to defray the operating expense of any state or federal

department (report a positive number to reduce the denominator). Line 5.2 – Examination fees in lieu of premium taxes as specified by state law (report a

positive number to reduce the denominator). Line 5.3 – Federal taxes and assessments allocated to PHPs (report a positive number to

reduce the denominator). Line 5.4 – State and local taxes and assessments (report a positive number to reduce the

denominator). State and local taxes and assessments including:

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(A) Any industry-wide (or subset) assessments (other than surcharges on specific claims) paid to state or locality directly.

(B) Guaranty fund assessments.(C) Assessments of state or locality industrial boards or other boards for operating

expenses or for benefits to sick employed persons in connection with disability benefit laws or similar taxes levied by states.

(D) State or locality income, excise, and business taxes other than premium taxes and state employment and similar taxes and assessments.

(E) State or locality premium taxes plus state or locality taxes based on reserves, if in lieu of premium taxes.

Line 5.5 – Amounts otherwise exempt from Federal income taxes for community benefit expenditures (report a positive number to reduce the denominator). See § 438.8(f)(3)(v).

MLR CalculationThe remainder of the worksheet takes the amounts identified above and summarizes them to calculate the Federal MLR using the definitions for numerator and denominator as outlined in §42 CFR 438.8. Additionally, this worksheet calculates the MLR for the DHHS method which aligns with the contract. The DHHS-defined MLR result based on reported experience is then compared to the minimum MLR threshold to calculate the estimated remittance. A proxy for the weighted minimum MLR threshold for the current YTD reporting period can be found within the Total Profitability schedule. Since membership mix may change throughout the year, the minimum MLR threshold for prior months should be identified from the prior month Total Profitability schedule.

Amounts shown on these schedules are estimates based on the PHP’s periodic reporting. The annual MLR reporting package will support the formal MLR reporting and remittance determination.

2.13 Schedule K: Outpatient PharmacySchedule K: Outpatient Pharmacy is intended to summarize information related to pharmacy services on a statewide basis, by month.

General InstructionsComplete the requested information in the columns associated with the corresponding month. For the first month of the reporting year, information will only be reported in the first of the twelve reporting columns of the report. The second month report for the year should build upon the first month submission by completing the second month column (i.e., the first month information from the original first month’s submission should be included in the second month’s report). Some information may not change from month to month. This process will be followed for all twelve months of the reporting year, with the final monthly report containing information from all twelve months, respectively. Data presented in this report shall include all paid covered outpatient pharmacy claims (such as retail pharmacy, specialty pharmacy, and mail order) unless specifically noted. Over the counter drugs should be included within this report. Each paid pharmacy claim shall also be sorted and reported as a brand or a generic based on the plan’s status of the National Drug Code on the date of service/adjudication.

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The report also includes a section for reporting physician-administered/other outpatient drug claims.

For lines other than 122 and 123, a pharmacy claim is defined as one fill of a prescription that is provided by a pharmacy based on a prescription to supply a prescribed medication, supply or device for a specific patient.

Lines 122 and 123 are the only rows that request information regarding physician-administered/other outpatient drug claims. Include all drug-related medical claims administered and billed through physician offices other than outpatient hospital settings. Claim count and paid amount information should be reported at the detail level and include all drug-related claims and dollars and exclude administrative claims and dollars. Each paid drug-related medical claim shall also be sorted and reported with the billing code and corresponding National Drug Code submitted on the date of service/adjudication. The remaining lines pertain to the claims dispensed through outpatient pharmacies. Medications associated with an inpatient hospitalization are not to be included in this report.

Input lines are numbered on the report template and will be utilized in these instructions for reference. Lines “Ex. 1”, “Ex. 2”, and “Ex. 3” are examples only.

The report is separated into two main sections, Pharmacy Contractual Information – Statewide and Pharmacy Claims Experience – Statewide. Many of the metrics requested are split into the four major categories of Non-Specialty Brand Drugs, Non-Specialty Generic Drugs, Specialty Brand Drugs, and Specialty Generic Drugs. These four categories would exclude physician-administered/other outpatient setting drug claims. Information related to physician-administered/other outpatient drug claims is requested separately.

Pharmacy Contractual InformationThe Pharmacy Contractual Information – Statewide section requests contractual terms agreed to by the PHP and its various vendors. This section should not represent actual claims experience. Actual claims experience will be reported in the subsequent Pharmacy Claims Experience – Statewide section of the report. If contractual terms vary by drug, provide a range of values in the cell. If particular contract terms require further explanation, use the comment box at the end of the report.

Lines 1, 4, 7, and 10 – Report the contractually agreed upon Benchmark Price Type for each of the four drug categories.

Lines 2, 5, 8, and 11 – Report the contractually agreed upon Ingredient Discount percentage or Markup percentage for each of the four drug categories.

Lines 3, 6, 9, and 12 – Report the contractually agreed upon Dispensing Fee (per claim) for each of the four drug categories.

Line 13 – Report the contractually agreed upon Dispensing Fee (per claim) for compound drug claims. Compound ingredients are reflected in the contractual ingredient benchmark pricing and applied discount/markup percentages in lines 1, 2, 4, 5, 7, 8, 10, and 11.

Note: Do not include any internal PHP (i.e., non-PBM) costs/expenses associated with the administration of the pharmacy benefit in lines 14 through 16.

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Line 14 – If applicable, report the total fees paid for contractually-agreed upon PBM fixed administrative fees or other arrangement not included in lines 15 or 16.

Line 15 – If applicable, report the total fees paid for contractually-agreed upon PBM per claim, administrative fees for pharmacy claim adjudication, and management. If the PBM uses spread pricing, include the spread here.

Line 16 – If applicable, report the total fees paid for contractually-agreed upon PBM administrative fees that were paid on a PMPM basis.

Lines 17 through 32 – Report the applicable vendor information (names and contract termination dates) for each vendor providing the listed services to the plan. If the same vendor provides multiple services, the vendor’s information should be included on each applicable line. If the plan performs a particular service without the assistance of an outside vendor, report “PHP” on the applicable line. If particular contract terms require further explanation, use the comment box at the end of the report.

Pharmacy Claims Experience – StatewideThe Pharmacy Claims Experience – Statewide section requests actual claims experience from the reporting month. Reported values should represent expenses incurred in the month with appropriate adjustments for IBNP estimates as necessary. If particular metrics require further explanation, use the comment box at the end of the report.

Lines 33 through 77 – Report the requested metrics for beneficiary counts, total pharmacy metrics, and each of the four drug categories. Each of the four drug categories are considered mutually exclusive. Exclude compound drug claims from this section.

Lines 77 through 82 – Report the requested metrics for compound drug claims. Exclude non-compound drug claims from this section.

Note: The Utilization Rate (% Total Paid) reported on lines 54, 64, 70, 76, and 81 should equal 100% and be associated with the total paid amount provided on line 39 so spend in each of the four drug categories can be computed. The Utilization Rate (% Total Claims) reported on lines 55, 65, 71, 77, and 82 should equal 100% and be associated with the total number of claims provided on line 38 so claim utilization in each of the four drug categories can be computed.

Lines 101 and 102 – Report total dollars avoided and total dollars recovered through COB/TPL activities associated with the pharmacy claims reported on line 38.

Line 103 – Report total copay dollars associated with the claims reported on line 38. Line 104 – Report total dollars spent on Medication Therapy Management (MTM) activities

(such as identifying patients for MTM services, MTM interventions, and MTM professional service fees).

Line 105 – Report total dollars paid for pharmacy claims delivered or shipped to a medical provider for administration.

Lines 107 through 109 – Report total rebate dollars associated with claims reported on line 38 on an accrual basis, including any expected amounts that are not guaranteed. Lines 108 and 109 will calculate automatically.

Lines 110 through 115 – Report the requested metrics associated with 340B activity. Lines 116 through 121 – Report the requested metrics associated with pharmacy audit

activities.

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Lines 122 and 123 – Using claim detail level, report total dollars paid and associated total number of claim lines for all physician-administered/other drugs in the clinic or outpatient setting (e.g., Health Care Common Procedure Coding System, current procedural terminology [CPT], revenue codes). For example, if one claim has three detail line items applicable to reporting here, report the total paid for those three line items and a count of three. If one claim has one detail line applicable to reporting here, report the total paid for that claim line and a count of one. Lines 122 and 123 should exclude vaccines, and the totals reported are mutually exclusive from the pharmacy totals reported on lines 38 and 39.

Comment box – Enter any additional comments or relevant information regarding how data was reported, and other comments relevant to the use of this information for capitation rate setting and/or program monitoring.

2.14 Schedule L: Additional Provider PaymentsThis schedule is used to track detailed payments to providers that are not incorporated in the PMPM capitation and maternity event rates. DHHS requires PHPs to make additional, utilization-based, directed payments to hospitals, local health departments, and public ambulance providers. DHHS will reimburse PHPs for these additional payments outside the normal capitation and maternity event capitated payments.

Payments should be classified by COS to differentiate inpatient, outpatient, professional, and transportation payments.

2.15 Schedule M: FQHC/RHC PaymentsThis report is a summary of PHP payments to FQHCs and RHCs for services, and a comparison of those payments to each FQHC’s or RHC’s Prospective Payment System (PPS) rates. The PHP is to reimburse FQHCs and RHCs for covered services at negotiated rates that are no less than rates to be defined by the DHHS and no less than rates paid to other providers for similar services in accordance with 1903(m)(2)(A)(ix) of the Social Security Act. The PHP will update the YTD report with each monthly submission.

As PPS rates may vary by provider and change periodically, Schedule M: FQHC/RHC Payments is designed to capture information by provider by month. List monthly aggregate payments and encounters by provider, as well as the PPS rates in effect for the effective dates of service. In order for the reported payments to reconcile with other schedules, this Schedule is designed for reporting based upon dates of service. Amounts reported should be based upon the PHP’s anticipated (accrued) payments for services, even if actual payments have not yet been paid.

However, as PPS rates may change within a reporting period, reporting payments by month allows for direct comparison to such rates. Although only one entry per provider will typically be necessary within any given month, if payments change within a month (e.g., scope of service change, etc.), report the aggregate amounts on different lines for the same month corresponding to the different PPS rates for their effective periods. For example, if a PPS rate changed on 9/4/xx for FQHC A, report the aggregate payments and encounters for 9/1/xx-9/4/xx on one line, and the aggregate payments and encounters for 9/5/xx-9/30/xx on another. Both

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lines can be referenced with the same monthly identification, and a clarifying disclosure should be provided in Schedule O: Supplemental Working Area.

Encounters for FQHC/RHC providers are based upon the DHHS definition of encounters for FQHC/RHC services, and are correlated to PPS rate determination. Report the number of encounters corresponding to the payments listed. Generally, in spite of the number of Medical services provided on any given day (i.e., line detail), an enrollee receives one encounter per day.

The PHP is responsible for reporting PPS rates in effect for the dates services were provided. PPS rates may be obtained from the provider or DHHS, but should be the rates issued by DHHS.

The PHP’s payments per encounter are automatically calculated within the report (accrued amounts divided by encounters), as are the equivalent PPS payments (encounters multiplied by the PPS rates). Any variance between the PHP’s payments and the calculated PPS equivalents is also automatically calculated.

2.15 Schedule N: TCOC ReportThis report allows DHHS to collect TCOC data to track cost growth and compare to national benchmarks to meet state law requirements. Risk adjusted cost growth for Medicaid enrollees must be at least two percentage points below national Medicaid spending growth as documented and projected in the annual report prepared for CMS by the Office of the Actuary for non-expansion states.

This schedule requires the input of specific monthly information for normalizing cost growth considering changes in enrollment and risk profiles.

Risk scores will be provided on a monthly basis by DHHS and should be entered for the appropriate categories of aid.

Medical expense PMPMs may be sourced from the total profitability schedule for the current month. Medical expense PMPMs for prior months should be sourced from prior reports.

The total cost of care (current and prior periods) will be weighted based on the membership mix flowing through the total profitability statement. These member months are automatically referenced below the main table.

On a monthly basis, please provide a summary of cost drivers and steps the PHP is taking to address the cost drivers and mitigate future cost growth within Schedule O – Supplemental Working Area and annually within Schedule ZZ – Annual Narrative.

2.16 Schedule O: Supplemental Working AreaThis schedule should be used by the PHP for working purposes or as a supplemental reference area for financial statement disclosures.

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3. Quarterly Reporting RequirementsQuarterly reports are due 45 days after the end of the fiscal quarter. The report shall include the schedules listed below, as well as all of the monthly reports.

3.01 Schedule P: Value-Added ServicesThis schedule is used to report value-added services provided for Medicaid beneficiaries beyond the scope of covered services. The costs included in this report are not used for capitation rate setting but may be provided to Medicaid beneficiaries by the PHP. In column B, provide the name of the service. In column C, please provide a brief description of the service and any notes or comments for DHHS. If the service is only available in a certain region, please include that information in the notes. In column D, provide the number of YTD units through the end of the quarter. In column E, provide the unique number of beneficiaries. This may be an unduplicated count, in cases where a beneficiary may have fallen into more than one rate cell within the reporting period. In column F, provide the YTD expenses. Column G will auto calculate the PMPM cost of the service. In column H, indicate whether the expense is included with reported encounters. Please include all value-added services approved by DHHS, even if there are zero expenses for the reporting period.

3.02 Schedule Q: Medicaid Claim AgingThis report provides information on outstanding claims at the end of a reporting period and the total claims processed during the reporting period. The claim inventory counts are to be reported by the appropriate expense (i.e., inpatient, ER, other) and aging (i.e., 1-30 days, 31-60 days, 61-90 days, 91-120 days, and greater than 120 days). Note the aging of a claim starts the day it is received by the PHP. The PHP is encouraged to run reports close to the reporting deadline to determine a more accurate estimate of outstanding and adjudicated claims that were in process as of the end of the reporting period. Claims should be counted at the header level, not the line item level. Explanations for aging that is over 90 days should be documented on Schedule O: Supplemental Working Area.

In addition, include a count of total claims adjudicated during the reporting period by appropriate claim category.

3.03 Schedule R: Medicaid Claim ProcessingThis report provides statistics on the count (header level) and dollar amount of claims processing statistics. This information must be completed by claims processing dates, not by service month. Prior Month and Second Prior Month amounts should tie to the preceding amounts reported on Schedule R: Medicaid Claim Processing for the previous month. The information is reported by month. Lines 1 through 7 relate to claim counts and lines 8 through 11 relate to dollar amounts. A description of each category is provided in the following table. Note: A partially paid claim should be considered a paid claim for purposes of counting claims; however, only the part that is paid should flow into the paid amount. The part of the claim that is not paid should be categorized as Claims Approved Not Paid.

Examples are listed in Appendix A.

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Line Category Description1 Total Number of Claims Received The total number of claims received during the month.2 Claims Approved And Paid Claims that have processed through the system and a

check/explanation of benefits (EOB) has been sent to the provider.

3 Claims Denied Claims that have processed through the system and have been denied.

4 Claims Approved Not Paid Claims that have processed through the system and a check/EOB has not been sent to the provider.

5 Claims Pended Claims that have processed but have pended for additional review.

6 Claims In Process or No Status Claims that are in process or that have no status within the claim system. This can include claims received but not input and claims awaiting processing.

7 Total Claims Summarization of lines 2 through 6.8 Claims Approved And Paid The dollar amounts of claims that have processed

through the system and a check/EOB has been sent to the provider. The dollar amount reported should be the PHP paid amount.

9 Claims Denied The dollar amounts of claims that have processed through the system and were denied. The dollar amount reported should be the provider billed amount.

10 Claims Approved Not Paid The dollar amounts of claims that have processed through the system and a check/EOB has not been sent to the provider. The dollar amount reported should be the PHP paid amount.

11 Claims Pended The dollar amounts of claims that have processed but have pended for additional review. The dollar amount reported should be the PHP allowed amount.

3.04 Schedule S: Medicaid Coordination of Benefits and Third Party LiabilityList all TPL resource payments made for members with active commercial, Medicare, casualty coverage, or credit balances on the date of claim service during the quarter. Provide the count of claims, count of claims cost avoided, amount billed, amount paid, and the total resource payments paid by other insurance for commercial and Medicare recipients. All claim counts and amounts should be reflected even if no COBs took place when adjudicating the claim. Claims cost avoided are those denied in the period for lack of evidence of COBs by the provider for a member with a known TPL resource on the date of service. For claims cost avoided, the amount billed should be reported. For claims that are adjusted in the period or for prior periods in the reporting quarter, each re-adjudication should be counted along with amounts reported. Report the count of members with active TPL resources at the end of the quarter on lines 8 and 9. Do not include counts or amounts for members where TPL subrogation is being pursued.

Detail must be maintained supporting reported amounts, including Medicaid identification number and transaction control or claim numbers. This detail must be made available upon request to DHHS within 14 days of the request.

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3.05 Schedule T: Medicaid Fraud and Abuse TrackingList all new, active, and closed fraud and abuse cases for the quarter. Include the count of related claims for each case by the provider name and/or case identification number. Indicate with a “Y” if the case is new, active, or closed. Do not include member-specific names or identification numbers on the schedule. Include cases and recoveries regardless of whether or not they are processed through the claims system.

3.06 Schedule U1: Total Utilization This report is meant to provide detailed information on utilization by COA and claims type. The columns of Schedule U1: Total Utilization are automatically calculated from the Medicaid Utilization Regional Schedules U2: Utilization Region 1 through U7: Utilization Region 6.

3.07 Utilization Schedules U2: Utilization Region 1 through U7: Utilization Region 6Schedules U2: Utilization Region 1 through U7: Utilization Region 6 are used to report specific Medicaid utilization by COA and claims type per region. It is a cumulative summarization of utilization for the current fiscal year. The report follows the COS as described in the Rate Book, or as defined below. The COS is intended to be mutually exclusive.

For each inpatient metric, report days and admissions. For overall inpatient PH and BH, also report all-cause readmissions.

Report the following days and admissions for as a subset of Inpatient-PH. Inpatient NICU – days and admissions of infants to the neonatal intensive care unit. Inpatient Surgery – days and admissions for surgical procedures. Maternity Events – days and admissions for maternity events that trigger maternity event

payments.

For outpatient hospital encounters, report the number of claims filed.

For nursing home encounters, report the number of days admitted to nursing homes.

For stays in hospital inpatient facilities, nursing homes and other institutional providers, count days by including the day of admission and excluding the day of discharge.

3.08 Schedule V: Cost AvoidanceThis schedule is designed to track costs avoided by National Provider Identifier (NPI). Cost avoidance can include, but is not limited to TPL, subrogation, and abuse, waste or fraud avoidance. Include provider NPIs for affected claims, the dates of service for the affected claims, a description of the cost avoidance activity, and the amount avoided or recovered. Amounts should be reported by incidence but may be aggregated for common NPIs and dates of service.

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3.09 Schedule W: VBP Methods List all VBP methods with activity during the plan year by provider and unique identifier, such as the NPI. Add a new line for each location where pricing may be different. If the contract is no longer active, enter the last date the arrangement was in effect in the “Active” column. Summarize the number of cases for each arrangement. Do not create a separate line for each case. In column H, please provide the type of alternative payment arrangement and frequency. Examples of alternative payment arrangements may include cost/risk sharing arrangements, provider incentives such as pay for performance or quality bonuses, bundled payments, etc. Examples of frequency may include per claim, by diagnosis or disease condition, by measurement period (define), etc.

3.10 Schedule X: Contributions to Health-Related ResourcesNet service and administrative expenses in alignment with DHHS’ quality strategy for investments to improve the health of North Carolinians. Schedule X: Contributions to Health-Related Resources is designed to inform DHHS of these reinvestment projects and the expenses related to providing Medicaid services.

Use column B to identify the investment project, column C for the start date, column D for the end date (if available), and column E for the county/counties served by the investment. List YTD expenses in column F. In column G, indicate whether the investment has a financial impact on Medicaid services, such as a reduction of ER usage. If column G is “yes”, in column H, identify the major COS (as listed in section 2.02) affected by the investment, and column I to project the amount of the impact to Medicaid. If column G is “no”, project the total one-time cost of the initiative. Use column K to describe the initiative and the location providing the initiative.

3.11 Schedule Y and Y1: Out of NetworkThese schedules are designed to capture out of network activity. The tables require separate tracking of inpatient PH, inpatient BH, ER PH, ER BH, and outpatient hospital and professional services. The category classifications should follow the hierarchy in the Rate Book for these categories. The first schedule captures PH and BH admissions by provider, as well as network status. The second schedule is broken into sub-tables to capture the percentage of out of network activity by classification and region.

Hospital admissions spanning multiple reporting periods shall be reported at the date of admission, and shall not be double counted if the claim is split into more than one payment.

Total admissions are expected to match the figures reported within the statewide utilization schedule. Total dollars billed by providers is expected to match the COS line items reported on the income statement.

The descriptions in the following table may be considered when completing the report.

Category Description

Line # These values reflect the unique provider name and NPI for each service category in the report

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Category Description

Provider NameAs displayed within the NPPES databasehttps://npiregistry.cms.hhs.gov/

NPI As displayed within the NPPES database

Current Network Status As of the date of the report, please provide the status of the provider: (In Network / Out of Network)

Region The service region where the provider is located

Total (Admissions or Dollars)These values reflect the total number of admissions or total paid amount within the reporting period

Total # Out of Network (Admissions or Dollars)

These values reflect the total number of admissions or total paid amount for services that are not in networkSingle case agreements are considered out of network; although, they may be paid at an in network rate or at 100% of the Medicaid fee-for-service (FFS) rate

% Out of Network

A calculated field that reflects the total number of admissions or the total paid amount divided by the number of admissions or paid amount that is out of network

Out of Network (Admissions or Dollars) with Negotiated Agreement or 100% FFS rate

These values reflect the number of admissions or amount paid to providers that are not in network, which are paid at a negotiated rate or no less than 100% of the Medicaid FFS rate

Out of Network (Admissions or Dollars) without Negotiated Agreement or 90% FFS rate

These values reflects the number of admissions or amount paid to providers that are not in network, which are paid at a negotiated rate nor more than 90% of the Medicaid FFS rate

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https://npiregistry.cms.hhs.gov/


4. Annual Reporting RequirementsAn annual report is due 60 days after the end of the fiscal year. The report shall include the schedules listed below, as well as all of the quarterly and monthly reports. Figures within the annual report should match the PHP’s audited financial statements for the Medicaid line of business.

4.01 Schedule Z: Annual NarrativeThis schedule provides the PHP a venue to annually describe activities to mitigate annual cost growth. The narrative should summarize cost drivers, programs in place to address those cost drivers, and plans for addressing future cost growth.

4.02 Schedule AA: Audited Financial StatementsIf the PHP has a parent company, include parent company audited financial statements.Insert the final audited parent company financial statements in this tab within 120 days after year end. Preferably, this can be accomplished by embedding the final statements in PDF format.

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Appendix A: Scenarios for Updating Schedule R: Medicaid Claim ProcessingMedicaid claims reporting should reflect Claim Header counts instead of Claim Detail line counts. Seven scenarios over a two-month period are included to outline how the Schedule H: Comparison should be completed.

For PHPs to program the Medicaid claims processing, use the hierarchical logic:

1. If any line on a claim is pended, the whole claim is pended.2. For claims that have not cleared the check cycle that are fully adjudicated, the claim is

Approved Not Paid.3. For fully adjudicated claims after the check cycle, if any line is paid, the claim is Approved

and paid.4. For fully adjudicated claims, if all lines are denied, the claim is Denied.

ScenariosThe following seven scenarios represent reporting in the Current Month column. Each scenario is one Claim Header that includes 10 claim detail lines with the summary of all seven at the bottom. Each claim detail line has a Claim Amount and Approved Amount of $10 (Claim Amount and Approved Amount will be the same value for these scenarios). For each scenario, DHHS has included the Schedule H: Comparison table to show the values in the current month based on the new DHHS guidance.

Current Month, 7 Claims (Headers), 10 Claim Detail Lines for $10 each.

1. All claim lines Approved and Paid

Count of claims processing statistics

Line # Category Current Month Prior Month Second Prior Month

1 Total Number of Claims Received 1

2 Claims approved and paid 1

3 Claims denied 0

4 Claims approved not paid 0

5 Claims pended 06 Claims in process or no status 0

7 Total claims 1 0 0

Dollar amount of claims processing statisticsLine # Category Current Month Prior Month Second Prior Month

8 Claims approved and paid $1009 Claims denied $0

10 Claims approved not paid $0

11 Claims pended $0

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2. All claim lines Denied





3 Claims denied 1







11 Claims pended $0

3. 10 claim lines Approved not Paid





3 Claims denied 0







11 Claims pended $0

4. 5 claim lines Approved and Paid, 5 lines Denied





3 Claims denied 0







11 Claims pended $0

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5. 6 claim lines Approved not Paid, 4 Lines Pended





3 Claims denied 0







11 Claims pended $100

6. 5 claim lines Denied, 5 lines Pended





3 Claims denied 0








7. 6 claim lines Approved not Paid, 2 lines Denied, 2 lines Pended





3 Claims denied 0








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All Seven Scenarios shown together.





3 Claims denied 1








Historical ReportingHistorical Reporting represents the values reported the month following the initial report. Data from the current month column does not change when moved to the prior month column. Changes to the status of claims are included in the current month value even though the claims received value is zero.

1. Claim 4 above: The 5 lines denied were re-adjudicated internally and are approved, +5 Approved and Paid lines. For reporting, the claim is considered Approved and Paid. The dollars reported in the current month should reflect only the additional payment amount.



1 Total Number of Claims Received 0 1

2 Claims approved and paid 1 1

3 Claims denied 0 0

4 Claims approved not paid 0 0

5 Claims pended 0 06 Claims in process or no status 0 0



8 Claims approved and paid $50 $509 Claims denied $0 $0

10 Claims approved not paid $0 $0

11 Claims pended $0 $0

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2. Claim 5 above: The 4 Pended claim lines have received a new status and the previously Approved claims lines are now paid, with the final claim having +8 approved and paid line, +2 denied lines. For reporting, the claim is considered Approved and Paid. The dollars reported in the current month should reflect only the additional payment amount.

Count of claims processing statisticsLine # Category Current Month Prior Month Second Prior Month



3 Claims denied 0 0

4 Claims approved not paid 0 05 Claims pended 0 16 Claims in process or no status 0 0


Dollar amount of claims processing statistics

Line # Category Current Month Prior Month Second Prior Month8 Claims approved and paid $80 $0

9 Claims denied $0 $0



3. Claim 6 above: The 5 Pended claim lines have received a new status, +4 Approved and Paid lines, +1 Denied line. For reporting, the claim is considered Approved and Paid. The dollars reported in the current month should reflect only the additional payment amount.




3 Claims denied 0 0

4 Claims approved not paid 0 05 Claims pended 0 16 Claims in process or no status 0 0



Line # Category Current Month Prior Month Second Prior Month8 Claims approved and paid $40 $0

9 Claims denied $0 $0



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4. Claim 7 above: The 2 Pended claim lines have received a new status and all previously Approved claim lines are now paid, +8 Approved and Paid lines. For reporting, the claim is considered Approved and Paid. The dollars reported in the current month should reflect only the additional payment amount.





3 Claims denied 0 0








Prior Month Summary of 4 adjusted Scenarios.





3 Claims denied 0 1








Zero Dollar ClaimsA Zero Dollar Claim represents a situation where a claim is approved, but no dollar amount is paid to the provider. For example, a zero-dollar claim would happen in a situation where a COB amount is equal to or more than the contract rate. These claims are still recorded even if they do not have a dollar amount recorded in lines 8 through 11.

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1. Claim with primary COB amount more than the Medicaid contract rate. All Approved and Paid (at $0).




3 Claims denied 0

4 Claims approved not paid 05 Claims pended 06 Claims in process or no status 0



Line # Category Current Month Prior Month Second Prior Month8 Claims approved and paid $0

9 Claims denied $0


11 Claims pended $0

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