Medical Timeliness reports include Long Term Care authorizations in the calculation of timeliness, and with the AFS organizational change to Regions, all existing reports have been modified to include Region and District and 3 new reports have been added (R11, R12, R14).
CG360R11 LTC SUMMARY – D SEC & AUTHS
CG360R12 DISTRICT COUNTY SUMMARY
CG360R14 REGION/DISTRICT/COUNTY/PROGRAM SUMMARY
How are the authorizations counted?
- Each Medical tab (D Section) certification/denial counts as one
- Each Nursing Home/ADvantage/Personal Care authorization when it changes from “A to F” or “A to D” status counts as one.
- A timely auth is one that moved from “A to F” or “A to D” within 45 days from the begin date (K45) and the date the case is cleared of all edits.
- Begin date counts as day zero.
How are the reports formatted?
The new CG360 R8 and R9 reports display has changed. These reports will display information in all 4 of the D section columns when the Medical tabs (D Section) are certified /denied in the report month. These certs/denials appear as follows:
|Case Number||App Date||Process Date||D SEC Status||Action D3||Reason D4||Reason D60||Process Days||Timely Untimely|
There are 5 Columns for authorizations
When a NH/ADv/SPPC authorization is added to a case in the report month and the status moves from A to F or A to D, each authorization displays in the new authorization columns. For each auth, the D Section current status and last case action will display:
|Case Number||Process Date||Timely Untimely||Auth Num||Auth Type||Auth Begin Date||Auth Process Date||Auth Status|
Are any authorizations excluded from the report?
Certain authorizations will not be included in these reports / calculations:
- Incorrectly coded auths, such as a PS auth with a K40 Provider number of J999999999
- Auths moved from “A to F” or “A to D” within 30 days of the closure of another LTC auth.
- Auths moved from “A to F” to “O” on the same date.
Medicaid Timeliness Reports in Content Manager OnDemand (CMOD)
- CMOD Reports CG360R1 through CG360R14 evaluate timeliness in terms of the certification or denial actions for the reporting period (previous month) by selecting the worker of record for each case action from PS2 Blocks A10 and A13 at the time of the action, as well as the application reason (D60) that is keyed or in place at the time of the action.
- However, certification actions where the Reason Action (D4) equal to “18*” or “20A” or “26*” are not considered for the reports.
- Proper coding of the Medicaid Application Reason is critical to measuring timeliness!
- If a Section B action takes place the same day as the Section D action, the report will apply the appropriate timeframe for the Section B program (SSP or TANF) by using the Section B Application Date (PS2 Block B1) and ignore any existing or made in the “Reason for Application” field (PS2 Block D60). The “SSA Clock” has been installed on Section D actions where “Reason for Application” (PS2 Block D60) is equal to “Short Term or State Supplement Application – Disability to be established by SSA” or a value of “D” in PS2 Block D60).
- On Section D actions such as this, the timeliness report program searches for changes in the status of the Social Security application, and begins the timeliness count from the SSA change of status date, rather than using the Application Date (D1).
- These actions, otherwise considered untimely by the normal rules of processing, are reviewed in terms of the SSA Clock above.
- For Timeliness Standards by program types, names, and corresponding application reasons, refer to the tables below (scroll down the page). Cases with D3=1 or R, and D4 = 18*, 20A, or 26* are excluded from the universe. Cases from county “00” are also excluded.
Medicaid Timeliness Standards by Program
|Case Prefix||Reason (D60)||Standards (Days)||Program Type||Program Name|
|A||Blanks or $||30||STC||SSP|
|B||Blanks or $||60||STC||SSP|
|D||Blanks or $||60||STC||SSP|
|C||Blanks or $||45||STC||PA TANF Medicaid|
|H||Blanks or $||45||STC||PA TANF Medicaid|
|ABCDHM||B||30||STC||Breast and Cervical Cancer|
|ABCDHM||H||45||LTC||Home/Comm Based Waiver|
|ABCDHM||P (and D4 = PE)||5||STC||Presumptive Applications|
|ABCDHM||S||30||STC||Health Benefits (FSS-1)|
|ABCDHM||W||20||STC||Health Benefits (SC-1)|
|ABCDHM||X||45||STC||QI1s – Qualifying Individuals Group|
|ABCDHM||Y||20||STC||Family Planning Waiver|
Medicaid Timeliness Reports in CMOD
|Report #||Report Title||Description||Desired RDS Recipient(s)|
|R1||State Summary||Count of Timely by State/Region; Percent Calculated||AFS/HRMS|
|R2||State – Program Summary||Count of Timely by State and Program; Percent Calculated||AFS/HRMS|
|R3||Area – County Summary||Count of Timely by Region/County ; Percent Calculated||AFS/HRMS (and others above), Regional Directors|
|R4||Area – Program Summary||Count of Timely by Region and Program; Percent Calculated||AFS/HRMS (and others), Regional Directors|
|R5||Area – County – Program Summary||Count of Timely by County and Program; Percent Calculated||AFS/HRMS (and others), Regional Directors, CD (Limit to County), AFS Supervisors|
|R6||County – Supervisor – Program Summary||Count of Timely by County/Supervisor and Program; Percent Calculated||AFS/HRMS (and others), Regional Directors, CD, AFS Supervisors|
|R7||Supervisor – Worker and Program Summary||Count of Timely by Supervisor/Worker; Percent Calculated||AFS/HRMS (and others), Regional Directors, CD, AFS Supervisors|
|R8||Supervisor – Worker Discrepancy Report||Listing of Untimely Actions, Case #, App Date, Process Date, Section Action, Reason Code, D60, Days Calculated and Displayed||AFS/HRMS (and others), Regional Directors, CD, AFS Supervisors|
|R11||LTC Summary – D Sec & Auths||Count of Timely Medical Sections and Authorizations as one action, “A” to “F” or “D” etc.||AFS/HRMS (and others), Regional Directors, CD, AFS Supervisors|
|R12||District/County/Supervisor||Count of Timely by Supervisor/Worker; Percent Calculated||AFS/HRMS (and others), Regional Directors, CD, AFS Supervisors|
|R14||Region/District/County/Program Summary||Count of Timely by Supervisor/Worker; Percent Calculated||AFS/HRMS (and others), Regional Directors, CD, AFS Supervisors|