Community Healthchoices

Appendix C
Reporting Requirements
A. Department Monitoring Requirements
To demonstrate compliance with 42 CFR 438.66, State Monitoring
Requirements, the Department must have in effect a monitoring system for CHC.
The Department's system must address all aspects of the managed care
program, including the performance of each CHC-MCO as required in 438.66
(b). The Department must use the data collected from its monitoring activities to
improve the performance of its managed care program, including, at a minimum
the areas noted in 438.66 (c).
In addition, 438.66 (e) requires the Department to submit to CMS, no later than
180 days after each contract year, a report on its managed care programs. The
first annual report for CHC is due to CMS no later than June 29, 2023 for the
2022 calendar year. The annual program report must provide information on and
an assessment of the operation of CHC on, at a minimum, the following areas:
* Financial performance of each CHC-MCO, including MLR experience.
* Encounter data reporting by each CHC-MCO.
* Enrollment and service area expansion (if applicable) of each CHC-MCO.
* Modifications to, and implementation of, MCO benefits covered under the
contract with the Department.
* Grievance, appeals, and State fair hearings for CHC.
* Availability and accessibility of covered services within the CHC-MCO
agreements, including network adequacy standards.
* Evaluation of the CHC-MCO's performance on quality measures, including
as applicable, consumer report card, surveys, or other reasonable
measures of performance.
* Results of any sanctions or corrective action plans imposed by the
Department or other formal or informal intervention on a CHC-MCO to
improve performance.
* Activities and performance of the beneficiary support system.
* Any other factors in the delivery of LTSS not otherwise addressed in
438.66 (e)(2)(i)-(ix) as applicable.
The CHC-MCO must comply with all state and federal reporting requirements
that are set forth in this Agreement and provided through Guidance from the
Department. If the CHC-MCO fails to submit the required reports within
timeframes specified, the Department shall assess sanctions upon the CHC-
MCO as specified in Section VIII.I, Sanctions, and Section VII D.2, Sanctions,
and Exhibits T, X, BB of this Agreement.

B. General
The CHC-MCO must comply with state and federal reporting requirements that
are set forth in this Agreement and provided in guidance from the Department.
The CHC-MCO must certify and submit to the Department the data required to
be certified under 42 C.F.R. 438.604, whether in written or electronic form. Such
certification must be submitted concurrently with the data and must be based on
the knowledge, information and belief of the Chief Executive Officer, Chief
Financial Officer or an individual who has delegated authority to sign for, and who
reports directly to, the CEO or CFO in accordance with 42 C.F.R. 438.604.
The CHC-MCO will provide the certification in the manner prescribed by the
Department.
The CHC-MCO must cooperate with the Department in all activities related to
compliance with federal mental health parity requirements. The CHC-MCO must
provide all information requested by the Department related to these activities
within ten (10) days of the Department's request.
For critical and urgent issues, the CHC-MCO is required to respond to the
Department the same day or within 12 hours. The CHC-MCO is required to
respond to the Department's questions and issues within three business days of
receiving questions and requests for clarification. The Department will determine
the appropriate contact method, (e.g., phone call or email to the CHC-MCO
Government Liaison or other CHC-MCO contact).
C. Systems Reporting
The CHC-MCO must submit electronic data as specified by the Department.
Whenever possible, the Department will provide reasonable advance notice of
modifications or additions to required electronic data submissions.
Information on the submission of the Department's data files is available on the
Pennsylvania HealthChoices Extranet.
1. Encounter Data Reporting
The CHC-MCO must record Encounter Data for internal use and submit
timely, complete, and accurate Encounter Data to the Department. The CHC-
MCO shall only submit Encounter Data for Participants enrolled in its CHC
plan on the date of service and must not submit duplicate records.
The CHC-MCO must maintain appropriate systems and mechanisms to obtain
all data from its Providers needed to comply with Encounter Data and TMSIS
reporting requirements.

The Department will provide a minimum of sixty (60) days advance written
notice to the CHC-MCO regarding changes to Encounter Data requirements.
Failure of a Provider or Subcontractor to provide the CHC-MCO with
necessary Encounter Data shall not excuse the CHC-MCO's noncompliance
with this requirement.
The CHC-MCO must comply with all sections of 42 C.F.R. 438.242,
including, but not limited to, compliance with Section 6504(a) of the Affordable
Care Act, which requires that Claims processing and retrieval systems collect
data elements necessary to meet the requirements of section 1903(r)(1)(F) of
the Act.
a. Data Format
The CHC-MCO must submit Encounter Data to the Department using
established protocols. Prior to submission of production data, the CHC-
MCO must pass Encounter Data certification for all transaction types.
i. The CHC-MCO must adhere to Encounter Data file specifications,
including the collection and maintenance of sufficient Participant
Encounter Data to identify the Provider who delivers any items or
services to Participants.
ii. The CHC-MCO must adhere to the file size, format specifications, and
file submission schedule provided by the Department. The CHC-MCO
must submit Participant Encounter Data to the Department at a
frequency and level of detail specified by CMS and the Department,
based on program administration, oversight, and program integrity
needs.
The CHC-MCO must provide Encounter Data files in the following ASC
X12 transactions:
* 837P
* Professional
* Professional Crossover
* Professional Drug
* 837I
* Inpatient
* Inpatient Crossover
* Outpatient
* Outpatient Crossover
* Outpatient Drug

* Long Term Care (LTC)
* 837D
* Dental
* NCPDP D.0
* NCPDP Pharmacy
* Compound Pharmacy
Failure of Subcontractors to submit Encounter Data timely shall not
excuse the CHC-MCO's noncompliance with this requirement.
b. Timing of Data Submittal
i. Provider Claims
The CHC-MCO must require Providers to submit claims ready for
adjudication to the CHC-MCO within one hundred eighty (180) days
after the date of service.
The CHC-MCO may include a requirement for more prompt
submissions of Claims or Encounter Data in Provider Agreements and
Subcontracts. Claims adjudicated by a third party vendor must be
provided to the CHC-MCO by the end of the month following the month
of adjudication.
ii. Encounter Submissions
All Encounter Data except NCPDP transactions must be submitted by
the CHC-MCO and approved by the Department on or before the last
calendar day of the third (3rd) month after the adjudication calendar
month in which the CHC-MCO adjudicated the Claim.
NCPDP transactions must be submitted and approved in the
Department's MMIS within thirty (30) days following the adjudication
date.
Encounter Data sent to the Department is considered approved when
all Department edits are passed.
A file with Encounter Data records that deny due to Department edits
will be returned to the CHC-MCO. These records must be corrected
and resubmitted as "new" Encounter records within the timeframe
referenced above.
Corrections and resubmissions must pass all edits before they are
approved by the Department.

When Error Status Code (ESC) denials occur due to MCO,
Subcontractor, or Provider system faults or limitations, it is the
responsibility of the MCO to make every attempt to remediate the
systems concerns within a reasonable amount of time. Based on the
impact of the errors and the length of time to implement a solution, the
MCO may be subject to Corrective Action.
Failure of Subcontractors to submit Encounter Data timely shall not
excuse the CHC-MCO's noncompliance with this requirement.
iii. Response Files
The CHC-MCO's Encounter Data system must be able to receive,
process, and reconcile the U277, NCPDP, and ESC Supplemental
response files. The CHC-MCO must also store the Department's MMIS
ICN associated with each processed Encounter Data record returned
on the files.
c. Data Completeness
The CHC-MCO must submit Encounter Data each time a Participant has
an Encounter with a Provider. The CHC-MCO must have a data
completeness monitoring program in place that:
i. Demonstrates that all Claims and Encounters submitted to the CHC-
MCO by its Providers and Subcontractors are submitted accurately and
timely as Encounters and that denied Encounters are resolved and
resubmitted,
ii. Evaluates Provider and Subcontractor compliance with contractual
reporting requirements, and
iii. Demonstrates the CHC-MCO has processes in place to act on
information from the monitoring program and takes appropriate action
to ensure full compliance with Encounter Data reporting requirements.
Upon request of the Department, the CHC-MCO must submit a Data
Completeness Plan for advance written review and approval. This Plan
must include the three (3) elements listed above.
d. Financial Sanctions
The CH-MCO must provide complete, accurate, and timely Encounter
Data to the Department. In addition, the CH-MCO must maintain complete
medical service history data.

The Department will request the CH-MCO submit a Corrective Action Plan
when areas of noncompliance are identified.
The Department may assess financial sanctions as provided in Exhibit X, Encounter Data
Submission Requirements and Damages Applications, based on the identification of
instances of non-compliance.
e. Data Validation
The CHC-MCO must assist the Department in its validation of Encounter
Data by making medical records and Claims data available as requested.
The validation may be completed by Department staff, independent
external review organizations, or both.
f. Release of Encounter Data
All Encounter Data for Participants is the property of the Department. The
CHC-MCO may use this data for the sole purpose of operating the CHC
Program under this Agreement.
g. Drug Rebate Supplemental File
The CHC-MCO must submit a complete, accurate, and timely monthly file
containing supplemental data for NCPDP, 837P Professional Drug, and
837I Outpatient Drug transactions used for the purpose of drug rebate
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dispute resolution. The file must be submitted by the fifteenth (15 ) day
of the month following the month in which the drug transaction was
processed in the Department's MMIS as specified on the Pennsylvania
HealthChoices Extranet.
The MCO Supplemental Data Status Report will be provided by the
Department to the CHC-MCO on or after the 20th of each month following
receipt of the Drug Rebate Supplemental File. CHC-MCOs must use this
report to reconcile and correct any errors on Drug Rebate data that was
submitted.
2. Third Party Liability Reporting
Third Party Resources identified by the CHC-MCO or its subcontractors, which
do not appear on the Department's TPL database, must be supplied to the
Department's Division of TPL within two (2) weeks of its receipt by the CHC-
MCO. The Department will contact the CHC-MCO when the validity of a
resource is in question. The CHC-MCO shall verify inconclusive resource
information within two (2) business days of notification by the Department that

the resource information is in dispute. However, if the verification notification is
requested on the last business day of the week, the CHC-MCO must respond
by the close of business that day to avoid a potential access to care issue for
its member. The method of reporting shall be by electronic submission via a
batch file or by hardcopy document, whichever is deemed most convenient and
efficient by the CHC-MCO for its individual use. For electronic submissions,
the CHC-MCO must follow the required report format, data elements, and
specifications supplied by the Department. For hardcopy submissions, the
CHC-MCO must use an exact replica of the TPL resource referral form supplied
by the Department. Submissions lacking information key to the TPL database
update process will be considered incomplete and will be returned to the CHC-
MCO for correction and subsequent resubmission.
3. PCP Assignment
The CHC-MCO must provide a weekly file (EVS-PCP) to the Department's
MMIS containing PCP assignments for all its Participants other than those who
have a Medicare PCP. This file is used to update the Department's Eligibility
Verification System.
The CHC-MCO must provide this file at least weekly or more frequently if
requested by the Department. The CHC-MCO must confirm that the PCP
assignment information is consistent with all requirements specified by the
Department by utilizing the response report provided by the Department. The
CHC-MCO must comply with the file submission requirements found on the
Pennsylvania HealthChoices Extranet.
4. Provider Network
The CHC-MCO must provide a monthly Network Provider File (PRV640M) to
the Department. The initial file must contain records for its entire Provider
Network, including Subcontractors. Subsequent monthly files should contain
only updates.
The CHC-MCO must confirm the information is consistent with all
requirements by utilizing the response report (PRM640M) provided by the
Department. The CHC-MCO must use this report to reconcile and correct any
errors. The CHC-MCO must comply with file submission requirements found
on the Pennsylvania HealthChoices Extranet.
5. Alerts
The CHC-MCO must report to the Department on a Weekly
Enrollment/Disenrollment/Alert File: pregnancy (not on eCIS), death (not on
eCIS), and returned mail.

The CHC-MCO must confirm the information is consistent with all
requirements specified on the Pennsylvania HealthChoices Extranet.
D. Operations Reporting
The CHC-MCO is required to submit such reports as specified by the Department
to enable the Department to monitor the CHC-MCO's internal operations and
service delivery. These reports include, but are not limited to:
1. Operations and Quality Reporting Requirements
As a condition of approval of the Waivers for the operation of CHC, CMS has
imposed specific reporting requirements related to the Home and Community
Based Waiver and overall CHC monitoring. OLTL has also established additional
Operations and Quality Management Reports to oversee CHC. Required reports
are identified on the Operations and Quality Management Reporting
Requirements Submission Schedule. CHC-MCOs are required to meet identified
due dates, submit accurate data, and provide requested documentation.
2. Fraud, Waste and Abuse,
The CHC-MCO must submit to the Department quarterly and annual statistical
reports which relate to its Fraud, Waste and Abuse detection and sanctioning
activities regarding Providers. The CHC-MCO must include information for all
situations where a Provider action caused an overpayment to occur and must
identify cases under review (including approximate dollar amounts), Providers
terminated due to Medicare/Medicaid preclusion, provider terminations for good
cause or best interest, overpayments recovered and cost avoidance issues
related to identifying and/or identified fraud, waste, and abuse (42 CFR
438.608(a)(2 )). The CHC-MCO must comply with all requirements regarding
Operations Report format and timeframes provided on the DHS/CHC-MCO
docuShare Reporting pages and on the HealthChoices Extranet at Managed
Care Program/Fraud and Abuse.
E. Financial Reports
The CHC-MCO must submit such reports as specified by the Department to assist
the Department in assessing the CHC-MCO's financial viability and compliance
with this Agreement.
The Department will distribute financial reporting requirements to the CHC-MCO.
The CHC-MCO must furnish all financial reports timely and accurately, with
content in the format prescribed by the Department. This includes, but is not
limited to, the CHC financial reporting requirements issued by the Department.

F. Equity
Not later than May 25, August 25, and November 25 of each Agreement year, the
CHC-MCO must provide the Department with:
A copy of quarterly reports filed with PID.
A statement that its Equity is in compliance with the Equity requirements or is
not in compliance with the Equity requirements.
If Equity is not in compliance with the Equity requirements, the CHC-MCO
must supply a report that provides an analysis of its fiscal health and steps
that management plans to take, if any, to improve fiscal health.
Not later than March 10 of each Agreement year, the CHC-MCO must provide
the Department with:
A copy of unaudited annual reports filed with PID.
A statement that its Equity is in compliance with the Equity requirements or is
not in compliance with the Equity requirements.
If Equity is not in compliance with the Equity requirements, the CHC-MCO
must supply a report that provides an analysis of its fiscal health and steps
that management plans to take, if any, to improve fiscal health.
G. Claims Processing Reports
The CHC-MCO must provide the Department with monthly Claims processing
reports with content in a format specified by the Department. The reports are due
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on the fifth (5 ) calendar day of the second (2 ) subsequent month. Claims
returned by a web-based clearinghouse (e.g., WebMD Envoy) are not considered
as Claims received and would be excluded from Claims reports.
The Department may impose the following sanction for the CHC-MCO's failure to
submit a timely Claims processing report that is accurate and fully compliant with
the reporting requirements: Two Hundred Dollars ($200.00) per day for the first
ten (10) calendar days from the date that the report is due, and One Thousand
Dollars ($1,000.00) per day for each calendar day thereafter.
H. Presentation of Findings
The CHC-MCO must obtain advance written approval from the Department
before publishing or making formal public presentations of statistical or analytical
material based on its CHC Participant Population.
I. Sanctions
1. The Department may impose sanctions for noncompliance with the
requirements under this Agreement and failure to meet applicable

requirements in Sections 1932, 1903(m), and 1905(t) of the SSA in
accordance with 42 C.F.R 438.700; 438.702 and 438.704 in addition to any
sanctions described in Exhibit B of this Agreement, Standard Terms and
Conditions for Services, and in Exhibit B(1) of this Agreement, DHS
Addendum to Standard Contract Terms and Conditions. The sanctions which
can be imposed shall depend on the nature and severity of the breach, which
the Department, in its reasonable discretion, will determine as follows:
a. Imposing civil monetary penalties of a minimum of One Thousand Dollars
($1,000.00) per day for noncompliance;
b. Requiring the submission of a corrective action plan;
c. Suspending or Limiting Enrollment of new Participants;
d. Suspension of payments;
e. Preclusion or exclusion of the CHC-MCO, its officers, managing employees
or other individuals with direct or indirect ownership or control interest in
accordance with 42 U.S.C. 1320a-7, 42 C.F.R. Parts 1001 and 1002; 62
P.S. 1407 and 55 Pa. Code 1101.75 and 1101.77;
f. Temporary management subject to applicable Federal or State law; and/or
g. Termination of the Agreement
2. Where this Agreement provides for a specific sanction for a defined infraction,
the Department may, at its discretion, apply the specific sanction provided for
the noncompliance or apply any of the general sanctions set forth in this
Section VIII.I, Sanctions. Specific sanctions contained in this Agreement
include the following:
a. Claims Processing: Sanctions related to Claims processing are provided
in Section VII D.2 of this Agreement, Sanctions.
b. Report or File, exclusive of Audit Reports: If the CHC-MCO fails to provide
any report or file that is specified by this Agreement by the applicable due
date, or if the CHC-MCO provides any report or file specified by this
Agreement that does not meet established criteria, a subsequent payment
to the CHC-MCO may be reduced by the Department. The reduction shall
equal the number of days that elapse between the due date and the day
that the Department receives a report or file that meets established criteria,
multiplied by the average Per-Member, Per-Month Capitation rate that
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applies to the first (1 ) month of the Agreement year. If the CHC-MCO
provides a report or file on or before the due date, and if the Department
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notifies the CHC-MCO after the fifteenth (15 ) calendar day after the due