Counselors - Peers - Marriage and Family Therapists - Addiction Counselors
Psychologists - Social Workers - Pre-licensure Professionals - Interns

...for a diverse, competent, and sustainable behavioral healthcare workforce.

The 2023-2024 RAE HCPF contracts have obligations to meet "Performance Standards" regarding provider support. 

For example, from the RAE 1 (United Healthcare) contract:


PERFORMANCE STANDARD 1: CALL CENTER ASA The Contractor shall ensure that

the average length of time callers are waiting in the call queue on the Provider Call Line before

the call is answered shall be three (3) minutes or less during each week.


PERFORMANCE STANDARD 2: PROVIDER RESPONSIVENESS The Contractor shall

respond to 95% of all provider questions, issues, or complaints within 2 business days.


PERFORMANCE STANDARD 3: PROVIDER PAYMENT The Contractor currently pays

providers through fee-for-service (FFS) contracts (where providers receive payment for each

service provided) as well as value-based contracts (VBC) that include capitation and the

processing of encounters where encounters are adjudicated for reporting and reconciliation, but

not for direct payment. To meet Performance Standard 3 the Contractor shall:


(a) pay or adjudicate at least 95% of all clean claims for FFS contracts within 30calendar

days of the date of receipt; and pay or adjudicate 99% of all clean claims for FFS

contracts within 60 calendar days of the date of receipt. Prepayment of claims forFFS

contracts within 30 or 60 calendar days of claims submission shall count as “paid”

and as timely payment. Contractor has and may continue to make provider prepayments for FFS contracts; AND


(b) make all capitation payments within 48 business hours of targeted release date.

Contractor shall adjudicate at least 95% of all clean encounters for VBC within 90

calendar days of the date of receipt; and adjudicate 99% of all clean encounters for VBC

within 120 calendar days of the date of receipt. The 90 and 120 calendar day adjudication

timelines for encounters in VBC are established since payment in the form of capitation

occurs regardless of encounter process timelines.


PERFORMANCE STANDARD 4: FINANCIAL AND TRANSACTIONAL CLAIMS

ACCURACY Contractor financial and transactional claims accuracy shall be 98% and 95%

respectively for all clean claims adjudicated, as reported no less frequently by the Contractor on

a calendar quarter basis (financial accountability shall be assessed weekly during each quarterly

calculation). The sample of claims reviewed each quarter, shall include at least 25 claims

(sampled randomly) that require prior authorization and/or utilization management to measure

the impact of the initially non-integrated Essette clinical management system as part of the audit

sample. The reporting for this Performance Standard will be based on an audit of a random

sampling of claims, following auditing industry standards with processes approved by the

Department, which shall not unreasonably withhold such approval.


PERFORMANCE STANDARD 5: ELIGIBILITY ACCURACY The Contractor shall load

95% of all daily compliant 834 eligibility files accurately within 24 business hours of receipt

from the State or its vendors with a 98% accuracy rate.


PERFORMANCE STANDARD 6: MEMBER AND PROVIDER PORTAL

FUNCTIONALITY Except for planned down time to perform scheduled maintenance or

support services, including upgrades, enhancements, or changes to the applicable software or

hardware, Member and Provider Portals and clinical platform (Essette) are operational, accurate,

and allow users to log in and complete all designed functionality (including display of any

member specific data).

 

Colorado Medicaid Behavioral Health Provider Network

info@combinebh.org


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