Monthly Care Coordination and Utilization Report Webinar

• M. Sophia Newman

• Molly Siegel

• Bridget Larson

• Katey Staley

• Nivedita Baliga

• Claims basics specific to reports

• Monthly Utilization Report

• Monthly Care Coordination Report

• Questions

• Two separate reports

• Monthly Utilization Report

  • Quality measures

• Monthly Care Coordination Report

  • Captures % of enrollees a plan has engaged with

• Utilization report relies on claims data as the single data source

  • Decreases demands on plans

  • Increases fidelity of data

  • Ensures equitable comparison of plans

• More prescriptive than other reports

• We will discuss claims data with respect to utilization report's specific requirements

• On the plan's enrollees only

• Available on 5th working day of the month via FTP from HFS

  • Plans without current enrollment have not seen it

• Retro look at enrollees; updated each month

  • for risk stratification purposes: 2 years of claims data, 7 years immunizations data

  • Utilization report is a snapshot of a single month

• Relational Database – 12 tables

  • Main claims file (1)

  • Ancillary files (11)

• Data Dictionary is available on CCCD website

  • Essential for data analysts; good for everyone

• Specific important fields

  • Table will be on website

This dictionary is intended to provide descriptions of the data regarding the Care Coordination Claims Data.

• CCCD Data Dictionary

• Important numerical codes in claims data are data type: character

  • ProviderID, RecipientID, RevenueCd

• Must import as text to save leading zeros

• True for any code marked CHAR in layouts

  • Occur throughout claims data

• From the Monthly Payment Enrollment Roster

• Enrollment on first day of month

• Full refresh

  • All new enrollees since last month's list

  • Plus all others continuing their enrollment

  • Minus members dis-enrolled/ dead after last month's list

• For this purpose, Recipient = Member = Enrollee

• Definition for claims data usage

• Every enrollee has a HFS-specific Recipient ID, AKA a RIN

• Enrollment rosters list these for each enrollee

• Claims data field: RecipientID

  • Key field on every single table in the claims data

  • Can use to join one claims table to another

• How to find the services members are getting, as per claims data:

  • Take list of all RecipientIDs from the Enrollment Roster

  • Pull all the claims associated with those IDs

  • This is the full claims data file for a given month

• Use a full list of all Recipient IDs each month

• Some may have no claims in month

• Reports are with respect to one month

• For analysis purposes, entire month used

• Enrollment field is per the first of month

• All other fields are with respect to entire month

• The reports are lagged three months

  • Report due 11/12 covers 8/1-31

  • Wait until reporting month, use data from time span being reported

  • Use enrollment roster for month being reported

  • Reporting due dates

• Underlies all fields in Utilization Report

• How is a network defined?

  • All the providers affiliated with plan

  • List all their HFS Provider ID numbers, pull all claims associated with those IDs - in network

  • All claims associated with any provider IDs OTHER THAN the IDs on your list - out of network

• Claims: ProviderID

  • In the main claims table

  • Don't use NPIs

• Measure: ER visits per 1000 members

• Measure only includes care inside ER

• Sum ER visits across all members

  • Each ER claim (visit/day) = 1

• Claims data: Table: Revenue

  • RevenueCd 0450-0459 and 0981

• Will reliably identify all ER visits

• Measure: Admissions per 1000 members

• Sum admissions across all members

  • Each admission = 1

  • Overlapping months - count first month only

• Claims data table: Institutional

  • InpatientAdmissions

  • Inpatient-Psychiatric is included

  • Other codes can be misleading

• Hospital as location for outpatient services

• For all members with an admission, total days in hospital

• ServiceToDt – ServiceFromDt = Length of Stay

• Sum Lengths of Stay for all members = Inpatient Days

• Alternative: use CoveredDays (Institutional table)

• Details

  • In and out on same day - days = 1

  • Parts of >1 mo. - include days in reported month

• Length of Stay = total days/ total admissions

• Total = in network + out of network

• % in network = (all events/ in-network events)*100

• Per Thousand = (events/enrollees)*1000

• Data comes mostly from plans

• Prescriptive on how to fill out template

• Flexibility to innovate on how these processes are completed

• Report is familiar to some plans

• Some changes have been made

• Same as the Utilization Report

• This field should match other report

  Care Coordination Report enrollees =

  Utilization Report enrollees =

  Monthly Payment Enrollment Roster number

• Same for ACEs and for CCEs

• ACEs: Must do on all enrollees within 90 days

  • Exceptions: If the comprehensive assessment is done within 90 days, no need for health risk screening.

• CCEs: Must complete on all enrollees within 30 days

• Both: May be done by non-clinical staff via mail or phone

• Two essential components to risk stratification

  • Health Risk Screenings

  • Claims data (2-year look back)

• Room to innovate in using claims data

  • Harder to give advice about details of methods

  • A plan must use its own method consistently

• Three levels: High, Medium, Low

  • Fixed Names in template

• ACEs: Must complete on all enrollees within 120 days

• CCEs: Must complete on all enrollees within 60 days

• Must use staff with clinical qualifications

  • MD/DO, NP/APN, PA, RN/BSN, MSW/LCSW

  • Does not have to be done by physician

• For high- and medium-risk members:

  • Standard is for assessment by a nurse

• For low-risk members:

  • May use social worker

  • Can conduct the assessment over the phone or online

• ACEs only: If members are current patients with a comprehensive assessment on file, a 120-day look-back from the ACE enrollment date also meets this requirement

• Both: Opportunity for preventative care education for all members

• Contracts:

  • ACE: Section 5.7.4

  • CCE: Section 5.6.7.3

• ACEs: Must be done for all medium and high-risk enrollees within 120 days

• CCEs: Must be done for all enrollees within 90 days

• Should be done at the time of the Comprehensive Assessment

• Considered complete if ≥1 care goal has been identified in writing by care coordination team

  • May be medical, psychosocial, etc.

  • Hickam's Dictum Redux

  • Fluid, living document

• Annual Report webinar (for CCEs)

• Sharepoint training (for ACEs)

• Claims Data (for both)

• Contact Project Managers

• Copy email to HFS.ACE.CCE@illinois.gov