Dental Benefit Plan Reporting Deliverables

Monthly Reports   Revision Date Due Date
022 Post Payment Recoveries (existence of TPL) - M  7/27/21 Due 15 calendar days of the end of each month except where indicated
107 Member Service Call Center - M   Due 15 calendar days of the end of each month except where indicated
109 Marketing and Member Education Materials Distributed - M    Due 15 calendar days of the end of each month except where indicated
113 Grievance, Appeal and Fair Hearing Log - M 5/26/21 Due 15 calendar days of the end of each month except where indicated
148 Monthly Debarment/Exclusion Verification Attestation   Due 15 calendar days of the end of each month except where indicated
167 Claims Payment Accuracy Report - M   Due 15 calendar days of the end of each month except where indicated
173 Denied Claims Report - M  7/27/21 Due 15 calendar days of the end of each month except where indicated
181 Provider Call Center - M 10/29/21 Due 15 calendar days of the end of each month except where indicated
182 Provider Complaint & Appeal Summary Report - M 5/26/21  Due 15 calendar days of the end of each month except where indicated
221 Claims Payment Summary - M  7/27/21 Due 15 calendar days of the end of each month except where indicated
       
Quarterly Reports    
018 Medical Loss Ratio - Q 10/9/18 Due May 31, August 31, November 30, and February 28, except where indicated
069 Utilization Management Dental Record Review Report - Q 5/26/21  Due April 30, July 30, October 30, and January 30, except where indicated
072 QAPI PCD Profile Reports - Q 5/26/21  Due April 30, July 30, October 30, and January 30, except where indicated
082 PCD Linkages - Q 5/26/21  Due April 30, July 30, October 30, and January 30, except where indicated
114 Grievance, Appeal and Fair Hearing Log (redacted) - Q/A 5/26/21  Due April 30, July 30, October 30, and January 30, except where indicated
119 QAPI Committee (minutes) - Q 08/15/17  Due April 30, July 30, October 30, and January 30, except where indicated
145 Fraud and Abuse Activity Report - Q 11/5/21  Due April 30, July 30, October 30, and January 30, except where indicated
147 Sampling of Paid Claims Report 9/22/21 Due April 30, July 30, October 30, and January 30, except where indicated
152 Act 710 Report 4/29/21 Due April 30, July 30, October 30, and January 30, except where indicated
183 Claims Processing Interest Payments - Q 5/26/21  Due April 30, July 30, October 30, and January 30, except where indicated
185 Quarterly Unaudited Financial Statement - Q (60 days after QTR)* 3/21/21  Due May 31, August 31, November 30, and February 28
188 PA Summary - Q  10/29/21 Due April 30, July 30, October 30, and January 30, except where indicated
217 QAPI Early Warning System Performance Measures - Q 10/29/21  Due April 30, July 30, October 30, and January 30, except where indicated
220 Network Adequacy Review - Q 5/26/21  Due April 30, July 30, October 30, and January 30, except where indicated
225 Network Summary Dental Report - Q  5/26/21 Due April 30, July 30, October 30, and January 30, except where indicated
      Due April 30, July 30, October 30, and January 30, except where indicated
Annual Reports    
017 Key Staff Organizational Chart Listing 8/29/17 January 30th 
019 Medical Loss Ratio - A 10/9/18 June 30th
053 NW Provider Development Management Plan - A   January 30th
068 Utilization Management Dental Record Review Stategy - A   January 30th
110 Marketing Activities Annual Review - A   January 30th
127 QAPI Performance Reporting Measures - A *   June 30th
132 Member Satisfaction Survey Report (CAHPS) - A   August 30th
133 Provider Satisfaction Survey Report - A   January 30th
138 QAPI Performance Improvement Projects (outcomes) 3/14/17 June 30th
146 Annual Fraud, Waste & Abuse Report    March 30th
151 Systems Refresh Plan - A   January 30th
157 Emergency Management Plan - A   January 30th
159 Back-up File List - A 5/26/21  January 30th
170 Form CMS 1513 Ownership and Control Interest Statement - A   March 30th
177 Total and OON Claims 7/9/19 July 30th (30 days after after the prior SFY)
184 "DRAFT" Annual Audited Financial Statement - A **   March 30th (90 days after year end)
184 Annual Audited Financial Statement - A   June 30th
189 Independent-Subcontractor EDP Audit (SSAE16) - A ***   Based on Audit Period (45 days after corporate audit complete)
216 QAPI Impact and Effectiveness of QAPI Program Evaluation - A   March 30th
221 Claims Payment Summary 5/10/19

July 30th

Q/A means Quarterly and Annually 

* Template not provided. Will accept Health Plans' corporate standard.

**Draft versions are due 90 days after year end.

***- 45 days after the corporate audit Period is comlete.