Medicaid MCO 3.0 Report Templates

The templates below are applicable to the Medicaid Managed Care Organization 3.0 contract effective January 1, 2023.

Weekly Reports (Due every following Wednesday by 5 p.m.) Published Date
150 Encounter Data Certification Form 11/3/22
316 Prior Authorization Denial Report for CSR 11/3/22
353 Chisholm Weekly PA Report 11/3/22
362 Transportation Addition/Deletion Report 11/3/22

 

Monthly Reports (Due 15th day of the month following end of reporting period except where indicated otherwise) Published Date
010 Grievance Appeal and SFH Report 4/2/24
022 Third Party Liability (TPL) Report 12/16/22
039 Case Management Report 3/5/24
045 Home Health Services Report 12/16/22
047 Crisis Response Team Home Health Services Report 12/16/22
054 Pharmacy Benefits Management Report 12/16/22
055 Pharmacy Report (RX055) 12/16/22
107 Member Service Call Center (Due 5th day of the month) 10/3/23
137 Pregnancy Report 12/16/22
148 Exclusion Database Attestation 12/16/22
162 Health Plan Drug Utilization Review Report 3/11/24
165 Lock-In Report 3/4/24
167 Claims Payment Accuracy Report 12/16/22
173 Denied Claims Report 12/16/22
175 Hepatitis C 6/1/23
178 Behavioral Health Pharmacy Utilization Report 1/22/24
181 Provider Call Center Report 11/15/23
182 Provider Complaint and Appeal Summary Report 9/14/23
221 Claims Payment Summary 12/16/22
323 Chisholm Monthly Behavioral Health ASD Report 12/16/22
325 Behavioral Health Pharmacy Report 1/12/23
326 Adverse Incident Report 6/23/23
337 Behavioral Health Out-of-State Treatment Report 12/16/22
354 Chisholm PCS Member Aging Out Report 12/16/22
360 NEMT Oversight Report 12/16/22
361 Community Case Management Report 6/10/24
407 MCO Crisis Line and Services Report 4/1/24
409 Behavioral Health Grievance, Appeal, and State Fair Hearing Logs 6/10/24
412 State Directed Payments: Nurse Recruitment and Retention 7/12/24

 

Bi-Monthly Reports (Due February 28, April 30, June 30, August 31, October 31 and December 31) Published Date
 020 Payment Discrepancy Report  12/16/22

 

Quarterly Reports (Due April 30, July 30, October 30, and January 30, except where indicated otherwise) Published Date
011A MCIP Achievement Report - Quality and Outcome Improvement Network 3/13/24
011B MCIP Achievement Report - Louisiana Quality Network 1/29/24
018 Quarterly Medical Loss Ratio (Due 5/31, 8/31, 11/30 and 2/28) 9/21/23
069 Utilization Management Medical Review Report 2/13/23
109 Marketing and Member Education Activities Report 2/13/23
119 QAPI Committee (Minutes) 2/13/23
145 Fraud Waste and Abuse Report 8/9/23
147 Sampling of Paid Claims Report 5/2/23
152 Act 710 Healthy Louisiana Claims Report 11/15/23
160 Medication Therapy Management Report 3/1/23
185 Quarterly Unaudited Financial Statement (Due 5/31, 8/31, 11/30 and 2/28) 2/28/23
188/188BH Service Authorizations 11/30/23
300 NCCI MCO Cost Savings (Due 1/15, 4/15, 7/15 and 10/15) 9/7/23
312 Gambling and Tobacco Report  (Due 8th day of the month following reporting period) 10/24/23
313 Access to Wraparound Services Report 2/27/23
317 PASRR Report 3/1/23
322 Community Tenure Report 2/13/23
328 Behavioral Health Provider Network Detail Report 2/28/23
329 Children in Restrictive Settings 2/27/23
336 Behavioral Health Providers by Level of Care Report 2/27/23
338 Behavioral Health Network Adequacy and GEO Access Review 2/28/23
339 Behavioral Health Prescriber Sufficiency Summary Report 3/1/23
346 Provider Credentialing and Contracting Report 10/11/23
348 Geo Access Mapping 3/1/23
358 Behavioral Health Quality Monitoring Report 10/20/23
359 Behavioral Health Network Appointment Availability Report 2/27/23
364 Enrollee Reassignment Report 2/27/23
408

Specialized Behavioral Health Provider Network Monitoring

3/1/23
410

State Directed Payments: EBP/LMHP Incentive/Retention

4/9/24
411

ABA QualityMonitoring Report

2/8/24

 

Semi-Annual Reports  Published Date Due Date
013 LDH MCO Physician Incentive Plan Report 12/16/22 Feb. 1 & Aug. 30
220 Network Adequacy Review 3/4/24 July 31 & Jan. 31
355 Evidence Based Practices 6/15/23 Aug. 1 & Feb. 1

 

Annual Reports  Published Date Due Date
011A MCIP Achievement Report - Quality and Outcome Improvement Network 3/13/24 March 30
011B MCIP Achievement Report - Louisiana Quality Network 1/29/24 March 30
012A MCIP Annual Reporting - Quality and Outcome Improvement Network 1/29/24 July 31
012B MCIP Annual Reporting Template - Louisiana Quality Network 1/29/24 July 31
017 Key Staff Organizational Chart Listing 3/5/24 Jan. 30
019 Medical Loss Ratio 8/1/23 March 31
053 Specialized Behavioral Health NW Provider Development Management Plan 1/6/23 Jan. 30
056 PCMH Implementation Plan 1/6/23 Jan. 31
068 Utilization Management Medical Record Review Strategy 9/26/23 Jan. 30
111 Call Center Quality Criteria and Protocol 1/6/23 Jan. 30
132 Member Satisfaction Survey (CAHPS) 6/13/23 Aug. 30
136 QAPI Program Description, Work Plan, Impact and Effectiveness of Program Evaluation 1/31/23 March 31
138 QAPI Performance Improvement Projects 9/26/23 March 15
141 Member Advisory Council 9/26/23 Jan. 30
157 Continuity of Operations Plan 9/26/23 Jan. 30
170 Disclosure of Ownership and Control Interest Statement 1/27/23 March 30
177 Total and out of Network Claims Report 5/15/23 July 30
184 Annual Audited Financial Statement 10/10/23 June 30
189 Independent-Subcontractor EDP Audit (SSAE16) 5/23/23 Based on Audit Period
334 Integration Assessment Report 2/21/24 March 28
349 Unmet Service Needs Resolution Plan 3/17/23 April 30
410 State Directed Payments: EBP/LMHP Incentive/Retention 4/9/24 July 30