Common use of Claims Payment Systemic Errors (CPSEs) Clause in Contracts

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, or denying claims that impact, or has the potential to impact, five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP shall submit the CPSE report and all communications to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Non-Compliance with CPSEs in Appendix N. 2. The MCOP shall follow all instructions as directed by ODM, including the CPSE reporting template instructions and guidelines. 3. The MCOP shall inform ODM of the status of all active CPSEs on the monthly report by including the following: a. A detailed description and scope of all active CPSEs; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notifications; f. The timeline for fixing the CPSE; g. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 4. The MCOP shall report all CPSEs on a monthly CPSE report housed on the MCOP’s Ohio Medicaid website. a. The CPSE report shall be public facing for anyone to view and/or on the MCOP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those providers who are unable to access the CPSE report; b. The CPSE report shall be updated at a minimum once a month, labeled to reflect the updated date; c. The CPSE report shall include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers impacted; iv. The timeline for fixing the CPSE; v. The date of claims adjustments or required provider action. 5. The MCOP shall have a policy and procedure to identify, communicate, and correct CPSEs. The MCOP shall keep the CPSE policy and procedure current to reflect the CPSE requirements. ODM reserves the right to review these and request changes if necessary. The MCOP shall include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A description of the process and timeline to determine root cause of the issues, including UAT testing; e. The timeframe to re-adjudicate claims, if applicable, or notify provider of an overpayment and the process for providers to dispute those actions; f. The description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above; g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOPMCP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, or denying claims claims. that impact, or has the potential to impact, five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP MCP shall submit the CPSE report and all communications to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Nonnon-Compliance compliance with CPSEs in Appendix N.N of this Agreement. 2. The MCOP MCP shall follow all instructions as directed by ODMXXX, including the CPSE reporting template instructions and guidelines. 3. The MCOP MCP shall inform ODM of the status of all active CPSEs on the monthly report by including the following: a. A detailed description and scope of all active CPSEs; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notifications; f. The timeline for fixing the CPSE; g. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 4. The MCOP MCP shall report all CPSEs on a monthly CPSE report housed on the MCOPMCP’s Ohio Medicaid website. a. The CPSE report shall be public facing for anyone to view and/or on the MCOPMCP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those impacted providers who are unable to access the CPSE report; b. The CPSE report shall be updated at a minimum once a month, labeled to reflect the updated date; c. The CPSE report shall include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers provider(s) impacted; iv. The timeline for fixing the CPSE; v. The date of claims adjustments or required provider action. 5. The MCOP MCP shall have a policy and procedure to identify, communicate, and correct CPSEs. The MCOP MCP shall keep the CPSE policy and procedure current to reflect the CPSE requirements. ODM reserves the right to review these and request changes if necessary. The MCOP MCP shall include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to: i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g.i.e., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A description of the process and timeline to determine root cause of the issues, including UAT testing; e. The timeframe to re-adjudicate claims, if applicable, or notify provider providers of an overpayment and the process for providers to dispute those actions; f. The description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above;; and g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, or denying claims that impact, or has the potential to impact, five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP shall submit the CPSE report and all communications to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Non-Compliance with CPSEs in Appendix N. 2. The MCOP shall follow all instructions as directed by ODMXXX, including the CPSE reporting template instructions and guidelines. 3. The MCOP shall inform ODM of the status of all active CPSEs on the monthly report by including the following: a. A detailed description and scope of all active CPSEs; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notifications; f. The timeline for fixing the CPSE; g. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 4. The MCOP shall report all CPSEs on a monthly CPSE report housed on the MCOP’s Ohio Medicaid website. a. The CPSE report shall be public facing for anyone to view and/or on the MCOP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those providers who are unable to access the CPSE report; b. The CPSE report shall be updated at a minimum once a month, labeled to reflect the updated date; c. The CPSE report shall include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers impacted; iv. The timeline for fixing the CPSE; v. The date of claims adjustments or required provider action. 5. The MCOP shall have a policy and procedure to identify, communicate, and correct CPSEs. The MCOP shall keep the CPSE policy and procedure current to reflect the CPSE requirements. ODM reserves the right to review these and request changes if necessary. The MCOP shall include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A description of the process and timeline to determine root cause of the issues, including UAT testing; e. The timeframe to re-adjudicate claims, if applicable, or notify provider of an overpayment and the process for providers to dispute those actions; f. The description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above; g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, denying or denying suspending claims that impact, or has the potential to impact, impact five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP shall must submit the MCOP’s CPSE report and all communications (CPSE Report) to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Non-Compliance with CPSEs as specified in Appendix N.T, Chart of Deliverables. 2. The MCOP shall must submit all communications regarding CPSEs to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx unless otherwise directed by XXX. 3. The MCOP must follow all CPSE instructions as directed by ODMXXX, including the CPSE reporting template instructions and guidelines. 34. The MCOP shall inform must report systemic errors to ODM within two business days of adjudication or identification, whichever is earlier. The MCOP must update the status of all active CPSEs on a weekly basis. The MCOP must report the monthly report by including identified errors at the followingprovider type level, such that each element below is detailed for the impact on each provider type. The MCOP must ensure each identified error has a unique error ID to tie each reported line to a specific error the MCOP is addressing. For each error, the MCOP must provide a specified begin date, and when resolved, a definitive end date. For each provider type impacted, the following information is required on a weekly basis: a. A detailed description and scope of all active CPSEs; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notifications; f. The timeline for fixing the CPSE; f. The number of claims impacted; and g. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 45. The MCOP shall must report all CPSEs on a monthly CPSE report housed posted on the MCOP’s Ohio Medicaid website. a. The CPSE report shall must be public facing for anyone to view and/or on the MCOP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those providers who are unable to access the CPSE report;view. b. The MCOP must update the CPSE report shall be updated at a minimum once a month, labeled month and must label the report to reflect the updated date;. c. The MCOP’s CPSE public report shall must include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers provider(s) impacted; iv. The timeline for fixing the CPSE;; and v. The date of claims adjustments or required provider action. 56. The MCOP shall must have a policy policies and procedure procedures to identify, communicate, and correct CPSEs. The MCOP shall must keep the its CPSE policy policies and procedure current to reflect the CPSE requirements. Upon request, the MCOP must submit its CPSE policies and procedures to ODM reserves the right to review these and request changes if necessaryfor review. 7. The MCOP shall MCOP’s CPSE policies and procedures must include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to: i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A full description of the process and timeline to determine root cause of analysis conducted when issues or defects are found, and the issuessoftware development life cycle (SDLC) processes followed, including UAT testingtimelines; e. The timeframe to re-adjudicate claims, if applicable, or notify provider providers of an overpayment and the process for providers to dispute those actions;actions in accordance with the requirements of this Agreement; and f. The A description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above; g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOPMCP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, or denying claims claims. that impact, or has the potential to impact, five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP MCP shall submit the CPSE report and all communications to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Nonnon-Compliance compliance with CPSEs in Appendix N.N of this Agreement. 2. The MCOP MCP shall follow all instructions as directed by ODMXXX, including the CPSE reporting template instructions and guidelines. 3. The MCOP MCP shall inform ODM of the status of all active CPSEs on the monthly report by including the following: a. A detailed description and scope of all active CPSEs; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notifications; f. The timeline for fixing the CPSE; g. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 4. The MCOP MCP shall report all CPSEs on a monthly CPSE report housed on the MCOPMCP’s Ohio Medicaid website. a. The CPSE report shall be public facing for anyone to view and/or on the MCOPMCP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those impacted providers who are unable to access the CPSE report; b. The CPSE report shall be updated at a minimum once a month, labeled to reflect the updated date; c. The CPSE report shall include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers provider(s) impacted; iv. The timeline for fixing the CPSE; v. The date of claims adjustments or required provider action. 5. The MCOP MCP shall have a policy and procedure to identify, communicate, and correct CPSEs. The MCOP MCP shall keep the CPSE policy and procedure current to reflect the CPSE requirements. ODM reserves the right to review these and request changes if necessary. The MCOP MCP shall include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to: i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g.i.e., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A description of the process and timeline to determine root cause of the issues, including UAT testing; e. The timeframe to re-adjudicate claims, if applicable, or notify provider providers of an overpayment and the process for providers to dispute those actions;those f. The description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above;; and g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOPMCP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, or denying claims claims. that impact, or has the potential to impact, five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP MCP shall submit the CPSE report and all communications to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Nonnon-Compliance compliance with CPSEs in Appendix N.N of this Agreement. 2. The MCOP MCP shall follow all instructions as directed by ODM, including the CPSE reporting template instructions and guidelines. 3. The MCOP MCP shall inform ODM of the status of all active CPSEs on the monthly report by including the following: a. A detailed description and scope of all active CPSEs; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notifications; f. The timeline for fixing the CPSE; g. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 4. The MCOP MCP shall report all CPSEs on a monthly CPSE report housed on the MCOPMCP’s Ohio Medicaid website. a. The CPSE report shall be public facing for anyone to view and/or on the MCOPMCP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those impacted providers who are unable to access the CPSE report; b. The CPSE report shall be updated at a minimum once a month, labeled to reflect the updated date; c. The CPSE report shall include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers provider(s) impacted; iv. The timeline for fixing the CPSE; v. The date of claims adjustments or required provider action. 5. The MCOP MCP shall have a policy and procedure to identify, communicate, and correct CPSEs. The MCOP MCP shall keep the CPSE policy and procedure current to reflect the CPSE requirements. ODM reserves the right to review these and request changes if necessary. The MCOP MCP shall include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to: i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g.i.e., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A description of the process and timeline to determine root cause of the issues, including UAT testing; e. The timeframe to re-adjudicate claims, if applicable, or notify provider providers of an overpayment and the process for providers to dispute those actions; f. The description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above;; and g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, or denying claims that impact, or has the potential to impact, five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP shall submit the CPSE report and all communications to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Non-Non- Compliance with CPSEs in Appendix N. 2. The MCOP shall follow all instructions as directed by ODMXXX, including the CPSE reporting template instructions and guidelines. 3. The MCOP shall inform ODM of the status of all active CPSEs on the monthly report by including the following: a. A detailed description and scope of all active CPSEs; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notifications; f. The timeline for fixing the CPSE; g. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 4. The MCOP shall report all CPSEs on a monthly CPSE report housed on the MCOP’s Ohio Medicaid website. a. The CPSE report shall be public facing for anyone to view and/or on the MCOP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those providers who are unable to access the CPSE report; b. The CPSE report shall be updated at a minimum once a month, labeled to reflect the updated date; c. The CPSE report shall include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers impacted; iv. The timeline for fixing the CPSE; v. The date of claims adjustments or required provider action. 5. The MCOP shall have a policy and procedure to identify, communicate, and correct CPSEs. The MCOP shall keep the CPSE policy and procedure current to reflect the CPSE requirements. ODM reserves the right to review these and request changes if necessary. The MCOP shall include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A description of the process and timeline to determine root cause of the issues, including UAT testing; e. The timeframe to re-adjudicate claims, if applicable, or notify provider of an overpayment and the process for providers to dispute those actions; f. The description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above; g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOPMCP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, or denying claims claims. that impact, or has the potential to impact, five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP MCP shall submit the CPSE report and all communications to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Nonnon-Compliance compliance with CPSEs in Appendix N.N of this Agreement. 2. The MCOP MCP shall follow all instructions as directed by ODM, including the CPSE reporting template instructions and guidelines. 3. The MCOP MCP shall inform ODM of the status of all active CPSEs on the monthly report by including the following: a. A detailed description and scope of all active CPSEs; ; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notificationsnotifications ; f. The timeline for fixing the CPSE; g. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 4. The MCOP MCP shall report all CPSEs on a monthly CPSE report housed on the MCOPMCP’s Ohio Medicaid website. a. The CPSE report shall be public facing for anyone to view and/or on the MCOPMCP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those impacted providers who are unable to access the CPSE report; b. The CPSE report shall be updated at a minimum once a month, labeled to reflect the updated date; c. The CPSE report shall include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers provider(s) impacted; iv. The timeline for fixing the CPSE; v. The date of claims adjustments or required provider action. 5. The MCOP MCP shall have a policy and procedure to identify, communicate, and correct CPSEs. The MCOP MCP shall keep the CPSE policy and procedure current to reflect the CPSE requirements. ODM reserves the right to review these and request changes if necessary. The MCOP MCP shall include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to: i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g.i.e., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A description of the process and timeline to determine root cause of the issues, including UAT testing; e. The timeframe to re-adjudicate claims, if applicable, or notify provider providers of an overpayment and the process for providers to dispute those actions; f. The description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above;; and g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOPMCP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, or denying claims claims. that impact, or has the potential to impact, five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP MCP shall submit the CPSE report and all communications to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Nonnon-Compliance compliance with CPSEs in Appendix N.N of this Agreement. 2. The MCOP MCP shall follow all instructions as directed by ODM, including the CPSE reporting template instructions and guidelines. 3. The MCOP MCP shall inform ODM of the status of all active CPSEs on the monthly report by including the following: a. A detailed description and scope of all active CPSEs; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notifications; f. The timeline for fixing the CPSE; g. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 4. The MCOP MCP shall report all CPSEs on a monthly CPSE report housed on the MCOPMCP’s Ohio Medicaid website. a. The CPSE report shall be public facing for anyone to view and/or on the MCOPMCP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those impacted providers who are unable to access the CPSE report; b. The CPSE report shall be updated at a minimum once a month, labeled to reflect the updated date; c. The CPSE report shall include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers provider(s) impacted; iv. The timeline for fixing the CPSE; v. The date of claims adjustments or required provider action. 5. The MCOP MCP shall have a policy and procedure to identify, communicate, and correct CPSEs. The MCOP MCP shall keep the CPSE policy and procedure current to reflect the CPSE requirements. ODM reserves the right to review these and request changes if necessary. The MCOP MCP shall include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to: i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g.i.e., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A description of the process and timeline to determine root cause of the issues, including UAT testing; e. The timeframe to re-adjudicate claims, if applicable, or notify provider providers of an overpayment and the process for providers to dispute those actions;those f. The description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above;; and g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, denying or denying suspending claims that impact, or has the potential to impact, five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP shall must submit the MCOP’s CPSE report and all communications (CPSE Report) to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Non-Compliance with CPSEs as specified in Appendix N.T, Chart of Deliverables. 2. The MCOP shall must submit all communications regarding CPSEs to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx unless otherwise directed by XXX. 3. The MCOP must follow all CPSE instructions as directed by ODMXXX, including the CPSE reporting template instructions and guidelines. 34. The MCOP shall inform must report systemic errors to ODM within two business days of adjudication or identification, whichever is earlier. The MCOP must update the status of all active CPSEs on a weekly basis. The MCOP must report the monthly report by including identified errors at the followingprovider type level, such that each element below is detailed for the impact on each provider type. The MCOP must ensure each identified error has a unique error ID to tie each reported line to a specific error the MCOP is addressing. For each error, the MCOP must provide a specified begin date, and when resolved, a definitive end date. For each provider type impacted, the following information is required on a weekly basis: a. A detailed description and scope of all active CPSEs; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notifications; f. The timeline for fixing the CPSE; g. The number of claims impacted; and h. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 45. The MCOP shall must report all CPSEs on a monthly CPSE report housed posted on the MCOP’s Ohio Medicaid website. a. The CPSE report shall must be public facing for anyone to view and/or on the MCOP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those impacted providers who that are unable to access the CPSE report;. b. The MCOP must update the CPSE report shall be updated at a minimum once a month, labeled and must label the report to reflect the updated date;. c. The MCOP’s CPSE public report shall must include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers provider(s) impacted; iv. The timeline for fixing the CPSE;; and v. The date of claims adjustments or required provider action. 5. The MCOP shall have a policy and procedure to identify, communicate, and correct CPSEs. The MCOP shall keep the CPSE policy and procedure current to reflect the CPSE requirements. ODM reserves the right to review these and request changes if necessary. The MCOP shall include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A description of the process and timeline to determine root cause of the issues, including UAT testing; e. The timeframe to re-adjudicate claims, if applicable, or notify provider of an overpayment and the process for providers to dispute those actions; f. The description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above; g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.

Claims Payment Systemic Errors (CPSEs). For the purpose of this appendix, a CPSE is defined as the MCOPMCP’s claims adjudication, including claims adjudication by a contracted vendor, either electronic or manual, incorrectly underpaying, overpaying, or denying claims claims. that impact, or has the potential to impact, five or more providers. ODM reserves the right to request and receive additional information for ODM to classify an issue as a CPSE. 1. The MCOP MCP shall submit the CPSE report and all communications to XxxxxxxxXXXX@xxxxxxxx.xxxx.xxx, unless otherwise directed by ODM, based on the ODM calendar of submissions schedule. A late or incomplete submission is subject to sanctions in accordance with Nonnon-Compliance compliance with CPSEs in Appendix N.N of this Agreement. 2. The MCOP MCP shall follow all instructions as directed by ODMXXX, including the CPSE reporting template instructions and guidelines. 3. The MCOP MCP shall inform ODM of the status of all active CPSEs on the monthly report by including the following: a. A detailed description and scope of all active CPSEs; ; b. The date the CPSE was first identified; c. The type(s) of all providers impacted; d. The number of providers impacted; e. The date(s) and method(s) of all provider notificationsnotifications ; f. The timeline for fixing the CPSE; g. The date(s) or date span(s) for all claim adjustment projects or notifications of claim overpayments, if applicable. 4. The MCOP MCP shall report all CPSEs on a monthly CPSE report housed on the MCOPMCP’s Ohio Medicaid website. a. The CPSE report shall be public facing for anyone to view and/or on the MCOPMCP’s provider portal. If the provider portal is used, timely communication of the CPSE must also be made to those impacted providers who are unable to access the CPSE report; b. The CPSE report shall be updated at a minimum once a month, labeled to reflect the updated date; c. The CPSE report shall include, at a minimum, the following information: i. A detailed description and scope of all CPSEs; ii. The date of first identification; iii. The type(s) of providers provider(s) impacted; iv. The timeline for fixing the CPSE; v. The date of claims adjustments or required provider action. 5. The MCOP MCP shall have a policy and procedure to identify, communicate, and correct CPSEs. The MCOP MCP shall keep the CPSE policy and procedure current to reflect the CPSE requirements. ODM reserves the right to review these and request changes if necessary. The MCOP MCP shall include, at a minimum, all the following in their CPSE policy and procedure: a. The use of input from internal and/or external sources to identify a CPSE, including but not limited to: i. User acceptance testing (UAT) activities; ii. Claims processing activities; iii. Provider complaints/inquiries; and iv. ODM inquiries. b. The identification of issues impacting smaller provider types (e.g.i.e., independent providers, etc.); c. A description of the process, including timelines, to escalate from initial identification to definition of the error; d. A description of the process and timeline to determine root cause of the issues, including UAT testing; e. The timeframe to re-adjudicate claims, if applicable, or notify provider providers of an overpayment and the process for providers to dispute those actions; f. The description of the process to complete and submit a completed CPSE report monthly to ODM, to report the status of CPSEs as specified above;; and g. A communication process, including timelines, to timely notify providers of identified CPSEs as directed above, including any other appropriate methods such as phone calls, emails, etc.