Arizona Health  Core Cost Containment System

Janice K. Brewer, Governor
Thomas J. Betlach, Director

December 11, 2014

Mark Fisher
Chief Executive Officer
Mercy Care Plan
4350 East Cotton Center Blvd. Bldg. D
Phoenix, AZ  85040

SUBJECT:   Final Results of Sanctionable Pended Encounters  June 2014

Dear Mr. Fisher:

This attached  information will provide the final aged pended encounter  sanctions for the quarter ending June  2014.    According  to  the  Contract,  Mercy  Care  Health  Plan  is  required  to  resolve  all  pended encounters within 120 calendar days of the processing date.  If this requirement is not met, the Contractor is subject to sanctions.

The  exception  to  the  above  is  when  the  pended  encounter  is  due  to  an  Arizona  Health  Care  Cost Containment   System  (AHCCCS)   error.    AHCCCS  error  is  defined  as  a  pended  encounter,  which AHCCCS   acknowledges   to  be  the  result  of  its  own  error,  and  requires  a  change  to  the  system programming,  an update to the database  reference table, or further  research  by AHCCCS.   Contractors must notify AHCCCS, in writing that the resolution of a pended encounter  depends on AHCCCS"instead of  the  Contractor.     Pended  encounters  do  not  qualify  as  AHCCCS  error  if  AHCCCS  reviews  the Contractor's  notification   and   asks   the   Contractor   to   research   the   issue   and   provide   additional substantiating  documentation, or if AHCCCS disagrees with the Contractor's claims of AHCCCS error.

AHCCCS distributed the preliminary  sanction results, including a summary of encounters excluded  from sanctions  as AHCCCS error  on  September  25, 2014.   The  Contractor  was  provided  an opportunity  to review the preliminary  results,  and challenge those encounters  believed to be sanctioned  in error.   The Contractor's mitigation  was considered,  and when appropriate,  the mitigated  encounters  were removed from the final sanctionable  encounters.   The preliminary  sanctionable  number of pended encounters  for June was 1,513 (Acute) and 251 (LTC) and the final sanction  number pended encounters for this quarter is 407 (Acute) and 58 (LTC).  The final sanction dollar amount is $2,895 (Acute) and $380 (LTC).

Even if sanctions  are waived, the Contractor is liable for addressing all pended encounters (except those errors  which  have  been  identified  as due to AHCCCS  error  or as being  under review  by AHCCCS). When error codes are identified  as an AHCCCS error and are corrected, or are identified as being under AHCCCS  review  and then  released,  the Contractor  is responsible  for  addressing  any  remaining  error codes and will be afforded a new 120 day clock for resolution.   However, the true age for these pended encounters will continue to appear on the Aging Reports.

801 East Jefferson, Phoenix, AZ 85034 • PO Box 25520, Phoenix,  AZ 85002 • 602-417-4000 • www.azahcccs.gov

Mr. Fisher
December 11, 2014
Page 2

Enclosed is a summary of the final sanction results.   Please retrieve your pended encounter sanction information  from AHCCCS'  FTP server.   The path is sftp.state.medicaid.us\MER\OTHER\ and the file names are:

•	MER June 2014 Final Sanctions.txt
•	MER June 2014 Final Excluded Enc.pdf
•	MER June 2014 Final Error Summary. pdf
•	MER June 2014 Final Age Category.pdf

Per the terms of the Contract, sanctions are not the Administration's  exclusive remedy.  In particular and without  limiting possible future actions, if any legal action  is brought against the Administration  as the result of your non-compliance  with the Contract, the Administration will seek compensation  from you for any damages arising from such legal action including but not limited to the Administration's cost of representation  as well as the cost of any attorneys' fees and costs payable to the party bringing the action.

If  you  have  any  questions  regarding  your  pended  encounter  sanctions,  please  contact  Gina  Aker  at
Gina.Aker@azahcccs.gov, (602) 417-4016.

Contracts & Purchasing, Administrator
Division of Business and Finance
Mail Drop #5700

cc: 		Shelli Silver Lori Petre Devra Navas Nancy Neroni Aker, Gina
Virginia Rountree Alvarez, Diana DAR File
herringm@aetna.com