Slide 1: Implementation Council
March 8, 2022
Commonwealth Care Alliance
Slide 2: One Care Rating Categories Definitions
Data is shown by rating category in this presentation. See rating category definitions below for reference:

F1- Facility-based Care. Individuals identified as having a long-term facility stay of more than 90 days
C3- Community Tier 3. High Community Need. Individuals who have a daily skill need of two or more Activities of Daily Living (ADL) limitations AND three days of skilled nursing need; and individuals with 4 or more ADL limitations
-In CY2014, C3 split into two subsets:
C3B: for C3 individuals with certain diagnoses (e.g. quadriplegia, ALS, Muscular Dystrophy and Respirator dependence) leading to costs considerably above the average for current C3
	C3A: for remaining C3 individuals
C2- Community Tier 2. Community High Behavioral Health. Individuals who have chronic and ongoing Behavioral Health diagnosis that indicates a high level of service need
-In CY2014, C2 split into two subsets
	C2B: for C2 individuals with co-occurring diagnoses of substance abuse and serious mental illness
	C2A: for remaining C2 individuals
C1- Community Tier 1 Community Other. Individuals in the community who do not meet F1, C2 or C3 criteria
Slide 3: Utilization Management Definitions
Approvals
A request is granted.

Approvals with Modifications (aka Partial Approvals)
A request is granted with a decrease or substitute.

Denials
A request has not been granted. Examples include:
•	Procedural denials- claim filed incorrectly or duplicative
•	Member’s plan maximum benefit reached 
•	Request for out-of-network provider with in-network options available 
•	Medical necessity criteria not met
Slide 4: Prior Authorization – Decision Letters
•	Decision letters are sent in response to all prior authorization requests received
o	Services not requiring prior authorization do not result in a letter. Instead, the member is kept informed by their Care Partner and/or provider.
•	Decision letters are sent to the member and their provider that explains the outcome of the request
•	Decision letter content depends on outcome
o	Approvals outline: 
•	Services being approved as well as amount approved
o	Approvals with Modification* (Partial Approvals only) outline: 
•	What was approved compared to the original request
•	Why we made this change
•	Member appeal rights and instructions
o	Denials outline: 
•	Why we denied this request
•	Member appeal rights and instructions
•	Members can appeal modifications and denials themselves, or have a care partner/trusted individual guide the appeal process

*Modifications considered "upgrades" are captured in the approvals category due to existing systems and processes
Slide 5: 93% of sent DME letters are Approvals
Of the 33,504 DME requests from 12,090 members sent since 2018* which resulted in a decision letter1:
•	93% were approvals (including partial)
•	7% were denials

Note: the following is shown in a pie chart on this slide.

DME Letter Outcomes
Approval (incl. partial) 	93%
Denial	7%

Note: the following is shown in a bar chart on this slide.

DME Letters Sent by Year
2018
Approval	831
Denial	47

2019
Approval	8665
Denial	649

2020
Approval	10793
Denial	619

2021
Approval	10882
Denial	1018

Table: DME Letters Sent By Year
Year	Approval N (%)	Denial N (%)	Total	
2018	831 (95%)	47 (5%)	878	
2019	8,665 (93%)	649 (7%)	9,314	
2020	10,793 (95%)	619 (5%)	11,412	
2021 YTD	10,882 (91%)	1,018 (9%)	11,900	
Grand Total	31,171 (93%)	2,333 (7%)	33,504	

*2018 is partial data reflecting Nov and Dec
1Letters are sent for DME requiring prior authorization 
Slide 6: DME1 Letters - Rating Category
Most DME letters are sent to C3A members.
-C1: 6%
-C2: 13% 
•	C2A: 12% 
•	C2B: 1% 
-C3: 80%
•	C3A: 73%
•	C3B: 7%
-F1: 1% 

Note: the following is shown in a bar chart on this slide.

DME Requests by Year and Rating Category

2018
C1	55
C2A	110
C2B	9
C3A	613
C3B	86
F1	5

2019
C1	584
C2A	1161
C2B	90
C3A	6671
C3B	742
F1	66

2020
C1	721
C2A	1413
C2B	133
C3A	8345
C3B	744
F1	56

2021
C1	800
C2A	1378
C2B	142
C3A	8818
C3B	701
F1	61

*2018 is partial data reflecting Nov and Dec
1Letters are sent for DME requiring prior authorization 
Slide 7: DME Letters1 – Year and Rating Category
Note: the following is shown in a bar chart on this slide.

2018

2018
C1 N = 55, Approval 93%, Denial 7%
C2 N = 119, Approval 92%, Denial 8%
C3 N = 699, Approval 95%, Denial 5%
F1 N = 5, Approval 100%

2019
C1 N = 584, Approval 93%, Denial 7%
C2 N = 1251, Approval 92%, Denial 8%
C3 N = 7413, Approval 93%, Denial 7%
F1 N = 66, Approval 91%, Denial 9%

2020
C1 N = 721, Approval 94%, Denial 6%
C2 N = 1546, Approval 94%, Denial 6%
C3 N = 9089, Approval 95%, Denial 5%
F1 N = 56, Approval 91%, Denial 9%

2021
C1 N = 800, Approval 92%, Denial 8%
C2 N = 1520, Approval 91%, Denial 9%
C3 N = 9519, Approval 92%, Denial 8%
F1 N = 61, Approval 95%, Denial 5%

*2018 is partial data reflecting Nov and Dec
1Letters are sent for DME requiring prior authorization