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Division of Health Care Management (DHCM)
DHCM is responsible for procuring contracts and the ongoing performance management of Managed Care Organizations
serving more than 1.4 million members with expenditures exceeding $10 billion annually. DHCM oversees 17 Managed
Care Contractors who purchase services from more than 90 Arizona hospitals and thousands of health care providers.
DHCM has ten units to perform these functions:
Calculates actuarially sound capitation rates for all Contractors. Considers trends in utilization and unit costs of various health care services, shifts in enrollment or demographics of various programs, and changes to covered benefits or provider reimbursements. Provides CMS with legally-required certifications of actuarial soundness for capitation rate updates and other capitation payments. Performs advanced analyses based on Executive and Legislative requests. Demonstrates calculation methods and assumptions to sister agencies or Contractors as needed. Participates in national discussions regarding funding and capitation rate development of new initiatives and populations. Assists in the development of payment reform initiatives and related quality distribution payment analysis. Assists in development and performs capitation impact calculations for health acuity adjustment methods including, but not limited to, reinsurance, reconciliation and risk adjustment.
Behavioral Health Customer Office
AHCCCS point of contact for information and for expressing complaints, concerns, and compliments pertaining to behavioral health service delivery through Tribal and Regional Behavioral Health Authorities (T/RBHAs). This Office provides oversight and monitoring of the T/RBHAs grievance process and coordinates with the T/RBHAs to promote appropriate issue resolution.
Clinical Information Management
Assist with data mining and analysis of health outcomes data, perform data stewardship for health outcomes data, provide data analysis to other units as requested, assist in the monitor and oversight of clinical performance measures, identify opportunities to improve Contractors’ clinical and non-clinical performance. Support Lean initiatives in the Division, test and produce data for routine reporting to conduct root cause analysis, statistical analysis and sampling, develop and redesign databases for units in the division as need arises and assist with the incorporation of descriptive and inferential statistics to clinical reports as needed.
Clinical Quality Management
Responsible for all quality management and oversight functions for all member populations. Monitor, measure, report and identify activities and opportunities to improve Contractor clinical and non-clinical performance rates. Ensure moms and babies receive all recommended care and services under EPSDT and appropriate prenatal care.
Data Analysis & Research
Assists Contractors with complete, timely and accurate encounter data submission, providing technical assistance with pended encounters and researching encounter problems. Validates completeness, timeliness and accuracy of encounter data. Designs methodology, data collection/validation, and sampling method for, and performs statistical analysis of, performance improvement projects, audits, and performance measures. Provides project management and/or operational expertise for DHCM information. Liaises with MCOs on all technical projects to be implemented by MCOs. Functions as DHCM technical lead on implementation of all new Agency initiatives, benefit changes, population changes, etc.
Finance & Reinsurance
Oversees the financial condition of all Contractors via review of quarterly and annual financial reports. Assists with and reviews capitation rate development data from the Actuarial Unit. Performs capitation rate reconciliations as dictated per contract. Analyzes, audits and processes reinsurance payments to Contractors. Manages the AHCCCS transplant contract negotiations with transplant facilities. Calculates supplemental payments to, and assessment payments from, Arizona hospitals. Analyzes hospital financial statements and reports on such data.
Oversee Contractors’ Medical Management functions including: prior authorization, Concurrent/retrospective/utilization review, Chronic Care/Disease Mgmt. programs. Audit and advice on member rights in relation to adverse decisions and appeals. Coordinate/case manage AIHP transplants. Monitor specialty contracts and reinsurance for certain medical conditions/transplants. Oversee case management programs of the 4 long- term care Managed Care Contractors and 6 tribal case management contracts.
Oversee operations of 13 Acute Care/Acute carve-out Managed Care Contractors and 4 Long-Term Care Managed Care Contractors. Conduct policy oversight to ensure accordance with AHCCCS policies, and state and federal mandates. Review and approve contractually-required deliverables. Lead annual contract amendments and periodic RFPs to solicit new Contractors. Assist with elevated member and provider inquiries.
Rates & Reimbursement
Establishes fee-for-service reimbursement rates for over 80,000 clinical services annually. Calculates supplemental payments to Arizona hospitals annually. Reconciles payments made to Federally Qualified/Rural Health Clinics and calculates the rates these clinics are paid. Reviews and adjusts payment methodologies periodically to improve cost-effectiveness and equity. Calculates nursing facility assessment payments. Calculates and reconciles tribal case management rates.
System of Care and Grants
Responsible for developing and overseeing the system of care developed by the Regional Behavioral Health Authorities (RBHAs) in order to provide sufficient services with best practices for populations such as Substance Use Disorder, Children system of care and Adult system of care. This unit provides technical assistance and monitoring of the RBHAs System of Care Plans and progress. This unit also oversees grants management for several federal grants which include Substance Abuse Block Grant (SABG), Mental Health Block Grant (MHBG), and other federal grants related to prevention and treatment services. Management of day to day federal grant activities include researching for grant, grant writing, implementation of grants (including contract management), and oversight and monitoring of grant.