H

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

December 11, 2014

Joseph Gaudio
Chief Executive Officer/Plan President
United Health Care Community Plan APIPA
1 East Washington Suite 900
Phoenix, AZ 85004

SUBJECT:   Final Results of Sanctionable Pended Encounters June 2014

Dear Mr. Gaudio:

This attached  information  will provide the final aged pended encounter  sanctions for the quarter ending June 2014.   According to the Contract, United Health Care Community Plan_Acute 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  quality  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  2,185  and the final  sanction  number  pended  encounters  for  this  quarter  is 1,382.   The  final sanction dollar amount is $16,210.

Even if sanctions  are waived, the Contractor  is liable for addressing all pended encounter(except  those errors  which  have  been  identified  as due  to AHCCCS  error  or as  being  under  reYiew 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. Gaudio
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\UHC_Acute\OTHER\ and the file names are:

•	UHC  Acute June 2014 Final Sanctions.txt
•	UHC_Acute June 2014 Final Excluded Enc.pdf
•	UHC_Acute June 2014 Final Error Summary.pdf
•	UHC_Acute 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.

Michael Veit
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 Jennifer_palumbo@uhc.com
DAR File