Appendix R Revisions Implemented


The Pennsylvania Department of Human Service (DHS) has implemented its planned revisions to encounter data submissions requirements and accompanying sanctions for non-compliance. These revisions are contained in a HealthChoices Behavioral Health (HC BH) Amendment dated July 1, 2017 and distributed as an updated Appendix R.

Timeliness Guidelines

The final Appendix R is identical to the draft version distributed in March with one exception: the submission deadline has been extended from within 60 days following the date the Behavioral Health Managed Care Organization (BH-MCO) adjudicated the provider’s encounter to within 90 days following the adjudication date. Note that, to be considered timely, encounters must be processed AND approved in PROMISe™ (i.e. pass PROMISe™ edits) by the deadline.

Previously, the submission deadline for encounters was on or before the last calendar day of the third month after the BH-MCO adjudicated the encounter. So, if a provider submitted an encounter early in the month, the BH-MCO could potentially have up to 120 days to get that encounter past PROMISe™ edits and still be complaint the submission deadline.

Sanction Provisions

Failure to maintain a 98% Professional and 95% Institutional encounter timeliness rate may result in sanctions against the BH-MCO. These sanctions range from 2% of monthly paid administrative revenue, or $2000, whichever is greater, up to $25,000 per month.

In addition to timeliness sanctions, DHS has also outlined the following tiered sanction schedule for accuracy and completeness of encounters.

% of sample with an errorSanction
Less than 1.00%None
1.00% - 4.99%1.0% of monthly paid Administrative revenue or $2,000, whichever is greater, up to $10,000 per month.
5.00% - 7.49%2.0% of monthly paid Administrative revenue or $2,000, whichever is greater, up to $25,000 per month.
7.50% - 9.99%2.5% of monthly paid Administrative revenue or $2,000, whichever is greater, up to $50,000 per month.
10.00% or greater5.0% of monthly paid Administrative revenue or $2,000, whichever is greater, up to $75,000 per month.

Outstanding Items

There are still outstanding items to be addressed with regards to Appendix R revisions:

  1. Although the revisions went into effect on July 1st, neither the service date range nor the adjudication date range subject to the requirements has been specified.
  2. It is unclear if percentages apply to claims or claim lines.
  3. It is not stated if denied claims will now be subject to Appendix R requirements. The word “paid” has been removed from the requirements, giving an implicit impression that denied claims will now be included, but this is not specifically stated.
  4. If DHS does include denied claims, it is not known if they will include all denied claims, or just a subset.
  5. It is unclear how accuracy and completeness of claims will be determined; what counts as an inconsistency or error.

With these revisions now in effect, it is hoped that DHS will clarify these, and any other outstanding items, that may arise with the revised requirements.