KPI Metrics

Metric

Actual

Target

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027-2028

2029-2030

Coverage & Eligibility Operations

Auto-Enrollment Rate

20

25

30

35

40

45

50

55

60

75

85

92

95

Eligibility Determination Cycle Time

45

40

35

30

28

25

23

21

20

10

5

2

1

Enrollment Completion Time

60

55

50

45

40

38

35

32

30

15

10

5

3

Churn Rate

30

28

26

24

23

22

21

20.5

20

15

12

8

5

Renewal Success Rate

60

62

65

68

70

73

76

78

80

88

92

95

97

Claims & Payment

Clean claim rate

80

82

84

86

87

88

89

89.5

90

93

95

97

98

First-pass adjudication rate

55

58

60

63

65

68

70

73

75

80

85

90

95

Denial Rate

14

13

12

11

11

10.5

10.2

10.1

10

8

6

4

3

Claims Turnaround Time

30

28

26

25

24

23

22

21

20

15

10

7

5

Provider Payment Timeliness

85

86

87

88

89

90

91

91.5

92

95

97

98.5

99.5

Member Support

Contact Center Speed to Answer

300

270

240

210

180

160

145

130

120

60

30

20

15

First-contact Resolution Rate

50

52

54

56

58

60

62

64

65

72

78

85

90

Grievance Rate (per 1,000)

6

5.7

5.4

5

4.7

4.5

4.3

4.1

4

3.5

3

2.5

2

Language Access Completion Rate

80

82

84

86

87

88

89

89.5

90

95

97

99

99.5

Prior Authorization & Medical Necessity Controls

Prior Auth Volume (per 1,000)

2500

2450

2400

2350

2300

2250

2200

2100

2000

1800

1600

1200

900

Prior Auth Decision Timeliness

80

82

84

86

87

88

89

89.5

90

93

95

98

99

Overturn Rate on Appeal

35

34

33

32

30

29

28

26.5

25

20

15

10

8

Provider Onboarding & Network Adequacy

Provider Credentialing Cycle Time

90

85

80

75

70

68

65

62

60

50

40

30

21

Directory Accuracy

60

62

65

68

70

72

75

78

80

88

92

95

98

Network Appointment Availability

55

57

60

63

65

68

70

73

75

82

88

92

95

Mental Health Access Time

21

20

18

16

15

14.5

14.2

14.1

14

10

7

5

3

Integrity, Auditability, and “Trust” KPIs

Fraud, Waste, Abuse, and Payment Accuracy

Improper Payment Rate

10.5

10.2

9.8

9.5

9

8.7

8.4

8.2

8

7.4

7

4

2.5

Pre-payment Prevention Rate

20

22

25

28

30

33

35

38

40

50

60

70

80

Recovery Rate

20

22

25

27

29

31

33

34

35

45

55

65

75

Investigation Cycle Time

120

110

100

90

80

75

70

65

60

45

30

21

14

False Positive Rate

45

42

40

38

36

34

33

31

30

25

20

15

10

Accountability & Traceability (non-negotiable)

Requirement-to-KPI Trace Coverage

20

25

30

40

50

55

60

65

70

85

95

99

100

Evidence Completeness

25

30

35

45

55

60

65

70

75

88

95

99

100

Change Control Compliance

60

62

65

70

75

78

80

83

85

92

96

99

100