122436 O5 - Attachment D - Performance Guarantees.xlsx
XLSX spreadsheet 39 KB Posted
- Solicitation number
- 122436 O5
- Issued by
- Blaine County, Nebraska
About this file
This document is an Attachment D Performance Guarantees spreadsheet for a Pharmacy Benefit Management (PBM) contract solicitation number 122436 O5. The file outlines specific performance metrics and financial penalties for a PBM service provider, detailing comprehensive performance guarantees across multiple operational domains including implementation, claims processing, member services, system performance, and administrative responsiveness. The performance guarantees cover areas such as error-free implementation, rebate payment accuracy, system access, claims processing, eligibility data management, and customer service response times.
The performance guarantees are structured with specific monetary penalties ranging from $2,000 to $50,000 per occurrence or measurement period, depending on the specific metric. Penalties are to be paid via ACH payment and cannot be used to offset administrative service fees. Key performance indicators include 99.9% financial accuracy for claims, 99.5% system uptime, mail service dispensing accuracy, claims processing turnaround times, phone response metrics, and legislative bill response times. The document also stipulates that performance guarantees will be based on self-reported results, with the potential for independent validation by the state, and that penalties will only be applied for errors directly caused by the PBM administrator.
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Text version
PBM_PGs
| Attachment D | Bidder: |
| Performance Guarantees | |
| Solicitation Number: 122436 O5 |
| The Plan will require specific performance guarantees. Please fill out the table below. In addition, you may provide other guarantees designed to differentiate your program. All guarantees shall be set and measured according to the timing of payments in the chart below. Measurement of performance guarantees may be based on internal self-reporting, subject to independent audit. | ||||
| Criteria | Standard | Measurement Criteria | Penalty Dollars | |
| at Risk | Timing of Payments | Confirm / |
Not Confirmed
| Implementation | |||||
| Error Free Implementation | PBM shall implement the plan benefit without any system errors or ID card delays. Online access to all Plan features prior to go-live date. | Plan Specific | $50,000 | Reported no later than 60 days after 'go-live' dates. | |
| Implementation Satisfaction Scorecard | The Plan may assess a penalty if the Plan benefits staff does not rate PBM implementation performance an average of 3 or better on a scale of 1 to 5 (5 being the best) | Plan Specific | $50,000 | Reported no later than 60 days after 'go-live' dates. | |
| Payment Accuracy & System Performance | |||||
| Quarterly Rebate Payments | Quarterly rebate payments/credits will be remitted to client within 60 calendar days from close of the respective quarter. | Plan Specific | 1% of the quarterly rebate payment for each quarterly miss | Annually | |
| Year-End Reconciliation and Reporting for Rebate Guarantees | PBM shall complete the year-end reconciliation of rebate guarantees no later than 210 calendar days following the close of the contract year. Within 210 days following the close of the contract year, PBM shall compensate client dollar for dollar for any rebate shortfall. | Plan Specific | $10,000 for reporting miss and $50,000 for payment miss | Annually | |
| Year-End Reconciliation and Reporting for Discount/Dispensing Fee Guarantees. | PBM shall complete the year-end reconciliation of discount and dispensing fee guarantees no later than 90 calendar days following the close of the contract year. Within 90 calendar days following the close of the contract year, PBM shall compensate client dollar for dollar for any shortfall in performance. | Plan Specific | $10,000 for reporting miss and $50,000 for payment miss | Annually | |
| Plan Administration Accuracy | Implementation of all plan design changes will be 100% accurate | Plan Specific | $20,000 | Annually | |
| Pricing Change Accuracy | Implementation of all pricing changes will be 100% accurate | Plan Specific | $20,000 | Annually | |
| Financial accuracy (electronic and paper claims) | Percentage of claim payments made without error relative to the total dollars paid will be at least 99.9% | BOB | $20,000 | Annually | |
| Mail Service Non-Financial Accuracy | The mail service pharmacy shall guarantee dispensing accuracy of at least 99.5% (correct participant name, correct participant address, correct drug, correct dosage form, and correct strength) | BOB | $20,000 | Annually | |
| System Downtime | At least 99.5% access to its systems by all the retail pharmacies in PBM's network 24 hours a day, 7 days a week, 365 days a year | BOB | $20,000 | Annually | |
| Claims Eligibility Data | Eligibility loads not to exceed one (1) business day after receipt | Plan Specific | $2,000 per occurrence | Annually | |
| Eligibility Data Error Reporting | Eligibility file error reporting on all eligibility file updates will be provided to the Plan within two (2) business days | Plan Specific | $2,000 per occurrence | Annually | |
| Claims Detail File | All claims detail files sent to external vendors will be provided within 48 hours of scheduled delivery date | Plan Specific | $2,000 per occurrence | Annually | |
| Timeliness of Response to Legislative Bills and Fiscal Notes | 100% of Legislative Bills and Fiscal Notes introduced will be responded to timely, as requested by the State, and in no less than 24-hours of initial receipt. | ||||
| Administrator will provide written responses regarding the potential impact of all Legislative Bills and Fiscal Notes introduced by the State and in the timing outlined in this PG. | Plan Specific | $2,000 per occurrence | Quarterly | ||
| Member Services | |||||
| Mail Turnaround – Prescriptions not requiring intervention | 95% of prescriptions dispensed within two (2) business days and 100% within four (4) business days | Plan Specific | $20,000 | Annually | |
| Mail Turnaround – Prescriptions requiring intervention | 95% of prescriptions dispensed within four (4) business days and 100% within seven (7) business days | Plan Specific | $20,000 | Annually | |
| Paper Claims Turnaround | 95% of prescriptions reimbursed within seven (7) business days and 100% within 10 business days | Plan Specific | $20,000 | Annually | |
| Phone Average Speed of Answer | 100% of calls to the Plan-specific toll-free line shall be answered within an average of 30 seconds (excluding IVR) | Plan Specific | $20,000 | Annually | |
| Phone Abandonment Rate | 100% of calls to the Plan-specific toll-free line shall be answered with an abandonment rate of 2% of less | Plan Specific | $20,000 | Annually |
| PG Conditions |
| 1) Any penalties shall be paid to the State via ACH payment. Penalties are not to be credited to invoices or used to offset ASO fees. |
| 2) For performance guarantee measures where interface between the Administrator and the State and/or the State’s vendor(s) is required, |
| the applicable penalties shall apply to the Administrator if, and only if, the error(s) or lack of timeliness is caused by the Administrator. |
| Penalties shall not apply to the Administrator due to errors caused by the State and/or one or more of the State’s vendors. |
| 3) Performance Guarantees will be based upon the Administrator's self-reported results. Please note the State may ask for validation of |
| reported PGs. |
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