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41NHA-S3992 - Exhibit A – Key Performance Measures (KPMs)
| KPM # |
| Key Performance Measure |
| Threshold |
| Impact Severity |
| 1 |
| Compliant with Nevada Law in all activities (SOW 2.2.7.) |
| 100% statutory compliance |
| 1 |
| 2 |
| Compliant with Federal Law in all activities (SOW 2.2.7.) |
| 100% statutory compliance |
| 1 |
| 3 |
| Compliant with all HIPAA and other relevant requirements for privacy and security in all activities. (SOW 13.2.1) |
| 100% compliance with HIPAA privacy and security regulations |
| 1 |
| 4 |
| Ensure no breaches in data access occur in accordance with state and federal regulations. (SOW 13.2.7.) |
| Zero data access breaches allowed |
| 1 |
| 5 |
| Reporting of breaches in data access (hardcopy and electronic data) in accordance with state and federal regulations shall be reported by the Contractor to the State. (SOW 13.2.7.) |
| Within one (1) hour of Contractor’s identification of the breach to State data. |
| 2 |
| 6 |
| Provide detailed Root Cause Analysis (RCA) for any system error or noncompliance event. (SOW 16.2.3.) |
| Submitted within 10 calendar days of resolution. Interim updates do not toll daily penalties. |
| 3 |
| 7 |
| Maintain continuity of the designated strategic account executive, account manager, and clinical account manager throughout the contract term. (SOW 2.2) |
| Provides temporary coverage within ten (10) business days after a vacancy occurs and place an NVHA-approved, qualified permanent replacement within sixty (60) calendar days. Performance is compliant only if the Contractor meets both deadlines and maintains the required interim coverage. |
| 1 |
| 8 |
| Correct PBM web portal failures (any failure of hardware, software, or infrastructure related to online websites and portals.) (SOW 4.2) |
| 100% functional 24 hours / 7 days a week / 365 days a year. All failures resolved within 24 hours. |
| 3 |
| 9 |
| Timely web portal maintenance notification. (SOW 13.5.7) |
| 100% of web portal standard maintenance notifications must occur at least three (3) calendar days prior to the web scheduled maintenance, excluding emergency (i.e., denial of service, hacking events, etc.) |
| 4 |
| 10 |
| Timely posting of online website and portal information (SOW 4.2) |
| The contractor shall ensure that the contractor’s online documents and content are current, accurate, and complete. 100% of final content shall be posted to the web within one (1) business day. |
| 2 |
| 11 |
| Maintain and staff a member and provider Help Desk including, but not limited to, toll-free lines, email communications, webinar communications, toll-free fax communication. (SOW 4) |
| Staff shall be available 24 hours a day/7 days a week. Dedicated Nevada specific staff shall be available from 8:00 a.m. to 5:00 p.m. Pacific Standard Time, Monday through Friday. |
| 2 |
| 12 |
| Maintain help desk quality: Average Speed of Answer (ASA). (SOW 4.1.12) |
| 80% answered in < 2 minutes; 90% answered in < 5 minutes (measured as a cumulative average over a calendar month) |
| 2 |
| 13 |
| Maintain help desk quality: Maximum Hold Time limits. (SOW 4.1.12) |
| Callers placed on hold only if necessary; hold duration shall not exceed 3 minutes (measured as a cumulative average over a calendar month). |
| 2 |
| 14 |
| Maintain help desk quality: First-Contact Call Resolution Rate (SOW 4.1.12) |
| Minimum 90% of incoming inquiries resolved accurately on initial contact (measured as a cumulative average over a calendar month). |
| 2 |
| 15 |
| Maintain help desk quality: Call Abandonment Rate thresholds. (SOW 4.1.12) |
| Daily abandonment rate must remain strictly below 3% after 1 minute in queue (measured as a cumulative average over a calendar month). |
| 2 |
| 16 |
| Maintain help desk quality: Average Call Handle Time limits. (SOW 4.1.12) |
| Average call handle time must remain strictly under 7 minutes per call (measured as a cumulative average over a calendar month) |
| 2 |
| 17 |
| Mandatory notification of claims system outages. (SOW 13.5.7) |
| Reported to NVHA within four (4) hours of discovery for adjudication platform interruptions lasting 10 minutes or longer. |
| 2 |
| 18 |
| Develop business and technical impact analysis and a remediation plan for all data security breaches. (SOW 13.2.9.7) |
| Submit a preliminary impact analysis and remediation plan within eight (8) hours of Contractor’s initial discovery or reasonable suspicion of any unauthorized data access or data breach. The final format, contents, and implementation milestones of the remediation plan shall be exclusively directed and approved by NVHA. |
| 2 |
| 19 |
| Processing turnaround for Member Prior Authorization requests. (SOW 7.1.22) |
| Provide response within twenty-four (24) hours of receipt of a request for prior authorization |
| 1 |
| 20 |
| Provide required contractual and operational reports. (SOW 11) |
| 100% compliance to timeframes determined by NVHA 100% compliance with delivery timeframes, formats, and frequencies exclusively directed by NVHA. |
| 2 |
| 21 |
| Electronic Transactions Files Processing capacity. (SOW 16) |
| 99.99% transaction file processing capability functional 24/7/365, excluding approved maintenance. |
| 2 |
| 22 |
| Processing time of all incoming and outgoing pharmacy transactions (SOW 16.2.1) |
| 100% of pharmacy transactions processed within a maximum of five (5) seconds unless exempted by NVHA. |
| 1 |
| 23 |
| Provide real-time access by State staff to the Contractor’s policy and procedure documents and all related business and clinical plans. (SOW 1.3.11) |
| 100% continuous system access compliance for state staff. |
| 1 |
| 24 |
| Failure to produce and distribute final quarterly rebate invoices within sixty (60) calendar days after the end of each calendar quarter. (SOW 15.1.17) |
| 100% compliance |
| 1 |
| 25 |
| Accuracy and collection of drug rebate revenues. (SOW 15.1) |
| 100% collection compliance. Contractor shall reimburse NVHA for the exact dollar value of any uncollected or lost rebate. |
| 1 |
| 26 |
| Contractor will provide a quarterly Rebate report of earned, expected, and paid rebates at the GPI-14 or NDC-level. (SOW 15.4.1) |
| 100% accuracy |
| 2 |
| 27 |
| Contractor will complete all pricing, rebate, guarantee, and invoice reconciliations and financial settlements within contractual timeframes, and all financial reports will be complete and accurate. (SOW 1.2.1) |
| 100% on-time compliance; at least 99.9% accuracy |
| 1 |
| 28 |
| Approved benefit changes, additions, and deletions will be configured accurately per approved specifications, and implemented by the mutually agreed effective date. (SOW 16.1) |
| 100% accuracy and on-time compliance |
| 2 |
| 29 |
| Contractor will accurately load, validate, and reconcile all eligibility records, historical claims, active prior authorizations, and mail/specialty transition data received from the incumbent vendor, with no interruption in Member access or therapy. (SOW 18.2.3) |
| At least 99.5% accuracy; no access/therapy interruption |
| 2 |
| 30 |
| Contractor will accurately process, validate, and load electronically submitted eligibility files. (SOW 1.3.8) |
| 100% of usable, error‑free eligibility files are loaded without error within 24 hours of receipt. |
[This will be measured as the number of eligibility files audited and found to be processed and loaded without error divided by the total number of eligibility files received. Measured and Reported Quarterly.]
| 31 |
| Claims will adjudicate with financial accuracy based on approved benefit configuration and NVHA eligibility. (SOW 14.1.24) |
| Maintain at least 99.99% accuracy for Retail, Mail Order, and Specialty claims. Measured and reported quarterly. |
| 1 |
| 32 |
| Prior authorizations, utilization management programs, quantity limits, step therapy, age edits, and other clinical programs will be administered accurately. (SOW 7.1.14, 7.1.20) |
| At least 99% accuracy |
| 3 |
| 33 |
| Vendor must perform according to approved project plans. (SOW 18.1) |
| 100% adherence to critical-path implementation timelines |
| 3 |
| 34 |
| Systemwide Claims Adjudication Platform Availability. (SOW 13.5.7) |
| Maintain monthly availability of at least 99.9% for mission-critical components of the Contractor’s Solution. |
| 1 |
| 35 |
| Failure by the Contractor to comply with a Change Control Memorandum (CCM) or Corrective Action Plan (CAP). (SOW 1.3.12) |
| 100% operational implementation of NVHA-directed contents, formats, and remediation milestone timelines, to be submitted within 5 business days. |
| 1 |
| 36 |
| Complete all implementation actions and requirements prior to Go-Live dates in accordance with approved schedules. (SOW 18) |
| 100% adherence to implementation timelines. |
| 1 |
| 37 |
| Provide requested State operational, claims, or program data (SOW 13.2.4) |
| 100% compliance. All requested state data must be delivered to NVHA in an accurate, complete, and NVHA-approved format within the timeframes specified in the request. |
| 2 |
| 38 |
| Outgoing contract end-of-lifecycle data offboarding (SOW 19.2) |
| Deliver 100% of all historical operational data, active claims history, and records to a successor vendor or NVHA in strict compliance with the approved Transition Plan milestones. |
| 1 |
| 39 |
| Post-termination data purge certification. (SOW 19.11.3) |
| Provide a legally binding, executive-signed attestation verifying complete deletion and secure destruction of Nevada data from all private contractor environments, facilities, and cloud servers |
| 1 |
| 40 |
| Defective system release updates and management (SOW 13.1.18) |
| Release deployments must result in zero platform instability, functionality loss, or interface disconnects with NVHA or MCO systems. |
| 1 |
| 41 |
| Unapproved System infrastructure modifications (SOW 13.1.15) |
| Obtain explicit written NVHA authorization prior to altering or substituting any production code baseline or core application infrastructure software. |
| 1 |
| 42 |
| Total net loss of pharmacies in the broadest network (excluding NVHA-requested removals and for-cause terminations) will not exceed threshold, measured annually (SOW 17.3) |
| No more than a 5% net loss of pharmacies in the broadest network over the contract term, except when pharmacies close, commit fraud, or must be removed for cause. |
Net loss is calculated using starting pharmacy count plus additions, minus allowed removals. Client‑requested removals are excluded. Measured annually.
| 43 |
| Retail Network Access: Members will have access to a participating retail pharmacy within a reasonable distance per applicable standards (SOW 17.3) |
| At least 97% of participants shall reside within 1.5 miles of a network pharmacy for Urban areas, within 3 miles for Suburban areas and within 10 miles for Rural areas. Measured and Reported Annually |
| 2 |
| 44 |
| Initial implementation ID card production and mailing (SOW 18.4.7) |
| Produce and distribute 100% of initial Member ID cards within five (5) business days after receipt and processing of initial eligibility records, and no later than fourteen (14) calendar days before the effective date. |
| 2 |
| 45 |
| Open enrollment support (SOW 18.4) |
| Provide the staffing, materials, and other support specified in the NVHA-approved implementation plan for 100% of scheduled open enrollment meetings. |
| 1 |
| 46 |
| Pre-implementation audit (SOW 18.3) |
| Complete the pre-implementation audit, including follow-up test claims, no later than fifteen (15) calendar days before the effective date. |
| 1 |
| 47 |
| Member service review and improvement (SOW 13.3.18) |
| Conduct quarterly customer service reviews with NVHA and member-service representatives to address Member inquiry trends, service issues, and improvement actions; document action items, owners, and status. |
| 4 |
| 48 |
| Account-team satisfaction (SOW 2.3.20) |
| NVHA-designated staff shall complete an annual evaluation using a survey and methodology approved by NVHA. The Contractor shall maintain an average score of at least 4.0 on a five-point scale. |
| 3 |
| 49 |
| Account management open-issue log (SOW 2.3.4) |
| Maintain an open-issue log and provide it to the NVHA at least monthly. Make the account team available for weekly status meetings to review open issues and their status. |
| 4 |
| 50 |
| Account management responsiveness (SOW 2.3.5) |
| The account team shall respond to the NVHA requests within two (2) business days and, when modeling is requested, provide a response or requested turnaround estimate within that timeframe. Issues requiring service warranty review shall be submitted for analysis within five (5) business days. |
| 2 |
| 51 |
| Retail direct-reimbursement claim processing and response (SOW 16.2.4) |
| Process for payment or reject and respond to 100% of retail direct reimbursement claims within five (5) business days. Performance shall not be measured as an average. |
| 3 |
| 52 |
| Mail-order turnaround for prescriptions requiring no intervention (SOW 17.4) |
| Dispense and ship 100% of prescriptions requiring no administrative or clinical intervention within two (2) business days after receipt. |
| 2 |
| 53 |
| Mail-order turnaround for prescriptions requiring administrative or clinical intervention (SOW 17.4) |
| Dispense and ship 100% of prescriptions requiring administrative or clinical intervention within four (4) business days after receipt. |
| 2 |
| 54 |
| Mail-order dispensing accuracy (SOW 17.4.1.a) |
| Maintain a mail-order dispensing accuracy rate of at least 99.996% per calendar quarter, calculated as prescriptions dispensed without a verified dispensing error divided by total prescriptions dispensed. |
| 1 |
| 55 |
| Member satisfaction with retail, mail-order, and specialty services (SOW 4.3.17) |
| Achieve at least 95% Member satisfaction, measured using a survey tool and methodology approved by the NVHA. |
| 3 |
| 56 |
| Ongoing Member ID card mailing (SOW 1.3.8) |
| Issue at least 99% of new Member ID cards within four (4) business days and 100% within seven (7) business days after receipt and processing of a processable eligibility record. |
| 4 |
| 57 |
| Written inquiry response time (SOW 4.1.13) |
| Respond to at least 98% of written inquiries within five (5) business days and 100% within seven (7) business days. Performance shall not be measured as an average. |
| 4 |
Impact Severity and Performance Credit Assessment
| Impact Severity Level |
| Performance Credit Assessment for Failure to meet Key Performance Measure |
| 1 |
| Two thousand dollars ($2,000.00) shall be deducted for each calendar day that the Contractor fails to meet each Tier 1 key performance measure. The amount of the deduction shall accrue each day the Contractor fails to meet each key performance measure. |
Each calendar day, the total deduction will equal two thousand ($2,000.00) multiplied by the total number of each unmet key performance measure.
For example, failure to meet one (1) key performance measure for three (3) days could result in a deduction of two thousand dollars ($2,000.00) multiplied by three (3) days to total six thousand dollars ($6,000.00). Failure to meet two key performance measures for three (3) days could result in a deduction of four thousand dollars ($4,000.00) per day multiplied by three (3) days to total twelve thousand ($12,000.00). For system availability or claims adjudication metrics, any unapproved outage occurring during a calendar day constitutes an automatic full-day assessment, subject to the Critical Safeguard Carve-Out below.
| 2 |
| One thousand dollars ($1000.00) shall be deducted for each calendar day that the Contractor fails to meet each Tier 2 key performance measure. |
One thousand dollars ($1000.00) multiplied by the total number of calendar days of the failure may be deducted for each subsequent calendar day the same key performance measure is unmet.
For example, failure to meet one (1) key performance for two (2) days could result in a deduction of $1000.00 multiplied by two (2) days for a deduction of two thousand ($2,000.00).
For trend-based performance measures evaluated on a monthly average (including KPM 12 through KPM 16), a failure to achieve the threshold across a calendar month means the Contractor shall be deemed out of compliance for every day of that month, and the daily Tier 2 assessment shall apply retrospectively.
| 3 |
| Two hundred and fifty dollars ($250.00) shall be deducted for each calendar day that the Contractor fails to meet each Tier 3 key performance measure. |
Two hundred and fifty dollars ($250.00) multiplied by the total number of calendar days of the failure may be deducted for each subsequent calendar day the same key performance measure is unmet.
For example, failure to meet one (1) key performance measure for two (2) days could result in a deduction of two hundred and fifty dollars ($250.00) multiplied by two (2) days for a deduction of one thousand ($500.00).
| 4 |
| One hundred twenty-five dollars ($125.00) shall be deducted per individual occurrence, per calendar day that the Contractor fails to satisfy a Tier 4 key performance measure. Deductions shall accrue continuously for each separate occurrence from the date of the initial failure until the deficiency is fully resolved to the satisfaction of NVHA. For example, if the Contractor fails to update three (3) distinct required key performance measures (3 occurrences) for a period of four (4) calendar days, the performance credit deduction shall equal $125.00 multiplied by 3 occurrences multiplied by 4 days = $1,500.00. |
| Repeat Occurrence Multiplier |
| If the same or substantially similar Contractor key performance measure failure occurs three (3) or more times within any rolling twelve (12)-month period, the applicable performance credit for the third occurrence shall be multiplied by two (2). For the fourth and all subsequent occurrences, the multiplier shall increase to three (3). NVHA retains the absolute authority to determine whether a failure is the same or substantially similar to a prior failure. |
Impact Severities and Corrective Action Plan
| Impact Severity Level |
| Corrective Action Plan timeline for Failure to meet Key Performance Measure |
| 1 |
| A corrective action plan will be put in place requiring that deficiencies be corrected within 1 week. |
| 2 |
| A corrective action plan will be put in place requiring that deficiencies be corrected within 2 weeks. |
| 3 |
| A corrective action plan will be put in place requiring that deficiencies be corrected within 3 weeks. |
| 4 |
| A corrective action plan will be put in place requiring that deficiencies be corrected within 4 weeks. |
41NHA-S3992 - Exhibit A – PBM Key Performance Measures (KPMs)