Appendix A - Service Level Agreements.xlsx
XLSX spreadsheet 38 KB Posted
- Solicitation number
- BD-26-1039-EHS01-ASHWA-128591
- Issued by
- Suffolk County, Boston City, Massachusetts
About this file
This is a Service Level Agreement (SLA) document for the Massachusetts Executive Office of Health and Human Services (EOHHS) detailing performance standards and metrics for a provider enrollment and management contractor. The agreement covers comprehensive services including provider enrollment and re-enrollment, provider revalidations, provider file updates, provider training and onboarding, claims processing, documentation management, technical support, information system delivery, and non-emergency transportation coordination. The SLA is subject to yearly review and amendment by mutual agreement between EOHHS and the contractor, with performance measured and reported monthly, quarterly, or semi-annually depending on the specific metric. The contract establishes 36 distinct key performance indicators (KPIs) organized across multiple service categories, with performance standards ranging from throughput metrics requiring 80-100% completion rates within specified timeframes to quality metrics requiring 92-98% error-free processing rates.
Penalties for failing to meet performance standards range from corrective action plans to monetary deductions of 5-15% of monthly invoice amounts, with maximum penalties capped by service category. For example, provider enrollment and re-enrollment violations carry a maximum 15% penalty, while provider file update inaccuracies also cap at 15%. Some metrics, such as SLA 13 regarding Customer Experience Score, do not allow rounding (3.97 does not round to 4), while others employ standard rounding to the nearest whole number at the 0.5 threshold. Data sources for measuring performance include the contractor's systems, the MMIS (Medicaid Management Information System), and EOHHS systems. The document includes detailed scenario examples illustrating how penalties are calculated when contractors fail to meet specified benchmarks, providing clarity on enforcement mechanisms and expected performance levels.
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SLA
| c |
| SLAs listed here are subject to yearly review and amendment mutually agreed upon by EOHHS and the Contractor |
Numbers for SLA will be rounded to the next whole number based on 0.5 range Example: 99.52% will be rounded to 100% and 99.48% will be rounded to 99% For detail understnading of how penality will be calculated, please refer to "Examples" column
| SLA # | Category | SLA | Performance Standard/Measure | Performance | ||
| Reporting Frequency | Penalty (% of Invoice) |
tc={FE9DB5ED-5024-4A1B-BAEC-BD8FBBFC5EFC}: [Threaded comment]
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Comment:
| Do we want a cumulative max here. | Data Source for Measure | Examples | ||
| Provider Enrollment/Provider Re-enrollment | ||||
| 1 | Throughput | Timely Processing of Provider Applications (whether submitted paper or portal): The rate shall be the percentage of non-MCE Provider applications processed to an “Enrolled” status within forty five (45) Calendar days from date of receipt. No eligible Provider may be denied within those 45 calendar Days. |
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
15% is max penality applied for "Provider Enrollment / Re-Enrollment" 100% of the complete, eligible non-MCE provider applications processed to an “Enrolled” status within forty five (45) Calendar days from date of receipt. Monthly 10% Contractor Scenario: applications completed between 91% - 99% Outcome: failed to meet 100% benchmark hence penality of 10% will be applied to monthly invoice amount 2 Throughput Timely Processing of Provider Applications (whether submitted via paper or portal): The rate shall be the percentage of non-MCE Provider applications processed to an “Enrolled” status within thirty (30) Calendar days from date of receipt. No eligible Provider may be denied within those 30 calendar Days.
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
15% is max penality applied for "Provider Enrollment / Re-Enrollment" 90% of complete, eligible non-MCE provider applications processed to an “Enrolled” status within forty five (45) Calendar days from date of receipt. Monthly 15% Contractor Scenario: 89% applications completed within 45 days Outcome: failed to meet 90% benchmark hence penality of 15% will be applied to monthly invoice amount
| 3 | Quality | Accuracy of completed provider applications either submitted electronically or paper | |||
| 15% is max penality applied for "Provider Enrollment / Re-Enrollment" | 95% of the completed applications are free from general errors both on the contractor system as well as in MMIS | Monthly | 15% | Contractor | Scenario: 94% of completed appliocations are free from general errors (6% error rate) |
Outcome: Failed to meet 95% benchmark (5% error rate). Hence 15% penalty will be pplied to monthly invoice amount
| 4 | Quality | Accuracy of completed provider applications either submitted electronically or paper | ||
| 15% is max penality applied for "Provider Enrollment / Re-Enrollment" | 98% of the completed applications are free of errors that result in inappropriate payment or are the sole reason for prevention of an appropriate payment in MMIS | |||
| Monthly | 10% | Contractor | Scenario: 97% of completed appliocations are free from general errors (3% error rate) |
Outcome: Failed to meet 98% benchmark (2% error rate). Hence 10% penalty will be pplied to monthly invoice amount
| Provider Revalidations | ||
| 5 | Throughput | Timely Processing of Provider Re-validations (whether submitted paper or portal): The rate shall be the percentage of non-MCE Provider revalidations processed to an completed revalidations or denied for not completing revalidations within 60 calendar Days. |
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
15% is max penality applied for "Provider Revalidation" Complete 100% of Fee For Service (FFS) Provider Revalidations within their 5-year revalidation date 'month in contractor system as well as in MMIS Monthly 15% Contractor Requirement: 5 FFS providers completing their 5 year with MH on 12/31/2026. They all need to be revalidated by 12/31/2026 Scenario: 4 providers are revalidated by 12/31/2026 and one provider is revaliated on 1/1/2027 Outcome: Failed to meet the 100% benchmark for the KPI. Hence 15% penalty will be applied to monthly inovice (Invocie for Dec 2026)
| 6 | Quality | Accuracy of provider revalidation applications submitted either electronically or paper | |||
| 15% is max penality applied for "Provider Revalidation" | 95% of the completed revalidation applications are free from general errors both on the contractor system as well as in MMIS | Monthly | 10% | Contractor | Requirement: 5 FFS providers completing their 5 year with MH on 12/31/2026. They all need to be revalidated by 12/31/2026 |
Scenario:
a) 4 providers are revalidated by 12/31/2026 and one provider is revaliated on 1/1/2027
b) All the 4 completed revalidations accounted for 94% free from general errors (6% error rate) Outcome:
a) Failed to meet the 100% benchmark for Trhoughout KPI
b) Failed to meet 5% error rate benchmark for Quality KPI Hence 15% (Thrroughput) penalty will be applied to monthly inovice (Invocie for Dec 2026)
| 7 | Quality | Accuracy of provider revalidation applications submitted either electronically or paper | ||
| 15% is max penality applied for "Provider Revalidation" | 98% of the completed revalidation applications are free of errors that result in inappropriate payment or are the sole reason for prevention of an appropriate payment in MMIS | |||
| Monthly | 5% | Contractor | Requirement: 5 FFS providers completing their 5 year with MH on 12/31/2026. They all need to be revalidated by 12/31/2026 |
Scenario:
a) all 5 providers are revalidated by 12/31/2026
b) All thw 5 completed revalidations accounted for 97% free from general errors (3% error rate) Outcome: Failed to meet 2% error rate benchmark for Quality KPI. Hence 5% penalty will be applied to monthly inovice (Invocie for Dec 2026)
| Provider File Updates | ||
| 8 | Throughput | Timely processing of Provider File Updates: The rate of timely completion of Provider File Updates shall be the percentage of Provider updates completed. |
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
15% is the maximum penalty applied for "Provider File Updates" 100% of requested provider file updates completed within 5 business days from the receipt of the update request in the contractor system as well as MMIS tc={00EEF9FC-7A55-4599-ADEF-A6BB98106B6D}: [Threaded comment]
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Comment:
Do we want any give here at all? Is it rounding to 100%? So if they hit 99.5%, they are ok? We might want to be more specific here.
Reply:
Updated the language and provided example to show how rounding will work tc={FE9DB5ED-5024-4A1B-BAEC-BD8FBBFC5EFC}: [Threaded comment]
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Comment:
Do we want a cumulative max here. Monthly 10% Contractor Scenario: 99% of requested provider file updates completed within 5 business days from the receipt Outcome: Failed to meet 100% completion benchmark. Hence 10% penalty will be applied to monhtly invoice (inovice for the month in which KPI is missed) 9 Throughput Timely processing of Provider File Updates: The rate of timely completion of Provider File Updates shall be the percentage of Provider updates completed.
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
15% is the maximum penalty applied for "Provider File Updates" 90% of requested provider file updates completed within 5 business days from the receipt of the update request in the contractor system as well as MMIS Monthly 15% Contractor Scenario: 89% of requested provider file updates completed within 5 business days from the receipt Outcome: Failed to meet 100% completion benchmark. Hence 15% penalty will be applied to monhtly invoice (inovice for the month in which KPI is missed) 10 Quality Accuracy of provider file updates: The rate shall be the percentage of Provider updates processed free from errors.
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
15% is the maximum penalty applied for "Provider File Updates" 95% of the completed requests are free from general errors both on the contractor system as well as in MMIS Monthly 15% Contractor Scenario: 94% of the completed provider file updates are general error freee (6% error rate) Outcome: Failed to meet benchmark of 5% error rate. Hence 15% penality will be applied to the monthly invoice (invocie for the month in which KPI is missed) 11 Quality Accuracy of provider file updates: The rate shall be the percentage of Provider updates processed free from errors.
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
| 15% is the maximum penalty applied for "Provider File Updates" | 98% of the completed requests are free of errors that result in inappropriate payment or are the sole reason for prevention of an appropriate payment in MMIS | |||
| Monthly | 10% | Contractor | Scenario: 97% of completed provider file updates are free of general error (3% error rate) |
Outcome: Failed to meet 2% error rate benchmark for the KPI. Hence 10% penalty will be applied to the monthly invoice amount (invoice for the month in which KPI is missed)
| Provider Training and onboarding | ||
| 12 | Throughput | General Education and Training Scope: |
1. EOHHS tools and resources (what is available where)
2. SOP and Job Aids
| Note: Exemptions to trainings and process will be at the sole discretion of EOHHS. | when less than 90% of newly enrolled providers complete the training within 60 days, contractor must conduct 3 additional outreach per outstanding provider requesting that they complete the required training. | Monthly | Corrective Action Plan | Contractor |
| Provider Survey | ||||
| 13 | Customer Experience Score (CES) | Overall provider experience with Contractor encompassing, |
1. Subject Matter Expertise
2. Communication
3. Technology
CES Scoring Scale:
1. Very Dissatisfied
2. Dissatisfied
3. Neutral
4. Satisfied
5. Very Satisfied CES of 4 and above for survey of at least 90% of total providers distributed as following 50% of newly enrolled providers 20% of revalidated providers 25% of Providers who submitted provider updates
| Rounding will not be applied to this KPI (Ex: 3.97 is not 4) | Quarterly | 15% | Contractor | |
| Provider Claims | ||||
| 14 | Throughput | Receive and process provider submitted 90-day waiver claims submitted on the POSC using HIPAA delay reasons 1, 4 and 8 within thirty (30) days of receipt. |
Delay Reason Codes:
1 – Proof of Eligibility Unknown or Unavailable 4 – Delay in Certifying Provider
| 8 – Delay in Eligibility Determination | 95% of 90-day waiver claims for delay reasons 1, 4 and 8 within thirty (30) days of receipt. | Monthly | 5% | MMIS/Contractor | ||||
| 15 | Quality | Accurately process 92% of 90-day waiver claims error free. | 92% of 90-day waiver claims error free. | Monthly | 5% | MMIS/Contractor | ||
| Documentation, Fulfillment, and Mailing | ||||||||
| 16 | Documentation | Document Management System: |
1. Keep Indexed record of all the required documentation
2. Any required documentation should be available and accessible within 2 business days of the request
| Documentation must be available within two (2) business days | ||||||||
| Monthly | Corrective Action Plan (CAP) | |||||||
| Contractor/MMIS | ||||||||
| 17 | Documentation | Document Management System: | ||||||
| Incorrect document attachment incidents violating Privacy and Security protocols for all the documentation. | Zero (0) incidents | Quarterly | EOHHS cost of correction | Contractor/MMIS | ||||
| Provider Misc Business Ops Functions | ||||||||
| 18 | EDI | EDI Trading Partner Testing | ||||||
| 100% of direct trading partners must be able to submit claims within thirty (30) calendar days from the date of issuance of the PID/SL . | Monthly | Corrective Action Plan (CAP) | Contractor | |||||
| 19 | Audit | Audit Support for - CMS, Single State Audit, Payment Error Rate Adjustment, Office of Inspector General Audits | 100% of the audits are successfully completed and submitted with all required documentation. | Quarterly | Corrective Action Plan (CAP) | Contractor | ||
| 20 | Provider Material | 1. Develop and update educational materials for providers by provider type |
2. Provider Business Process support - access to electronic versions of documents
| 3. Support MassHealth Publication team with data for ad-hoc publications | Produce quarterly log of provider materials that are added / updated / obsoleted / ad hoc requests with version history | Quarterly | Corrective Action Plan (CAP) | Contractor | |
| 21 | Provider Review Committee (PRC) | Coordinate, facilitate, and support monthly PRC meeting | 1. Identify and refer providers that failed MH criteria to PRC - within one (1) business day of decision |
2. Disenroll non-compliant providers and send disenrollment letters within fifteen (15) business days of the decision
3. Send disposition letters to providers within ten (10) business days of the PRC decision.
| 4. Produce monthly summary and dashboard of PRC | Monthly | Corrective Action Plan (CAP) and passthrough of monitory expenses to MassHealth as a result of missing the SLAs . | MassHealth | |
| Provider Contact Center and Support | ||||
| 22 | Communication | Email Support: Response time |
1. Produce monthly Email Encounter Report (EER) detailing all email encounters and resolution metrics
2. Produce Quarterly and yearly email encounter trending report. 1. Acknowledgement of receipt within one (1) business day.
2. Response to acknowledged email received to customers satisfaction within four (4) business days of acknowledgement of the receipt.
| Monthly | 5% | Contractor | ||
| 23 | Quality | Email Support: Quality of Responses | 1. Submit 10% of final response email for quality review excluding acknowledgements. |
2. 100% accuracy of responses
| Monthly | Corrective Action Plan(CAP) | Contractor | |
| 24 | Self Service Options | 1. Request for New Enrollment Application |
2. Check MassHealth Enrollment Status
3. Check Application Status
4. Request Training
5. EDI Requests
6. Learning Management System (LMS) Exclusion: Any technical maintenance or unavailability of EOHHS servers that will impact availability of Self Service Options 1. All Self Service Options should be available to the providers 24x7x365 days
2. Produce utilization dashboard of all the self service options, as mutually agreed upon by EOHHS and the contractor
| Monthly | Corrective Action Plan(CAP) | Contractor | ||||||
| Technical Support | ||||||||
| 25 | Technical Support to Portal and Self Service option Users | Provide technical Support to Portal and Self Service option Users | 100% of user requests for technical assistance with portal or self service tools are resolved within three (3) business days from the date it was requested | Monthly | Corrective Action Plan(CAP) | Contractor | ||
| 26 | Technical Support to Portal and Self Service option Users | Provide technical Support to Portal and Self Service option Users | 80% of user requests for technical assistance with portal or self service tools are resolved within one (1) business day from the date it was requested | Monthly | Corrective Action Plan(CAP) | Contractor | ||
| 27 | Urgent Technical Support to Portal and Self Service option Users | Provide technical Support to Portal and Self Service option Users | ||||||
| URGENT Requests: Priority 1 incident in which service is completely down and unavailable to all users. Resolved shall be defined as service has been resorted using a temporary or permanent workaround and/or fix | 100% of user's URGENT requests for technical assistance are resolved within two (2) business days | Monthly | Corrective Action Plan(CAP) | Contractor | ||||
| Information System and Management | ||||||||
| 28 | Functional Requirements | Delivery of functional requirements | Delivery of 100% of the functional requirements that were signed off on by both EOHHS and the Contractor are within the scope of all requirements for the planned information system release. | Semi Annually | Corrective Action Plan(CAP) | EOHHS | ||
| 29 | Minimization of Information System Defects | Post production validation of the functional requirement | Less than 5% defects identified for each functional requirements that were signed off on by EOHHS and the Contractor are within the scope of all the requirements. | Quarterly | Corrective Action Plan(CAP) | EOHHS | ||
| 30 | Minimization Of Bad Data originating in non-Contractor information systems | Maintain data integrity and quality of the data in both the Contractor systems and other integrated systems | Instances of Bad Data are resolved in timely manner according to data correction process that is mutually agreed upon by EOHHS and the Contractor |
1. Within 20 Business days, resolve 80% of Bad data received from non-Contractor information systems prior to inclusion in any submission to EOHHS
2. Ensure that no more than 2% of records in contractors systems contain bad data
| 3. Ensure that not more than 1% of records sent to any EOHHS system are rejected due to Bad Data or any other data integrity issues | Monthly | Corrective Action Plan(CAP) | EOHHS | |||||
| 31 | Release / Change Order Timelines | Release Schedule and Change Order Timeline | Information System release/ system change delivered within the specified project timeline. | Quarterly | Corrective Action Plan(CAP) | EOHHS | ||
| 32 | Technical defects outside functional requirements | Technical defects such as system performance, coding issues, impact on existing functionality, and user experience. | Less than 1% defects outside functional requirements | Quarterly | Corrective Action Plan(CAP) | Contractor | ||
| 33 | Response Time | Portal and Information System response time |
Level A - Simple Information retrieval Level B - More interactive data submission Provider Portal shall have an average response time of Level A - 3 seconds or less Level B - 6 seconds or less for 2000 or fewer concurrent users
| Contractor shall produce quarterly dashboard of system response time. | Quarterly | Corrective Action Plan(CAP) | Contractor | ||
| 34 | Management | Implementation Plan, Release Plan and Project Plan. | Level A: Submit each required plan at implementation and quarterly thereafter in an approvable status and on time for each Key Function | ||
| Level B: Plan requiring modifications prior to Approval will only require one round of edits | Quarterly | Corrective Action Plan(CAP) | Contractor | ||
| Non Emergency Transportation (NETA) | |||||
| 35 | NETA | Process NETA Provider Requests. | |||
| 1. Process 100% of NETA provider requests for transportation within three (3) business days from the date it was submitted. | |||||
| 2. Produce monthly dashboard of NETA Provider requests. | Monthly | Corrective Action Plan(CAP) | Contractor | ||
| Provider Directory | |||||
| 36 | Provider Directory Information Update: Response Time | Portal, Self Service options and associated Information System response time | 1. A provider's request to update the information that appears in the provider directory must be processed within six (6) calendar days from the receipt of the update request in contractor system as well as MMIS. | ||
| 2. Non-MCE Providers enrollment information must appear in the provider directory within two (2) business days after the provider becomes active. | Monthly | Corrective Action Plan(CAP) | Contractor/MMIS |
Do we want a cumulative max here.
Do we want any give here at all? Is it rounding to 100%? So if they hit 99.5%, they are ok? We might want to be more specific here.
Updated the language and provided example to show how rounding will work
Examples
| SLA # | Category | SLA | Performance Standard/Measure | Performance | |
| Reporting Frequency | Penalty | ||||
| (% of Invoice) | Data Source for Measure | Examples | |||
| Provider Enrollment/Provider Re-enrollment | |||||
| 1 | Throughput | Timely Processing of Provider Applications (whether submitted paper or portal): The rate shall be the percentage of non-MCE Provider applications processed to an “Enrolled” status within forty five (45) Calendar days from date of receipt. No eligible Provider may be denied within those 45 calendar Days. |
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
15% is max penality applied for "Provider Enrollment, reinstatement, reactivation, and conversion". 100% of the eligible non-MCE provider applications processed to an “Enrolled” status within forty five (45) Calendar days from date of receipt. Monthly 10% Contractor Scenario: Approved applications must be processed in accordance with EOHHS - approved procedures such as receipt of application and to the issuing applicable correspondence to providers.
Processed between 91% - 99% Outcome: Failed to meet 100% benchmark hence penalty of 10% will be applied to monthly invoice amount.
2 Throughput Timely Processing of Provider Applications (whether submitted via paper or portal): The rate shall be the percentage of non-MCE Provider applications processed to an “Enrolled” status within thirty (30) Calendar days from date of receipt. No eligible Provider may be denied within those 30 calendar Days.
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
15% is max penality applied for "Provider Enrollment, reinstatement, reactivation, and conversion". 90% of complete, eligible non-MCE provider applications processed to an “Enrolled” status within forty five (45) Calendar days from date of receipt. Monthly 15% Contractor Scenario: 89% applications completed within 45 days Outcome: failed to meet 90% benchmark hence penality of 15% will be applied to monthly invoice amount
| 3 | Quality | Accuracy of completed provider applications (whether submitted paper or portal) such as from the receipt of application to the issuance of applicable correspondence to providers. | |||
| 15% is max penality applied for "Provider Enrollment, reinstatement, reactivation, and conversion". | 95% of the completed applications are free from general errors both on the contractor system as well as in MMIS | Monthly | 15% | Contractor | Scenario: 94% of completed applications (in accordance with EOHHS approved policies and procedures) are free from error (6% error rate). |
Outcome: Failed to meet 95% benchmark (5% error rate). Hence 15% penalty will be applied to the monthly invoice amount
| 4 | Quality | Accuracy of completed provider applications either submitted electronically or paper | ||
| 15% is max penality applied for "Provider Enrollment, reinstatement, reactivation, and conversion" | 98% of the completed applications are free of errors that result in inappropriate payment or are the sole reason for prevention of an appropriate payment in MMIS | |||
| Monthly | 10% | Contractor | Scenario: 97% of completed applications are free from general errors (3% error rate) |
Outcome: Failed to meet 98% benchmark (2% error rate). Hence 10% penalty will be applied to monthly invoice amount
| Provider Revalidations | ||
| 5 | Throughput | Timely Processing of Provider Re-validations (whether submitted paper or portal): The rate shall be the percentage of non-MCE Provider revalidations processed to an completed revalidations or denied for not completing revalidations within 60 calendar Days.; ”completed” is defined as approved or denied. Approval should occur within forty-five (45)calendar days, and must comply with EOHHS approval criteria such as; the issuance of applicable provider correspondence, validation of documentation, updating MMIS with all applicable changes, reviewing for quality as required, etc. |
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
15% is max penality applied for "Provider Revalidation" Complete 100% of Fee For Service (FFS) Provider Revalidations within their 5-year revalidation date 'month in contractor system as well as in MMIS Monthly 15% Contractor Requirement: 5 FFS providers completing their 5 year with MH on 12/31/2026. They all need to be revalidated by 12/31/2026 Scenario: A provider that has a revalidation date of 12/31/2026 must be revalidated according to EOHHS and CMS requirements.
Outcome: Failed to meet the 100% benchmark for the KPI. Hence 15% penalty will be applied to monthly invoice (Invoice for Dec 2026)
| 6 | Quality | Accuracy of provider revalidations( whether submitted either paper or portal) in accordance with EOHHS approved policies and procedures must be processed at a 100% free from error. | |||
| 15% is max penality applied for "Provider Revalidation" | 95% of the completed revalidation applications are free from general errors both on the contractor system as well as in MMIS | Monthly | 10% | Contractor | Requirement: 5 FFS providers completing their 5 year with MH on 12/31/2026. They all need to be revalidated by 12/31/2026 |
Scenario: Quality shall be assessed in adherence to EOHHS approved policies and procedures, such as adherence to all CMS and EOHHS timelines, preliminary assessment of provider data 30 days prior to launch, applicable and timely provider correspondence, validation of provider documentation, keying applicable updates in MMIS panels, etc.
Outcome:
a) Failed to meet the 100% benchmark for Throughout KPI
b) Failed to meet 5% error rate benchmark for Quality KPI Hence 15% (Throughput) penalty will be applied to monthly invoice (Invoice for Dec 2026)
| 7 | Quality | Accuracy of provider revalidation applications submitted either electronically or paper | ||
| 15% is max penality applied for "Provider Revalidation" | 98% of the completed revalidation applications are free of errors that result in inappropriate payment or are the sole reason for prevention of an appropriate payment in MMIS | |||
| Monthly | 5% | Contractor | Requirement: 5 FFS providers completing their 5 year with MH on 12/31/2026. They all need to be revalidated by 12/31/2026 |
Scenario:
a) all 5 providers are revalidated by 12/31/2026
b) All the 5 completed revalidations accounted for 97% free from general errors (3% error rate) Outcome: Failed to meet 2% error rate benchmark for Quality KPI. Hence 5% penalty will be applied to monthly invoice (Invoice for Dec 2026)
| Provider File Updates | ||
| 8 | Throughput | Timely processing of Provider File Updates: The timely completion of Provider File Updates is based on completion within five (5) business days from the date of receipt of the request. 100% of update requests must be processed within that time frame. |
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
| 15% is the maximum penalty applied for "Provider File Updates" | 100% of requested provider file updates completed within 5 business days from the receipt of the update request in the contractor system as well as MMIS | |||
| Monthly | 10% | Contractor | Scenario: 99% of requested provider file updates completed within 5 business days from the receipt |
Outcome: Failure to meet 100% completion benchmark. Hence 10% penalty will be applied to monthly invoice (invoice for the month in which KPI is missed).
9 Throughput Timely processing of Provider File Updates: The timely completion of Provider File Updates is based on completion within five (5) business days from the date of receipt of the request. 90% of update requests must be processed within that time frame.
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
15% is the maximum penalty applied for "Provider File Updates" 90% of requested provider file updates completed within 5 business days from the receipt of the update request in the contractor system as well as MMIS Monthly 15% Contractor Scenario: 89% of requested provider file updates completed within 5 business days from the receipt Outcome: Failure to meet 90% completion benchmark. Hence 15% penalty will be applied to monthly invoice (invoice for the month in which KPI is missed).
10 Quality Accuracy of provider file updates: The rate shall be the percentage of Provider updates processed free from errors.
Exemptions to timelines and process for provider file update will be at the sole discretion of EOHHS and CMS.
15% is the maximum penalty applied for "Provider File Updates" 95% of the completed requests are free from general errors both on the contractor system as well as in MMIS Monthly 15% Contractor Scenario: 94% of the completed provider file updates are free from error (6% error rate).
Outcome: Failed to meet benchmark of 5% error rate. Hence 15% penalty will be applied to the monthly invoice (invoice for the month in which KPI is missed).
11 Quality Accuracy of provider file updates: The rate shall be the percentage of Provider updates processed free from errors.
Exemptions to timelines and process for revalidations will be at the sole discretion of EOHHS and CMS.
| 15% is the maximum penalty applied for "Provider File Updates" | 98% of the completed requests are free of errors that result in inappropriate payment or are the sole reason for prevention of an appropriate payment in MMIS | |||
| Monthly | 10% | Contractor | Scenario: 97% of completed provider file updates are free of general error (3% error rate) |
Outcome: Failed to meet 2% error rate benchmark for the KPI. Hence 10% penalty will be applied to the monthly invoice amount (invoice for the month in which KPI is missed)
| Provider Training and onboarding | ||
| 12 | Throughput | General Education and Training Scope: |
1. EOHHS tools and resources (what is available where)
2. SOP and Job Aids
| Note: Exemptions to trainings and process will be at the sole discretion of EOHHS. | when less than 90% of newly enrolled providers complete the training within 60 days, contractor must conduct 3 additional outreach per outstanding provider requesting that they complete the required training. | Monthly | Corrective Action Plan | Contractor |
| Provider Survey | ||||
| 13 | Customer Experience Score (CES) | Overall provider experience with Contractor encompassing, |
1. Subject Matter Expertise
2. Communication
3. Technology
CES Scoring Scale:
1. Very Dissatisfied
2. Dissatisfied
3. Neutral
4. Satisfied
5. Very Satisfied CES of 4 and above for survey of at least 90% of total providers distributed as following 50% of newly enrolled providers 20% of revalidated providers 25% of Providers who submitted provider updates
| Rounding will not be applied to this KPI (Ex: 3.97 is not 4) | Quarterly | 15% | Contractor |
| Provider Claims | |||
| 14 | Throughput | Receive and process 90-day waiver claims for delay reasons 1, 4 and 8 within thirty (30) days of receipt. |
Delay reason:
1 – Proof of Eligibility Unknown or Unavailable:
4 – Delay in Certifying Provider:
| 8 – Delay in Eligibility Determination | 95% of 90-day waiver claims for delay reasons 1, 4 and 8 within thirty (30) days of receipt. | Monthly | 5% | MMIS/Contractor | |||
| 15 | Quality | Accurately process 92% of 90-day waiver claims error free. | 92% of 90-day waiver claims error free. | Monthly | 5% | MMIS/Contractor | |
| Documentation, Fulfillment, and Mailing | |||||||
| 16 | Documentation | Document Management System: |
1. Keep Indexed record of all the required documentation
2. Any required documentation should be available and accessible within 2 business days of the request
| Documentation must be available within two (2) business days | |||||||
| Monthly | Corrective Action Plan (CAP) | ||||||
| Contractor/MMIS | |||||||
| 17 | Documentation | Document Management System: | |||||
| Incorrect document attachment incidents violating Privacy and Security protocols for all the documentation. | Zero (0) incidents | Quarterly | EOHHS cost of correction | Contractor/MMIS | |||
| Provider Misc Business Ops Functions | |||||||
| 18 | EDI | EDI Trading Partner Testing | |||||
| 100% of direct trading partners must be able to submit claims within thirty (30) calendar days from the date of issuance of the PID/SL . | Monthly | Corrective Action Plan (CAP) | Contractor | ||||
| 19 | Audit | Audit Support for - CMS, Single State Audit, Payment Error Rate Adjustment, Office of Inspector General Audits | 100% of the audits are successfully completed and submitted with all required documentation. | Quarterly | Corrective Action Plan (CAP) | Contractor | |
| 20 | Provider Material | Develop, review, and distribute provider material per EOHHS standards. | Produce quarterly log of provider materials that are added / updated / obsoleted / ad hoc requests with version history | Quarterly | Corrective Action Plan (CAP) | Contractor | |
| 21 | Provider Review Committee (PRC) | Coordinate, facilitate, and support monthly PRC meeting | In accordance with EOHHS approved policies and procedures the vendor must: | ||||
| 1. | Identify and refer providers that are not in good stead to the PRC Coordinator within one (1) business day of determination. | ||||||
| 2. | Coordinate and facilitate monthly PRC meetings | ||||||
| 3. | Send all applicable disposition letters (approval, denial, termination) to providers within fifteen (15) business days of the PRC decision. | ||||||
| 4. | Update the MMIS system in accordance with the decisions and timelines of the PRC | ||||||
| 5. | Update and distribute a monthly dashboard of case outcomes | Monthly | Corrective Action Plan (CAP) and passthrough of monitory expenses to MassHealth as a result of missing the SLAs . | MassHealth | |||
| Provider Contact Center and Support | |||||||
| 22 | Communication | Email Support: Response time |
1. Produce monthly Email Encounter Report (EER) detailing all email encounters and resolution metrics
2. Produce Quarterly and yearly email encounter trending report. 1. Acknowledgement of receipt within one (1) business day.
2. Response to acknowledged email received to customers satisfaction within four (4) business days of acknowledgement of the receipt.
| Monthly | 5% | Contractor | |
| 23 | Quality | Email Support: Quality of Responses | 1. Submit 10% of final response email for quality review excluding acknowledgements. |
2. 100% accuracy of responses
| Monthly | Corrective Action Plan(CAP) | Contractor |
| 24 | Self Service Options | 1. Request for New Enrollment Application |
2. Check MassHealth Enrollment Status
3. Check Application Status
4. Request Training
5. EDI Requests
6. Learning Management System (LMS) Exclusion: Any technical maintenance or unavailability of EOHHS servers that will impact availability of Self Service Options. 1. All Self Service Options should be available to the providers 24x7x365 days
2. Produce utilization dashboard of all the self service options, as mutually agreed upon by EOHHS and the contractor
| Monthly | Corrective Action Plan(CAP) | Contractor | |||||
| Technical Support | |||||||
| 25 | Technical Support to Portal and Self Service option Users | Provide technical Support to Portal and Self Service option Users | 100% of user requests for technical assistance with portal or self service tools are resolved within three (3) business days from the date it was requested | Monthly | Corrective Action Plan(CAP) | Contractor | |
| 26 | Technical Support to Portal and Self Service option Users | Provide technical Support to Portal and Self Service option Users | 80% of user requests for technical assistance with portal or self service tools are resolved within one (1) business day from the date it was requested | Monthly | Corrective Action Plan(CAP) | Contractor | |
| 27 | Urgent Technical Support to Portal and Self Service option Users | Provide technical Support to Portal and Self Service option Users | |||||
| URGENT Requests: Priority 1 incident in which service is completely down and unavailable to all users. Resolved shall be defined as service has been resorted using a temporary or permanent workaround and/or fix | 100% of user's URGENT requests for technical assistance are resolved within two (2) business days | Monthly | Corrective Action Plan(CAP) | Contractor | |||
| Information System and Management | |||||||
| 28 | Functional Requirements | Delivery of functional requirements | Delivery of 100% of the functional requirements that were signed off on by both EOHHS and the Contractor are within the scope of all requirements for the planned information system release. | Semi Annually | Corrective Action Plan(CAP) | EOHHS | |
| 29 | Minimization of Information System Defects | Post production validation of the functional requirement | Less than 5% defects identified for each functional requirements that were signed off on by EOHHS and the Contractor are within the scope of all the requirements. | Quarterly | Corrective Action Plan(CAP) | EOHHS | |
| 30 | Minimization Of Bad Data originating in non-Contractor information systems | Maintain data integrity and quality of the data in both the Contractor systems and other integrated systems | Instances of Bad Data are resolved in timely manner according to data correction process that is mutually agreed upon by EOHHS and the Contractor |
1. Within 20 Business days, resolve 80% of Bad data received from non-Contractor information systems prior to inclusion in any submission to EOHHS
2. Ensure that no more than 2% of records in contractors systems contain bad data
| 3. Ensure that not more than 1% of records sent to any EOHHS system are rejected due to Bad Data or any other data integrity issues | Monthly | Corrective Action Plan(CAP) | EOHHS | ||||
| 31 | Release / Change Order Timelines | Release Schedule and Change Order Timeline | Information System release/ system change delivered within the specified project timeline. | Quarterly | Corrective Action Plan(CAP) | EOHHS | |
| 32 | Technical defects outside functional requirements | Technical defects such as system performance, coding issues, impact on existing functionality, and user experience. | Less than 1% defects outside functional requirements | Quarterly | Corrective Action Plan(CAP) | Contractor | |
| 33 | Response Time | Portal and Information System response time |
Level A - Simple Information retrieval Level B - More interactive data submission Provider Portal shall have an average response time of Level A - 3 seconds or less Level B - 6 seconds or less for 2000 or fewer concurrent users
| Contractor shall produce quarterly dashboard of system response time. | Quarterly | Corrective Action Plan(CAP) | Contractor | |
| 34 | Management | Implementation Plan, Release Plan and Project Plan. | Level A: Submit each required plan at implementation and quarterly thereafter in an approvable status and on time for each Key Function | |
| Level B: Plan requiring modifications prior to Approval will only require one round of edits | Quarterly | Corrective Action Plan(CAP) | Contractor | |
| Non Emergency Transportation (NETA) | ||||
| 35 | NETA | Process NETA Provider Requests. | ||
| 1. Process 100% of NETA provider requests for transportation within three (3) business days from the date it was submitted. | ||||
| 2. Produce monthly dashboard of NETA Provider requests. | Monthly | Corrective Action Plan(CAP) | Contractor | |
| Provider Directory | ||||
| 36 | Provider Directory Information Update: Response Time | Portal, Self Service options and associated Information System response time | . | |
| 1. | A provider's request to update the information that appears in the provider directory must be processed within five (5) business days from the receipt of the update request and appear in the provider directory. | |||
| 2. | A Fee-for-Service provider, as defined in the EOHHS directory policies and procedures, who is applying to MassHealth must appear in the provider directory within five (5) business days after the provider becomes active. | Monthly | Corrective Action Plan(CAP) | Contractor/MMIS |
&"Times New Roman,Regular"&14MassHealth Business Support Services RFR &"-,Bold"&F&"-,Regular" Attachment A- Model Contract
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File details come from the government source that posted it. Updated .