attachment-1-rfp-2027-dpqi-01-eqro-scope.pdf

New Hampshire Department of Health and Human Services External Quality Review Organization (EQRO)

Appendix A – Scope of Services

RFP-2027-DPQI-01-EQRO Contractor Initials __________

v. 1.0 Page 1 of 34 Date __________

The final Scope of Services is subject to modification based on the proposal submitted by the selected Vendor

Scope of Services

1.1. The Contractor must provide External Quality Reviews (EQRs) of healthcare services provided to NH Medicaid beneficiaries by Department contracted Medicaid managed care entities (MCEs) including three Medical Care Organizations (MCO) and one Dental Organization (DO), and any MCEs that may be added during the course of the resulting contract.

1.2. The Contractor must ensure services are available statewide.

1.3. For the purposes of this Agreement, all references to business hours mean Monday through Friday from 8:00 am to 5:00 pm, EST.

1.4. The Contractor must host a Secure FTP site for the Contractor, MCOs, DO, and DHHS to post/download documents, in accordance Exhibit E, DHHS Information Security Requirements and completed Appendix H, IT Requirements Workbook.

2. External Quality Review Organization (EQRO) for Managed Care Organization (MCO) Contracts

2.1. The Contractor must maintain all the qualifications of an External Quality Review Organization (EQRO) as outlined in 42 CFR 438.354 and complete EQRs in accordance with all applicable laws and regulations and current EQR Protocols.

2.2. Review of MCO Contractual Compliance:

2.2.1. The Contractor must conduct annual reviews for all sections of the Department’s most current contract with each MCO, pursuant to 42 CFR 438.358 (b)(1)(iii) and the current federal Centers for Medicare& Medicaid Services (CMS) EQR Protocol #3, to determine the MCO’s compliance with federal regulations and the state contract provisions relative to the quality, appropriateness, and the timeliness of, and access to care and services provided by the MCO to New Hampshire Medicaid enrollees.

2.2.2. The Contractor must create a methodology and the tools used to conduct the contract compliance audit, which must be submitted for written approval by the Department. The audit must include the following activities in accordance with the current CMS EQR Protocol #3. The Contractor must:

2.2.2.1. Establish compliance thresholds;

2.2.2.2. Perform preliminary review;

2.2.2.3. Conduct virtual MCO site visit(s);

v. 1.0 Page 2 of 34 Date __________

2.2.2.4. Compile and analyze findings; and

2.2.2.5. Report results to the Department.

2.2.3. If there is a new MCO added, the Contractor must include a comprehensive evaluation of all contract provisions to determine MCO compliance with state and federal standards for access to care, structure and operations, and quality measurement and improvement.

2.2.4. For the Department contracted MCOs, one third of the contract standards must be evaluated in each subsequent year so that all contract provisions are evaluated at least once every three (3) years.

In addition, for contract standards that are found to be out of compliance, the standards for the applicable MCO must be reviewed in the subsequent year.

2.2.5. If the Contractor determines that the MCO(s) are out of compliance with any contract standard(s), the Contractor must work with the Department to collaboratively manage a Corrective Action Plan process with the MCOs to resolve deficiencies in a timely manner.

2.2.6. The Contractor must produce a stand-alone MCO-specific report for the audit within thirty (30) calendar days of the completion of the activity and include results in the annual EQR Technical Report.

2.3. Validation of MCO Performance Measures

2.3.1. The Contractor must, pursuant to 42 CFR 438.358 (b)(1)(ii), validate, no less than annually, the MCO performance measures required by the Department. The Department will select up to twenty (20) performance measures annually, from Exhibit O, in the most recent contract between the Department and the MCOs to be included in the performance measure validation audit.

2.3.2. The Contractor must create a methodology and the tools used to conduct the MCO Performance Measure audit for written approval by the Department. The audit must include the activities below, in accordance with current CMS EQR Protocol #2:

2.3.2.1. Pre-site visit activities;

2.3.2.2. Virtual visit activities; and

2.3.2.3. Post-site activities.

2.3.3. The Contractor must use performance measures as defined by the Department, annually, as a component of the performance measure validation audit.

2.3.4. The performance measure validation audit will not include a review of

v. 1.0 Page 3 of 34 Date __________ measures that are calculated by using a medical record review.

2.3.5. The Contractor must not perform the Information Systems Capabilities Assessment (ISCA) if the MCO is able to provide verification that the ISCA was completed within the past twelve (12) months by a National Committee for Qualified Assurance Health Plans (NCQA) certified Healthcare Effectiveness and Data Information Set (HEDIS) auditor.

2.3.6. The Contractor must provide technical assistance, to the Department and MCOs, as needed. This includes the availability to answer questions about EQRO activities posed by MCEs and the Department, and data requests from the EQRO to MCEs which may be required to complete an activity.

2.3.7. The Contractor must produce an MCO-specific stand-alone report for each MCO for the audit within thirty (30) calendar days of the completion of the activity and include results in the annual EQR Technical Report.

2.4. Validation of Performance Improvement Projects (PIP)

2.4.1. The Contractor must validate, in accordance with 42 CFR 438.358 (b)(1)(i) each MCO’s PIPs required by the Department and ensure they are consistent with the most recent CMS Protocols for External Quality Review (EQR) activities.

2.4.2. The Contractor must create a rapid cycle PIP methodology and the tools used to conduct the evaluation of the performance improvement projects for written approval by the Department. The validation must include the activities below, in accordance with the current CMS EQR Protocol #1:

2.4.2.1. Assessing the study methodology;

2.4.2.2. Verify PIP study findings for projects involving non-audited performance measures; and

2.4.2.3. Evaluate overall validity and reliability of study results.

2.4.3. The Contractor must conduct two (2) rapid-cycle PIPs concurrently, each with a duration of eighteen (18) months. The Contractor must work with the Department to determine the concurrent PIP topics.

2.4.4. The Contractor must use PIP requirements, as defined in the most current contract between the Department and the MCOs.

2.4.5. The Contractor must produce an MCO-specific stand-alone PIP report for each MCO including a description of each of the MCO’s PIP activities, interventions, barriers, and the results of the PIP validation within thirty (30) calendar days of the completion of the activity.

v. 1.0 Page 4 of 34 Date __________

2.4.6. The results of the PIP validation must be included in the annual EQR Technical Report.

2.5. Conduct Validation of Provider Network Adequacy

2.5.1. The Contractor must conduct annual activities to validate each MCO’s provider network to assure compliance with 42 CFR 438.68, per 42 CFR 438.358(b)(1)(iv).

2.5.2. The Contractor must create a methodology and tools to validate compliance of each MCO’s provider network before written approval by the Department. The validation must include the activities below, in accordance with the current EQR Protocol #4:

2.5.2.1. Define the scope of the validation;

2.5.2.2. Identify data sources for validation;

2.5.2.3. Review Information Systems underlying network adequacy monitoring data, methods, and results;

2.5.2.4. Communicate preliminary findings to managed care plans;

and

2.5.2.5. Submit findings to state.

2.5.3. The Contractor must produce a stand-alone report within thirty (30) calendar days of the completion of the activities and include results in the annual EQR Technical Report.

2.6. Validation of Encounter Data Reported by the MCO

2.6.1. The Contractor must evaluate and validate encounter data reported by the MCOs to the Department in accordance with the New Hampshire Medicaid Care Management (MCM) contracts and 42 CFR 438.358 (c)(1).

2.6.2. The Contractor must evaluate and validate encounter data submitted to the State by the MCOs via New Hampshire’s Medicaid Management Information System (MMIS) in accordance with the Department’s standards for encounter data, including:

2.6.2.1. An operational definition of an “encounter” and the types of encounters (e.g. physician, hospital, laboratory, etc.);

2.6.2.2. Standards for encounter data accuracy and completeness;

and

2.6.2.3. Objective standards to which encounter data shall be compared.

2.6.3. The Contractor must create a methodology and the tools used to conduct the validation of encounter data, for written approval by the

v. 1.0 Page 5 of 34 Date __________

Department. The validation must include the activities below, in accordance with the current CMS EQR Protocol #5:

2.6.3.1. Annually review State requirements for collecting and submitting encounter data;

2.6.3.2. Annually review the MCO’s capacity to produce accurate and complete encounter data. The vendor must use the most recent Information System Capabilities Assessment (ISCA) completed by a NCAQ HEDIS compliance auditor;

2.6.3.3. Annually analyze MCO electronic encounter data for

accuracy and completeness;

2.6.3.4. Working with the Department to establish the initiation and frequency of the review of medical records to confirm the findings of the analysis of encounter data; and

2.6.3.5. Annually submit findings.

2.6.4. The Contractor must receive industry standard 837 encounter files directly from the MCOs to conduct validation activities.

2.6.5. The Contractor must:

2.6.5.1. Accept/reject reported encounters.

2.6.5.2. Detect data patterns, such as:

2.6.5.2.1. Under- or over-reporting of data over time.

2.6.5.2.2. Utilization patterns.

2.6.5.3. Prepare a certification letter for each MCO attesting to the level of completeness and accuracy of the Encounter Data submitted by the MCO to the Department.

2.6.5.4. Issue weekly, monthly, and quarterly reports containing MCO specific findings and aggregate MCO results concerning the validity of this encounter data.

2.6.5.5. Provide technical assistance to the Department and the MCOs to reach an agreed upon level of consistency and accuracy in the encounter data.

2.6.5.6. Provide technical assistance to the Department’s MMIS and to the MCOs as deficiencies are discovered through the encounter data validation process to improve data accuracy and completeness.

2.6.5.7. Consult with the Department to improve data validation for the Department’s MMIS.

v. 1.0 Page 6 of 34 Date __________

2.6.6. The Contractor must conduct additional validation annually by comparing all encounters submitted by the MCOs to the Department against encounters residing in the MCOs data system.

2.6.7. The Contractor must provide the results of this annual validation in a stand-alone aggregate report within thirty (30) calendar days of the completion of the activities.

2.6.8. The Contractor must include results in the annual EQR Technical Report.

2.7. Implementation of Secret Shopper Survey

2.7.1. The Contractor must, pursuant to 42 CFR 438.68 (f)(1-5), conduct an annual secret shopper survey with each contracted MCO to determine compliance with the electronic provider directory requirements in CMS 438.10(h) and appointment wait time requirements for the following provider types:

2.7.1.1. Primary Care providers;

2.7.1.2. Obstetric and gynecological providers;

2.7.1.3. Outpatient mental health and substance use disorder

providers; and

2.7.1.4. The provider type that provides the service type chosen by the State.

2.7.2. The Contractor must assess the appointment wait time standards.

2.7.3. The Contractor must create a methodology and tools to implement a Secret Shopper Survey for the Department’s written approval.

2.7.4. The Contractor must provide a report to the Department within thirty

(30) calendar days of the completion of the activities.

2.7.5. The Contractor must include results in the annual EQR Technical Report.

2.8. Implementation of other Surveys

2.8.1. The Contractor must administer three (3) member and/or provider surveys in compliance with 42 CFR 438.358(c)(2).

2.8.2. The Contractor must conduct:

2.8.2.1. Semi-annual (twice a year) qualitative member focus groups and/or surveys on topics related to the MCM program that are requested by the Department;

2.8.2.2. One (1) provider satisfaction survey in year three (3) of the contract then every three (3) years thereafter, utilizing a tool

v. 1.0 Page 7 of 34 Date __________ provided by the Department; and

2.8.2.3. One (1) revealed caller survey that includes each contracted MCO in year two (2) of the contract and every three (3) years thereafter.

2.8.2.3.1. The Contractor will determine compliance with the

electronic provider directory requirements in CMS 438.10(h) and appointment wait time requirements for the following provider types:

2.8.2.3.1.1. Physical Health Specialists that

provide the service types chosen by the State.

2.8.3. The Contractor must create a methodology and tools to administer surveys, which shall be approved by the Department. The surveys shall be administered in the following activities defined below:

2.8.3.1. Identify survey purpose(s), objective(s) and intended use;

2.8.3.2. Select the survey instrument;

2.8.3.3. Develop the sampling plan;

2.8.3.4. Develop a strategy for maximizing the response rate;

2.8.3.5. Develop a quality assurance plan;

2.8.3.6. Implement the survey;

2.8.3.7. Prepare and analyze the data obtained from the survey; and

2.8.3.8. Document the survey process and results.

2.8.4. The Contractor must work with the MCOs to communicate

documentation and data needs.

2.8.5. The Contractor must produce a stand-alone report for each activity within thirty (30) calendar days of the completion of each activity within the deliverables section of 6.1., and include results in the annual EQR Technical Report.

2.9. Conduct Focus Studies of Health Care Quality

2.9.1. The Contractor must conduct studies on quality, that focus on a particular aspect of clinical or non-clinical services at a point in time, per 42 CFR 438.358 (c)(5).

2.9.2. The Contractor must be responsible for conducting:

2.9.2.1. One (1) annual quality study; and

2.9.2.2. One (1) biennial roundtable quality meeting that must focus on a MCM quality topic.

v. 1.0 Page 8 of 34 Date __________

2.9.3. The Contractor must create a methodology and tools to administer quality studies which must be approved by the Department. The quality focus studies must include the following activities listed below (from the current CMS EQR Protocol #9):

2.9.3.1. Select the study topic(s);

2.9.3.2. Define the study question(s);

2.9.3.3. Select the study variable(s);

2.9.3.4. Study the whole population or use a representative sample;

2.9.3.5. Use sound sampling methods;

2.9.3.6. Reliably collect data;

2.9.3.7. Analyze data and interpret study results; and

2.9.3.8. Report results to the state.

2.9.4. The annual quality study must focus on an element of the MCM program which must be approved by the Department and may include but is not limited to care management, utilization management, behavioral health benefits, or pharmacy benefits.

2.9.4.1. The Contractor must produce a stand-alone report within thirty (30) calendar days of the completion of the activities and include results in the annual EQR Technical Report.

2.9.5. The Contractor must organize and host a biennial virtual roundtable quality meeting beginning in Year One (1) of the contract then every two (2) years thereafter for targeted stakeholders and staff to discuss a quality topic which shall be approved by the Department and is related to the MCM program.

2.9.5.1. The Contractor must produce a stand-alone report within thirty (30) calendar days of the completion of the activities.

2.10. Project Management and Support

2.10.1. The Contractor must develop and provide a written Implementation Plan which shall include:

2.10.1.1. Tasks, start dates, end dates, and responsible party (EQRO or DHHS). The plan shall define how they will orientate and provide sufficient technical assistance to DHHS and the MCOs to complete the following EQRO activities:

2.10.1.1.1. Review of MCO Contractual Compliance;

2.10.1.1.2. Validation of MCO Performance Measures;

v. 1.0 Page 9 of 34 Date __________

2.10.1.1.3. Validation of Performance Improvement

Projects (PIPs);

2.10.1.1.4. Validation of Network Adequacy;

2.10.1.1.5. Validation of Encounter Data Reported by the

MCO;

2.10.1.1.6. Secret Shopper Survey;

2.10.1.1.7. Semi-annual Focus Studies - Qualitative

Member Focus Survey;

2.10.1.1.8. Provider Satisfaction Survey;

2.10.1.1.9. Revealed Caller Survey;

2.10.1.1.10. Quality Study;

2.10.1.1.11. Roundtable Quality Meeting; and

2.10.1.1.12. EQR Technical Report.

2.11. The Contractor must host bi-weekly (every two (2) weeks) conference calls with the Department staff throughout the contract period and must provide bi-weekly (every two (2) weeks) written status reports to the Department.

2.12. The Contractor must respond, via email or by phone, to all inquiries from the Department within two (2) business days.

2.13. The Contractor must have appropriate staff to conduct all contracted EQR activities and shall assign the following key leadership roles: a contract manager who spends at least 0.50 FTE of time to manage the EQRO contract with NH DHHS, and a project lead for each review activity under the EQRO contract.

2.14. Submission of a proposal indicates acceptance of the conditions specified in this RFP to staff and subcontractor resources and competencies. The Department reserves the right to accept or reject any of the EQRO contractor’s employees or subcontractors assigned to this project and to require their replacement at any time.

2.15. The Contractor must collaborate with the Department by aiding in the proactive identification of contract issues to develop real time solutions, adopt improvements, and implement risk mitigation strategies.

3. Scope of Services – EQRO for Dental Organization (DO) Contract

3.1. The Contractor must maintain all the qualifications of an External Quality Review Organization (EQRO) outlined in 42 CFR 438.354 and complete EQRs in accordance with all applicable laws and regulations, and current EQR Protocols.

v. 1.0 Page 10 of 34 Date __________

3.2. Review of Dental Organization (DO) Contractual Compliance:

3.2.1. The Contractor must conduct annual reviews for all contract sections of the Department’s most current contract with the Dental Organization (herein referred to as “DO”), pursuant to 42 CFR

438.358 (b)(1)(iii) and current federal CMS Protocol #3 for EQR, to determine the DO’s compliance with federal regulations and the state contract provisions relative to the quality, appropriateness, and timeliness of, and access to care and services provided by the DO to all New Hampshire Medicaid enrollees.

3.2.2. The Contractor must create a methodology and the tools used to conduct the contract compliance audit, which must be submitted for written approval by the Department. The audit must include the following activities in accordance with the current CMS EQR Protocol #3:

3.2.2.1. Establish compliance thresholds;

3.2.2.2. Perform preliminary review;

3.2.2.3. Conduct virtual DO site visit;

3.2.2.4. Compile and analyze findings; and

3.2.2.5. Report results to the Department.

3.2.3. If there is a new DO added, the Contractor must include a comprehensive evaluation of all contract provisions to determine DO compliance with state and federal standards for access to care, structure and operations, and quality measurement and improvement.

3.2.4. For Department contracted DO, one third of the contract standards must be evaluated annually so that all contract provisions are evaluated at least once every three (3) years. In addition, for contract standards that are found to be out of compliance, the standards for the DO must be reviewed in the subsequent year.

3.2.5. If the Contractor determines that the DO is out of compliance, the Contractor must work with the Department to collaboratively manage a Corrective Action plan process with the DO to resolve deficiencies in a timely manner.

3.2.6. The Contractor must produce a stand-alone DO-specific report for the audit within thirty (30) calendar days of the completion of the activity and include results in the annual DO EQR Technical Report.

3.3. Validation of DO Performance Measures

3.3.1. The Contractor must, pursuant to 42 CFR 438.358(b)(1)(ii), validate,

v. 1.0 Page 11 of 34 Date __________ no less than annually, the DO performance measures required by the Department. The Department will select up to twenty (20) performance measures annually, from Exhibit O in the most recent contract between the Department and the DO to be included in the performance measure validation audit.

3.3.2. The Contractor must create a methodology and the tools to conduct the DO Performance Measure audit for written approval by the Department. The audit must include the activities below, in accordance with the current CMS EQR Protocol #2:

3.3.2.1. Pre-onsite visit activities;

3.3.2.2. Virtual visit activities; and

3.3.2.3. Post-site activities.

3.3.3. The Contractor must use performance measures as defined by the Department, annually, as a component of the performance measure validation audit.

3.3.4. The performance measure validation audit will not include a review of measures that are calculated by using a medical record review.

3.3.5. The Contractor must not perform the Information Systems Capabilities Assessment (ISCA) if the DO is able to provide verification that the ISCA was completed within the past twelve (12) months by a Utilization Review Accreditation Commission (URAC) certified Dental Quality Alliance (DQA) and/or Healthcare Effectiveness and Data Information Set (HEDIS) auditor.

3.3.6. The Contractor must provide technical assistance to the Department and the DOs as needed.

3.3.7. The Contractor must produce a DO-specific stand-alone report for the audit within thirty (30) calendar days of the completion of the activity and include results in the annual EQR DO Technical Report.

3.4. Validation of DO Performance Improvement Projects (PIP)

3.4.1. The Contractor must validate, in accordance with 42 CFR 438.358 (b)(1)(i) one (1) DO PIP required by the Department and ensure it is consistent with the most recent CMS Protocols for EQR activities.

3.4.2. The Contractor must create a rapid cycle PIP methodology and tools to conduct the evaluation of the performance improvement projects for written approval by the Department. The validation must include the activities below, in accordance with the current EQR Protocol #1:

3.4.2.1. Assess the study methodology.

3.4.2.2. Verify PIP study findings for the project involving a non-

v. 1.0 Page 12 of 34 Date __________ audited performance measure.

3.4.2.3. Evaluation of overall validity and reliability of study results.

3.4.3. The duration of the rapid-cycle PIP will be eighteen (18) months.

3.4.4. The Contractor must use PIP requirements, as defined in the most current contract between the Department and the DO.

3.4.5. The Contractor must produce a DO-specific stand-alone PIP report including a description of the DO PIP, activities, interventions, barriers, and the results of the PIP validation within thirty (30) calendar days of the completion of the activity.

3.4.6. The results of the PIP validation shall be included in the annual DO EQR Technical Report.

3.5. Conduct Validation of DO Provider Network Adequacy

3.5.1. The Contractor must conduct annual activities to validate each DO provider network to assure compliance with 42 CFR 438.68, per 42 CFR 438.358(b)(1)(iv).

3.5.2. The Contractor must create a methodology and tools to validate compliance of the DO’s provider network for written approval by the Department. The validation must include the activities below in accordance with the current EQR Protocol #4:

3.5.2.1. Define the scope of the validation;

3.5.2.2. Identify data sources for validation;

3.5.2.3. Review Information Systems underlying network adequacy monitoring data, methods, and results;

3.5.2.4. Communicate preliminary findings to managed care plans;

and

3.5.2.5. Submit findings to the Department. the State.

3.5.3. The Contractor must produce a stand-alone report within thirty (30) calendar days of the completion of the activities and include results in the annual EQR DO Technical Report.

3.6. Validation of Encounter Data Reported by the DO

3.6.1. The Contractor must evaluate and validate encounter data reported by the DO in accordance with the New Hampshire DO contract and 42 CFR 438.358(c)(1).

3.6.2. The Contractor must evaluate and validate encounter data submitted by the DO via New Hampshire’s Medicaid Management Information System (MMIS) in accordance with the Department’s standards for

v. 1.0 Page 13 of 34 Date __________ encounter data, including:

3.6.2.1. An operational definition of an “encounter” and the types of encounters, including but not limited to dentist and laboratory.

3.6.2.2. Standards for encounter data accuracy and completeness.

3.6.2.3. Objective standards to which encounter data shall be compared.

3.6.3. The Contractor must create a methodology and the tools used to conduct the validation of encounter data, for written approval by the Department. The validation must include the activities below in accordance with the current CMS EQR Protocol #5:

3.6.3.1. Annually review State requirements for collecting and submitting encounter data;

3.6.3.2. Annually review the DO’s capacity to produce accurate and complete encounter data. The vendor shall use the most recent Information System Capabilities Assessment (ISCA) completed by an NCQA HEDIS compliance auditor to conduct this validation;

3.6.3.3. Annually analyze the DO electronic encounter data for accuracy and completeness;

3.6.3.4. Working with the Department to establish the initiation and frequency of the review of medical records to confirm the findings of the analysis of encounter data; and

3.6.3.5. Annually submit findings to the Department.

3.6.4. The Contractor must receive industry standard 837 encounter data files directly from the DO to conduct validation activities.

3.6.5. The Contractor must:

3.6.5.1. Accept/reject reported encounters.

3.6.5.2. Detect data patterns, such as:

3.6.5.2.1. Under- or over-reporting of data over time.

3.6.5.2.2. Utilization patterns.

3.6.5.3. Prepare a certification letter for the DO attesting the level of completeness and accuracy of the Encounter Data submitted by the DO to the Department.

3.6.5.4. Issue weekly, monthly, and quarterly reports containing DO specific findings and aggregate DO results concerning the

v. 1.0 Page 14 of 34 Date __________ validity of this encounter data.

3.6.5.5. Provide technical assistance to the Department and the DO to reach an agreed upon level of consistency and accuracy in the encounter data.

3.6.5.6. Provide technical assistance to the Department’s MMIS and to the DO as deficiencies are discovered throughout the encounter data validation process to improve data accuracy and completeness.

3.6.5.7. Consult with The Department to improve data validation for The Department’s MMIS.

3.6.6. The Contractor must conduct an additional validation annually by comparing all encounters submitted by the DO to the Department against encounters residing in the DOs data system.

3.6.7. The Contractor must provide the results of this annual validation in a stand-alone aggregate report within thirty (30) calendar days of the completion of the activities.

3.6.8. The Contractor must include results in the annual DO EQR Technical Report.

3.7. Implementation of DO Secret Shopper surveys

3.7.1. The Contractor must, pursuant to 42 CFR 438.68 (f)(1-5) conduct an annual secret shopper survey with the contracted DO to determine compliance with the electronic provider directory requirements in CMS 438.10(h).

3.7.2. The Contractor must assess the appointment wait time standards.

3.7.3. The Contractor must create a methodology and tools to implement a secret shopper survey for the Department’s written approval.

3.7.4. The Contractor must provide a report within thirty (30) calendar days of the completion of the activities using the CMS content form, and submission times in compliance with 48 CMS 438.207(d).

3.7.5. The Contractor must include results in the annual DO EQR Technical Report.

3.8. Implementation of other DO Surveys

3.8.1. The Contractor must administer two (2) provider surveys in compliance with 42 CFR 438.358(c)(2).

3.8.2. The Contractor must conduct:

3.8.2.1. One (1) qualitative member focus groups and/or surveys in the first year then every three (3) years thereafter, on topics

v. 1.0 Page 15 of 34 Date __________ related to the DO program that are requested by the Department; and

3.8.2.2. One (1) dental provider satisfaction survey in the third year then every three (3) years thereafter, utilizing a tool provided by the Department.

3.8.3. The Contractor must create a methodology and tools to administer surveys, for written approval by the Department, The Contractor must:

3.8.3.1. Identify survey purpose(s), objective(s) and intended use;

3.8.3.2. Select the survey instrument;

3.8.3.3. Develop the sampling plan;

3.8.3.4. Develop a strategy for maximizing the response rate;

3.8.3.5. Develop a quality assurance plan;

3.8.3.6. Implement the survey;

3.8.3.7. Prepare and analyze the data obtained from the survey; and

3.8.3.8. Document the survey process and results.

3.8.4. The Contractor must work with the DO to communicate

documentation and data needs.

3.8.5. The Contractor must produce a stand-alone report within thirty (30) calendar days of the completion of each activity within deliverables Section 6.2. and include results in the annual DO EQR Technical Report.

3.9. Conduct Focus Studies of Dental Care Quality

3.9.1. The Contractor must conduct studies on quality that focus on a particular aspect of clinical or non-clinical services at a point in time, per 42 CFR 438.358 (c)(5).

3.9.2. The Contractor must, in Year Two (2) of the DO Agreement, and every three (3) years thereafter, conduct a study on quality that focus on a particular aspect of clinical or non-clinical services at a point in time, per 42 CFR 438.358 (c)(5).

3.9.3. The Contractor must create a methodology and tools to administer quality studies for written approval by the Department. The quality focus study must include the following activities in accordance with current CMS EQR Protocol #9:

3.9.3.1. Select the study topic(s);

3.9.3.2. Define the study question(s);

3.9.3.3. Select the study variable(s);

v. 1.0 Page 16 of 34 Date __________

3.9.3.4. Study the whole population or use a representative sample;

3.9.3.5. Use sound sampling methods;

3.9.3.6. Reliably collect data;

3.9.3.7. Analyze data and interpret study results; and

3.9.3.8. Report results to the state.

3.9.4. The Contractor must ensure the quality study will focus on an element of the adult dental program which must be approved by the Department and may include but is not limited to utilization management and dental benefits.

3.9.5. The Contractor must produce a stand-alone report within thirty (30) calendar days of the completion of the activities and include results in the annual DO EQR Technical Report.

3.10. Dental Project Management and Support

3.10.1. The Contractor must develop and provide a written Implementation Plan which must include:

3.10.1.1. Tasks, start dates, end dates, and responsible party (EQRO or DHHS). The plans shall define how they will orientate and provide sufficient technical assistance to the Department and the DO in order to complete the following EQRO activities:

3.10.1.1.1. Review of DO Contractual Compliance;

3.10.1.1.2. Validation of DO Performance Measures;

3.10.1.1.3. Validation of Performance Improvement

Project (PIP);

3.10.1.1.4. Validation of Network Adequacy;

3.10.1.1.5. Validation of Encounter Data Reported by the

DO;

3.10.1.1.6. DO Secret Shopper;

3.10.1.1.7. DO Focus Studies;

3.10.1.1.8. DO Provider Satisfaction Survey;

3.10.1.1.9. DO Quality Studies; and

3.10.1.1.10. DO Technical Report.

3.11. The Contractor must host bi-weekly (every two (2) weeks) conference calls with the Department staff throughout the contract period.

3.12. The Contractor must provide bi-weekly (every two (2) weeks) written status

v. 1.0 Page 17 of 34 Date __________ reports to the Department.

3.13. The Contractor must respond, via email or by phone, to all inquiries from the Department within two (2) business days.

3.14. The Contractor must have appropriate staff to conduct all contracted EQR activities and must assign the following key leadership roles: a contract manager who spends at least .20 FTE of time to manage the EQRO contract with the Department, and a project lead for each review activity under the EQRO contract.

3.15. Submission of a proposal indicates acceptance of the conditions specified in this RFP to staff and subcontractor resources and competencies. The Department reserves the right to accept or reject any of the EQRO contractor’s employees or subcontractors assigned to this project and to require their replacement at any time.

4. Reporting - EQRO for MCO Contracts

4.1. Produce a detailed Technical Report

4.1.1. The Contractor must produce an annual detailed Technical Report pursuant to 42 CFR 438.364 (a). The report must include results for each MCO participating in New Hampshire Medicaid’s Care Management program with results for each of the following EQR activities:

4.1.1.1. Contract compliance audit;

4.1.1.2. Performance measure validation audit;

4.1.1.3. Performance improvement project validation;

4.1.1.4. Network Adequacy validation;

4.1.1.5. Encounter data validation;

4.1.1.6. Secret Shopper survey;

4.1.1.7. Additional quality studies; and

4.1.1.8. Additional EQR activities.

4.1.2. Pursuant to 42 CFR 438.350 (a), the Technical Report must include:

4.1.2.1. A description of how data was aggregated and analyzed;

4.1.2.2. Conclusions drawn regarding the quality, timeliness, and access to care furnished by the MCOs;

4.1.2.3. For each activity as outlined in Section 5.1. Technical Report:

4.1.2.3.1. Objectives;

v. 1.0 Page 18 of 34 Date __________

4.1.2.3.2. Summary of methods of data collection and

analysis;

4.1.2.3.3. Summary of data obtained for each activity; and

4.1.2.3.4. Conclusions drawn from the data to include but

not be limited to strengths and opportunities for improvement.

4.1.2.4. Overall assessment of each MCO’s strengths and

weakness for quality, timeliness, and access to health care services furnished to Medicaid beneficiaries;

4.1.2.5. Overall assessment of the compliance of the State of New Hampshire’s Medicaid Care Management Quality Strategy with 42 CFS 438.340;

4.1.2.6. Recommendations for improving the quality of health care services by each MCO, including how New Hampshire can target goals and objectives in the quality strategy;

4.1.2.7. Methodologically appropriate, comparative information about all MCOs for selected HEDIS and CAHPS measurements; and

4.1.2.8. Assessment of the degree to which each MCO has

addressed effectively the recommendations for quality improvement made by the EQRO during previous years.

The assessment of the MCOs efforts shall be conducted by the Contractor reviewing the MCOs annual Quality Assessment and Performance Improvement reports.

4.1.3. The report must include additional reports and activities the EQRO conducted during the reporting year (e.g. surveys, focus studies, etc.).

4.1.4. The initial draft of the Technical Report must be submitted annually to the Department no later than December 1st and the final report no later than April 1st.

5. Reporting – EQRO for DO Contract

5.1. Produce a detailed DO Technical Report

5.1.1. The Contractor must produce an annual detailed Technical Report pursuant to 42 CFR 438.364 (a). The report must include results for the DO with results for each of the following EQR activities:

5.1.1.1. Contract compliance audit;

5.1.1.2. Performance measure validation audit;

v. 1.0 Page 19 of 34 Date __________

5.1.1.3. Performance improvement project validation;

5.1.1.4. Network adequacy validation;

5.1.1.5. Encounter data validation;

5.1.1.6. Secret Shopper survey;

5.1.1.7. Additional quality studies; and

5.1.1.8. Additional EQRO activities.

5.1.2. Pursuant to 42 CFR 438.350 (a), the Technical Report must include:

5.1.2.1. A description of how data was aggregated and analyzed;

5.1.2.2. Conclusions drawn regarding the quality, timeliness, and access to care furnished by the DO;

5.1.2.3. For each activity as outlined in Section 6.1. Technical Report:

5.1.2.3.1. Objectives;

5.1.2.3.2. Summary of methods of data collection and

analysis;

5.1.2.3.3. Summary of data obtained for each activity; and

5.1.2.3.4. Conclusions drawn from the data to include but

not be limited to strengths and opportunities for improvement.

5.1.2.4. Overall assessment of the DO’s strengths and weaknesses for quality, timeliness, and access to dental services furnished to Medicaid beneficiaries;

5.1.2.5. Overall assessment of the compliance of the State of New Hampshire’s Medicaid Care Management Quality Strategy with 42 CFR 438.340;

5.1.2.6. Recommendations for improving the quality of dental

services by the DO, including how the Department can target goals and objectives in the quality strategy;

5.1.2.7. Methodologically appropriate, comparative information about the DO for selected HEDIS and Consumer Assessment of Healthcare Providers and Systems (CAHPS) measurements; and

5.1.2.8. Assessment of the degree to which the DO has addressed effectively the recommendations for quality improvement made by the EQRO during previous years. The assessment

v. 1.0 Page 20 of 34 Date __________ of the DO’s efforts shall be conducted by the Contractor reviewing the DO’s annual Quality Assessment and Performance Improvement reports.

5.1.3. The Contractor must ensure the reports include activities the EQRO conducted during the reporting year to include but not limited to surveys and focus studies.

5.1.4. The initial draft of the Technical Report must be submitted annually to the Department no later than December 1st and the final report no later than April 1st.

6. Deliverables

6.1. Summary of MCO Deliverables:

Reference General Topic Area

Periodicity Deliverable Due Date

1 Review of MCO Contract Compliance

Annual Written report within thirty (30) days after the completion of the activity.

2 Validation of

MCO

Performance Measures

Annual Written report within thirty (30) days after the completion of the activity.

3 Validation of MCO PIPs

TBD but no less than annually

Written report within thirty (30) days after the completion of the activity.

4 Validation of Provider Network Adequacy

Annual Written report within thirty (30) days after the completion of the activity.

5 Validation of Encounter Data Reported by the MCO

Weekly, monthly, quarterly, annually

Annual written Aggregate Report and annual certification letter TBD.

6 Implementation of Surveys-

Annual Written report within thirty (30) days after the

v. 1.0 Page 21 of 34 Date __________

Secret Shopper Survey completion of the activity.

7 Implementation of MCM Surveys- Semi- Structured Qualitative member focus group &/or survey

Semi-annual Written report within thirty (30) days after the completion of the activity.

8 Implementation of Surveys- Provider Satisfaction Survey

Every three (3) years; starting in Year three

(3) of the contract

Written report within thirty (30) days after the completion of the activity.

9 Implementation of Surveys- Revealed Caller Survey

Every three (3) years; starting in Year two (2) of the contract

Written report within thirty (30) days after the completion of the activity.

10 Focus Studies of Health Care Quality- Quality Study

Annual Written report within thirty (30) days after the completion of the activity.

11 Focus Studies of Health Care Quality- Roundtable Quality Meeting

Biennial;

starting in Year One (1) of the contract

Virtual roundtable meeting to the Department Stakeholders and staff.

Written conference agenda and materials at least five (5) business days prior to conference. Completed individual evaluations and evaluation summary within five (5) business days of conference. Summary report within thirty (30)

v. 1.0 Page 22 of 34 Date __________ days after the completion of the activity.

12 Produce a detailed Technical Report

Annual Written report- draft report no later than December 1st, beginning on 12/1/2027. Final report no later than April 1st, beginning 4/1/2028.

13 Implementation Plan for each of the above-mentioned activities

Annual Written plan, no later than August 1st beginning 8/1/2026.

14 Host bi-weekly conference calls

Every two (2) weeks

Written agenda and written status reports, including the name of the EQRO project lead for each activity.

6.2. Summary of DO Deliverables:

Reference General Topic Area Periodicity Deliverable Due Date

1 Review of DO Contract Compliance

Annual Written report within thirty (30) days after the completion of the activity.

2 Validation of DO Performance Measures

Annual Written report within thirty (30) days after the completion of the activity.

3 Validation of DO

PIP

TBD but no less than annually

Written report within thirty (30) days after the completion of the activity.

v. 1.0 Page 23 of 34 Date __________

4 Validation of DO Provider Network Adequacy

Annual Written report within thirty (30) days after the completion of the activity.

5 Validation of Encounter Data Reported by the DO

Weekly, monthly, quarterly, annually

Annual written Aggregate Report and annual Certification Letter TBD.

6 Implementation of DO Surveys- Dental Secret Shopper Survey

Annual Written report within thirty (30) days after the completion of the activity.

7 Implementation of DO Surveys- Qualitative member focus group &/or survey

Every three (3) years; starting in Year one (1) of the contract thirty (30) days after the completion of the activity.

8 Implementation of DO Surveys- Dental Provider Satisfaction Survey

Every three (3) years; starting in Year three

(3) of the contract the completion of the activity.

9 Focus Studies of Dental Care Quality- Quality Study

Every three (3) years; starting in Year two (2) of the contract the completion of the activity.

10 Produce a detailed DO Technical Report

Annual Written report- draft report no later than December 1st, beginning on 12/1/2027. Final report no later than April 1st, beginning

v. 1.0 Page 24 of 34 Date __________

4/1/2028.

11 DO Implementation Plan for each of the above-mentioned activities

Annual Written plan, no later than August 1st, beginning 8/1/2026.

12 Host bi-weekly DO conference calls

Every two (2) weeks

Written agenda and written status reports, including the name of the EQRO project lead for each activity.

6.3. The Contractor may be required to provide other key data and metrics to the

Department in a format specified by the Department.

6.4. Background Checks

6.4.1. Prior to permitting any individual to provide services under this Agreement, the Contractor must ensure that said individual has undergone:

6.4.1.1. A criminal background check, at the Contractor’s expense, and has no convictions for crimes that represent evidence of behavior that could endanger individuals served under this Agreement;

6.4.1.2. A name search of the Department’s Bureau of Adult and Aging Services (BAAS) State Registry, pursuant to RSA 161-F:49, with results indicating no evidence of behavior that could endanger individuals served under this Agreement; and

6.5. Confidential Data

6.5.1. The Contractor must meet all information security and privacy requirements as set by the Department and in accordance with the Department’s Information Security Requirements Exhibit as referenced below.

6.5.2. The Contractor must ensure any individuals involved in delivering services through this Agreement contract sign an attestation agreeing to access, view, store, and discuss Confidential Data in accordance with federal and state laws and regulations and the Department’s Information Security Requirements Exhibit. The Contractor must ensure said individuals have a justifiable business need to access confidential data. The Contractor must provide attestations upon

v. 1.0 Page 25 of 34 Date __________

Department request.

6.5.3. Transferring, Receiving, Protecting, and Storing Data

6.5.3.1. The Contractor must preserve the confidentiality, integrity, and accessibility of the State of New Hampshire data with administrative, technical, and physical information security controls and measures. Such controls and measures shall conform to all applicable federal, state, and industry standards, which the Contractor applies to its own information processing environment. In addition, the vendor must ensure that the same controls and measures are applied by any subcontractor’s information processing environment utilized to process or store State of New Hampshire protected data. The Contractor must:

6.5.3.1.1. Ensure all resources assigned to perform

contract services, including subcontractors, follow federal and state laws, rules and regulations and shall not use Medicaid data for any purposes outside of the scope of this contract without the express written consent of the Department.

6.5.3.1.2. Ensure all reports and performance measures

will be reported in the aggregate and will not include member identifiable information.

6.5.3.1.3. Abide by the Department’s confidentiality

requirements and security protocols.

6.5.3.1.4. Abide by all federal and state laws, rules and

regulations including Federal law 42 CFR Part 2 which prohibits unauthorized disclosure of these records.

6.5.3.2. Provide the Department with its summary and analytic data files used to conduct the evaluation upon request. These files must be provided with an accompanying data dictionary, organized, and clearly labeled.

6.5.3.2.1. Organized;

6.5.3.2.2. Clearly labeled; and

6.5.3.2.3. Accompanied by a data dictionary.

v. 1.0 Page 26 of 34 Date __________

6.5.3.3. Work with the Department to ensure that appropriate data use agreements are in place to obtain needed data.

6.5.3.4. Understand Medicaid data and processing protocols and ensure that all resources assigned to perform contract services follow federal regulations.

6.5.3.5. Comply with appropriate security protocols to include procedures defined in HIPAA and the Health Information Technology for Economic and Clinical Health (HITECH) Act.

All transactions designed for the storage and retrieval of the information shall meet these requirements.

6.5.3.6. Ensure any and all electronic transmission or exchange of any State of New Hampshire data shall be secured using Secure File Transfer Protocols using no less than 128bit encryption and appropriate transfer mechanisms.

6.5.3.7. Ensure all current employees are aware of their

responsibilities to protect protected health information (PHI) and other confidential information. Prior to gaining access to confidential information and each year thereafter, all of the Contractor’s employees and subcontractors who have access to confidential information shall be required to sign a confidentiality/nondisclosure agreement as part of the Contractor’s assignment to provide contracted services.

6.5.3.8. Ensure the secure storage of the Department-provided data, ensuring any storage media is encrypted, locked and retain control of access of any storage areas and or facilities.

6.5.3.9. Ensure all facilities and offices have appropriate layers of physical access controls and monitoring ensuring access is restricted to authorized personnel only.

6.5.3.10. Ensure daily operations include policies that require all confidential information be secured at the end of the duty day to prevent inadvertent disclosure to unauthorized personnel.

6.5.3.11. Ensure confidential information in paper form is stored in a separate, secure room or in locked file cabinets, accessible to authorized personnel only. Any data authorized for destruction shall be destroyed according to Federal, State, and industry standards and certified and documented in writing by the data destruction agent.

6.5.3.12. Ensure all data, and any copies thereof, are returned to the Department upon Department request or no later than the

v. 1.0 Page 27 of 34 Date __________ contract expiration date, whichever occurs first, unless otherwise instructed by the Department to destroy copied data.

6.5.4. Ensure continuous control of security access to confidential or protected information by immediately adjusting or removing any individual whose employment status or position has changed. Ensure continuous control of security access to confidential or protected information and to ensure that individual accesses are immediately removed or adjusted for any individual whose employment status or positions have changed.

6.5.5. The Contractor must comply with all requirements included in Appendix H – IT Requirements Workbook.

6.6. Privacy Impact Assessment

6.6.1. Upon request, the Contractor must allow and assist the Department in conducting a Privacy Impact Assessment (PIA) of its system(s)/application(s)/web portal(s)/website(s) or Department system(s)/application(s)/web portal(s)/website(s) hosted by the Contractor, if Personally Identifiable Information (PII) is collected, used, accessed, shared, or stored. To conduct the PIA the Contractor must provide the Department access to applicable systems and documentation sufficient to allow the Department to assess, at minimum, the following:

6.6.1.1. How PII is gathered and stored;

6.6.1.2. Who will have access to PII;

6.6.1.3. How PII will be used in the system;

6.6.1.4. How individual consent will be achieved and revoked; and

6.6.1.5. Privacy practices.

6.6.2. The Department may conduct follow-up PIAs in the event there are either significant process changes or new technologies impacting the collection, processing or storage of PII.

6.7. Department Owned Devices, Systems and Network Usage

6.7.1. Contractor End…