Attachment 4 CCN Next Gen West QASP by CA.docx

QUALITY ASSURANCE SURVEILLANCE

PLAN (QASP)

VA Community Care Network Next Generation Medical West

DATE: 05/01/2025

PRE-DECISIONAL DRAFT

Contract Information and Approval

Contract Number Contractor

Senior Contracting Officer: Date

Program Manager Date

Table of Contents

This Quality Assurance Surveillance Plan (QASP) is developed pursuant to the requirements listed in the Performance Work Statement (PWS), entitled Community Care Network (CCN) Medical. This plan sets forth the procedures and guidelines Department of Veterans Affairs – Veteran Health Administration (VHA), Office of Integrated Veteran Care (IVC) will use in ensuring the required performance standards or services levels are achieved by the Contractor.

Purpose The purpose of this plan is to identify the methods and procedures the government will use to ensure it receives the services/products under this contract as identified in the Performance Work Statement (PWS). This plan shall provide the Contracting Officer’s Representative (COR) with a proactive way to avoid unacceptable or deficient performance and provide verifiable input for the required performance report via the Contractor Performance Assessment Reporting System (CPARS).

Intent The intent is to use this QASP as a tool to hold the contractor accountable for quality control and to encourage the contractor to take appropriate steps to control and improve quality. The contractor is responsible for developing an efficient methodology to ensure they meet and/or exceed the required thresholds of service as outlined in this acquisition. The government intends to perform surveillance on this contract in accordance with this Quality Assurance Surveillance Plan (QASP) but reserves the right to monitor the contract in any manner necessary, at any times necessary, and at all necessary places to ensure that the rendered services conform to contract requirements. The government reserves the right to perform quality assurance at the subcontract level and perform quality assurance at the contractor's place of business, if applicable. Non-conforming services discovered with subcontractors or providers will be addressed with the prime contractor for resolution.

Scope This QASP has been developed to evaluate contractor performance while implementing the Performance Work Statement (PWS). It is designed to provide an effective surveillance method of monitoring contractor performance for each listed objective on the Performance Requirement Summary (PRS) (Attachment 1). The contract is for the delivery of healthcare services to include but is not limited to medical, surgical, mental health, urgent and emergent pharmacy, durable medical devices, and skilled home health services. The delivery of healthcare services also includes provider network management, claims payment, and case management.

Government Performance Surveillance Approach The PWS structures the acquisition around “what” service or quality level is required, as opposed to “how” the Contractor should perform the work, focusing on outcomes and results not process. This QASP defines the performance surveillance approach taken by IVC and the Contract Performance Management (CPM) CORs to monitor the Contractor’s performance against the expected outcomes or performance objectives identified. Consistent and effective performance surveillance allows for the ability to properly manage contract performance. This is largely dependent on implementing a mature capability for reviewing and analyzing the information generated through performance assessment. The ability to, both proactively and reactively, make decisions based on the analysis of performance data is the cornerstone of successful contract performance management.

Performance management focuses on assessing whether outcomes are being achieved and to what extent. This approach migrates away from scrutiny of compliance with the processes and practices used to achieve the outcome. A performance-based approach enables the Contractor to take responsibility for how the work is performed, as long as the processes are within the stated constraints. The only exceptions to process reviews are those required by law (federal, state, and local) and compelling business situations, such as safety and health. A “results” focus provides the Contractor flexibility to continuously improve and innovate over the course of the contract as long as the critical outcomes expected are being achieved and/or the desired performance levels are being met.

Contractor Quality Assurance The Contractor is responsible for the quality of all services provided. The Contractor measures that quality through the Contractor’s own Quality Assurance (QA) program. The Contract is required by the PWS to implement a QA program and develop and implement a Quality Assurance Plan (QAP). The QAP will set forth the staffing and procedures for self-inspecting the quality, timeliness, responsiveness, customer satisfaction, and other performance requirements in the PWS. The Contractor’s QAP will be incorporated into the awarded contract for added accountability. The government representative(s) will monitor performance and review performance reports furnished by the Contractor to determine how the Contractor is performing against communicated performance objectives. However, the Contractor will be responsible for making required changes in staffing, processes, and practices to ensure performance is managed effectively.

The Contractor must comply with the PWS requirements and meet or exceed the performance standards identified in the PRS. The PRS includes key performance objects and their associated minimum performance standards. The Contractor’s performance will be assessed by the Government against the requirements of the PWS and the PRS. Minimum acceptable quality level (AQL) compliance will be calculated using the methodology defined in this QASP. Penalties will be applied when the performance measures are not met, as stated in the PRS. The process and anticipated calculations for determining Contractor’s performance is set forth in sections of this plan.

ROLES AND RESPONSIBILITIES

Organization: Department of Veterans Affairs, VHA IVC Contracting Officer The CO is responsible for monitoring contract compliance, contract administration, and for resolving any differences between the observations documented by the VHA IVC, COR, and Contractor. The CO shall ensure performance of all necessary actions for effective contracting, ensure compliance with the contract terms, and shall safeguard the interests of the United States in the contractual relationship. The CO shall also ensure that the contractor receives impartial, fair, and equitable treatment under this contract. The CO will designate one full-time Regional COR as the primary government authority for performance management and additional CORs to assist the contract performance management. The number of additional representatives serving as technical inspectors depends on the complexity of the services measured, as well as the contractor’s performance, and must be identified and designated by the CO. The CO is ultimately responsible for the final determination of the adequacy of the contractor’s performance.

Contract Specialist The CS is responsible to act as an acquisition consultant in support of the Contracting Officer and serve as a liaison between the contracting office, IVC, and the CPM CORs.

Program Manager IVC will assign a Program Manager with the responsibility, and relevant discretional authority to make decisions on behalf of the program which will be relayed through the CORs for action on the contract. The PM will be responsible for managing all business and technical risk of the program to ensure effective systems and services are delivered to the stakeholders on schedule, within budget and at the required levels of performance.

Contracting Officer’s Representative The COR is designated in writing by the CO to act as his or her authorized representative to assist in administering this contract. COR limitations are contained in the written appointment letter. The contractor will receive a copy of all COR appointment letters. The COR is responsible for technical administration of the project and ensures proper government surveillance of the contractor’s performance. The COR is not empowered to make any contractual commitments or to authorize any contractual changes on the government’s behalf. Any changes that the contractor may affect the contract price, terms, or conditions shall be referred to the CO for action. The COR will have the responsibility for maintaining the quality assurance file and completing QA monitoring forms used to document the inspection and evaluation of the contractor’s work performance. Government surveillance may occur under the inspection of services clause for any service relating to the contract. Additional advisors will be included, as needed.

Performance Monitors / Subject Matter Experts The COR will work with subject matter experts (SMEs) whom will be designated as Performance Monitors to assist in monitoring performance. The Performance Monitors will provide technical feedback on specific areas of performance. Performance Monitors have no authority to make changes or decisions, but will provide feedback and technical advice to the COR.

Performance Evaluation The required performance standards and/or quality levels are included in the PWS and the PRS. If the Contractor meets the required service or performance level, it will be paid the monthly amount agreed in the contract. Failure to meet the required service or performance level will result in a deduction from the monthly amount and will be documented in CPARS, and / or other penalties allowable under the FAR, as appropriate.

Evaluation Assessment Periods The government has identified key performance objectives which will be monitored for minimum compliance based upon the surveillance methods below.

The following are parameters for evaluation of contract performance:

· The Contractor’s performance against stated AQLs will be calculated monthly, quarterly, semi-annually, and/or annually as specified in the PRS.

· Continuous evaluation of performance will serve to advise the Contractor of trends indicating the likelihood of the exercising of optional tasks or option periods and / or the need to apply penalties allowed per the FAR.

· All evaluation periods will include calculations of the performance objectives identified in the PRS. The purpose of the performance evaluations is to jointly assess Contractor’s performance during the period, identify strengths and improvements that occurred during the period, and recommend appropriate actions to achieve contract objectives.

· For each evaluation period, the COR and designated subject matter experts will prepare the appropriate performance and evaluation reports, documenting the Contractor’s performance and corresponding rating recommendation in accordance with the performance assessment methodology set forth in the Surveillance Plan.

· Performance assessment results and supporting rationale will be reviewed by the Contracting Officer.

· The Contractor will receive the results of these recommendations along with necessary supporting material.

Performance Standards Evaluation Methods Surveillance Techniques To minimize the performance management burden, simplified surveillance methods will be used by the government to evaluate Contractor performance when appropriate. The methods of surveillance may include, but are not limited to, and may change in terms of method, schedule, frequency, and surveillant as need to adequately monitor performance:

a. AUDIT. Typically performed by internal and external organization to the VA under the direction of the CO/COR.

b. DIRECT OBSERVATION. Can be performed periodically or through 100% surveillance.

c. MANAGEMENT INFORMATION SYSTEMS (MIS). Evaluates output using management information reports. Best used for general surveillance and may need to be supplemented by periodic inspections.

d. PERIODIC INSPECTION. Uses a comprehensive evaluation of selected outputs. Inspections may be scheduled [Daily, Weekly, Monthly, Quarterly, or annually] or unscheduled, as required.

e. USER SURVEY. Combines elements of validated user complaints and random sampling. Random survey is conducted to solicit user satisfaction. Appropriate for high quantity activities that have historically been satisfactory. May also generate periodic and 100% inspections.

f. VALIDATED USER/CUSTOMER COMPLAINTS. Relies on the user of the service to identify deficiencies. Complaints are then investigated and validated. Highly applicable to services provided in quantity and where quality is highly subjective.

g. 100% INSPECTION. Evaluates all outputs. Most applicable to small quantity, but highly important services. May be used where there are written deliverables and stringent requirements such as tasks required by law, safety, or security.

h. PERIODIC SAMPLING. Variation of random sampling. However, sample is only taken when a deficiency is suspected. Good follow-up to MIS analysis. Sample results are applicable only for the specific work inspected. Since sample is not entirely random, it cannot be applied to total activity performance.

i. RANDOM SAMPLING. Designed to evaluate the outputs of the award requirement by randomly selecting and inspecting a statistically significant sample. Highly recommended for large quantity repetitive activities with objective and measurable quality attributes.

j. Progress or status meetings.

k. Analysis of contractor's progress reports. (Evaluate cost, schedule, etc.)

l. Performance reporting. Evaluate metrics for a specific time period. Develop metrics or use metrics found in MIS.

Surveillance results may be used as the basis for actions (to include payment deductions) against the contractor. In such cases, the Inspection of Services clause in the Contract becomes the basis for the CO’s actions.

Customer Feedback The Contractor is expected to establish and maintain professional communication between its employees and customers. The primary objective of this communication is customer satisfaction. Customer satisfaction is the most significant external indicator of the success and effectiveness of all services provided and can be measured through customer complaints.

Performance management drives the Contractor to be customer focused through initially and internally addressing customer complaints and investigating the issues and/or problems, but the customer always has the option to communicate complaints to the CO as opposed to the Contractor.

Customer feedback may also be obtained either from the results of formal customer satisfaction surveys or from random customer complaints.

Acceptable Quality Levels The AQLs included in the PRS are structured in a way that allows the Contractor to manage how the work is performed, motivating them to comply with the contract requirements and meet the overall contract objectives.

The following actions will be taken to ensure the AQLs are assessed accurately and in a timely way:

· No later than 20 days prior to the end of the evaluation period, the COR will establish a schedule for each required evaluation process.

· Performance Monitors will submit performance assessments of each performance objective in the PRS to the COR.

· The COR will compile an evaluation report summarizing the results of the assessment for each performance objective.

· No later than 10 days after the evaluation period ends, the COR will submit the assessment summary to the CO.

· The CO will submit the assessments to the Contractor within 15 days after the evaluation(s) of that period.

· The Contractor must submit its concurrence or any relevant disputes to the CO. The Contractor may present additional pertinent information concerning the assessment for the CO’s consideration.

· The CO may discuss with Contractor any performance concerns and may apply penalties per the FAR as appropriate for failure to meet contract requirements.

Ensuring Performance Quality Assurance Documentation Quality Assurance (QA) surveillance will be continually conducted throughout the contract, with open communication between the Contractor, RB and FDO. Certain factors help facilitate this surveillance:

The Performance Management Feedback Loop: The performance management feedback loop begins with the communication of expected outcomes. Performance standards are expressed in the PWS and PRS and will be assessed using the performance monitoring techniques shown in Appendix A, Performance Objective Calculations.

Monitoring Forms: The government’s QA surveillance, accomplished by the CORs and PMs, will be reported using the monitoring forms in attachment below. The forms, when completed, will document the government’s assessment of the Contractor’s performance under the contract to ensure that the required results performance levels are being achieved.

The CO and COR(s) will retain a copy of all completed QA surveillance forms. Appendix B contains an example of Sample Quality Assurance Monitoring Form.

Determining Performance The Government will use the evaluation methods cited to determine whether the performance standards/service levels/AQLs have been met, not met, or exceeded. If the Contractor has not met the minimum requirements, it may be asked to develop a corrective action plan, as required by the PWS, to show how and by what date it intends to bring performance up to the required levels. Failure to meet an AQL may result in equitable adjustments being applied.

Reporting Results At the end of each quarter, the PM will prepare a written report for the VHA IVC summarizing the overall results of the quality assurance surveillance of the Contractor’s performance. This written report, which will include the Contractor’s monthly and quarterly reports and the completed quality assurance monitoring forms (attachment below), will become part of the QA documentation. It will enable the government to demonstrate whether the Contractor is meeting the stated objectives and/or performance standards, including cost/technical/scheduling objectives.

Reviews and Resolution The CO and PM will require the Contractor to meet with the CPM Office and other government personnel during the quarterly Program Management Review (PMR) and monthly if deemed necessary to discuss performance evaluation. The CO and PM will define a frequency of in-depth reviews with the Contractor, including appropriate self-assessments by the Contractor; however, if the need arises, the Contractor will meet with the CO and PM as often as required or per the Contractor’s request. The agenda of the reviews may include:

· Monthly performance assessment data and trend analysis and Monthly Progress Reports (MPRs)

· Quarterly Progress Report (QPR) and PMR agenda

· Corrective Action Plan (CAP)

· Issues and concerns of both parties

· Projected outlook for upcoming months and progress Recommendations for improved efficiency and/or effectiveness

· Additional performance or programmatic concerns The CO, PM and COR will coordinate and communicate with the Contractor to resolve issues and concerns regarding performance that fall below the CCN AQL standards listed in the PRS. The CO, COR and PM and Contractor will jointly formulate tactical and long-term courses of action. Decisions regarding changes to metrics, thresholds, or service levels will be clearly documented.

Incentives and Disincentives Incentives are not currently authorized under this contract. A disincentive plan is not currently in place for this contract; however, penalties authorized by the FAR may be applied, as determined by CO.

Changes And/Or Modifications to the QASP and PRS The QASP will be finalized upon contract award and a copy will be provided to the Contractor for informational purposes only. The Contracting Officer may make unilateral changes to the QASP, as well as to any method(s) of surveillance, surveillance schedule(s), and frequency(ies) of surveillance identified in the QASP PRS. Changes to the performance objectives, AQL or standards identified in the QASP PRS shall be executed via bilateral modification between VA and the Contractor in accordance with the FAR.

Proposed Changes Changes to the QASP, PRS, or PWS as applicable may be proposed by either the Government or the Contractor prior to the next relevant evaluation period. Proposed changes must be submitted to the Contracting Officer, allowing reasonable time to for review, comment, and modification of the contract, as appropriate.

Method for Making Changes Proposed changes will be submitted to the CO. Recommended changes will be coordinated by the COR and presented to the PM for approval. The CO will review and approve all changes to the QASP and / or PRS before any changes take effect. The CO will execute modifications as appropriate.

Performance Objective Calculations

PO1.1

Contractor ensures Veteran travel time by car meets drive time standards reflected in the performance work statement in each Catchment Area.

*Catchment Area drive time acceptability determined by station pass/fail rate. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the performance work statement at least 90% of the time for at least 2 out of the 3 months for the quarter assessed.

(performance standard, AQL/ratings, and penalties apply to each Catchment Area, and is NOT applied to the total average performance of all Catchment Areas).

Each Catchment Area station pass rate:

See PRS

Sampling of Veteran Drive times based on Veteran address and Provider Directory using Contractor GIS

Quarterly, or more/less as determined by VA Data Source: Veteran Address in VA Eligibility File/Referral and Provider address in the Provider Directory. Contractor GIS Tool. EDI 837 (Provider Claim Submission Date).

Steps:

1. Use statistical software (e.g. Rat Stat) to pull a statistically significant sample of claims for EACH Station (grouped by Catchment Area) from all the claims submitted within the period assessed (as determined by the EDI 837 Provider Claim Submission Date). A sample must be pulled for EACH Station for each month for the quarter assessed.

2. With the Contractor’s/TPA’s GIS Tool, for each claim in the sample set (by Station), use the Veteran’s address in VA’s Eligibility File/ Referral and the Provider’s address (as identified in the Provider Directory) to whether the Veteran drive time was met for that claim.

3. Determine:

(a) how many claims are in each sample set, per Station, per month

(b) how many claims met the drive time standard (as assessed in Step 2) for each Station, for each month.

4. Determine if each station met veteran travel times by car drive time standards. Stations are determined to have passed if veteran travel times by car meets drive time standards reflected in the performance work statement at least 90% of the time for at least 2 out 3 months for the quarter assessed.

e.g.

Month 1

(a) total claims in Station 1 = 100

(b) total claims in Station 1 that met drive time standard = 91 91 / 100 x 100% = 91% =PASS Month 1 Month 2

(a) total claims in Station 1 = 100

(b) total claims in Station 1 that met drive time standard = 95 95 / 100 x 100% = 95% = PASS Month 2 Month 3

(a) total claims in Station 1 = 100

(b) total claims in Station 1 that met the drive time standard = 88 88 / 100 x 100% = 88% = FAIL Month 3 Station 1 PASSED 2 / 3 Months = Station 1 PASSED

5. Determine how many Stations within each Catchment Area Passed.

6. Determine the pass rate for each Catchment Area.

Example pass rate: 5/6 of stations within Catchment Area (met or exceeded 90%) = 83.3% *% will NOT be rounded down or up

7. Use % calculated in step 4 to determine which AQL/rating has been met or not met.

e.g. Catchment Area 3 Pass Rate = 83.3% = ACCEPTABLE (see PRS for AQL for each Catchment Area) *% will NOT be rounded down or up

* AQL ratings apply to each Catchment Area and is NOT applied to the total average performance of all Catchment Areas.

PO1.2

For each station, Contractor ensures Veteran wait times meets standards reflected in the performance work statement.

Monthly or more/less as determined by VA Data Source: EDI 835 and 837. Referral data.

From Field Name: Referral Approval Date To Field Name: First Date of Service on first claim received from provider listed on Referral Steps:

1. Develop/run automated query against all data (claims) submitted for that period assessed (e.g. query conducted on September 15th for August 15th – September 14th). Measured from Referral Approval Date to the First Date of Service on the first claim received from the provider listed on the Referral.

2. Analyze results of query to determine:

(a) total number of claims, per station, submitted during the period assessed

(b) total number of claims, for each station, that met appointment timeliness standards as stated in the PWS.

3. For each station, calculate % of claims that met appointment timeliness standards (from step 2 above):

(b) / (a) X 100% = % of claims that met appointment timeliness standards *% will NOT be rounded down or up

4. Use % calculated in step 3 to determine if AQL has been met or not met for each station.

*% will NOT be rounded down or up

PO1.3

Contractor ensures provider data displayed in each of the following required Provider Directory fields for Urgent Care providers is complete and accurate:

-NPI Number -CareSite Name -CareSite Address -CareSite Phone -CareSite Fax -CareSite Email -Quarterly Attestation at least every 90 days

Quarterly or more/less as determined by VA Data Source: Contractor Provider Directory validated against publicly available sources as well as data confirmed through direct contact with provider.

Steps:

1. Pull a statistically significant sample from all Urgent Care claims submitted within the period assessed.

2. Analyze results of the query to determine the total number of Urgent Care providers in the sample set for the period assessed.

3. Analyze the information in the Contractor’s Provider Directory for each Urgent Care Provider in the sample set to determine whether each of the required data fields (total of 7 required fields as part of this assessment) in the Provider Directory is complete and accurate. Information will be verified using the NPPES NPI Registry and publicly available information on the internet and if there is any discrepancy, calling the site for verification. Each required field, for each Urgent Care Provider, that is found to be not completed or inaccurate equals one (1) failure.

4. Determine:

(a) total number of required fields in the Sample Total # Urgent Care Providers in Sample X 7 (Total Number of Required Fields for each Provider Directory Record) = Total Number of Required Fields in Sample

(b) the total number of inaccuracies for all Urgent Care Providers in the Sample (errors or incomplete fields) as determined in Step 3.

5. Calculate error rate:

(b) / (a)) X 100% = error rate.

e.g.

Total fields in sample= 100 Total inaccuracies/errors = 5 Error rate = 5% *% will NOT be up or down

6. Use % calculated in step 5 to determine if AQL has been met or not met.

*% will NOT be up e.g. 100% - 5% = 95%

95% < 97% = DOES NOT MEET AQL

PO2.1

Contractor ensures inbound calls reach the Contractor Contact Center.

Monthly or more/less as determined by VA Data Source: Contractor Contact Center system Steps:

1. Run automated report on all calls that entered the queue during the period assessed.

2. Determine:

(a) total number of calls that entered the queue

(b) number of calls blocked from entering the queue

3. Calculate the blockage rate:

e.g.

200 calls blocked / 6,000 calls entered queue X 100% = 3.3% abandonment rate *% will NOT be rounded down or up

4. Use % calculated in step 3 to determine if AQL has been met or not met.

*% will NOT be rounded down or up e.g. 3.3% < 5% = MEETS AQL

PO2.2

Contractor ensures calls in Contractor Contact Center queue reach a live Contractor Call Center agent.

Monthly or more/less as determined by VA Data Source: Contractor Contact Center system Steps:

1. Run automated all calls that entered the queue during the period assessed.

2. Determine:

(a) total number of calls that entered the queue

(b) number of calls that abandoned (disconnected) after entering the queue

3. Calculate the abandonment rate:

(b) / (a) X 100% = Abandonment rate e.g.

122 calls abandoned / 5,870 calls entered queue X 100% = 1.1% abandonment rate *% will NOT be rounded down or up

4. Use % calculated in step 3 to determine if AQL has been met or not met.

*% will NOT be rounded down or up e.g. 1.1% < 5% = MEETS AQL NOTE: So-called short abandonments will NOT be excluded from the calculation.

PO2.3

Contractor ensures callers reach a live Contractor Contact Center agent in 2 minutes or less.

Monthly or more/less as determined by VA Data Source: Contractor Contact Center system Steps:

1. Run automated report on all calls that entered the queue during the period assessed.

2. Determine:

(a) total number of calls that entered the queue

(b) number of calls that reach a live agent in 2 minutes or less.

3. Calculate the % of calls that reach a live agent in 2 minutes or less:

(b) / (a) X 100% = % Calls that reached a live agent in 2 minutes or less e.g.

5,600 calls reach live agent in 2 minutes or less / 6,000 total calls entered queue X 100% = 93.3% of calls reached a live agent in 2 minutes or less *% will NOT be rounded down or up

4. Use % calculated in step 3 to determine if AQL has been met or not met.

*% will NOT be rounded down or up e.g. 93.3% <95% =DOES NOT MEET AQL

PO2.4

Contractor fully resolves VA-provided ticketing tool tickets within:

Tier 1 - 3 business days Tier 2 - 5 business days Tier 3 - 90 days Tier 4 (Provider Onboarding) - 180 days

Monthly or more/less as determined by VA Data Source: VA Ticketing Tool From Ticket Submission Date To Ticket Resolution/Closure Date Steps:

1. Develop/run automated query against all tickets, by Tier, submitted for that period assessed (e.g. query conducted on September 15th for August 1st – August 30th). Measured from ticket submission to ticket closure.

2. Analyze results of query, for each Tier, to determine:

(a) total number of Tickets submitted per Tier during the period assessed

(b) number of tickets, per Tier, fully resolved within the maximum number of days allotted for each Tier.

*Sample claim adjudication time calculation:

Ticket Submission Date: 8/1/2999 Ticket Resolution/Closure Date: 8/4/2999 Claim adjudication time = 3 days

3. Calculate % of tickets submitted and fully resolved, for each Tier, within the number of days allotted for each Tier (from step 2 above):

(b) / (a) X 100% = % of tickets fully resolved within the number of days allotted *% will NOT be rounded down or up

4. Use % calculated in step 3 to determine if AQL has been met or not met.

*% will NOT be rounded down or up

PO2.5

Contractor fully resolves VA-provided ticketing tool tickets on the first submission.

Monthly or more/less as determined by VA Data Source: VA Ticketing Tool From Field Name: X To Field Name: Y Steps:

1. Develop/run automated query against all tickets submitted for that period assessed (e.g. query conducted on September 15th for August 1st – August 30th). Measured from X Field to Y Field

2. Analyze results of query to determine:

(a) total number of Tickets submitted during the period assessed

(b) number of tickets fully resolved on the first submission. This is determined by calculating the number of tickets resolved without reopening the ticket after closing.

3. Calculate % of tickets fully resolved on the first submission (from step 2 above):

(b) / (a) X 100% = % of tickets fully resolved on the first submission *% will NOT be rounded down or up

4. Use % calculated in step 3 to determine if AQL has been met or not met.

*% will NOT be rounded down or up

PO3.1

Contractor processes / adjudicates all network provider claims no later than 30 days after provider submits claim to TPA.

From Provider Claim Submission Date (EDI 837 - Loop 2300, DTP Segment with Qualifier Code 050) to TPA Adjudication Date (EDI 835)

≥ 98% Processed/adjudicated in 30 days or less 100% inspection

Monthly or more/less as determined by VA Data Source: Raw EDI 837 -Provider to TPA (Loop 2300, DTP Segment with Qualifier Code 050) and Raw EDI 835 - TPA to Provider Steps:

1. Develop/run automated query against all data (claims) submitted for that period assessed (e.g. query conducted on September 15th for August 15th – September 14th). Measured from EDI 837 - Loop 2300, DTP Segment with Qualifier Code 050 to EDI 835

2. Analyze results of query to determine:

(a) total number of claims submitted during the period assessed

(b) number of claims submitted and adjudicated in 30 days or less *Sample claim adjudication time calculation:

Provider Claim Submission Date: 10/1/2999 TPA Adjudication Date: 10/30/2999 Claim adjudication time = 30 days

3. Calculate % of claims submitted and adjudicated in days or less (from step 2 above):

(b) / (a) X 100% = % of claims submitted and adjudicated in 30 days or less *% will NOT be rounded down or up

4. Use % calculated in step 3 to determine if AQL has been met or not met.

*% will NOT be rounded down or up

PO3.2

Contractor accurately matches all claims to the correct referral (authorization), in accordance with the PWS (See exhibit 38 of Manual, Referral Matching Rule)

Monthly or more/less as determined by VA Data Source: EDI 837 COB Steps:

1. Use statistical software (e.g. Rat Stat) to pull a random sample from all the claims submitted within the period assessed.

2. Analyze results of the query to determine the total number of claims in the sample set for the period assessed.

3. Analyze sample set to confirm that all 7 referral matching elements (PWS/Manual References in PRS) are complete and accurate. Failure to accurately complete any one or more of the 7 referral matching elements equals one (1) failure of that claim as matching a valid referral.

4. Determine total number of claims with all 7 referral matching elements completed accurately.

5. Calculate % of claims submitted with all 7 referral matching elements completed accurately. (from step 4 above):

Total number of claims with all 7 referral matching elements accurate and complete / total number of claims in sample X 100% = % of claims with all 7 referral matching elements complete and accurate.

*% will NOT be rounded down or up

6. Use % calculated in step 4 to determine if AQL has been met or not met.

*% will NOT be rounded down or up

PO3.3

Contractor minimizes use of out-of-network providers for non-emergency episodes of care.

<1% Institutional Out-of- Network Provider Usage

AND

<3% Professional Out-of-Network Provider Usage 100% inspection

Monthly or more/less as determined by VA Data Source: EDI 837 COB Steps:

1. Develop/run automated query of all non-emergency episode of care claims for that period assessed (e.g. query conducted on September 10th for August 1st – August 30th).

2. Analyze results of the query to determine the total number of claims in the period assessed.

3. Analyze the sample set to determine the number of out-of-network claims.

4. Calculate % of out-of-network claims for:

a. Institutional EOCs/claims

b. Professional EOCs/claims Total number of out-of-network claims / total number of claims in sample X 100% = % of out-of-network claims.

*% will NOT be rounded down or up

5. Use % calculated in step 4 to determine if AQLs have been met or not met.

*% will NOT be rounded down or up

Sample Quality Assurance Monitoring Form

SAMPLE QUALITY ASSURANCE

MONITORING FORM

PERFORMANCE OBJECTIVE, SERVICE or STANDARD:

SURVEY PERIOD:

SURVEILLANCE METHOD (Check):

LEVEL OF SURVEILLANCE (Check):

r Monthly r Quarterly r As needed

PERCENTAGE OF ITEMS SAMPLED DURING SURVEY PERIOD:______ %

ANALYSIS OF RESULTS:

Observed Service Provider Performance Measurement Rate: ______%

Narrative of Performance During Survey Period:

PREPARED BY: ___________________________________ DATE: ________________

Acronym List

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