Attachment 5 CCN Next Gen West QASP PRS by CA.pdf

Pillar PO # Performance Objective (PO) Performance Work

Statement (PWS) Reference

Performance Standard Acceptable Quality

Level (AQL) Surveillance Method

PO1.1 Access:

Drive Time

3.1 Medical Network

Establishment and Maintainance

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 pass rate:

*Example Catchment Area 14 pass rate: 7/8 of stations within that Catchment Area passed (met or exceeded 90%) = 87.5% = Met 87% AQL **See PRS Attachment 1 Station Names

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

Quarterly, or more/less as determined by VA. Once annually, at minimum.

PO1.2 Access:

Appointment Timeliness (Appointment Availability)

3.1 Medical Network

Establishment and Maintainance

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

≥ 90% 100% inspection of claims data

Monthly or more/less as determined by VA.

Once annually, at minimum.

PO1.3 Provider Data Accuracy 3.7 Medical Network Provider Data for VA's Provider Directory and

6.2.3 Medical Network

Provider Attestation

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

≥ 97% Sampling of Contractor provider data file

Quarterly or more/less as determined by VA. Once annually, at minimum.

PO2.1 Contractor Contact Center Operations - Blockage Rate

6.7.1 Contractor

Contact Center Performance Requirements

Contractor ensures inbound calls reach the Contractor Contact Center.

*Inbound calls are considered to be blocked (having not reached the Contractor Contact Center) if they cannot be connected immediately because either

(a) no circuit is available at the time the call arrives, or (b) the voice which is programmed to block calls from entering the queue when the queue backs up and the inbound call receives a busy signal.

≥ 95% (less than 5% of inbound calls blocked) 100% inspection of Contractor Contact Center data

Monthly or more/less as determined by VA.

Once annually, at minimum.

QASP Attachment 1 - CCN Performance Requirement Summary (PRS ) - MEDICAL WEST

Customer Service

PO2.2 Contractor Contact Center Operations - Call Abandonment Rate

6.8.1 Contractor

Contact Center Performance Requirements

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

*The abandoned calls are those calls that voluntarily disconnect after entering the queue but before reaching an agent. It includes all calls that enter the queue.

≥ 95% (less than 5% are abandoned) 100% inspection of Contractor Contact Center data

Monthly or more/less as determined by VA.

Once annually, at minimum.

PO2.3 Contractor Contact Center Operations - Average Speed of Answer

6.8.1 Contractor

Contact Center Performance Requirements

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

≥ 95% 100% inspection of Contractor Contact Center data

Monthly or more/less as determined by VA.

Once annually, at minimum.

PO2.4 VA-Provided Ticketing Tool - Timeliness of Resolution

6.3 Contractor Use of

Va-Provided Ticketing Tool

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

≥ 95% (for Each Tier) 100% inspection

Monthly or more/less as determined by VA.

Once annually, at minimum.

PO2.5 VA-Provided Ticketing Tool - Ticket Resolution Rate

6.3 Contractor Use of

Va-Provided Ticketing Tool

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

≥ 80% 100% inspection

Monthly or more/less as determined by VA.

Once annually, at minimum.

PO3.1 Claims Processing Timeliness 10.1 Claims Submission and Processing Timeframes

Contractor 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)

*Sample claim adjudication time calculation:

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

≥ 98% Adjudicated in 30 days or less

100% inspection

Monthly or more/less as determined by VA.

Once annually, at minimum.

PO3.2 Accuracy: Claims Referral/Auth Matching

10.2 Claims

Processing and Adjudication

Contractor accurately matches all claims to the correct referral (authorization) in accordance with

PWS.

≥ 95% Sampling

Monthly or more/less as determined by VA.

Once annually, at minimum.

PO3.3 Out-of Network Provider Usage 3.2 Medical Provider Network

Contractor minimizes use of out-of-network providers for 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.

Once annually, at minimum.

Claims / Invoicing

Draft PRS - WEST