Attachment Ca- QASP Medical East by CA.docx

QUALITY ASSURANCE SURVEILLANCE

PLAN (QASP)

VA Community Care Network Next Generation Medical East

DATE: 11/20/2025

PRE-DECISIONAL DRAFT

Contract Information and Approval

Contract Number Contractor

Contracting Officer Date

Contracting Officer’s Representative Date

Table of Contents

Purpose of Quality Assurance Surveillance Plan 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 of this QASP is to provide a structured framework for assessing the Contractor’s performance, ensuring that the Contractor maintains effective quality controls, and promoting continuous quality improvement through the period of performance (PoP). The Contractor is responsible for developing an efficient methodology to ensure they meet and/or exceed the required thresholds of service as outlined in the PWS. The Government intends to perform surveillance on this contract in accordance with this QASP but may make updates to this QASP, as required, to ensure that the rendered services conform to contract requirements. Any non-conforming services discovered with the Contractor, subcontractors or providers will be addressed with the 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) (PWS Attachment C). 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 equipment, and skilled/unskilled home health services. The delivery of healthcare services also includes provider network management and claims payment.

Government Performance Surveillance Approach The Government will use a structured performance surveillance approach to monitor and evaluate the Contractor's delivery of medical services in accordance with the PWS. Oversight will be conducted by the COR. This approach focuses on outcomes and measurable results, consistent with performance-based acquisition principles. Rather than prescribing how the Contractor performs the work, VA will assess the extent to which performance outcomes and services levels identified in the PWS are achieved.

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 COR will review Contractor self-assessment results and reporting of performance and perform ad hoc audit/inspection of the results of the Contractor’s self-assessment or reassess performance at VA’s discretion to ensure compliance with the contractual requirements. VA will leverage automation and/or technological solutions, such as the VA ticketing system, to the maximum extent to objectively assess the Contractor’s performance using raw data that VA either receives or has access to via contractual requirements (e.g. electronic data transmission, EDI claims data, Contractor’s geo-mapping solution, etc.). As VA technology, tools, processes, etc. mature, VA will increase use of direct assessment by VA and decrease use of Contractor self-assessment for performance surveillance with ad-hoc audits/inspection.

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 developing and maintaining an effective Quality Assurance (QA) program that ensures all services and deliverables provided under this contract meet the performance standards set forth in the PWS. The Contractor's QA program should include procedures for self-monitoring, identifying performance issues, implementing corrective actions, and continuously improving service delivery. The COR will monitor performance and review performance reports furnished by the Contractor to determine how the Contractor is performing against communicated performance objectives (PO). However, the Contractor will be responsible for making required changes in staffing, processes, and practices to ensure performance is managed effectively.

The Contractor shall 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. The process and anticipated calculations for determining Contractor’s performance is set forth in sections of this plan.

ROLES AND RESPONSIBILITIES

Contracting Officer The CO is responsible for the overall administration of the contract. It ensures that the performance monitoring and quality assurance activities conducted under this plan align with the terms and conditions of the contract.

The CO’s responsibilities include approving and maintaining the QASP; appointing CORs to perform technical oversight in accordance with this plan; reviewing surveillance results and COR reports for contractual compliance; taking contractual actions when performance issues arise, including the application of any remedies.

Contract Specialist The CS is responsible for serving as an acquisition advisor in support of the CO and acting as a liaison between the CO, IVC, and the COR(s).

Contracting Officer’s Representative The Contracting Officer Representative (COR) is designated by the Program Officer and delegated by the CO to assist in administering this contract. COR limitations are contained in a written appointment letter. The Contractor will receive a copy of the 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 does not have the authority to make any contractual agreement, modification, or commitments on behalf of the Government. Any changes that may affect the contract price, terms, or conditions shall be referred to the CO for action. The COR must maintain the quality assurance file and ensure QA monitoring forms are used to document the inspection and evaluation of the Contractor’s work performance.

Performance Monitors / Subject Matter Experts The COR will work with subject matter experts (SMEs) whom will be designated by the PM as Performance Monitors to assist in monitoring performance. The COR will maintain a list, by position and name, of the designated Performance Monitors and will validate this list with the PM at least annually. However, the PM is responsible for providing the COR with updates (e.g. replacements, additions, deletions, etc.) to the list when changes are required outside of the annual validation. 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 as a part of the performance evaluation process outlined in this QASP and throughout the contract as necessary.

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 be documented in CPARS. Surveillance results may be used as the basis for actions against the Contractor, such as reducing the contract price to reflect the reduced value of the services performed. In such cases, the Inspection of Services clause in the Contract becomes the basis for the CO’s actions.

Evaluation Assessment Periods The Government has identified key POs 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.

· All evaluation periods will include calculations of the POs 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 the Contractor 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 performance assessment results and/or recommendations or concerns about the results of performance assessments 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. 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.

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:

· Performance Monitors will submit performance assessments of each PO in the PRS to the COR NLT 10 calendar days after the evaluation period ends. – OR – No later than the 15th day of each Month, the Contractor shall submit the Contract Performance Reports as required in PWS section 2.5.1, Performance Surveillance and Assessment: Network Adequacy, Customer Service, Claims/Invoicing, and Value-Based Care to the COR.

· The COR will compile an evaluation report summarizing the results of the VA assessment and/or review of the Contractor’s self-assessment for each PO.

· No later than 20 calendar days after the evaluation period ends, the COR will submit the assessment summary to the CO.

· The CO will submit the results of VA assessments to the Contractor within 10 calendar days after receiving the evaluation(s) from the COR.

· The Contractor must submit any relevant disputes to the CO. The Contractor may present additional pertinent information concerning the assessment for the CO’s consideration. The CO will review the information and make a final determination.

Ensuring Performance Quality Assurance Documentation Quality Assurance (QA) surveillance will be continually conducted throughout the contract PoP, with open communication between the Contractor and COR. 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 in accordance with the PRS and audited 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 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 and Contractor Performance Reports provided by the Contractor. Appendix B contains an example of Sample Quality Assurance Monitoring Form.

Determining Performance The Government and Contractor will use the evaluation methods cited in Section 4 of this QASP 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, they shall develop a Quality Improvement Plan (QIP), as required by PWS section 2.5.3, Quality Improvement Plan, to show how and by what date it intends to bring performance up to the required levels.

Reporting Results At the end of each quarter, the COR will prepare a written report 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 (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 Contractor shall meet with the COR and other Government personnel during the quarterly Program Management Review (PMR) to discuss performance evaluation. The agenda of the reviews may include, but are not limited to:

· 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, 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 and formalized via contract modification.

Incentives and Disincentives The Contractor is eligible for incentives and disincentives under this contract. The PRS identifies the corresponding incentive/disincentive available for each PO, as applicable. Refer to QASP Attachment 1, Incentive/Disincentive Plan, for additional details on the assessment and implementation of the incentives outlined in the PRS.

Changes and /or Modifications to the QASP The QASP will be finalized upon contract award and a copy will be provided to the Contractor for informational purposes only. VA will review the QASP annually at a minimum and update as necessary.

Proposed Modifications to the PRS or PWS Changes to the PRS or PWS as applicable may be proposed by either VA or the Contractor prior to the next relevant evaluation period. Proposed changes must be submitted to the Contracting Officer for review, comment, and modification of the contract, when required.

Method for Making Changes Proposed changes will be submitted by the COR to the CO. 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

Steps:

See PRS for Calculation Methodology.

Steps:

See PRS for Calculation Methodology

Steps:

See PRS for Calculation Methodology

Steps:

See PRS for Calculation Methodology

Steps:

See PRS for Calculation Methodology

PO1.6

Data Source: EDI 835 and 837. Referral data.

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

See PRS for Calculation Methodology

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

See PRS for Calculation Methodology

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

See PRS for Calculation Methodology

PO1.9

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 (as determined by the EDI 837 Provider Claim Submission Date).

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 6 required fields as part of this assessment) in the Provider Directory is complete and accurate. Information will be verified using the 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 6 (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% >90% = MEETS AQL

PO2.1

Data Source: Contractor Contact Center system Steps:

1. Sample from all calls that entered the queue within 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% blockage 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

Data Source: Contractor Contact Center system Steps:

1. Sample from all calls that entered the queue within 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

Data Source: Contractor Contact Center system Steps:

1. Sample from all calls that entered the queue within the period assessed.

2. Determine:

(a) total number of calls that entered the queue

(b) number of calls that reach a live agent in 30 seconds or less.

3. Calculate the % of calls that reach a live agent in 30 seconds or less:

(b) / (a) X 100% = % Calls that reached a live agent in 30 seconds or less e.g.

5,600 calls reach live agent in 30 seconds or less / 6,000 total calls entered queue X 100% = 93.3% of calls reached a live agent in 30 seconds 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% >80% = MEETS AQL

From: Ticket Creation Date To: Ticket Submission Date Steps:

1. Sample from all tickets, per Tier, resolved within the period assessed (e.g. query conducted on September 15th for August 1st – August 30th).

2. Analyze sample in query, for each Tier, to determine:

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

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

*Sample time calculation:

Ticket Creation Date: 8/1/2999 Ticket Submission/Resolution Date: 8/4/2999 Ticket resolution time = 3 days

3. Calculate % of tickets, for each Tier, that were fully resolved 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

Data Source: VA Ticketing Tool Steps:

1. Sample from all tickets submitted within the period assessed (e.g. query conducted on September 15th for August 1st – August 30th).

2. Analyze sample in 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 “Approved” by VA without having been previously rejected*.

*Rejected tickets are those tickets that were resolved by the Contactor in the ticketing tool but upon review by VA, they were determined to NOT be fully resolved and were thus “rejected” and sent back to the Contractor for additional information or further resolution.

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

From: First Ticket Rejection Date To: Final Submission Date Steps:

1.Sample from all tickets, per Tier, Approved by VA within the period assessed that were previously rejected. (e.g. query conducted on September 15th for August 1st – August 30th).

2. Analyze sample in query, for each Tier, to determine:

(a) total number of tickets that have been Approved by VA that had previously been rejected*.

(b) total number of previously rejected* tickets submitted within the maximum number of days allotted.

*Sample time calculation:

First Ticket Rejection Date: 8/1/2999 Final Ticket Submission Date: 8/4/2999 Resolution time since first rejection = 3 days

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

(b) / (a) X 100% = % of rejected 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

Steps:

See PRS for Calculation Methodology *See approved Incentive/Disincentive Plan for details on applying incentives / disincentive payments.

**VA will make the final determination as to whether or not a ticket has been adequately resolved. A resolved ticket is a ticket in which the VA has determined that the Contractor’s submitted resolution adequately and fully addresses (resolves) the issue.

PO3.1

Data Source: Raw EDI 837 and Raw EDI 835 data Steps:

1. Sample from all data (claims) adjudicated within the period assessed (e.g. query conducted on September 15th for August 15th – September 14th). Measured from EDI 837 Provider Claim Submission Date- Loop 2300, DTP Segment with Qualifier Code 050 to TPA Adjudication Date (EDI 835)

2. Analyze results of query to determine:

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

(b) number of claims adjudicated in 30 days or less from date of submission *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 30 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

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

Data Source: EDI 837 COB Steps:

1. Sample from all episode of care claims submitted within the 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 submitted 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

PO3.4

Data Source: Status and Participating Provider Report, Eligible Veteran Report, and EDI 837 claims data Steps:

1. Inspect all APM related claims resolved within the period assessed. (e.g. query conducted on September 15th for August 15th – November 14th).

2. Analyze results of query to determine:

(a) total number of APM related claims adjudicated / paid during the period assessed

(b) number of APM related claims accurately adjudicated / paid

3. Calculate % of APM related claims accurately adjudicated / paid (from step 2 above):

(b) / (a) X 100% = % of APM related claims accurately adjudicated / paid *% 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

From: Initial Date of Service To: Documentation Submission Date Steps:

1. Run a report from claims data to determine the number of authorized initial appointments within the period assessed.

2. Review a statistically significant sample of medical documentation submitted for initial appointments within Contractor's Central Submission System.

3. For each encounter, calculate timeliness of submission based on the initial date of service to the date of provider documentation submission. If the submission is less than or equal to 30 days of the initial appointment, it passes. If it is more than 30 days after the initial appointment, it fails.

4. Determine:

(a) Total number of encounters in the sample

(b) Total number of encounters that failed to meet the timeliness requirement

5. Calculate the fail rate.

number of encounters that failed (b) / total number of encounters in sample (a) X 100 = error rate percentage. (b) / (a) X 100% = error rate.

e.g.

Total encounters in sample (a)= 100 Total encounters failed (b) = 5 Fail rate = 5% *% will NOT be up or down

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

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

95% ≥ 90% = MEETS AQL

PO4.2

Data Source: Contractor’s Central Submission System From: Appointment Completion Date of Service To: Documentation Submission Date Steps:

1. Run a report from claims data to determine the number of authorized follow-on appointments within the period assessed.

2. Review a statistically significant sample of medical documentation submitted for follow-on appointments within Contractor's Central Submission System.

3. For each encounter, calculate timeliness of submission based on the appointment completion date of service to the date of provider documentation submission. If the submission is less than or equal to 30 days of the appointment completion date, it passes. If it is more than 30 days after the initial appointment, it fails.

4. Determine:

(a) Total number of encounters in the sample

(b) Total number of encounters that failed to meet the timeliness requirement

5. Calculate the fail rate.

number of encounters that failed (b) / total number of encounters in sample (a) X 100 = error rate percentage. (b) / (a) X 100% = error rate.

e.g.

Total encounters in sample (a)= 100 Total encounters failed (b) = 5 Fail rate = 5% *% will NOT be up or down

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

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

95% ≥ 90% = MEETS AQL

PO4.3

Data Source: Contractor’s Central Submission System From: Date of Service To: Documentation Submission Date Steps:

1. Run a report from claims data to determine the number of authorized inpatient care appointments within the period assessed.

2. Review a statistically significant sample of medical documentation submitted for inpatient care appointments within Contractor's Central Submission System.

3. For each encounter, calculate timeliness of submission based on the date of service to the date of provider documentation submission. If the submission is less than or equal to 30 days of the appointment, it passes. If it is more than 30 days after the initial appointment, it fails.

4. Determine:

(a) Total number of encounters in the sample

(b) Total number of encounters that failed to meet the timeliness requirement

5. Calculate the fail rate.

number of encounters that failed (b) / total number of encounters in sample (a) X 100 = error rate percentage. (b) / (a) X 100% = error rate.

e.g.

Total encounters in sample (a)= 100 Total encounters failed (b) = 5 Fail rate = 5% *% will NOT be up or down

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

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

95% ≥ 90% = MEETS AQL

PO4.4

Data Source: Contractor’s Central Submission System From: Date of Urgent Care Episode To: Documentation Submission Date Steps:

1. Run a report from claims data to determine the number of authorized first appointments within the period assessed.

2. Review a statistically significant sample of medical documentation submitted for urgent care appointments within Contractor's Central Submission System.

3. For each encounter, calculate timeliness of submission from the date of urgent care episode to the date of provider documentation submission. If the submission is less than or equal to three (3) business days from the initial appointment, it passes. If it is more than three (3) business days after the appointment, it fails.

4. Determine:

(a) Total number of encounters in the sample

(b) Total number of encounters that failed to meet the timeliness requirement

5. Calculate the fail rate.

number of encounters that failed (b) / total number of encounters in sample (a) X 100 = error rate percentage. (b) / (a) X 100% = error rate.

e.g.

Total encounters in sample (a)= 100 Total encounters failed (b) = 5 Fail rate = 5% *% will NOT be up or down

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

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

95% ≥ 90% = MEETS AQL

PO4.5

Data Source: Contractor's Central Submission System From: Initial Creation Date of Care Plan To: Documentation Submission Date Steps:

1. Run a report from claims data to determine the number of authorized dialysis care appointments within the period assessed.

2. Review a statistically significant sample of medical documentation submitted for Dialysis Interdisciplinary Care Plans for appointments within Contractor's Central Submission System.

3. For each encounter, calculate timeliness of submission based on the initial creation date of the care plan to the date of provider documentation submission. If the submission is less than or equal to 30 days of the initial creation date, it passes. If it is more than 30 days after the initial creation date, it fails.

4. Determine:

(a) Total number of encounters in the sample

(b) Total number of encounters that failed to meet the timeliness requirement

5. Calculate the fail rate.

number of encounters that failed (b) / total number of encounters in sample (a) X 100 = error rate percentage. (b) / (a) X 100% = error rate.

e.g.

Total encounters in sample (a)= 100 Total encounters failed (b) = 5 Fail rate = 5% *% will NOT be up or down

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

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

95% ≥ 90% = MEETS AQL

PO4.6

Data Source: Contractor's Central Submission System From: Last Day of Month Summarized To: Monthly Note Submission Date Steps:

1. Run a report from claims data to determine the number of authorized dialysis care appointments within the period assessed.

2. Review a statistically significant sample of monthly comprehensive dialysis notes for appointments within Contractor's Central Submission System.

3. For each encounter, calculate timeliness of submission based on the reported month end date to the date of documentation submission. If the submission is less than or equal to 30 days of the reported month end date, it passes. If it is more than 30 days after the initial creation date, it fails.

4. Determine:

(a) Total number of encounters in the sample

(b) Total number of encounters that failed to meet the timeliness requirement

5. Calculate the fail rate.

number of encounters that failed (b) / total number of encounters in sample (a) X 100 = error rate percentage. (b) / (a) X 100% = error rate.

e.g.

Total encounters in sample (a)= 100 Total encounters failed (b) = 5 Fail rate = 5% *% will NOT be up or down

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

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

95% ≥ 90% = MEETS AQL

Steps:

See PRS for Calculation Methodology.

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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