Attachment G Performance Standard Examples~1.pdf

Attachment G – Overall Administration Performance Standards

Criteria Performance Standard Damages

Per Member (PM) for that monthly timeframe

Web Sites/Member Portals/Consumer Reporting

Web-site availability

100% Except for routine maintenance

$0.10/PM per occurrence up to eight (8) hours of continual downtime

$0.10/PM for each additional occurrence past the initial eight (8) hours

HIPAA/Compliance

The disclosure of Personal Health Information and/or Protected Health Information for ASE or PSE members

“0” occurrences

$0.30/PM per occurrence

Documentation required in the BAA (in the event of notification of any security incident as defined in the BAA) completed within specified dates

$0.10/PM for minor incidents (PII only, less than 10 unique incidents)

$0.15/PM for moderate incidents (>10 PII or >0 PHI)

$0.20/PM for major incidents (>50 either/or PII/PHI)

Minor, moderate, or major designation will be determined by EBD per incident.

Use of EBD’s Secure Task System

$0.10/PM for each occurrence not used

Use of Secure File Transfer Protocol

$0.10/PM for each occurrence not used

Communication

Education, enrollment or general communication material

100% reviewed and approved by the EBD Communication Manager

$0.10/PM for each communication not approved

Provider quality of care issues and documentation

Provided within five (5) business days from request of information

$0.10/PM per request after five (5) business days

Criteria Performance Standard Damages

Audit

Comply with a reasonable request to inspect facilities, equipment, and system support operations (if not specified in other Performance Standards)

Within three (3) business days of request

$0.30/PM for each day late over three (3) business days per each request

Respond to an initial finding from an inspection

Within 30 calendar days of request

$0.30/PM for each day late past 30 calendar days per each request

Respond to a finding from an inspection in the form of a corrective action plan

Within 20 calendar days of EBD’s notification of the finding to the Contractor

$0.30/PM for each day late past 20 calendar

Produce the records requested in a timely fashion

Within three (3) business days of request

$0.10/PM per request per workday

Correct the records if the records do not comply with terms and conditions

Within 14 calendar days of request

$0.10/PM for each day late past 14 calendar

Accounting/Reporting

Ad hoc reporting

Provided by EBD’s determined deadline

$0.10/PM for each day late

Monthly Reports and documentation not specified in other Performance Standards

Provided by deadlines

Quarterly Reports and

Criteria Performance Standard Damages

Annual Reports and

Damage Payment from Contractor

Received by EBD 30 calendar days of damage(s) invoice date

$0.30/PM for each day late

Operations, Systems and Security

Accurately process enrollment additions, changes, and deletions

Within three (3) calendar days of the creation date of the file provided by

EBD

$0.15/PM for each day late

Compare the weekly file provided by EBD and generate an enrollment mismatch report to

EBD.

Within fourteen (14) calendar days of the creation date of the full file

$0.20/PM per each day late

Provide an eligibility reconciliation file that provides basic demographic and plan selection information for members.

Provided by the third (3rd) business day of each month

Additions, changes, and deletions processed correctly

99% Accuracy

$0.10/PM for each error over 99%

Correction process for enrollment and demographic additions, changes, and deletions

Completed by deadline

Report incomplete or unreadable information to EBD

Within one (1) calendar day of receipt of information

Criteria Performance Standard Damages

Implementation

Comply with mutually agreed upon deadlines for Implementation

(this damage will be assessed in the first quarter of 2019 )

$0.50/PM for not meeting a deadline during implementation

$25,000 (one-time, TBD by EBD when criteria and dates are set during Implementation meeting)

Administrative

Account Manager

In Place by deadline

$0.20/PM for each day late

Transparent administration

100% transparency

$0.10/PM per occurrence

Attachment G – Health Insurance

Criteria Performance Standard

Transparency

Notify EBD, in writing, if a physician and/or facility are removed from your network

Work cooperatively with any of EBD’s contracted Contractor.

$0.30/PM per occurrence per determination of

EBD

Enrollment/Eligibility after Implementation

Timeliness of ongoing eligibility updates

99% within three (3) working days from date eligibility updates submitted

$0.10/PM per each day late

Accuracy of ongoing eligibility file updates

99%

$0.10/PM per each file with less than 99% accuracy

Claims paid after termination notification

No claims paid beyond three (3) working days of termination notification

$0.10/PM per each claim paid after 3 working days

Claims Processing Time

After receipt, percent of claims reimbursed or processed within 30 days

$0.15/PM per each day late

Pended Claims processed within 45 days

Claims Processing Accuracy

Overall processing accuracy (financial and statistical)

Overall financial accuracy (based on dollars paid)

Criteria

Performance Standard

Claims to EBD

Provide EBD with a weekly claims file in an amended HIPAA compliant format

Provided weekly by the deadline

$0.15/PM per each week late

Remittance File

Provide EBD with a bi-weekly remittance file in an amended HIPAA compliant format to update the claims loaded into EBD’s system

Provided by deadline

Network/Provider File

Provide EBD with a file containing provider information on a weekly basis.

Provided by weekly deadline

Quarterly Claims Files

Provide complete and accurate file of adjudicated claims in the specified format and location.

Provide quarterly by deadline

EBD, Legislative Audit and any company chosen by EBD allowed to audit 100% of member claims.

$0.15/PM per occurrence of non-allowance or less than 100%

Adhere to the EBD quarterly claims audit schedule for delivery of claims audit files, pickup of files, delivery of hard copy claims and preparation of responses.

Completed on specified schedule

$0.15/PM per occurrence of any item not completed on schedule

Requests for Information

EBD’s request for documentation

Provided within three (3) business days from the request unless an extension has been approved prior to the due date.

Criteria Performance Standard Damages

Member/Transparency Reporting

Provider Status report

Basic cost data report

Basic quality data report

MMSEA111 CMS Quarterly Reporting

$0.30/PM per each day late

Quality Performance Reporting

Production of data on requested Population Health/Custom Care Management targets

Subsequent contract years, Population Health/Custom Care targets (reported on a quarterly basis)

99% of 100% of plan membership

$0.15/PM per occurrence when less than

Compliance

Compliance with State and Federal Plan Mandates (EOB’s, online Coverage Policies, etc.)

$0.15/PM per occurrence of non-compliance

Criteria Performance Standard Damages

General Administration/Customer Service/Communication

Toll-free telephone access between 8 a.m. and 5 p.m.

Monday-Friday (only State recognized holidays exempt)

$0.10/PM per occurrence

Percent of calls answered within 30-seconds

95%

$0.10/PM per occurrence when less than 95% for the month

Percent of calls abandoned

< or = to 3% $0.10/PM per occurrence when above 3% for the month

Percent of written inquiries responded to

95% within three (3) business days $0.10/PM per each 1% below 95% for the month

Percent of written inquiries responded to

100% within five (5) business days

Network Management

Percent of network providers audited on-site each year

3%

$0.15/PM when less than 3% for the year

Physician Wait Time

Routine appointment scheduled

95% within seven (7) days

Urgent appointment scheduled

95% within 24 hours

Satisfaction

Member with Contractor’s role with Plan

95% satisfied or very satisfied

$0.15/PM per each 1% below 95%

Member with PCP

90% satisfied or very satisfied

PCP with Plan

95% satisfied or very satisfied

Criteria Performance Standard Damages

Accounting

Required Reports and documentation provided monthly

$0.15/PM per each report late documentation provided quarterly documentation provided annually

Attachment G – Medical Management

Criteria Performance Standard Damages

Notification of change in Account Manager

Notify EBD, in writing of change in Account Manager and/or ownership

Notify EBD in writing of change at least 72 business hours in advance

$0.20/PM for each day late

Medical Management Guidelines

Utilizing Trigger Lists

Utilize 99% Monthly

$0.20/PM for each error in trigger list utilization

Pre-Admission reviews and outpatient diagnostic testing reviews

Completed within two (2) business days of initial request to Contractor

$0.20/PM for each day late per occurrence

Utilization Management

Pre-certifications

Completed within two (2) business days of identification

$0.20/PM for each day late per occurrence

Customer Service

Nurse Line Availability

$0.10/PM for every hour unavailable for each occurrence of Nurse Line down

Customer Service/Communication

Toll-free telephone service

Available at specified hours

$0.10/PM for every hour phone service is unavailable

Calls answered timely five (5) days per week, excluding State holidays

95% of calls answered within 30 seconds

$0.10/PM for over 95% of calls are not answered within 30 seconds

< or = to 6% monthly

$0.20/PM when call abandonment rate is over 6%

Criteria Performance Standard Damages

Requests for Information (EBD)

EBD’s requests for information

Met no later than 24 business hours from the date and time of the request for information, unless an extension has been requested and approved PRIOR to the due date.

$0.20/PM per day for each occurrence over 24 hours

Requests for Information (Member)

Member’s requests for information

Met no later than five (5) business days from the date of the request for information, unless an extension has been requested and approved PRIOR to the due date.

$0.20/PM per day for each occurrence over five (5) business days without approved extension

Reporting (Member)

Cost savings reports

Provided within 30 days of Medical Management case closure or upon request of EBD

$0.20/PM for each day late for each request

Reporting (EBD)

Cost and Case Management Report

Completed monthly within three (3) business days of the end of the previous month

$0.10/PM for each day late per report

High Cost Claims

Completed monthly within three (3) business days of the end of the previous month

Performance Report

Within 45 days from the end of the previous quarter

Case Management Plan Performance Report

Completed annually by 30 days after the end of each plan year

Access to analytics/predictive modeling software OR provides reports to EBD

Software access or weekly reports provided by deadline

$0.20/PM for each day late per report or for each day access not available

Criteria Performance Standard Damages

File Processing

Enrollment additions, changes, and deletions

Process clean file within 24 hours of receipt

$0.10/PM for each day late and/or per error

File errors reported to EBD

Within 72 hours of receipt of file containing errors

$0.10/PM for each day over 72 hours that the error is not reported

Legislative Audit

EBD, Legislative Audit and/or any company chosen by EBD will be allowed to audit 100% of member case files per RFP requirements

$10.00/PM for each time 100% access is not accommodated per request

Attachment G – Employee Assistance Program

Criteria Performance Standard Damages

Per Contract (PC) for that monthly timeframe

Network

Notification of any changes to Statewide network

Within 3 business days of the change

$0.10/PC for each day late

State audits of Contractor

All audits allowed and positive finding addressed as required per the RFP

$0.10/PC per occurrence of non-allowance and/or of each finding

Requests for Information

Reponses to requests for information

Provide accurate and comprehensive response no later than 24 hours from the date of the request for information, unless an extension has been approved

$0.10/PC for each day late

Customer Service/Communication

Helpline

Answered by a live person 24-hours per day, 365 days per year, including holidays

$0.10/PC per occurrence

Percent of calls answered within 30-seconds

95% daily

$0.10/PC per each day below 95%

< or = to 4% daily

$0.10/PC per each day below threshold

Wait Time

Routine appointment

100% of requested appointments will be scheduled within 48 hours

$0.05/PC per occurrence

Urgent appointment

100% of requested appointments will be scheduled within 24 hours

$0.10/PC per occurrence