Attachment H - Past Performance Signable Form.pdf

Business Reference Response to Past Performance Questionnaire For:

State of North Carolina Request for Proposal (RFP) Number: 30-2026-017-DHB

Provider Data Management Credentialing Verification Organization (PDM/CVO)

PART A: Name of Vendor Submitting Proposal

NAME OF VENDOR:

PART B: Company / Respondent Providing Reference

NAME OF COMPANY / AGENCY:

RESPONDENT ADDRESS: CITY, STATE & ZIP: RESPONDENT TELEPHONE NUMBER:

RESPONDENT E-MAIL ADDRESS:

RESPONDENT NAME AND TITLE:

PART C: Contract Information

PROGRAM TITLE:

BRIEF PROGRAM DESCRIPTION AND WORK PERFORMED:

CONTRACT TYPE (TIME AND MATERIAL, FIXED PRICE, COST): CURRENT PROGAM PHASE (DESIGN, OPERATIONS):

PERIOD OF PERFORMANCE (INCLUDING ALL OPTIONS): CONTRACT DOLLAR VALUE (INCLUDING ALL OPTIONS):

CONTRACTORS ROLE (PRIME OR SUB): WAS THIS A COMPETITIVELY AWARDED CONTRACT (YES / NO):

PART D: Performance Information

In the tables that follow, indicate your rating for the contractor’s performance by placing an “X” in the appropriate code to the right of each question. Refer to the Rating Descriptions above. Provide supporting information and comments for each response in the space provided. Attach additional pages if more space is needed.

TECHNICAL / BUSINESS EXPERTISE

TE1: Contractor understood the Provider Enrollment or PDM/CVO Solution and provided the technical expertise required to meet contract performance.

SUPPORTING INFORMATION: E V S M U N/A

TE2: Contractor provided staff with appropriate technical skills and training commensurate with those required for successful project completion.

TE3: Contractor deployed a Provider Enrollment or PDM/CVO Solution to a State Medicaid program.

TE4: Contractor provided an effective solution for the Provider Enrollment or PDM/CVO Solution.

TE5: Contractor solution that was deployed did not substantially deviate from solution that was proposed.

Code Rating Descriptions

E EXCEPTIONAL – Performance meets contractual requirements and exceeds many requirements to the Agency’s benefit. The contractual performance was accomplished with few minor problems for which corrective actions taken by the contractor were highly effective.

V VERY GOOD – Performance meets contractual requirements and exceeds some requirements to the Agency’s benefit. The contractual performance was accomplished with some minor problems for which corrective actions taken by the contractor were effective.

S SATISFACTORY – Performance meets contractual requirements. The contractual performance contains some minor problems for which corrective actions taken by the contractor appear or were satisfactory.

M MARGINAL – Performance does not meet some contractual requirements. The contractual performance reflects a serious problem for which the contractor has not yet identified corrective actions or the contractor’s proposed actions appear only marginally effective or were not fully implemented.

U UNSATISFACTORY – Performance does not meet most contractual requirements and recovery is not likely in a timely manner. The contractual performance being assessed contains serious problem(s) for which the contractor’s corrective actions appear or were ineffective.

QUALITY OF SERVICES

QS1. Contractor provided and followed effective quality control plan to meet program objectives.

SUPPORTING INFORMATION: E V S M U N/A

QS2. Contractor corrected deficiencies in a timely manner and pursuant to their quality control procedures.

SUPPORTING INFORMATION: E V S M U N/A

SCHEDULE AND COST

SC1. Contractor delivered services within the required time period specified by contract requirements.

SUPPORTING INFORMATION: E V S M U N/A

SC2. Contractor performed the effort within the estimated cost/price and actual costs/rates realized closely reflected the negotiated costs/rates.

SUPPORTING INFORMATION: E V S M U N/A

SC3. Contractor submitted accurate invoices on a timely basis.

SUPPORTING INFORMATION: E V S M U N/A

SC4. Contractor demonstrated cost efficiencies in performing the required effort.

SUPPORTING INFORMATION: E V S M U N/A

N/A NOT APPLICABLE – Unable to provide a rating. Contract did not include performance for this aspect, performance was not observed, or information was not available. Do not know.

PART E: General Comments and Signature PLEASE PROVIDE ANY ADDITIONAL COMMENTS CONCERNING THIS CONTRACTOR’S PERFORMANCE, AS DESIRED.

Based on what you know today about the Contractor’s ability to execute what they promised in their proposal, would you award another contract to the Contractor, if given the choice? Yes or No. Please explain in the area below.

Have there been any indications that the Contractor has had any financial problems? Yes or No. Please explain in the area below.

RESPONDENT SIGNATURE: Please provide your signature confirming the information you have provided is an objective assessment of the Contractor’s past performance.

Thank you for your prompt response and assistance!