ATTM 010 CONTRACT FOR NON-EMERGENCY MEDICAL TRANSPORTATION COORD.docx

ATTACHMENT 010

Contract for Non-Emergency Medical Transportation Coordinator Services

TABLE OF CONTENTS

RECITALS

SIGNATURE PAGE 112

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This Contract is entered into as of the [Effective Day] day of [Effective Month], 2025, by and between the South Carolina Department of Health and Human Services, 1801 Main Street, Post Office Box 8206, Columbia, South Carolina, 29202-8206, hereinafter referred to as "Department" and [Awarded Offeror], [Awarded Offeror’s Address], hereinafter referred to as the "Contractor".

RECITALS

WHEREAS, the Department is the single state agency responsible for the administration in South Carolina of a program of Medical Assistance under Title XIX of the Social Security Act and makes all final decisions and determinations regarding the administration of the Medicaid program.

WHEREAS, the United States Department of Health and Human Services has allocated funds under Title XIX of the Social Security Act to the Department to perform certain functions.

WHEREAS, consistent with the South Carolina State Plan for Medical Assistance, the Department posted Request for Proposals 5400029919 seeking the services of a qualified Non-Emergency Medical Transportation Coordinator to provide transportation services through a risk-based payment structure, which meets the definition of a Non-Emergency Medical Transportation Broker.

WHEREAS, the Contractor represents and warrants that it meets applicable standards to enter into a risk-based contract, operate as a broker of NEMT, and receive such funds for the services to be performed under this Contract as specified by Title XIX of the Social Security Act, federal regulations promulgated pursuant thereto, and the South Carolina State Plan for Medical Assistance.

WHEREAS, the Contractor desires to provide such NEMT services and Work as more specifically outlined in this Contract.

NOW THEREFORE, the parties to this Contract, in consideration of the mutual promises, covenants, and stipulations set forth herein, agree as follows:

Section 1. CONTRACT PERIOD

The Effective Date of this Contract is [the first day of the Maximum Contract Period as specified on the final statement of award]. The initial term of this Contract is three (3) years from the Effective Date. Regardless, this Contract expires no later than the last date stated on the final statement of award.

At the end of the initial term, and at the end of each renewal term, this Contract shall automatically renew for a period of one (1) year unless Contractor receives notice that the state elects not to renew the Contract at least one hundred twenty (120) days prior to the date of renewal. Regardless, this Contract expires no later than the last date stated on the final statement of award. Contractor acknowledges that, unless excused by Section 11-57-320, if the Contractor is on the then-current Iran Divestment Act List as of the date of any Contract renewal, the renewal will be void ab initio.

Section 2. GENERAL PROVISIONS

2.1. Overarching Responsibilities

The Contractor shall perform the Non-Emergency Medical Transportation (NEMT) services in the State of South Carolina for Members.

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2.1.1. The Contractor shall manage all aspects of transportation provided under the NEMT program. The Contractor shall ensure appropriate provision of NEMT to Members, establish a Network of qualified Transportation Providers, operate a contact center for Members, verify Member eligibility, approve and arrange for NEMT, provide reimbursement to the Transportation Providers, establish Transportation Provider record keeping requirements, and track and report NEMT utilization.

2.1.2. The Contractor shall oversee and remain accountable for all functions and responsibilities of the Contractor arising pursuant to this Contract, including any functions and/or responsibilities the Contractor delegates to a Subcontractor, partner, affiliate, or other party.

2.2. Notice

2.2.1. Any notices shall be in writing and shall be deemed duly given:

2.2.1.1. upon actual delivery, if delivery is by hand,

2.2.1.2. upon receipt by the transmitting party of automated confirmation or answer back from the Member's device if delivery is by telex, telegram, facsimile, or electronic mail, or

2.2.1.3. upon deposit into the United States mail, if postage is prepaid, a return receipt is requested, and either registered or certified mail is used.

2.2.2. Notice to Contractor shall be:

[insert Contractor information]

2.2.3. Notice to the State shall be to:

South Carolina State Fiscal Accountability Authority Division of Procurement Services 1333 Main Street, Suite 700 Columbia, South Carolina 29201

2.2.4. Either party may designate a different address for notice by giving notice in accordance with this paragraph.

2.3. Definitions

Certain capitalized terms and acronyms used in this Contract shall be defined more specifically as outlined in Appendix A.

2.4. Entire Agreement

The Contractor shall comply with all of the provisions of this Contract, including appendices and any amendments, and shall act in good faith in its performance. The Contractor shall be bound by the contractual requirements stated herein. In the event of a dispute between the Contractor and the Department, the Contractor acknowledges and agrees that the Department’s interpretation shall rule. The Contractor agrees that failure to comply with the provisions of this Contract may result in the assessment of liquidated damages, the initiation of Correction Action Plans, and/or termination of the Contract in whole or in part, as set forth in this Contract. The Contractor shall comply with all applicable Department Policies and procedures in effect throughout the duration of this contract period. The Contractor shall comply with all Department bulletins and manuals relating to the provision of NEMT services under this Contract. The Contractor agrees that it is responsible for compliance with all relevant Department Policies, procedures, handbooks, bulletins, and manuals that relate in any way to this Contract. Where the provisions of the Contract differ from the requirements set forth in the handbooks and/or manuals, then the Contract provisions shall control. The Department, at its discretion, may issue Medicaid bulletins to inform the Contractor of changes in Policies and procedures that may affect this Contract. The Department is the only party to this Contract that may issue Medicaid bulletins.

2.5. NEMT as a Medicaid Benefit

The NEMT service benefit is authorized under Section 1902(a)(70) of the Social Security Act and 42 CFR 440.170 and requires the Department to: (a) ensure necessary transportation to and from Medical Providers; (b) use the most appropriate form of transportation; and (c) include coverage for transportation and related travel expenses necessary to secure medical examinations and treatment. The Department has retained Contractor through this Contract to meet those requirements.

2.6. CMS Approval of Contract

This Contract is subject to the final approval of CMS. If CMS fails to approve, the Department has the right to alter and amend this Contract to satisfy CMS requirements or to terminate this Contract, if such satisfaction cannot be obtained.

Section 3. CONTRACTOR ADMINISTRATIVE REQUIREMENTS 3.

3.1. General Administrative Requirements

The Contractor shall:

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3.1.1. Have in place the organizational, operational, managerial, and administrative systems capable of fulfilling all Contract requirements.

3.1.2. At a minimum, operate Monday through Friday, 8:00 a.m. to 6:00 p.m. Eastern Time (ET) with the exception of New Year’s Day, Memorial Day, July 4th, Labor Day, Thanksgiving Day and Christmas Day.

3.1.3. Not employ or contract with any individual who has been debarred, suspended or otherwise lawfully prohibited from participating in any public procurement activity or from participating in non-procurement activities.

3.1.4. Be obligated to screen all employees and Subcontractors to determine whether any of them have been excluded from participation in any state or federal health care programs.

3.1.5. Ensure all staff, Transportation Providers, and Subcontractors have appropriate training, education, experience, liability coverage and orientation to fulfill the requirements of their positions.

3.1.6. Employ sufficient personnel and Subcontractors of appropriate education, training, experience, and/or licensure to ensure that the requirements set forth in this Contract are met in a timely fashion.

3.1.7. Maintain compliance with contractual obligations. If noncompliance exists, the Department may employ additional monitoring and regulatory action including, but not limited to, requiring the Contractor to hire additional staff. Nothing in this section should be construed as preventing the Department from implementing any liquidated damages or Corrective Action Plans as specified in Section 15 and/or terminating this Contract. If, at any point, the Contractor fails to maintain compliance with contractual obligations, the Department reserves the right to enact any or all corrective measures defined in this Contract or available at law.

3.1.8. Be responsible for costs associated with on-site audits or other oversight activities that result when functions are located outside of the State of South Carolina.

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3.2. Staffing Requirements

The Contractor’s staff shall include, but is in no way limited to, the positions identified in this Section.

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3.2.1. The Contractor shall provide staff to perform the functions required under this Contract. The Contractor must ensure that all staff have appropriate training, education, experience, and orientation to fulfill the requirements of their positions.

3.2.2. The Contractor shall provide a staffing plan for NEMT services prior to the Operational Start Date for the Department’s approval. The staffing plan must include, at a minimum, a description of the duties, authority and responsibilities, experience, and qualifications of each of the staff, including those designated as Key Staff in Section 3.2.5. The Contractor shall include in the staffing plan procedures to secure and retain professional staff. The Contractor shall update this staffing plan annually on the anniversary of the Effective Date.

3.2.3. Additional staffing requirements:

3.2.3.1. The Contractor shall remove any of the Contractor's employees from contact with Members when the Contractor determines that:

3.2.3.1.1. The employee is not handling calls or scheduling trips in accordance with the performance standards of this Contract, or

3.2.3.1.2. Prior retraining of the employee has not resulted in corrected performance

3.2.3.2. The Contractor shall train Member service representatives in the area of dispute resolution.

3.2.3.3. The Contractor shall establish and maintain a Member advocate position or a properly trained staff person whose responsibility is to resolve Member Complaints. The Contractor shall provide the advocate's contact information to the Department upon the initial establishment of the position and upon any changes to the position thereafter.

3.2.4. Within thirty (30) days after the Effective Date of the Contract, the Contractor shall provide an organizational chart(s) indicating the number and geographic location of all staff that will perform duties under the Contract, including Contractor and Subcontractor staff. Key Staff members, off-site (i.e., location other than the Contractor's contact center facility) staff, and Subcontractor staff must be clearly identified as such on each organizational chart. The Contractor shall provide a revised organizational chart upon the change of Key Staff within thirty (30) calendar days of the change taking effect.

3.2.5. The Contractor shall employ the Key Staff members listed in Exhibit 1: Key Staff, as well as other staff as needed to effectively and efficiently manage and coordinate Contract responsibilities for the Department.

Exhibit 1: Key Staff

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3.2.6. The Department shall have the right to require that the Contractor remove any individual (whether or not they are identified as Key Staff) from assignment to this Contract. The Department may require the removal or reassignment of any Contractor or Subcontractor employee that the Department deems unacceptable. The Department’s decision on this matter is not subject to appeal. Notwithstanding the above provisions, the parties acknowledge and agree that the Contractor may terminate any of its employees that perform Work or services under this Contract, as permitted by applicable law. Replacement activity for Key Staff removed or resigning shall begin within five (5) business days. If the vacancy persists beyond forty-five (45) calendar days, the Contractor shall include status updates in a weekly report until the position is replaced.

3.2.7. Except in the circumstance of the unforeseeable loss of a Key Staff member, the Contractor shall provide written notification to the Department of anticipated vacancies of Key Staff within five (5) business days of receiving the Key Staff person’s notice to terminate employment or five (5) business days before the vacancy occurs, whichever occurs first. At that time, the Contractor shall present the Department with a written interim plan to cover the responsibilities created by the Key Staff vacancy. Likewise, the Contractor shall notify the Department in writing within five (5) business days after a candidate’s acceptance to fill a Key Staff and the candidate may not start on this Contract until they have been approved by the Department.

3.2.8. The Contractor shall be responsible for ensuring all functions under this Contract are readily reportable to the Department at all times regardless of the location of those functions. The Contractor shall ensure the location of any staff or performance of operational functions outside of the State of South Carolina does not compromise the delivery of integrated NEMT services and the seamless experience for Members and Transportation Providers. South Carolina-based staff shall maintain a full understanding of the operations conducted outside of the State of South Carolina and must be prepared to discuss these operations with the Department upon request, including during unannounced site visits.

3.3. MCO Coordination

The Contractor shall have a designated employee, qualified by training and experience, to serve as a liaison with the MCOs to promote the most optimal outcomes in terms of integrating and coordinating services between both delivery systems. This employee shall serve as a point of contact for the MCOs in helping to resolve operational (i.e., sharing of data/information) and care coordination concerns/issues; and shall work directly with the Department on strategic planning efforts to advance the Department's goals in coordinating NEMT and medical services, as well as reporting on any operational or access to care issues.

3.4. Subcontracting and Delegation of Authority

Notwithstanding any relationship(s) that the Contractor may have with any Subcontractor, the Contractor maintains ultimate responsibility for adhering to and otherwise fully complying with all terms and conditions in this Contract. The Contractor shall obtain prior approval from the Department ninety (90) days prior to the effective date of the subcontract for any delegate who will be satisfying any of Contractor’s responsibilities outlined in this Contract.

The Contractor shall:

3.4.1. Utilize written agreements for all subcontracting and delegations of activities under this Contract.

3.4.2. Be responsible for ensuring that the Subcontractor adheres to all applicable requirements set forth in this Contract.

3.4.3. Specify the delegated activities and reporting responsibilities of the Subcontractor within the subcontract agreement.

3.4.4. Include with subcontracts, provision for revoking the delegation or imposing other remedies if the Subcontractor’s performance is unsatisfactory.

3.4.5. Ensure Subcontractors meet any specified accreditation standards prior to subcontracting.

3.4.6. Monitor the Subcontractor’s performance on an ongoing basis, to include at least an annual review. This includes conducting formal reviews according to a review schedule that is consistent with industry standards, state laws, and as set forth by the Department, as applicable.

3.4.7. Pass down the requirements set forth in Section 17.30. Inspection and Retention of Records.

3.4.8. Take corrective action if the Contractor and/or Subcontractor identify deficiencies or areas for improvement related to the Subcontractor’s performance of the delegated activity.

3.4.9. Ensure the Contractor’s rights and obligations set forth in this Contract are not amended or altered if the Subcontractor subcontracts any of the delegated activity to another, and all Subcontractors and sub-subcontractors remain subject to the applicable requirements of this Contract.

3.4.10. Submit prior notice to the Department of any further delegation by the Subcontractor.

3.4.11. Ensure all subcontracts fulfill the requirements of this Contract for the service or activity delegated by the subcontract.

3.4.12. Access the Office of Inspector General (OIG) electronic databases on a monthly basis to identify whether any individuals with whom the Contractor has a relationship, contractual or otherwise, are prohibited from receiving federal funds through this Contract.

3.4.13. Shall ensure all Department data to which the Subcontractor is given access is maintained in compliance with the terms of this Contract.

3.4.14. Shall ensure a contingency plan is in place for each Subcontractor to provide for continuity of care should the Subcontractor cease to provide services that are the subject of the subcontract.

Section 4. MEMBER AND MEDICAL PROVIDER SERVICES

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4.1. Member Eligibility

South Carolina has Members in the traditional Fee for Service program and in multiple Managed Care Organizations (MCOs). Regardless of the Medicaid delivery model, any Member needing and eligible for NEMT will contact the Contractor for service. The Contractor will receive and process the 834-eligibility file as detailed within the Department’s Report Guide to identify Members. This Report Guide will be available on the Department’s dedicated webpage for NEMT services.

The Contractor shall:

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4.1.1. Systematically update its eligibility/enrollment databases within twenty-four (24) hours of receipt of said files. Any outbound 834 transactions that fail to update/load systematically must be manually updated within twenty-four (24) hours of receipt.

4.1.2. Report to the Department within twenty-four (24) hours, in a form and format provided by the Department, 834 transactions not processed within the above time frames and include information regarding when the transactions were completed.

4.1.3. Initiate a Corrective Action Plan (CAP) for resolution of the issues preventing the Contractor from compliance resulting from any transactions that are not updated/loaded within twenty-four (24) hours of receipt from the Department and/or persistent issues with high volumes of transactions that require manual upload.

4.1.3.1. If the Contractor has reason to believe they may not meet these requirements based on unusual circumstances, the Contractor must notify the Department of the reason and expectation of resolution and the Department may make an exception and not require a CAP.

4.1.3.2. Updates to an active Eligibility CAP shall be made daily until resolved. Failure to submit or meet the goals of the CAP may be subject to liquidated damages for performance or compliance failures as outlined in Section 15 of this Contract.

4.1.4. Transmit to the Department, in the formats and methods specified in Department’s Report Guide or as otherwise specified by the Department: Member address changes and telephone number changes.

4.1.5. Uniquely identify a distinct Member across multiple populations and systems within the Contractor’s span of control.

4.1.6. Identify potential duplicate records for a single Member and, upon confirmation of said duplicate record by the Department, resolve the duplication such that the enrollment, service utilization, and Member interaction histories of the duplicate records are linked or merged.

4.1.7. NEMT services are only available to Members according to Exhibit 2: Eligible Populations.

Exhibit 2: Eligible Populations

* The Department reserves the right to add additional populations

Limited Medicaid Coverage:

SLMB

Qualified Medicare Beneficiary Family Planning

Excluded

4.2. Verifying Eligibility

4.2.1. The Department bears responsibility for Medicaid eligibility determinations. Upon being determined eligible for Medicaid services, each Member receives a South Carolina Healthy Connections identification card. A Member enrolled with a Managed Care Organization may also have an identification card for the MCO. However, possession of the Medicaid card does not guarantee Medicaid eligibility for a specific date of service. The Contractor must verify a Member’s Medicaid eligibility for each trip.

4.2.2. The Contractor shall verify the Member’s eligibility by relying on a daily data file provided by the Department. The Contractor shall verify eligibility, when the Member’s information is not shown on the daily data file, via one of these methods:

4.2.2.1. The Department’s Interactive Voice Response System (IVRS). A toll-free number is available for Medical Providers to call for information regarding a Member’s last Medicaid payment and eligibility verification. The IVRS toll free number is 1-888-809-3040.

4.2.2.2. South Carolina Web-Based Claims Submission and Eligibility Verification System. This allows the Medical Provider to verify eligibility using a web-based tool. Contact the Provider Support Center at 1-888-289-0709 for information or for access to this tool.

4.2.2.3. An appropriate Department external access point (i.e., point of service (POS) device).

4.2.3. The Contractor may not recover payments from Members or Transportation Providers for Contractor-assigned trips provided to ineligible individuals.

4.3. Member Enrollment Effective Date

The effective date of enrollment will be the beginning of the month for new Members specified on the 834 unless stated otherwise by the Department.

4.4. Satisfaction Surveys

4.4.1. Trip-based Member Feedback Survey

4.4.1.1. The Contractor must offer Member feedback surveys to every Member at the end of their scheduled trip to measure Member satisfaction. The Contractor shall design a feedback mechanism that is intuitive and accessible, similar in simplicity and effectiveness to rating systems used by popular rideshare services.

4.4.1.2. Survey Distribution

The Contractor shall provide multiple options for distributing the feedback survey to Members, including but not limited to:

4.4.1.2.1. SMS/Text messaging

4.4.1.2.2. Email

4.4.1.2.3. In-app notifications

4.4.1.3. The distribution method must ensure that the majority of Members can easily receive and access the survey.

4.4.1.4. Survey Content and Length

The feedback survey shall be concise, containing no more than five (5) to seven (7) questions. Survey questions shall focus on key service aspects such as punctuality, driver behavior, vehicle cleanliness, and overall satisfaction.

4.4.1.5. The Contractor shall submit the feedback surveys and distribution method to the Department for approval prior to administering the surveys.

4.4.1.6. Ease of Response

The feedback process shall be quick and straightforward, taking no more than two (2) to three (3) minutes to complete. The Contractor shall minimize the burden on the Member while still collecting meaningful feedback.

4.4.1.7. Confidentiality

The Contractor shall ensure that Member feedback is collected anonymously to encourage honest and candid responses. The Contractor shall implement measures to protect Member privacy and confidentiality

4.4.1.8. Collection and Analysis

The Contractor shall provide the raw survey data to the Department and summarize the results, reporting to the Department on a quarterly basis. Based on the survey results, the Department may, at its discretion, require a CAP, as described in Section 15.

The Contractor must develop a CAP when Members report significant levels of dissatisfaction, when a pattern of Complaints are detected or when a serious Complaint is reported.

4.4.2. Medical Provider Satisfaction Surveys

The Contractor must conduct an annual survey of Medical Providers to determine the perception of the quality of the NEMT services and to discover Medical Provider misuse of the NEMT program.

4.4.2.1. The Contractor must conduct an annual survey of Medical Providers to whom a Member was transported to determine if appointments were actually scheduled, if the Member was seen at the designated time, and if the appointment was Medically Necessary. The Contractor shall submit the surveys and sampling method to the Department for approval prior to administering the surveys. The Contractor shall provide the raw survey data to the Department and summarize the results, reporting to the Department on an annual basis. Based on the survey results, the Department may, at its discretion, require a CAP, as described in Section 15.

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4.5. External NEMT Materials

The Contractor is responsible for informing and educating Members, counties, Medical Providers (e.g., dialysis centers), Medical Provider associations, community-based organizations (e.g., Area Agencies on Aging) and consumer representatives about NEMT services.

4.5.1. The Contractor will create written materials for potential Members and Members in a style and reading level that will utilize easily understood language and format to accommodate the reading skills of Medicaid Members. In general, the writing must be at no higher than a sixth (6th) grade level, as determined by any one of the indices below, taking into consideration the need to incorporate and explain certain technical or unfamiliar terms to assure accuracy:

Flesch – Kincaid;

Fry Readability Index;

PROSE The Readability Analyst (software developed by Educational Activities, Inc.);

Gunning FOG Index; and or McLaughlin SMOG Index

4.5.2. The written materials must be produced in English, Spanish and other languages used by at least five percent (5%) of the Member population, as determined by the Department.

4.5.3. All correspondence and written materials developed by the Contractor, intended for a Member, must be multilingual, and must be reviewed and approved by the Department prior to distribution. The Contractor shall ensure that Member information is clearly communicated with Culturally Competency. The Contractor shall make special provisions, as required under Section 1557 of the Affordable Care Act, for Members and their families who have Limited English Proficiency, or are hearing or vision impaired, including telecommunications device for the deaf (TDD)/ teletypewriters (TTY) and multi-lingual capabilities.

4.5.4. The Contractor must inform Members that information is available upon request in alternative formats and how to obtain it. Alternative formats include Braille, large font letters, audiotape, alternative languages, and verbal explanation of written materials.

4.5.5. Contractor must submit to the Department for review and approval all materials in any media that the Contractor produces for dissemination to actual and/or potential Members including but not limited to materials produced for Member education, outreach, and marketing.

4.5.6. Materials must be submitted to the Department at least forty-five (45) calendar days prior to the intended use of the materials. Materials include any call scripts, website pages, written communications other than incidental individual responses to individual inquiries. The Department shall review such documents in draft form and determine whether to grant approval for Contractor to disseminate such documents.

4.5.7. Contractor's policies and procedures pertaining to the NEMT program produced for dissemination to actual and potential Members, including but not limited to procedures for determining eligibility for NEMT coverage, also shall be subject to inspection and approval by the Department.

4.5.8. The Contractor must have in place policies and procedures to ensure that materials are accurate in content, accurate in translation relevant to language or alternate formats and do not defraud, mislead or confuse the Member. The Contractor must provide information requested by the Department for use in Member education and enrollment upon request.

4.6. Ongoing Member Engagement and Education

The Contractor shall develop and maintain a Member Engagement and Education Plan and shall submit this plan prior to the Operational Start Date and annually thereafter, to the Department.

4.6.1. The Member Engagement and Education Plan must include information on:

4.6.1.1. Informing Members of their rights, which include the right to:

4.6.1.1.1. Be treated with respect and with due consideration for dignity and privacy;

4.6.1.1.2. Receive information about available service options and alternatives presented in a manner appropriate to the Member's condition and ability to understand;

4.6.1.1.3. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation;

4.6.1.1.4. To freely exercise his or her rights, and that the exercise of those rights does not adversely affect the way the Contractor and/or its Transportation Providers, or the Department, treats the Member.

4.6.1.2. Evaluating how to best communicate with Members on how to access NEMT services, including different modalities the Contractor will utilize to keep Members apprised of upcoming NEMT trips.

4.6.1.3. Coordinating with Medical Providers and MCOs in developing strategies to address Member no shows or cancellations, with the goal being to support Members in accessing Covered Services.

4.6.2. The Contractor shall develop and publicize any Contractor incentive programs for the purpose of improving compliance with and the use of NEMT services, including decreasing “no show” instances.

4.6.2.1. Member communication materials must include information on how to contact the Contractor and schedule NEMT services, information regarding the Contractor’s policies and procedures, and information on the Complaint process. This information must also include what Members should expect from the service (e.g., identification of the vehicle, driver, timeframes, etc.).

4.6.2.1.1. The Contractor is responsible for educating Members on acceptable behavior to exhibit during transport. The Contractor must inform Members on their policy regarding Members who are chronically late or absent for scheduled trips. The policy will also cover Members whose behavior enroute threatens the safety of the Member, the driver, other passengers or the safe operation of the vehicle. Excessive incidents may result in loss of some transportation options. For example, the Contractor may require Members who are habitual no-shows to call when they are ready to for Pick-up.

4.7. Contact Center Operations

4.7.1. The Contractor must establish and maintain a staffed, toll-free, contact center to respond to telephonic and written requests and questions from various sources, including but not limited to Members, Authorized Representatives, Medical Providers, Transportation Providers, MCOs, the public, the Department, and other stakeholders.

4.7.2. A toll-free number must be staffed to meet the requirements of this Contract and shall include an automated system that is available twenty-four (24) hours a day, seven (7) days a week. This automated system must be capable of notifying the Contractor of incoming messages and ensuring that all contacts are returned within thirty (30) minutes during non-peak hours. The system must also provide callers with instructions on what to do in the case of an emergency or if an Urgent Trip is needed, as well as providing the option to leave a message for a return call. This messaging should include clear guidance on the necessary content of a message and when it will be returned. All messaging content must be reviewed and approved by the Department prior to implementation.

4.7.3. The Contractor must have a toll-free number dedicated for incoming calls to take Complaints by live voice between the hours of 8:00 a.m. and 6:00 p.m. ET, Monday through Friday with the exception of New Year’s Day, Memorial Day, July 4th, Labor Day, Thanksgiving Day and Christmas Day and by a voice messaging system for all other hours with return call required within one (1) business day of the voice message. In addition, Complaints may also be taken at any time by other means (fax, web interface, letter, e-mail).

4.7.4. The contact center must be capable of responding to telephonic and written inquiries from various sources.

4.7.5. Telephony System

The Contractor shall be responsible for the installation, operation, and monitoring of a telephony system for the contact center. The system must:

4.7.5.1. Effectively and efficiently manage all calls received and assign incoming calls to available staff in an efficient manner;

4.7.5.2. Transfer calls to other telephone lines;

4.7.5.3. Provide detailed analysis as required for the reporting requirements, as specified, including the quantity, length and types of calls received, elapsed time before the calls are answered, the number of calls transferred or referred; abandonment rate; wait time; busy rate; response time; and call volume;

4.7.5.4. Provide a message that notifies callers that the call may be monitored for quality control purposes;

4.7.5.5. Measure the number of calls in the queue, and identify peak times;

4.7.5.6. Measure the length of time callers are on hold;

4.7.5.7. Measure the total number of calls and average calls handled per day/week/month;

4.7.5.8. Measure the average hours of use per day;

4.7.5.9. Assess the busiest times and days by number of calls;

4.7.5.10. Record calls to assess whether answered accurately;

4.7.5.11. Provide a backup telephone system that shall operate in the event of line trouble, emergency situations including natural disasters, or other problems so that access to the telephone lines are not disrupted;

4.7.5.12. Provide Interactive Voice Response (IVR) options that are user- friendly to Members and include a decision tree illustrating the IVR system as required by Section 4.7.6; and

4.7.5.13. Inform the Member to dial 911 if there is an emergency.

4.7.6. Interactive Voice Response (IVR)

4.7.6.1. The Contractor shall install, operate, and monitor an IVR capable of performing, but not limited to, the following:

4.7.6.1.1. Alert callers that the call may be monitored and recorded for Quality Assurance purposes;

4.7.6.1.2. Inform the caller to dial 911 if there is an emergency;

4.7.6.1.3. Provide self-service information to callers;

4.7.6.1.4. Route Members requiring assistance with NEMT services to live agents during business hours;

4.7.6.1.5. Route Members who are stranded or have other problems requiring immediate attention for trip recovery to a live agent priority queue. This queue must be staffed whenever Members are in transit;

4.7.6.1.6. Route Medical Providers requiring assistance with NEMT services to live agents during business hours;

4.7.6.1.7. Route Medical Providers requiring assistance for scheduling dialysis standing order trips to live agents during business hours; and

4.7.6.1.8. Route callers to a Complaint queue for live agent assistance during business hours and voice messaging system during non-business hours.

4.7.7. Caller Privacy

The Contractor must train contact center staff and respect a caller’s right to privacy and confidentiality. The Contractor must train contact center staff on compliant protocol for verifying the identity of a caller and authority of a caller (if the caller is not the Member).

When a Member calls the contact center, the contact center must follow a standard procedure to verify the Member’s or Authorized Representative’s identity. The Contractor shall submit to the Department for approval their proposed identity verification procedure to be placed in their policies and procedures. The procedure must comply with Medicaid safeguarding, HIPAA, and all state and federal requirements protecting protected health information (PHI)/ personally identifiable information (PII).

4.7.8. Contact Center Resources

4.7.8.1. The Contractor shall have sufficient telephonic resources to support inbound and outbound call volumes.

4.7.8.2. The Contractor shall have sufficient data and network resources to support inbound and outbound data and information exchanges.

4.7.8.3. The Contractor shall provide sufficient resources to achieve compliance with contact center performance measures found in Section 4.7.12 and prevent disruption to service access.

4.7.8.3.1. In the event of power failure or other telephone operations failure, the Contractor shall have a back-up system capable of operating the telephone system for a minimum of eight (8) hours, at full capacity, with no interruption of services or data collection. The Contractor shall notify the Department within one (1) hour when its telephone system is on a back-up system or is inoperative for periods longer than thirty (30) minutes. The Contractor shall have a manual back-up procedure to allow requests to continue being processed if the system is down.

4.7.9. Contact Center Staffing

The Contractor shall ensure sufficient staffing of the contact center, adjusted for peak call-volume time. It is the responsibility of the Contractor to adjust resources as necessary to achieve compliance with contact center performance measures found in Section 4.7.12.

4.7.9.1. The contact center and its staff must be physically located in the United States. The contact center must have dedicated staff trained to respond to telephonic and written questions and requests including, but not limited to, such topics as:

4.7.9.1.1. Explanation of Contractor’s policies and procedures

4.7.9.1.2. Scheduling of NEMT

4.7.9.1.3. Information regarding Prior Authorization requirements

4.7.9.1.4. Information regarding NEMT

4.7.9.1.5. Resolution of service problems

4.7.9.1.6. Member Complaints

4.7.9.1.7. Contact center availability and operation

4.7.9.2. The Contractor must provide staff fluent in English, Spanish and other languages where the language is used by at least five percent (5%) of the Member population as identified by the Department.

4.7.9.3. The Contractor shall make special provisions, as required under Section 1557 of the Affordable Care Act, for Members and their families who have Limited English Proficiency, or are hearing or vision impaired, including telecommunications device for the deaf (TDD)/ teletypewriters (TTY) and multi-lingual capabilities.

4.7.9.4. The Contractor must provide a staffed, after-hours access line for callers to inquire about previously scheduled rides or same day requests for transport (including hospital, psychiatric facilities, or other inpatient facility discharges).

4.7.9.5. In accordance with Section 12.2.6, the Contractor must ensure a criminal history check is performed prior to employment of contact center staff and re-screening is periodically performed.

4.7.10. Contact Center Staff Training

4.7.10.1. The Contractor shall provide comprehensive training for contact center staff before they engage in any public contact, including answering scheduling calls, or respond to the public in writing. This training must include:

4.7.10.1.1. Sensitivity training on assisting aged and disabled persons.

4.7.10.1.2. Training on Cultural Competency.

4.7.10.1.3. Training in customer service delivery, contact center etiquette, and soft skills, including de-escalation techniques for managing hostile callers.

4.7.10.1.4. Training in communicating with individuals who are hearing or speech impaired.

4.7.10.1.5. Training on handling sensitive information and maintaining confidentiality as required by Section 4.7.7.

4.7.10.1.6. Training in using assistive technologies and tools for better caller interaction.

4.7.10.1.7. Training in stress management and self-care techniques for staff to ensure high-quality service delivery.

4.7.10.2. The Contractor must ensure access to necessary resources to assist Members with questions and trip recovery related to overnight trips.

4.7.10.3. Service staff, including scheduling staff, must be trained and knowledgeable in all aspects of NEMT service operations including scheduling, Prior Authorization procedures and Complaint processes. The Contractor shall provide a written comprehensive contact center training plan for all service staff during prior to the Operational Start Date. Changes to the contact center staff training plan must be submitted to the Department no later than thirty (30) calendar days prior to requested implementation. This contact center staff training plan is to be updated at a minimum of annually as indicated in Section 11 Reporting Requirements.

4.7.11. Contact Center Policies and Procedures

The Contractor must develop contact center policies and procedures that address staffing, hours of operation, access, and response standards, monitoring of calls via recording or other means, and compliance with standards. The Contractor shall make the policies and procedures available to the Department for review prior to Operational Start Date and any time thereafter within ten (10) business days of request.

4.7.12. Contact Center Performance Standards

The Contractor shall report on a schedule specified Section 11 Reporting Requirements and Report Guide, the following contact center performance standards:

4.7.12.1. Eighty percent (80%) of calls must be answered within thirty (30) seconds, measured on a monthly basis;

4.7.12.2. The average speed of answer shall be three (3) minutes or less, measured on a monthly basis;

4.7.12.3. The average hold time shall be sixty (60) seconds or less, measured on a monthly basis;

4.7.12.3.1. Hold time is the measure of time when a customer service representative places a caller on a hard hold. Placing a caller on mute (soft hold) is not permitted.

4.7.12.4. No more than one percent (1%) of incoming calls shall receive a busy signal measured on a monthly basis;

4.7.12.5. An abandoned rate of calls of not more than five percent (5%);

4.7.12.5.1. The abandoned rate of calls equals the number of calls abandoned each month divided by the total calls received each month.

4.7.13. Contact Center Quality Assurance

The Contractor shall record all calls for quality control, program integrity, performance standards compliance and training purposes. Contact center supervisors’ lines shall also be recorded. Administrative lines do not need to be recorded. The Contractor shall archive the call recordings from the date of the telephone call and provide access within seventy-two (72) hours to the Department upon request. The Contractor shall monitor at least five (5) “live” calls monthly of each contact center staff member by listening to the conversation in progress. The Contractor shall use this monitoring to identify problems or issues that need to be addressed and for quality control and training purposes. The Contractor shall document and retain results of this monitoring and subsequent training and submit such documentation to the Department upon request.

4.7.13.1. If the Department determines it is necessary to conduct onsite monitoring of the Contractor’s contact center functions, the Contractor is responsible for all reasonable costs incurred by Department or its authorized agent(s) relating to such monitoring if the contact center is located outside of South Carolina.

Section 5. NETWORK

5.

5.1. General Requirements

5.1.1. The Contractor shall establish a comprehensive Network of Transportation Providers to deliver NEMT to eligible Members statewide. The Network must include diverse modes of available transportation as described in Section 8.7.

5.1.2. The Contractor must provide a Network description, including the methodology the Contractor used to determine the sufficient number of Transportation Providers required, vehicle types needed to cover the Medicaid population, and the targeted total of each type of Transportation Provider. The description and supporting documentation must be submitted to the Department for approval ninety (90) days after the Effective Date of this Contract. The description and supporting documentation must be updated and submitted to the Department annually for approval.

5.1.3. The Contractor must have capacity, through signed Transportation Provider Agreements and other arrangements (such as public bus and train service, free services or reduced cost services, or mileage reimbursement), to meet all Members’ NEMT needs.

5.1.4. The Contractor shall provide services for all Members throughout the State as described in Section 8.7. The Contractor shall coordinate appropriate Medically Necessary and Department approved Exceptional Travel as explained in Section 8.12 of this Contract.

5.1.5. The Contractor shall demonstrate that the Network provides adequate access in each city or county in the South Carolina Medicaid Services Area (SCMSA), based on the number of Members and the number of trips provided.