Section_F_-_Deliveries_and_Performance.pdf

United States Department of Labor

(DOL)

Workers’ Compensation Medical Bill Process (WCMBP)

Section F Deliveries or Performance

Office of Workers’ Compensation Programs (OWCP)

Section F - Deliveries or Performance

F-i

Table of Contents

Section Page

F.1 CLAUSE INCORPORATION

F.2 PERIODS OF PERFORMANCE

F.3 PLACE OF PERFORMANCE

F.4 STOP WORK ORDER

F.5 DELIVERY SCHEDULE

F.6 WAIVER OF DELIVERY SCHEDULE: EXPRESS INTENT TO FORBEAR

F.7 NOTICE TO THE GOVERNMENT OF DELAYS

F.8 PERFORMANCE INCENTIVES

F.9 PERFORMANCE STANDARDS

F.9.1 Contract Transition F.9.1.1 Implementation Milestones F.9.1.1.1 Significant Milestones F.9.1.1.2 Deliverables

F.9.1.2 Ongoing Documentation Delivery F.9.1.3 Performance Deficiency Correction – Corrective Action Plan

F.9.1.4 Ongoing Operational Certification F.9.1.5 Certification Deficiency Correction – Corrective Action Plan

F.9.2 Information Security Standards

F.9.2.1 Security Notification

F.9.2.2 Security – Data Protection

F.9.3 Staffing F.9.3.1 Staffing – Key Position

F.9.4 Central Mailroom F.9.5 Document Imaging

F.9.5.1 Document Imaging – Incoming F.9.5.2 Document Imaging – Processing

F.9.6 Claimant Bill Development F.9.6.1 Document Processing

F.9.7 Bill Scan / Data Entry

F.9.7.1 Bill Scan / Data Entry Process F.9.7.2 Bill Scan / Data Entry Accuracy

F.9.8 Bill Processing F.9.8.1 Bill Processing – Processing Time

F.9.8.2 Bill Processing – Contractor Error F.9.8.3 Best Scan Possible

F.9.9 Third Party Liability F.9.10 Prompt Payment Bill Processing

F.9.10.1 Bill Processing – PPA Processing

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F.9.11 Return to Provider F.9.12 Edits and Audits F.9.13 Claimant Eligibility F.9.14 Provider Enrollment and Management

F.9.14.1 Provider Enrollment Package Request F.9.14.2 Provider Enrollment F.9.14.3 Provider Enrollment Notification F.9.14.4 Provider Management F.9.14.5 Provider Expiring License Notification and Deactivation

F.9.14.6 Provider Enrollment Package Images F.9.14.7 Call Center – Provider Inquiries

F.9.15 Authorizations F.9.15.1 Authorization Disposition F.9.15.2 Authorization Image Transmission F.9.15.3 Authorization Level 2 Processing F.9.15.4 Authorization Level 3 Processing F.9.15.5 Authorization Completion F.9.15.6 Triage Nurse – Notification

F.9.15.7 Triage Nurse – Provider Notification

F.9.16 Treatment Suites

F.9.17 Bill Pricing F.9.18 Pharmacy

F.9.19 Bill Resolution Requirements Performance Metric F.9.20 Payment Files Process: RV/EFT and 1099

F.9.20.1 Bill Payment – Remittance Voucher Imaging F.9.20.2 Bill Payment – 1099-MISC Processing F.9.20.3 Bill Payment – 1099-MISC -Timeliness

F.9.20.4 Bill Payment – Payment File Transmission

F.9.21 Fee Schedule Appeals

F.9.22 Adjustment Processing F.9.22.1 Adjustments F.9.22.2 Adjustments Entry

F.9.23 Fraud and Abuse Detection

F.9.24 Reporting F.9.24.1 Management Reporting - Availability F.9.24.2 Performance Reporting

F.9.24.3 Report-based Corrective Action Plans F.9.24.4 Invoice Reporting

F.9.25 Change Management F.9.25.1 Change Management – Accuracy F.9.25.2 Change Management - Timeliness

F.9.26 Communications F.9.26.1 Call Center – Speed of Answer

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F.9.26.2 Call Center – Response Accuracy F.9.26.3 Call Center –Average Response Time F.9.26.4 Call Center – Same Day Response

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FAR References

Reference Page

FAR 52.252-2, Clauses Incorporated By Reference (FEB 1998) FAR 52.242-15, Stop-Work Order (AUG. 1989)

List of Tables

Table Page

Table 1 WCMBP Plan Deliverables

Table 2 WCMBP Recurring Deliverables

Table 3 Positive Performance Incentives

Table 4 Negative Performance Incentives

Table 5 Significant Milestones and Acceptance Criteria

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F.1 Clause Incorporation

FAR 52.252-2, Clauses Incorporated By Reference (FEB 1998)

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer (CO) will make their full text available. Also, the full text of a clause may be accessed electronically at https://acquisition.gov/far/current/pdf/FAR.pdf.

All FAR references are formatted as illustrated in the incorporated clause below:

FAR 52.242-15, Stop-Work Order (AUG. 1989)

F.2 Periods of Performance

The WCMBP contract, including the base contract and options, may encompass up to seven years of services. The period of performance will begin from the date of contract award:

Base Year

Option 1

Option 2

Option 3

Option 4

Award Term 1

Award Term 2

The Government anticipates this contract to be effective for a 12-month period from the date of contract award, with the Government’s unilateral right to exercise up to six (6) option periods. Award Terms 1 and 2 are based on contract performance during Option Periods 1 through 4.

F.3 Place of Performance

The Contractor shall perform all primary activities at the Contractor’s facilities, in locations specified in the fully-executed contract, using Contractor-supplied systems.

The Contractor shall provide on-site resources for OWCP staff and representatives as stated in the Performance Work Statement (PWS), titled as Section C. The Contractor shall ensure that the contractor’s facilities, involved in bill processing and all other functions described in the PWS, meet two geographical requirements:

1. All facilities will be located in the continental U.S. and will be in compliance with the location requirements in Section 1.3.3 of the PWS.

2. All facilities will be within 180 minutes travel time by automobile from a commercial airport (as calculated by http://www.mapquest.com/directions/ [1]).

F.4 FAR 52.242-15, Stop-Work Order (AUG. 1989)

The CO may, at any time, by written order to the Contractor, require the Contractor to stop all, or any part, of the work called for by this contract for a period of 90 days after http://www.mapquest.com/directions/

F-6 the order is delivered to the Contractor, and for any further period to which both parties agree. This order will be specifically identified as a stop-work order that has been issued under this clause. Upon receipt of a stop-work order, the Contractor shall comply immediately with its terms and take all reasonable steps to minimize the costs, allocable to the work covered by the order, incurred during the period of work stoppage.

Within a period of 90 days after a stop-work order is delivered to the Contractor, or within any extension of that period to which the parties have agreed, the CO is expected to either:

Cancel the stop-work order; or

Terminate the work covered by the order as provided in the Termination clause in Section I of this contract.

When a stop-work order, issued under this clause, is canceled or the period of the order or any extension thereof expires, the Contractor shall resume work. The CO then, if applicable, will make an equitable adjustment in the delivery schedule, the estimated cost, the fee, or a combination thereof, and in any other terms of the contract that may be affected, and modify the contract, in writing, if:

The stop-work order results in an increase in the time required for, or in the Contractor’s cost properly allocable to, the performance of any part of this contract;

and

The Contractor asserts its rights to the adjustment within 30 days after the end of the period of work stoppage and provided that the CO decides that the facts justify the action, the CO may receive and act upon the claim submitted at any time before final payment under this contract.

If a stop-work order is not canceled and the work covered by the order is terminated for the convenience of the Government, the CO will allow reasonable costs resulting from the stop-work order in arriving at the termination settlement.

If a stop-work order is not canceled and the work covered by the order is terminated for default, the CO may allow, by equitable adjustment or otherwise, reasonable costs resulting from the stop-work order.

F.5 Delivery Schedule

The Government expects the Contractor to provide deliverables throughout the period of performance of the WCMBP Contract. A majority of these deliverables are identified in the PWS but some of the deliverables are identified in other sections of this solicitation. The Contractor shall deliver the deliverables listed in Table 1, Table 2, Section C (PWS), and Section L (Instructions). Section J includes templates for selected reports and letters. A vendor library, that includes detailed descriptions of key deliverables, will be made available to the successful offeror..

Table 1 WCMBP Plan Deliverables

Title Discuss in Proposal

Deliver in Proposal

Contract

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Project Management) - - - Project Management Plan (PMP) Yes No Yes

Project Schedule Yes Yes Yes Staffing Plans Yes No Yes

Key Position Resumes Yes Yes Yes Categorized Position Resumes Yes No Yes

Other Staff Resumes No No Yes Key Personnel List Yes Yes Yes

Letter(s) of Intent for Key Positions Yes Yes No Facilities Plan Yes No Yes

Subcontract Management Plan Yes Yes Yes Configuration Management Plan Yes No Yes

Quality Management Plan Yes No Yes

Implementation - - -

Technical Implementation Plan Yes No Yes Systems Architecture Description Yes No Yes

Requirements Specification Document Yes No Yes Functional Specification Document Yes No Yes Requirements Traceability Matrix Yes No Yes Bi-Monthly Functional Demo(s) Yes No Yes

Data Management Plan Yes No Yes

Training Plan Yes No Yes Training Materials Yes No Yes

User Manuals Yes No Yes Reports Aids Yes No Yes

Test Planning - - - WCMBP Test Management Plan Yes No Yes

Performance Test Plan As necessary (overview) No Yes Volume Test Plan As necessary (overview) No Yes

System Integration Test Plan As necessary (overview) No Yes Parallel Test Plan As necessary (overview) No Yes

Test Artifacts for Systems Integration Test As necessary (overview) No Yes Test Artifacts for Parallel Test As necessary (overview) No Yes Test Artifacts for Volume Test As necessary (overview) No Yes

Test Artifacts for Performance Test As necessary (overview) No Yes Test Readiness Review for Systems Integration

Test As necessary (overview) No Yes

Test Readiness Review for Parallel Test As necessary (overview) No Yes Test Readiness Review for Volume Test As necessary (overview) No Yes

Test Readiness Review for Performance Test As necessary (overview) No Yes Test Report and Results for Systems

Integration Test As necessary (overview) No Yes

Test Report and Results for Parallel Test As necessary (overview) No Yes Test Report and Results for Volume Test As necessary (overview) No Yes

Test Report and Results for Performance Test As necessary (overview) No Yes Test Report and Results from Performance

Testing

Operations - - - Operations Plan Yes No Yes

Assumption of Operations Plan Yes No Yes Provider Outreach Plan Yes No Yes Claimant Outreach Plan Yes No Yes

Medical Bill Operations Manual For DFEC As necessary (overview)

No Yes

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Medical Bill Operations Manual For DEEOIC As necessary (overview)

No Yes

Medical Bill Operations Manual For DCMWC As necessary (overview)

No Yes

Medical Bill Operations Manual For DLHWC (Upon government’s request)

As necessary (overview) No Yes

Call Flows and Call Scripts (IVR and Call Center)

As necessary (overview) No Yes

Transition-Out Plan As necessary (overview)

No Yes

Corrective Action Plans As necessary (overview) No Yes

System Certification & Accreditation Documents

System Security Plan (CSAM Input) Yes No Yes Security Risk Assessment Yes No Yes

Rules of Behavior As necessary (overview) No Yes Contingency Plan As necessary (overview) No Yes

Incident Response Plan No No Yes POA&M As necessary (overview) No Yes

MOUs / ISAs As necessary (overview) No Yes Security Control Assessment (CSAM Input) No No Yes

NIST Security Self Assessment As necessary (overview) No Yes C&A (CSAM Input) As necessary (overview) No Yes

The Contractor shall submit the deliverables listed in Table 1 to the Government. These deliverables are organized and presented in Table 1 based on the WCMBP area for which the deliverable will be developed. The exact dates for the delivery of each deliverable will be defined when the Project Schedule is finalized. Table 2 lists the currently identified WCMBP Recurring Deliverables with the delivery intervals. This list is subject to change.

Table 2 WCMBP Recurring Deliverables

Implementation Phase:

Document Interval Program

Project Status Report Weekly All

Project Schedule Update Weekly All

Program Management Report Monthly All

Executive Program Management Report Quarterly All

Operations Phase:

Services Denied by Bills Examiner On Demand DCMWC

Services Force Paid by Bills Examiner On Demand DCMWC

Determination Test and DCMWC Consultant Bills on Suspense File On Demand DCMWC

Aged Detail Suspense Report Daily DCMWC

Top 10 Bills Approved for Payment Weekly DCMWC

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Voucher and Schedule of Payments Weekly DCMWC

Denied Determination Test and DCMWC Consultant Bills Weekly DCMWC

Paid Determination Test and DCMWC Consultant Bills Weekly DCMWC

Bill/Document Total Count Control Report Original Paid and Denied Bills – Summary or Detail Option

Weekly DCMWC

Bill/Document Total Count Control Report Paid and Denied Adjusted Bills

Weekly DCMWC

Remittance Activity Control Totals On Demand DCMWC

Claimant EFT Register Weekly DCMWC

Claimant Check Register Weekly DCMWC

Provider Check Register Weekly DCMWC

Final Payment Summary Weekly DCMWC

Provider EFT Register Weekly DCMWC

Medical Bill Audit Sample On Demand DCMWC

Black Lung Audit Check List On Demand DCMWC

Audit Summary Form On Demand DCMWC

Services Denied by Bills Examiners On Demand DEEOIC

Services Force Paid by Bills Examiners On Demand DEEOIC

Aged Detail Suspense Report Daily DEEOIC

Prompt Pay Bills Summary – Paid and Denied Quarterly DEEOIC

Bills Processing Paid, Denied and Adjustments Summary by Bill Type

Weekly DEEOIC

Claimant Check Register Weekly DEEOIC

Voucher and Schedule of Payments (Check) Weekly DEEOIC

Remittance Activity Control Totals On Demand DEEOIC

Bill Timeliness/Prompt Pay Report Quarterly DEEOIC

Provider Check Register Weekly DEEOIC

Provider EFT Register Weekly DEEOIC

Prompt Payment Act (PPA) Report Quarterly DEEOIC

Voucher and Schedule of Payments Weekly DEEOIC

Medical Bill Audit Sample On Demand DEEOIC

Energy Audit Check List On Demand DEEOIC

Audit Summary Form On Demand DEEOIC

EEOICP Authorization Pended more than 3 Days Report Monthly As Requested

DEEOIC

Weekly/Year-to-Date Financial Summary Weekly DFEC

FECA Pended Authorizations Report Monthly As Requested

DFEC

Medical Policy/Criteria Listing by Procedure Code/Modifiers Yearly and As Required

DFEC

Medical Policy/Criteria Listing by Diagnosis Yearly and As Required

DFEC

List of Reports generated by the WCMBP Quarterly DFEC

Edit/Audit Analysis by Edit/Audit Bill Type Report Weekly DFEC

PDCS Interface Summary Report Weekly/Monthly As Requested

DFEC

OCR HCFA TCN/Batch Control Report Weekly As Requested

DFEC

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Medical Policy/Criteria Listing by Diagnosis Yearly and As Required

DFEC

List of Reports generated by the WCMBP DFEC

OCR UB TCN/Batch Control Report Weekly As Requested

DFEC

Resolved Billed/Paid Amount Report Weekly DFEC

Weekly Approved Pay Summary by Bill Type Weekly DFEC

Prompt Payment Act (PPA) Report of Prompt Pay Testing and OWCP Consultant Bills in Suspense File

Weekly DFEC

Inpatient Bill Monitoring Report Quarterly DFEC

Claim Credit Exception Report Weekly DFEC

Claim Adjustment Exception Report Weekly DFEC

Gross Adjustment Exception Report Weekly DFEC

Weekly Inventory of Adjusted Bills Weekly DFEC

Suspended Aging Report By Edit Group Weekly DFEC

Services Denied By Bills Examiners On Demand DFEC

Services Force Paid by Bills Examiners On Demand DFEC

Bill Type Suspense Action Summary Report Weekly DFEC

Forced/Denied Exception Monitoring Report Weekly DFEC

Age of Bills Upon Arrival in Edit Group Report Weekly DFEC

Check Register Report Weekly DFEC

Provider EFT Register Report Weekly DFEC

Suspended Aging Report By Edit Group and TCN Weekly DFEC

Remittance Vouchers to Providers Weekly DFEC

Remittance Vouchers to Claimants Weekly DFEC

Medical Payment Summary Quarterly/ Yearly DFEC

Text Edit/Audit Control Report Weekly DFEC

Weekly/Year-to-date Final Payment Summary Weekly DFEC

Over/Under Payment Detail Report Weekly or As Requested

DFEC

Top 10 Bills Approved For Payment Weekly or As Requested

DFEC

Voucher and Schedule of EFT Payments Weekly DFEC

Prompt Payment Act (PPA) Report of Denied Prompt Pay Testing and OWCP Consultant Bills

Weekly DFEC

Prompt Payment Act (PPA) Financial Summary Report of Paid Prompt Pay and OWCP Consultant Bills

Monthly DFEC

Check Register Statistical Data Weekly DFEC

Provider Form 1099 Summary Earning Report and Provider Earning Report Form

Yearly DFEC

Provider Adjustment Overpayment Report Weekly DFEC

Mass Credit/Adjustment Analysis Report On Demand DFEC

Bills Returned and Voided Summary Report Weekly DFEC

Edit Action Summary Report Daily DFEC

Edit/Audit Group Action Summary Report Daily DFEC

Eligibility Suspended Bill Aging Report Weekly DFEC

Age of Bills Processed to Resolution Report Weekly DFEC

Suspended Bill Aging Report by Age Weekly DFEC

Suspended Bill Edit Worksheet Daily DFEC

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Alphabetic Listing of Payable Drugs and Medical Policy/Criteria Yearly and As Required

DFEC

Provider File report by ZIP Code Yearly and As Required

DFEC

Provider File Report by Tax ID Yearly and As Required

DFEC

Provider File Report by Alphabetic Name Yearly and As Required

DFEC

Provider File Report By Provider Number Quarterly and As Required

DFEC

Provider File Update Report Weekly DFEC

Text Edit/Audit Control and Associated Explanation of Benefit Report Monthly and As Requested

DFEC

FECA Authorization Pended more than 3 Days Report Monthly As Requested

DFEC

DRG Summary Report Weekly As Requested

DFEC

FECA Prior Authorization Letter Generation Report Daily DFEC

Prompt Pay Cost Summary Report Quarterly DFEC

Treatment Cost Summary Report Quarterly DFEC

Durable Medical Equipment Cost Summary Report Quarterly DFEC

Vocational Rehabilitation/ Home Health/Contract Nursing Cost Summary Report

Quarterly DFEC

Treatment Travel Cost Summary Report Quarterly DFEC

Drug Cost Summary Report Quarterly DFEC

Outpatient Bill Monitoring Report Quarterly DFEC

Authorization Related Bill Processing Monitoring Report Quarterly DFEC

Drug Bill Monitoring Report Quarterly DFEC

Provider Large Payment Monitoring Report Weekly DFEC

Claimant Large Payment Monitoring Report Weekly DFEC

Weekly Over $50,000 Bill Report Weekly DFEC

Quality Assurance - Identified Error Report Monthly DFEC

Field Level Accuracy Report On Demand DFEC

Transmit Report As Required DFEC

Daily Summary - Documents Processed Daily DFEC

FECA Case Statistical Summary Report On Demand DFEC

FECA Case Statistical Detail Report On Demand DFEC

DFEC Imaging - Transmit Report As Required DFEC

DFEC Imaging - Transmit Report Summary As Required DFEC

DFEC Imaging - Control Report As Required DFEC

DFEC Imaging - Accuracy Report As Required DFEC

Status Report – one for each OWCP Program Daily and As requested

COR

WCMBP Performance Report Card – one for each Program Monthly COR

Invoice Report Detail – Includes all three Programs Monthly COR

Invoice Report Detail – Comprehensive Error Adjustment Report Monthly COR

Invoice Report Detail – Pass-through Report Monthly COR

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License Termination Warning As Required DCMWC, DEEOIC,DFEC

Program Totals Report Daily DCMWC, DEEOIC,DFEC

F.6 Waiver of Delivery Schedule: Express Intent to Forbear

None of the following shall be regarded as an extension, waiver, and/or abandonment of the delivery schedule and/or a waiver of the Government’s right to terminate for default;

(i) Delay by the Government in terminating for default;

(ii) Acceptance of delinquent deliveries; and/or

(iii) Acceptance or approval of samples submitted either after default in delivery and/or in insufficient time for the Contractor to meet the delivery schedule.

Any assistance rendered to the Contractor on this contract and/or acceptance by the Government of delinquent goods or services hereunder, will be solely for the purpose of mitigating damages, and is not to be construed as an intention on the part of the Government to condone any delinquency, or as a waiver of any rights the Government may have under subject contract.

Notwithstanding the foregoing, this provision is not intended to permit the Government to extend its forbearance period in perpetuity. Accordingly, the Government’s right to terminate for default based on a particular failure(s) by the contractor must be exercised within a reasonable period of time, which is defined for purposes of this procurement contract as a period extending

6 years following the contractor’s receipt of a formal Cure Notice from the Contracting Officer specifying the failure (or failures) forming the basis for the termination decision.

F.7 Notice to the Government of Delays

The Contractor shall immediately notify the CO and the COR in writing, giving pertinent details, in the event the Contractor:

Encounters difficulty in meeting performance requirements

Anticipates difficulty in complying with the contract delivery schedule or completion date

Becomes aware that an actual or potential situation is delaying or threatens to delay the timely performance of this contract

This notification is considered informational in character only, and this provision is not to be construed as a waiver by the Government of any delivery schedule or date, or any rights or remedies provided by law or under this contract.

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F.8 Performance Incentives

In addition to the Award Term(s) discussed in Section H, the contractor may qualify for Positive Performance Incentives for exceeding (i.e., satisfactorily completing prior to the scheduled date) certain performance metric standards, or may be assessed Negative Performance Incentives for failure to meet certain performance metrics. Negative Performance Incentives are necessary to protect the Government from the adverse effects of a contractor’s failure to adhere satisfactorily to the contract schedule. The failure to meet one performance metric may lead to failures to meet other such metrics, in a cascading effect. Any of these failures may cause the Government to incur additional costs that cannot be determined with certainty at the outset of the contract, but which may reasonably be approximated by the schedule of Negative Performance Incentives provided for here.

Amounts due the Government as Negative Performance Incentives may be assessed by deduction from any money payable to the Contractor pursuant to this contract, or by offset against any other money due the contractor from the United States. The Government will notify the Contractor in writing of any such assessment at least thirty

(30) calendar days prior to the date the Government makes the deduction or offset. If no monies are due, or if the amounts due are insufficient to satisfy any assessed Negative Performance Incentives, the Government may enforce such Negative Performance Incentives by asserting Government claims for the amount of the assessments. Performance Incentives (both Positive and Negative) will be calculated on the basis of business days. A Negative Performance Incentive, arising from any failure to meet a performance metric, may be assessed separately or in combination with other assessments for other failures. Multiple assessments may relate to overlapping periods of time, so long as each assessment is calculated for just one failure.

Negative Performance Incentives will neither accrue nor be assessed when the contractor’s failure to meet a specified metric is due to Government-ordered suspension or Stop-Work, or to diminution or delay of service arising from causes beyond the control and without the fault or negligence of the Contractor. Examples of such causes include (1) acts of God or of the public enemy, (2) acts of the Government in either its sovereign or contractual capacity, (3) fires, (4) floods, (5) epidemics, (6) quarantine restrictions, (7) strikes, (8) freight embargoes, (9) unusually severe weather, and (10) Government-declared disasters. Although evaluation of the contractor’s performance against performance metrics will occur throughout the term of the contract, in order to allow for a ramp-up period, Negative Performance Incentives related to metrics assigned to the Operations Phase will accrue, but will not be enforced (i.e., assessed) until six (6) months after the Contractor is scheduled to assume responsibility for operations of the WCMBP. The Government may, in its sole discretion, reduce the amount of, or waive entirely, any assessment of Negative Performance Incentives. The exercise of such discretion in any instance(s) shall not be construed as a waiver of the Government’s right to enforce any Negative Performance Incentive in any other instance(s).

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All Performance Metrics are listed in Section F.10. The Performance Metrics with Positive Performance Incentives are itemized in Table 3, along with the associated incentive payment.

Table 3 Positive Performance Incentives

Section Metric Positive Incentive F.9.1.1.1 Significant Milestone – Operational Go-

Live $5,000 for each business day, up to a maximum of 30 business days

The Performance Metrics with Negative Performance Incentives are itemized in

Table 4, along with the associated payment due to the Government.

Table 4 Negative Performance Incentives

Section Metric Negative Incentive F.9.1.1.1 Significant Milestone – Operational Go-Live The Contractor shall be liable for a daily charge of $149,000 for each business day after the go live date. For purposes of this section only, Business Days are defined as: weekdays Mon-Fri (Federal Holidays excluded). If there is a contract change to the Go-Live date, then this negative incentive will apply to the changed milestone date.

F.9.2.2 Security – Data Protection The Contractor shall take corrective actions, as determined by the Government on a case by case basis, in redress of unauthorized PII disclosures that are determined to be the fault of the Contractor

F.9.8.2 Bill Processing – Contractor Error The Contractor shall reprocess and/or adjust incorrectly adjudicated/paid bills at no charge to the Government, as many times as required until the bill is correctly adjudicated and paid

F.9.14.5 Provider Expiring License Notification and Deactivation The Contractor shall be liable for any medical bills paid to a provider with expired license due to the Contractor’s failure to deactivate medical providers once license deactivation deadline has been passed

F.9.20.3 Bill Payment – 1099-MISC Timeliness The Contractor shall be responsible for any fines, fees or other expenses charged by the IRS as noted in IRS Publication 1220 for the tax year in which the late 1099s were postmarked after the mandatory mail by date

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F.9 Performance Standards

The following sections define the performance metrics for the WCMBP program. The Contractor shall calculate and report on its performance against these metrics to the Government during WCMBP Operations. As discussed above, the Government may award positive incentive cash payment(s) or assess negative incentive deductions based on the Contractor’s performance against the performance metrics.

The performance metrics are arranged by functional area, similarly to the PWS. The PWS functional areas include references to appropriate metrics in this section.

Section H discusses the award of contract extension(s) - called Award Term(s) – based on the Contractor’s performance against the Award Term Plan (ATP).

F.9.1 Contract Transition

F.9.1.1 Implementation Milestones

F.9.1.1.1 Significant Milestones

The Contractor shall meet all significant implementation milestones as set forth in the

Contractor’s project schedule, and as approved and accepted by the Government according to the published criteria in Section E of this contract. Significant milestones include those that impact the overall implementation schedule critical path including:

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Table 5 Significant Milestones and Acceptance Criteria

Key Milestone Deliverable Acceptance Criteria

1. Preliminary Design Review (PDR) -- Requirements Phase Complete

1. Requirement Specification Document (RSD)

2. Functional Specification Document (FSD)

3. Requirements Traceability Matrix (RTM) for Requirements Phase (shows mapping for all requirements thru the RSD and FSD level)

4. Updated IMS if appropriate

5. Meeting minutes/action items

1. All requirements are included in the RSDs and all functional requirements are included in the FSDs, and the RSDs and FSDs have been reviewed and approved by the Government.

2. Mapping for all requirements through the RSD and FSD level has been documented in the RTM for Requirements Phase, and the RTM for Requirements Phase has been reviewed and approved by the Government.

3. Contractor has conducted a successful Preliminary Design Review for the Government:

Preliminary designs and flows are presented by contractor

Detailed timelines for completing detailed designs are reviewed and confirmed with each stakeholder to be accurate

All follow-ups and risks that are generated from the PDR have been documented with plans for resolution/closure approved by the government.

4. Resolution / closure plans for all known action items that are not closed as of the milestone have been reviewed and approved by the Government. Each resolution / closure plan should state when and how the action item will be resolved / closed.

5. PDR meeting minutes have been approved by the government.

2. Critical Design Review (CDR) - Design Phase Complete

1. System Architecture Description - describes how the system should function and be constructed to provide the capabilities defined in the FSDs. This document includes:

Logical architecture

Physical architecture

Data model

Security model

Interfaces – External and Internal

User roles

2. RTM for Design Phase

(expands mapping for all

1. System Architecture Description has been reviewed and approved by the Government.

2. Detailed technical designs have been completed and briefed to the Government.

3. Mapping for all requirements through the

RSD, FSD, and configuration item/allocated baseline levels has been documented in the RTM for Design Phase, and the RTM for Design Phase has been reviewed and approved by the Government.

4. Contractor has conducted a successful Critical Design Review for the Government:

All contractor organizations involved in Development and Testing are present and accounted for

F-17 requirements to the configuration item/allocated baseline level)

3. Updated IMS if appropriate

4. Meeting minutes/action items

Detailed designs that each contractor organization is responsible for are discussed / reviewed, including Screen flows Screen designs Form and letter designs Report designs Detailed system interface designs Data mapping

Detailed timelines for completing development and testing are reviewed and confirmed with each stakeholder to be accurate.

All follow-ups and risks that are generated from the CDR have been documented with plans for resolution/closure approved by the government.

5. Resolution / closure plans for all known action items that are not closed as of the milestone have been reviewed and approved by the Government. Each resolution / closure plan should state when and how the action item will be resolved / closed.

6. CDR meeting minutes have been approved by the government.

3. Development Phase Complete

1. SIT Plan

2. SIT Test Artifacts, to include:

Test Scenarios

Test Cases

Use Cases

Test Scripts and Procedures

3. RTM for Development

Phase (expands mapping for all requirements to the test scenario and test case level)

4. SIT TRR documentation

5. Bi-Monthly Functional

Demo(s)

1. Bi-Monthly Functional Demo(s) showing increasing functionality achieved by the development teams have been conducted at agreed upon dates for Government.

2. The completed software was delivered into the test environment with functionality as specified in the FSDs.

3. All code in the development baseline is completed, unit tested, and signed off by the Contractor development team

4. Unit test documentation as defined in the Contractor’s Unit Test process completed for each component tested provided in the TRR documentation

5. All software components are under CM control and stored in the version controlled repository

6. SIT TRR successfully conducted and the meeting minutes have been approved by the government.

7. Unit testing is complete and results are available for Government review

8. SIT Plan is complete and has been approved by

DOL

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9. Resolution / closure plans for all known action items that are not closed as of the milestone have been reviewed and approved by the Government. Each resolution / closure plan should state when and how the action item will be resolved / closed.

10. SIT Test artifacts have been approved by the Government

4. System Integration Test, Parallel and P&V Test Phase Complete

1. SIT Test Report

2. Parallel Test Artifacts

3. Parallel TRR Documentation

4. Parallel Test Report

5. Performance and Volume

Test Artifacts

6. Performance and Volume

TRR Documentation

7. Performance and Volume

Test Report

8. RTM for Testing Phase

(expands mapping for all requirements to the test scenario and test case level with test result documented)

Systems Integration Test (SIT)

1. All SIT test cases executed with disposition as

“passed” or “failed” by the Contractor.

2. All SIT defects have been documented and available for government review.

3. Any other SIT exit criteria, as described in the

DOL approved SIT test plan, have been met

4. SIT Test results generated and reviewed with

DOL, and any test results that DOL does not concur with are documented with mitigation plan agreed upon by DOL and the Contractor

5. No severity level 1 or 2 defects open. Severity level 3 and 4 defects are prioritized and have a corrective action plan stating what the Contractor will do and when the defect will be fixed or when a work around will be identified.

Volume & Performance Test (V&P)

6. All V&P test cases executed with disposition as “passed” or “failed” by the Contractor.

7. All V&P defects have been documented and available for government review.

8. Any other V&P exit criteria, as described in the DOL approved V&P test plan, have been met

9. V&P Test results generated and reviewed with DOL, and any test results that DOL does not concur with are documented with mitigation plan agreed upon by DOL and the Contractor

10. No severity level 1 or 2 defects open. Severity level 3 and 4 defects are prioritized and have a corrective action plan stating what the Contractor will do and when the defect will be

Parallel Test

11. All parallel test cases executed with disposition as “passed” or “failed” by the Contractor.

12. All parallel test defects have been documented

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13. Any other parallel test exit criteria, as described in the DOL approved parallel test plan, have been met

14. Parallel Test results generated and reviewed with DOL, and any test results that DOL does not concur with are documented with mitigation plan agreed upon by DOL and the Contractor

15. No severity level 1 or 2 defects open. Severity level 3 and 4 defects are prioritized and have a corrective action plan stating what the Contractor will do and when the defect will be fixed or when a work around will be

16. GAT TRR successfully conducted

5. Government Acceptance Testing Complete

1. Assumption of Operations Plan

1. All GAT test cases executed with a disposition as “passed” or “failed” by the Contractor.

With written Government approval, test cases can have a disposition as “waived” or “deferred” within GAT.

2. Defects corrected during GAT are regression tested, documented, and available for government review.

3. Any other GAT exit criteria, as described in the DOL approved GAT test plan, have been met

4. GAT Test results generated and reviewed with DOL, and any test results that DOL does not concur with are documented with mitigation plan agreed upon by DOL and the Contractor

5. No severity level 1 or 2 defects open. Severity level 3 and 4 defects are prioritized and have a corrective action plan stating what the Contractor will do and when the defect will be

6. Operational Readiness Review and Certification Complete

1. Operational Certification Checklist

2. Operational Certification Statement

3. Operations Readiness Review documentation

1. Operational Certification Checklist completed and approved by DOL

2. Operations Readiness Review conducted successfully

3. Operational Certification Statement completed and submitted to DOL

7. Transition to Go Live Phase Complete

1. WCMBP Solution 1. Successful completion of all tasks / activities outlined in Assumption of Operations Plan

2. DOL has granted approval in writing for system Go Live

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Applicable Phase(s): Implementation Phase

Applicable Requirement(s): Applicable to numerous milestone-related requirements throughout Attachment 3 – Performance Work Statement, and E.2.1.

Method of Measurement: As Scheduled – The Government will track and monitor the Contractor’s compliance with agreed upon dates.

Performance Metric: All deliverables listed for the milestone are 100% timely and accepted by the Government and all acceptance criteria listed for the milestone have been satisfied as confirmed by the Government

Positive Performance Incentive: For each business day, before the agreed date for the Operational Go-Live event that the Contractor’s full operational WCMBP capability is certified by the Government as ready to perform the Operational Requirements, the Government will pay a positive incentive of $5,000 for each business day, up to a maximum of 30 (business) days.

Negative Performance Incentive: The negative performance incentive will be $149,000 for each business day after the go live date. , For purposes of this section only, Business Days are defined as: weekdays Mon-Fri (Federal Holidays excluded).

If there is a contract change to the Go-Live date, then this negative incentive will apply to the changed milestone date.

F.9.1.1.2 Deliverables

The Contractor shall submit acceptable deliverables on time, as set forth in the Contractor’s project schedule and as approved by the Government. Acceptance is according to the published criteria in Section E of this contract.

Applicable Phase(s): Implementation Phase

Applicable Requirement(s): Applicable to numerous deliverable-related requirements throughout Attachment 3 – Performance Work Statement, and E.2.1.

Method of Measurement: Timely delivery and quality deliverable– The Government will review deliverables for acceptance (quality deliverable), and track and monitor the Contractor’s compliance with agreed upon dates.

Performance Metric: Deliverables are 100% timely and accepted by the Government

Positive Performance Incentive: None

Negative Performance Incentive: None

F.9.1.2 Ongoing Documentation Delivery

The Contractor shall deliver acceptable updates to the following documentation within 5 business days of the start of each Federal fiscal quarter:

Requirements Specification

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Central Bill Process Medical Bill Operations Manual

Applicable Phase(s): Implementation and Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0021 – C.R0024, E.2.1.

Method of Measurement: Quarterly – The Government will review deliverables for acceptance, and monitor the Contractor’s compliance with all dates.

Performance Metric: Deliverables are 100% timely and accepted by the Government

Positive Performance Incentive: None

Negative Performance Incentive: None

F.9.1.3 Performance Deficiency Correction – Corrective Action Plan

Upon identification by the Government of a deficiency in performance, the Contractor shall develop a corrective action plan for delivery within three (3) business days, unless otherwise provided under separate contract provisions, for the metric(s) in question.

The Contractor shall modify and finalize the corrective action plan within one (1) workday after receiving Government feedback.

Applicable Phase(s): Implementation and Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0038

Method of Measurement: Periodic – The Government will monitor the Contractor’s performance.

Performance Metric: Deliverables are 100% timely

Positive Performance Incentive: None

Negative Performance Incentive: None

F.9.1.4 Ongoing Operational Certification

The Contractor shall maintain its operational certification, including compliance with all FISMA requirements, according to the Government’s specifications, with regard to the Contractor’s operations, including supporting systems, processes, call center, reporting, Federal security requirements, disaster recovery site, documentation, staffing, etc.

Applicable Phase(s): Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0124, C.R0142

Method of Measurement: Ongoing – The Government will monitor the Contractor’s compliance.

Performance Metric: Government certification of operational capability is maintained at 100%

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Positive Performance Incentive: None

Negative Performance Incentive: None

F.9.1.5 Certification Deficiency Correction – Corrective Action Plan

The Contractor shall immediately notify the Government when any deficiency is identified that may negatively impact certification or recertification requirements. The Contractor shall develop and submit corrective action plan(s) for the deficiency(s) within three (3) business days and modify and finalize the corrective action plan within one (1) workday after receiving Government feedback. Upon approval of the corrective action plan by the Government, the Contractor shall correct the deficiency(s) without negative performance incentives being assessed. If the Government determines that deficiency(s) is so substantial as to significantly degrade operations, the Government’s Certification will be removed.

Applicable Phase(s): Operations

Applicable Requirement(s): Addresses requirements including, but not limited to R0038

Method of Measurement: Ongoing – The Contractor monitors WCMBP performance

Performance Metric: Notice provided upon identification of deficiency in 100% of instances

Positive Performance Incentive: None

Negative Performance Incentive: None

F.9.2 Information Security Standards

The following performance metrics are associated with security requirements.

F.9.2.1 Security Notification

As documented in Section 3.2.2 of the PWS, the Contractor shall use a Government-approved report form to notify the Government of all security incidents involving Personally Identifiable Information (PII) within one (1) hour of becoming aware of the incident

Applicable Phase(s): Implementation and Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0175, C.R0176

Method of Measurement: Periodic – The Government will monitor the timeliness of the Contractor’s reports of known incidents against time of occurrence. Additional documentation related to time of incident confirmation may be considered if provided by the Contractor.

Performance Metric: Notice is 100% timely

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Negative Performance Incentive: None

F.9.2.2 Security – Data Protection

The Contractor shall protect the Personally Identifiable Information (PII) of all claimants, providers, and Government employees from unauthorized disclosure.

Applicable Phase(s): Implementation and Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0153-C.R0159

Method of Measurement: Monthly – the Government will monitor reports for any occurrence of unauthorized disclosure.

Performance Metric: Zero (0) unauthorized disclosures of PII

Positive Performance Incentive: None

Negative Performance Incentive: The Contractor shall take corrective actions, as determined by the Government on a case by case basis, in redress of unauthorized PII disclosures that are determined to be the fault of the Contractor.

F.9.3 Staffing

The following Performance Metrics are associated with staffing requirements.

F.9.3.1 Staffing – Key Position

The Contractor shall ensure that no Key Positions remain unfilled due to attrition or scheduled leave for more than 30 consecutive calendar days

Applicable Phase(s): Implementation and Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0208

Method of Measurement: Periodic – The Government will monitor backfill times for Key Positions as vacancies occur.

Performance Metric: Zero (0) Key Positions unfilled due to attrition or scheduled leave for more than 30 consecutive calendar days

Positive Performance Incentive: None

Negative Performance Incentive: None

F.9.4 Central Mailroom

There are no Performance Metrics associated with mailroom requirements.

F.9.5 Document Imaging

The following Performance Metrics are associated with imaging requirements.

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F.9.5.1 Document Imaging – Incoming

The Contractor shall ensure that all OWCP mail received is opened, scanned, indexed, and made available to the Government within a monthly average of 2 business days.

Applicable Phase(s): Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0238 – C.R0295, C.R0422, C.R1011--C.R1012, C.R1039 --C.R1041, C.R1092 --

C.R1094, C.R1104—CR1118

Method of Measurement: Monthly – The Government will monitor performance reports for timeliness and completion rate of OWCP mail handling, imaging/indexing, and transmittal.

Performance Metric: 100% of the documents received have been processed through the processing procedures, required to make the document available to the Government, within a monthly average of 2 business days.

OWCP documents are considered ‘available when placed on the landing zone for pick up by DOL and uploaded onto the Government network.

Bill-related documents are considered available when loaded into the Contractor’s document repository and corresponding data transmitted to the bill processing system.

Return to Provider (RTP) / Return to Claimant (RTC) letters are considered available when loaded into the Contractor’s document repository and accessible for viewing to authorized users.

Negative Performance Incentive: None.

F.9.5.2 Document Imaging – Processing

The Contractor shall maintain, during each reporting period, the accuracy levels specified in the PWS of 99.5% for document key fields and 98% accuracy for all other fields

Applicable Phase(s): Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0286

Method of Measurement: Monthly – The Government assessment of performance reports based on the Contractor’s daily quality control monitoring of all documents imaged using a minimum 2% random sample.

Performance Metric: Reporting period accuracy levels of 99.5% for document key fields, and 98% accuracy for all other fields

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F.9.6 Claimant Bill Development

The following Performance Metrics are associated with claimant bill development requirements.

F.9.6.1 Document Processing

The Contractor shall ensure that all OWCP document mail is processed and data is transmitted to the Government within a monthly average of 2 business days from receiving the mail into the contractor’s facility.

Applicable Phase(s): Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0278

Method of Measurement: Monthly – The Government will monitor performance reports for timeliness and completion rate of OWCP document handling, imaging/indexing, and transmittal.

Performance Metric: 100% of OWCP documents received have been processed through the processing procedures, required to make the document available to the Government, within a monthly average of 2 business days. Positive Performance Incentive: None

Negative Performance Incentive: None

F.9.7 Bill Scan / Data Entry

The following Performance Metrics are associated with bill scan / data entry requirements.

F.9.7.1 Bill Scan / Data Entry Process

The Contractor shall ensure that all bills received are opened, scanned, and made available to the Government within a monthly average of 2 business days

Applicable Phase(s): Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0238 – C.R0247, C.R0316 – C.R0346, C.R1039, C.R1040, C.R1104

Method of Measurement: Monthly – The Government’s assessment of performance reports.

Performance Metric: 100% bills received are processed through appropriate data entry procedures within a monthly average of 2 business days of receipt.

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F.9.7.2 Bill Scan / Data Entry Accuracy

The Contractor shall maintain reporting period accuracy levels of 99.5% for bill data entry in key fields, and 98% accuracy for all other fields. Key fields include but are not limited to:

Pay to Provider

Date of Service

Procedure Codes

Claimant ID

Units

Charges

Diagnosis for all bill types

Medicare Number

For UB bills also Blocks 50B (Payer), 67, 80 and Revenue Codes

Applicable Phase(s): Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0342

Method of Measurement: Monthly – The Government’s assessment of performance reports based on the Contractor’s daily quality control monitoring of each receipt date using a minimum 2% random sample by bill type.

Performance Metric: Reporting period accuracy levels of 99.5% for bill data entry in key fields, and 98% accuracy for all other fields.

Positive Performance Incentive: None

Negative Performance Incentive: None

F.9.8 Bill Processing

The following Performance Metrics are associated with bill processing requirements.

F.9.8.1 Bill Processing – Processing Time

The Contractor shall pay or deny bills (excluding Prompt Pay & Determination bills) within 28 calendar days of receipt. Contractor’s processing time does not include time spent by the Government to review bills.

Applicable Phase(s): Operations

Applicable Requirement(s): Addresses requirements including, but not limited to C.R0377

Method of Measurement: Monthly – The Government’s assessment of performance reports

Performance Metric: 100% of the received bills (excluding Prompt Pay & Determination bills) are processed through appropriate procedures to pay or deny within 28 calendar days of receipt

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Negative Performance Incentive: None

F.9.8.2 Bill Processing – Contractor Error

The Contractor shall ensure that bill processing errors caused by the Contractor, that result in Reprocessing/Adjustments, do not exceed two (2) percent of the total number bill lines and pharmacy bill adjustments

Applicable Phase(s):…