J-06 Sample Award fee Plan

Award Fee Plan For

Durable Medical Equipment

Medicare Administrative

Contractor

(DME MAC)

Effective Date

TBD

Evaluation Period

TBD

RFP-CMS-2010-0004

Attachment J-6 Sample Award Fee Plan 1

I. OVERVIEW

This document provides the Award Fee Evaluation Plan for the Jurisdiction X Durable Medicare

Equipment Medicare Administrative Contractor (DME MAC) contract awarded to Contractor X.

The performance criteria contained within this plan will be used, along with other performance-related information, to determine the amount of award fee that will be earned by Contractor X.

The purpose of utilizing the award fee process is to motivate and reward Contractor excellence in the performance of contract requirements critical to program success, while Contractor X meets at least minimum acceptable performance levels in all other areas.

The award fee may be awarded in whole, in part, or not at all based on evaluated performance exceeding minimum contract requirements.

II. THE AWARD FEE PLAN

The award fee plan describes how the Contractor will be evaluated and how the award fee will be administered. The plan identifies the criteria to be used to evaluate the Contractor’s performance as it relates to the award fee for the performance period. The plan also identifies the roles and responsibilities of those who will participate in the evaluations.

The Award Fee Plan:

Is approved by the Contracting Officer, the Performance Evaluation Board (PEB), and the Fee Determining Official (FDO);

Allocates the fee pool among performance categories;

Specifies the evaluation cycle;

Identifies the roles and responsibilities of those who will participate in the evaluation;

and

Describes criteria for evaluating the Contractor’s performance.

The FDO may unilaterally change the award fee plan prior to the beginning of an evaluation period. Contractor X will be notified of changes to the plan by the Contracting Officer, in writing, before the start of the affected evaluation period. Changes to this plan that are applicable to a current evaluation period will be incorporated by mutual consent of both parties.

1.0 Fee Arrangement

The fee arrangement is negotiated based on the total estimated cost of the contract. There are regulatory limitations on total fee (cumulative base fee and award fee) for a Cost Plus Award Fee contract. The fee consists of two parts, the base fee and the earned award fee.

1.1 Base Fee. The base fee can be viewed as the minimum compensation for the resources a Contractor uses or the investment it may undertake in order to perform the contract.

Attachment J-6 Sample Award Fee Plan 2

1.2 Earned Award Fee. The earned award fee is the amount of fee set aside in the contract that is available to be earned by the Contractor for exceeding minimum contract requirements. The Contractor is not guaranteed a minimum amount of award fee. Consequently, some, none, or the entire maximum available award fee may be earned. The amount of the fee awarded to the Contractor is unilaterally determined by the Government’s evaluation of the Contractor’s performance which exceeds contract requirements.

1.3 Prerequisite for Eligibility for Award Fee. In order to participate in the Award

Fee program described in this document, the Contractor must obtain at least a minimum score of “Fair” in each individual perspective/evaluation criterion for the most recent National Institutes of Health (NIH) Contractor Performance

System (CPS) evaluation during the evaluation period.

2.0 Performance Evaluation Periods

Period Period of Performance

Implementation TBD

Operational TBD

The final determination of the award fee earned will be accomplished within 90 days after the end of the performance evaluation period. Please note unless otherwise specified in the plan, the award fee period will begin with the first full month of the award fee period and end with the last full month of the period.

3.0 Organizational Structure for Award Fee Administration

The award fee organizational structure is established for administering the award fee provisions of this contract. The organization consists of the following:

Fee Determining Official (FDO). The FDO is the Director, Medicare

Contractor Management Group in the Center for Medicare

Management, CMS. The responsibilities of the FDO are to:

Approve the award fee plan and any significant changes;

Review the PEB report, Contractor input, and other pertinent performance data; and

Make a final determination of award fee earned and payable for each evaluation period.

The FDO will consider any other information available which relates to the

Contractor’s performance of all other contract requirements in the final determination of fee earned.

Attachment J-6 Sample Award Fee Plan 3

The FDO may determine a higher or lower award fee than that which is recommended by the PEB. However, supporting documentation and rationale shall substantiate such changes. This final determination shall be made within 90 days of the end of the award fee evaluation period.

Performance Evaluation Board (PEB). The PEB is comprised of the Project

Officer; Contracting Officer; Director, Division of Performance Assessment, Panel Chair; Director, Eastern MAC Program Management Division; and

Director, Division of MAC Budget & Data Analysis. The responsibilities of the

PEB are to:

Review Performance Monitors’ evaluation of the Contractor’s performance;

Consider all evaluation information from pertinent sources;

Prepare a report to the FDO on the recommendation of an award fee to be earned by the Contractor; and

Substantiate the recommended award fee to the FDO.

The PEB report shall be delivered to the FDO 75 days after the end of the evaluation period.

Performance Monitors. Performance Monitors are CMS staff who maintain written records of the Contractor’s performance in their assigned evaluation area(s) so that a fair and accurate evaluation is obtained. Performance Monitors will review and consolidate periodic monitoring information for inclusion in their performance monitor reports, which are due to the PEB no later than 45 days after the end of the evaluation period.

Contractor Input. Contractor X may provide a written award fee performance evaluation self-assessment to the PEB chair within 30 days of completion of the award fee evaluation period. The Contractor should provide as much detail as is necessary to assist the evaluators in making their final determination; however, any written self-assessment shall not exceed 20 pages in length. When preparing the self-assessment, the Contractor shall use the attached Award Fee Evaluation template (see Attachment A).

Notification to the Contractor. The Contractor shall receive written notification of the award fee determination within 90 days of the end of the contract year.

III. AWARD FEE CATEGORIES - SCORING

1.0 Award Fee Categories:

1.1 Implementation Evaluation Period (if applicable)

CMS will assess the Contractor’s performance against the stated metrics in the following areas:

Attachment J-6 Sample Award Fee Plan 4

-Successful Claims Workload Cutover

-Risk Mitigation

1.2 Operational Evaluation Period

CMS will assess the Contractor’s performance against the stated metrics in the following areas:

Contract Administration

Provider Customer Service Program

Accuracy of Written Appeal Redetermination Letters

Beneficiary Inquiries

Program Integrity Support

System Security

2.0 Distribution of Award Fee Pool

2.1 Implementation

The award fee will be distributed in the following manner for the implementation period:

Performance Categories Award Fee Pool Distribution – Program

Management

Successful Claims Workload Cutover 60%

Risk Mitigation 40%

Total 100%

2.2 Operational

The award fee will be distributed to the metrics for the Program Management and

Medicare Integrity Program areas in the following manner for the operational evaluation period.

Performance Metric

Award Fee Pool

Distribution -

Program Management

Award Fee Pool

Distribution -

Medicare Integrity

Program

Contract Administration 40% 40%

Provider Customer Service Program

– accuracy 10% N/A

Provider Customer Service Program

– website 10% N/A

Accuracy of Written Appeal 20% N/A

Attachment J-6 Sample Award Fee Plan 5

Performance Metric

Award Fee Pool

Distribution -

Program Management

Award Fee Pool

Distribution -

Medicare Integrity

Program

Redetermination Letters

Beneficiary Inquiries 5% N/A

Program Integrity Support -overpayments N/A 30%

Program Integrity Support – law enforcement support N/A 30%

System Security 15% N/A

Total 100% 100%

In addition, CMS will provide an overall adjectival rating for the Contractor’s award fee performance based on the percentage of award fee earned in compliance with the following chart:

Award Fee Adjectival Rating Award Fee Pool Earned Description

Excellent 91% - 100% Contractor has exceeded all or almost all of the significant award fee criteria and has met substantially all cost, schedule, and technical performance requirements of the contract.

Very Good 76% - 90% Contractor has exceeded many of the significant award fee criteria; and has met substantially all cost, schedule, and technical performance requirements of the contract.

Good 51% - 75% Contractor has exceeded some of the significant award fee criteria;

and has met substantially all cost, schedule, and technical performance requirements of the contract.

Satisfactory No Greater Than 50% Contractor has met all or almost all of the significant award fee criteria and has met substantially all cost, schedule and technical performance requirements of the contract.

Unsatisfactory 0% Contractor has failed to meet either all or almost all of the

Attachment J-6 Sample Award Fee Plan 6

Award Fee Adjectival Rating Award Fee Pool Earned Description significant award fee criteria; or substantially all cost, schedule and technical performance requirements of the contract.

The FDO will take into account the Contractor’s overall performance on the contract, when making an earned award fee determination. The FDO, may at his or her discretion, reduce the amount of the award fee under the contract, or determine not to make payment of any award fee, for example, if the Contractor exceeds its budget amount or if the Contractor otherwise has not managed its costs under the contract in an efficient and effective manner. In the event that an award fee metric is no longer applicable, CMS reserves the right to reallocate the award fee pool associated with that metric among the remaining award fee criterion and disperse accordingly.

3.0 Award Fee Process

At the end of the award fee evaluation period, the Project Officer reviews the work performed during that period. The Project Officer and the CMS Performance Monitors evaluate the

Contractor’s performance in accordance with the Performance Metrics and the Statement of

Work. The Project Officer and the CMS Performance Monitors make a recommendation regarding the percentage of fee to be awarded. This recommendation is subject to the

Contracting Officer’s review of the Contractor’s performance of the contract. This recommendation is provided to management and, finally, the FDO. The FDO has the prerogative to change the recommendation. Within 90 days after the end of the evaluation period, the FDO will make a determination and an official letter will be issued by the

Contracting Officer stating the earned award fee.

4.0 Award Fee Metrics

4.1 Implementation

The Contractor shall be evaluated by the Project Officer and the Implementation Lead using the following evaluation criteria:

Award Fee Criterion 1: Successful Claims Workload Cutover

The Contractor successfully implements each workload segment on the final approved implementation plan cutover date. Successful implementation means that 95% of clean claims are processed within the claims payment floor and ceiling specified in IOM Pub. 100 – 04, Chapter 1, sections 80.2.1.1 and 80.2.1.2

Award Fee Criterion 2: Risk Mitigation

The Contractor appropriately mitigates and/or takes action when segment risks affect segment implementation and/or operations. For example, when migrating to an Enterprise Data Center

(EDC), contingency plans are in place by the Contractor for non-base applications. In addition, Attachment J-6 Sample Award Fee Plan 7 the Contractor proactively communicates with CMS regarding any impending problems during the implementation period.

4.2 Operational Award Fee Metrics

The Contractor shall be evaluated using the following operational evaluation criteria:

Award Fee Criterion 1: Contract Administration

This category measures how well the DME Medicare Administrative Contractor (MAC) is managed, monitored, administered and has quality control procedures implemented. CMS will consider at a minimum the Contractor’s performance in the areas of cost and project management.

Rating Examples of factors CMS will consider

(this is not an all-inclusive list):

Percentage of Award

Fee Earned

Excellent

The DME MAC demonstrated superior performance.

The DME MAC proactively proposes innovative and cost effective solutions to problems that are implemented in the Contractor’s own jurisdiction (e.g., automating manual operations).

The DME MAC focused on identifying and solving problems, with no negative impact to CMS.

The DME MAC is consistently under budget.

Collaboration with other entities, including other MACs is evidenced by positive program improvements and problem solving that has broad program benefit.

80% - 100%

Very Good

The DME MAC’s performance exceeded Statement of Work standards.

The DME MAC proactively proposes innovative and cost effective solutions to problems that have the potential to be “piloted” or implemented in the

Contractor’s jurisdiction (e.g., automating manual operations).

Problem solving only requires

60% - 79%

Attachment J-6 Sample Award Fee Plan 8

Rating Examples of factors CMS will consider

(this is not an all-inclusive list):

Percentage of Award

Fee Earned guidance and does not consume additional government resources.

The DME MAC does exhibit cost savings.

Good

The majority of the DME MAC’s performance was clearly above average. Problem solving consumes minimal additional government resources.

Quality end results are consistently delivered according to schedule.

40% - 59%

Average

The DME MAC’s performance is consistent with that of an average contractor. The DME MAC meets the

Statement of Work standards. For example, deliverables are submitted timely. In addition, the Contractor submits accurate and timely voucher/invoices, negotiated contract estimated costs (issued by the contracting officer as a contract modification) and monthly cost reports in CMS ART, as well as all, other necessary financial management reports/information in accordance with CMS instructions.

0%

The data source for this metric is the Contracting Officer and Project Officer who will evaluate on an ongoing basis.

Award Fee Criterion 2: Provider Customer Service Program - Accuracy

This criterion measures the accuracy with which the Contractor’s Customer Service

Representatives (CSRs) respond to Medicare policy questions. In order to earn the award fee for this metric, the Contractor has to achieve an 85% accuracy rate for the award fee period. The data source for this metric is CMS monthly initiated calls to the Contractor with a summary score reported for the period of performance. In order to achieve the 85% accuracy rate for this period, assuming 10 CMS monthly initiated calls, the Contractor would have to achieve a correct score for at least 102 of the 120 calls during the 12 month award fee period.

Attachment J-6 Sample Award Fee Plan 9

In order for the response to be included in the sample for this metric, the response must be provided by the CSR that was originally posed the question, even if the response is provided as a call back within 10 business days of the inquiry.

Award Fee Criterion 3: Provider Customer Service Program - Website

This criterion measures the Contractor’s rating on the Medicare Contractor Website Customer

Satisfaction Survey. The survey, which is nationally benchmarked, is administered by ForeSee

Results and appears on all Medicare Administrative Contractors’ websites. The award fee for this metric can only be implemented after results for 300 surveys are completed.

In order to earn the award fee for this metric, the average of three website satisfaction scores from the last two months of an evaluation period must be greater than the average of three website satisfaction scores from two consecutive beginning months of the evaluation period.

The three scores for these two averages are taken from the first day of the first month, the last day of the last month, and the last day of the second month of the two month period. Each of the three scores is also based on approximately 300 preceding completed surveys.

The average score from the beginning two months of the evaluation period must be 54 or higher to qualify. If it is not, then the beginning score is computed from months 2 and 3 of the evaluation period. If the score still is not 54 or higher, then the score is computed from each succeeding two month period until the qualifying score is achieved. A beginning two month period shall not overlap the last two months of the evaluation period. An award for this metric will not be given if an average score of 54 or higher, for either the beginning or last two month of the evaluation period, is not achieved.

The baseline score of the evaluation period is the qualifying score. For example, if the average score of the first, the 30 th and the last day of the beginning two-month period is 58, this is the baseline score. In this case, to earn the award for this metric, the average of three website satisfaction scores from the last two months of the evaluation period must be greater than 58.

When the Award Fee Period (AFP) start date is after the 1 st of the month, but before the 15 th, that day is considered the first day of the first month. The second day is the last day of the first month, and the third day is the last day of the second month. If necessary to consider succeeding time periods (because 54 or higher was not achieved) the baseline score will be computed from the scores on the first and last day of the immediate next month and the last day of the month after that. If the AFP starts after the 15 th of the month, then the first day is the first day of the following month. The second day is the last day of that month and the third day is the last day of the next month. If necessary to consider succeeding time periods (because 54 or higher was not achieved) the baseline score will be computed from scores on the first and last day of the immediate next month and the last day of the month after that.

If the average score ends in .5 or higher, the average score will round up to the nearest whole number. If the average score ends in .4 or lower, the average score will round down to the nearest whole number.

Attachment J-6 Sample Award Fee Plan 10

The table below shows the allocation percentages for this award fee criterion based on the increase over the minimum qualifying or baseline score.

Beginning Period

Average

Satisfaction Score

Evaluation

Period Score

Increase

Allotment

Percentage

Beginning Period

Average

Satisfaction Score

Evaluation

Period Score

Increase

Allotment

Percentage

54 – 56 6+ 100 71 – 73 3+ 100

5 90 2 90

4 80 1 80

3 70 0 70

2 50

57 – 61 6+ 100 74 – 75 2+ 100

5 85 1 90

4 70 0 to -2 80

3 55

62 – 66

5+ 100 >75

0 to + 100

4 90 -1 or -2 90

3 70 -3 or -4 80

67 – 70 4+ 100

3 90

2 80

See Attachment B to find out where to obtain the scores for the metric.

Award Fee Criterion 4: Accuracy of Written Appeal Redetermination Letters

This criterion measures the accuracy of Medicare Redetermination Notices (MRN) issued by the

Contractor, fully or partially affirming denials of DME claims.

Medicare regulations and program manual instructions both require that MRN affirmations contain an explanation of how relevant coverage rules (which include, but are not limited to, coverage rules included in laws, regulations, National Coverage Determinations, Local Coverage

Determination, and Internet Only Manual provisions) apply to the facts and circumstances involved in the case being appealed. This portion of the MRN is generally referred to as the

“rationale,” or underlying reason, for the decision, and is considered by CMS to be the most vital element of the MRN affirmation letter. For the Contractor to succeed on this award fee metric, affirmation MRNs must include, among other required elements, a clear explanation of how pertinent coverage rules and CMS policies apply to the facts of the case. This would include: a clear statement of applicable coverage rules; an indication of which were not met; and an explanation of why the facts of the case do not support coverage or payment for the item or service at issue.

Attachment J-6 Sample Award Fee Plan 11

MRN affirmations must meet all other requirements as outlined in CMS manuals and 42 CFR

405.900ff, including, when applicable, accurate determinations regarding the limitation on liability provision (Section 1879 of the Act), the waiver of overpayment recovery provision

(Section 1870 of the Act), and the refund requirements for both assigned claims (Section 1879[h] of the Act), and non-assigned claims (Sections 1834[j][4] and 1834[a][18] of the Act). Specific procedures and guide language for these determinations are contained in Chapter 30 of IOM

100-4.

This metric will be evaluated by CMS based on a review of randomly selected affirmation MRN decision letters completed during the evaluation period. This metric will be evaluated using a points system to assess quality (see Attachment C). Relatively more scoring weight will be assigned to the “rationale” and financial liability (as applicable) areas noted above. All other elements of the MRN as described in IOM 100-4, Section 310.5, and 310.7 (model notice), as well as program regulations, will also be scored.

Award Fee will be earned as follows:

Overall Accuracy Score

(Percentage)

% of Award Fee

Earned

99.5-100%

100%

98-99.4% 90%

96.5-97.9% 80%

95-96.4% 70%

93.5-94.9% 60%

92-93.4% 50%

<92% No Fee

For this metric, values of five (5) and above are rounded up and values of four (4) and below are rounded down. Therefore, a value of 99.5% or above would be rounded to 100% and values of

99.4% would be rounded to 99%.

Award Fee Criterion 5: Beneficiary Inquiries

This criterion measures the timeliness of responses to complex inquiries forwarded from

1-800-Medicare/Beneficiary Contact Center (BCC) or from CMS Regional Officers.

In order to be eligible for participation in this criterion, the Contractor shall respond to beneficiary telephone and written inquiries within 25 business days for at least 75% of inquiry cases and within 45 business days for 95% of inquiry cases referred by 1-800-Medicare/

Beneficiary Contact Center via the Next Generation Desktop. Both timeliness standards must be met to be eligible for participation in this award fee criterion. Timeliness will be calculated using the Next Generation Desktop summary (i.e., not monthly) data for the entire award fee evaluation period. The National Data Warehouse Complex Inquiry materialized view is to be

Attachment J-6 Sample Award Fee Plan 12 used as the single source for reporting. Please refer to JSM/TDL-09256 to review information on how this metric is calculated.

Award fee for this criterion will be based on the number of months in the award fee period that the Contractor responds to 80% of beneficiary telephone and written inquiries within 10 business days. The percentage of award fee earned will be calculated by dividing the number of months the Contractor achieved the 80% performance level by the number of months in the award fee period. For example, if there are 12 months in the award fee period and the Contractor achieves the 80% rate for seven of the 12 months, the Contractor would earn 58% of the award fee for this metric.

For this metric, values of five (5) and above are rounded up and values of four (4) and below are rounded down. Therefore, a value of 79.5% would be rounded to 80% and values of 79.4% would be rounded to 79%.

Award Fee Criterion 6: Program Integrity Support -Overpayments

This criterion measures the timeliness of submitting overpayment information to the Program

Safeguard Contractors (PSCs)/Zone Program Integrity Contractors (ZPICs). The Joint Operating

Agreement between the PSC and the MAC or the ZPIC and the MAC is required to contain information on how the Contractors will coordinate overpayment issues. In order to earn award fee dollars for this metric, the MAC shall provide a monthly report to the PSC or ZPIC listing all demand letters issued and overpayment dollars recouped, as a result of PSC or ZPIC initiated activities, by the 10 th of the month for the prior month’s activities. The report shall contain at a minimum the following fields: provider name, provider number, date of the demand letter, amount of the demand letter, and amount paid by the provider.

Award Fee will be earned as follows: 100% of the available award fee for this criterion will be awarded if the MAC submits zero (0) reports late to the PSC or ZPIC; 75% of the of the available award fee for this criterion will be awarded if the MAC submits one (1) report late to the PSC or ZPIC; 50% of the available award fee for this criterion will be awarded if the MAC submits two (2) reports late to the PSC or ZPIC; and 0% of the available award fee for this criterion will be awarded if the MAC submits three (3) or more reports late to the PSC or ZPIC.

Award Fee Criterion 7: Program Integrity Support - Law Enforcement Support

This criterion measures the Contractor’s responsiveness to PSC/ZPIC requests for information.

In order to earn an award fee for this metric, the Contractor must furnish the PSC/ZPIC all requested information needed to support PSC/ZPIC investigations for case referrals to law enforcement and to fulfill law enforcement requests for information (RFIs) in accordance with the timeframes and guidelines established in the PSC or ZPIC/MAC Joint Operating Agreement.

In any area where the HEAT Strike Force is present, the expectation is for the Contractor to provide the PSC/ZPIC with requested information in the expedited timeframe specified by the

PSC/ZPIC. It is important to note that the Strike Forces will continue to target new areas on an ongoing basis.

Attachment J-6 Sample Award Fee Plan 13

The award fee will be earned as follows: 100% of the available award fee for this criterion will be awarded if the Contractor submits zero (0) responses late to the PSC/ZPIC; 75% of the available award fee for this criterion will be awarded if the Contractor submits one (1) response late to the PSC/ZPIC; 50% of the available award fee for this criterion will be awarded if the

Contractor submits two (2) responses late to the PSC/ZPIC; and 0% of the available award fee for this criterion will be awarded if the Contractor submits three (3) or more responses late to the

PSC/ZPIC.

Award Fee Criterion 8: System Security

This criterion measures the Contractor’s compliance with CMS’ system security standards. In order to earn the award fee dollars for this metric, the MAC shall receive no high risk electronic data processing (EDP) findings as a result of any applicable Chief Financial Officer (CFO) audits

(including CFO Desktop Reviews) or Section 912 evaluation. The scoring for this metric will be pass/fail.

Attachment J-6 Sample Award Fee Plan 14

Attachment A

Contractor Name [insert]

Award Fee Plan Self-Assessment

DME MAC Region [insert]

Contract Number [insert]

Evaluation Period: [insert]

A. Executive Summary:

The Executive Summary of the Contractor’s Award Fee Self-Assessment shall provide an overview of the Contractor’s performance during the award fee period. In addition, the

Contractor shall provide information on how well it performed on the award fee criteria compared to the last award fee evaluation period.

B. Implementation Evaluation Criteria Analysis:

Evaluation Criterion #1: Successful Claims Workload Cutover

Metric: The Contractor successfully implements each workload segment on the final approved implementation plan cutover date. Successful implementation means that all critical workloads are being processed.

Contractor Assessment: The Contractor shall provide narrative, by workload segment, describing its performance in implementing each workload segment.

Workload Segment Approved

Implementation Plan

Cutover Date

Actual Date

Workload Was

Implemented

Successful Y/N

Segment 1

Segment 2

Segment 3

Segment 4

Evaluation Criterion #2: Risk Mitigation

Metric: The Contractor appropriately mitigates and/or takes action when segment risks affect segment implementation and/or operations. For example, when migrating to an

Enterprise Data Center (EDC), contingency plans are in place by the Contractor for non-

Attachment J-6 Sample Award Fee Plan 15 base applications. In addition, the Contractor proactively communicates with CMS regarding any impending problems during the implementation period.

Contractor Assessment: The Contractor shall provide narrative, by workload segment, describing any applicable implementation risks, and what actions were taken to mitigate such risk.

C. Operational Evaluation Criteria Analysis:

This section of the report shall detail the Contractor’s assessment of its performance against the award fee metrics for the award fee evaluation period. This template provides guidance on what minimum information should be included in the Contractor’s

Self-Assessment. If the Contractor did not achieve the desired level of performance necessary to earn award fee for a particular metric, the Contractor shall include narrative outlining what actions it is taking to increase performance in that area. The

Contractor’s Self-Assessment should not exceed 20 pages.

The following is [Contractor’s] assessment of its performance on the following operational award fee criteria:

Evaluation Criterion #1: Contract Administration

Metric: This category measures how well the Medicare Administrative Contractor

(MAC) is managed, monitored, administered and has quality control procedures implemented. CMS will consider at a minimum the Contractor’s performance in the areas of cost and project management. See the Award Fee Plan for how award fee will be earned.

Contractor Assessment: The [Contractor’s] performance was [excellent/very good good/average] for this criterion during the award fee period. The Contractor shall include narrative to substantiate its rating in this area.

Evaluation Criterion #2: Provider Customer Service Program - Accuracy

Metric: This criterion measures the accuracy with which the Contractor’s Customer

Service Representative (CSRs) respond to Medicare policy questions. In order to earn the award fee for this metric, the Contractor has to achieve an 85% accuracy rate for the award fee period. The data source for this metric is CMS monthly initiated calls to the

Contractor with a summary score reported for the period of performance.

Attachment J-6 Sample Award Fee Plan 16

Contractor Assessment: The results for the period of performance are as follows:

Total Calls Accurate Inaccurate Incomplete Over all

Performance

Based on the data listed above, the [Contractor] [met/did not meet] the performance threshold for this award fee criterion.

Evaluation Criterion #3: Provider Customer Service Program - Website

Metric: This criterion measures the Contractor’s rating on the Medicare Contractor

Website Customer Satisfaction Survey. The survey, which is nationally benchmarked, is administered by ForeSee Results and appears on all Medicare Administrative

Contractors’ websites. The award fee for this metric can only be implemented after results for 300 surveys are completed.

In order to earn the award fee for this metric, the average of three website satisfaction scores from the last two months of an evaluation period must be greater than the average of three website satisfaction scores from two consecutive beginning months of the evaluation period. The three scores for these two averages are taken from the first day of the first month, the last day of the first month period, and the last day of the second months of the two month period. Each of the three scores is based on approximately 300 preceding completed surveys.

The average score from the beginning two months of the evaluation period must be 54 or higher to qualify. If it is not, then the beginning score is computed from months 2 and 3 of the evaluation period. If the score still is not 54 or higher, then the score is computed from each succeeding two month period until the qualifying score is achieved. A beginning two month period shall not overlap the last two months of the evaluation period. An award for this metric will not be given if an average score of 54 or higher, for either the beginning or last two month of the evaluation period, is not achieved. Please see the Award Fee Plan for additional details on how this metric will be scored.

Contractor Assessment: The [Contractor] [reached/did not reach] the minimum qualifying score. The [Contractor] achieved a [ __] increase during this award fee period and therefore achieved [ ___%] of the award fee allocated to this criterion.

Attachment J-6 Sample Award Fee Plan 17

Evaluation Criterion #4: Accuracy of Written Appeals Redetermination Letters

Metric: This criterion measures the accuracy of Medicare Redetermination Notices

(MRNs) issued by the Contractor, fully or partially affirming denials of DME claims.

Contractor Assessment: A contractor assessment is not necessary for this award fee criterion. This metric will be evaluated by CMS based on a review of randomly selected affirmation MRN decision letters completed during the evaluation period.

Evaluation Criterion #5: Beneficiary Inquiries

Metric: This criterion measures the Contractor’s compliance with the timeliness of responses to complex inquiries forwarded from 1-800-Medicare/Beneficiary Contact

Center (BCC) or from CMS Regional Offices.

In order to be eligible for participation in this criterion, the Contractor shall respond to beneficiary telephone and written inquiries within 25 business days for at least 75% of inquiry cases and within 45 business days for 95% of inquiry cases referred by 1-800-

Medicare/Beneficiary Contact Center via the Next Generation Desktop (NGD). Both timeliness standards must be met to be eligible for participation in this award fee criterion. Timeliness will be calculated using the NGD summary (i.e., not monthly) data for the entire award fee evaluation period. The National Data Warehouse Complex

Inquiry materialized view is to be used as the single source for reporting. Please refer to

JSM/TDL-09245 to review information on how this metric is calculated.

Award fee for this criterion will be based on the number of months in the award fee period that the Contractor responds to 80% of beneficiary telephone and written inquiries within 10 business days.

Contractor Assessment: The results for the period of performance are as follows:

# of Complex

Inquiries

During Award

Fee Period

% Complete Within

25 Business Days

% Complete Within

45 Business Days

Eligible to Earn

Award Fee -

Y/N

Month in

% Complete Within 10

Business Days

# Complete Within

10 Business Days

Met/Did Not

Meet

January

Attachment J-6 Sample Award Fee Plan 18

Month in

% Complete Within 10

Business Days

# Complete Within

10 Business Days

Met/Did Not

Meet

February

March

April

May

June

July

August

September

October

November

December

Evaluation Criterion #6: Program Integrity - Overpayments

Metric: This criterion measures the timeliness of submitting overpayment information to the Program Safeguard Contractors (or future Zone Program Integrity Contractors

ZPICs). The Joint Operating Agreement between the PSC and the MAC is required to contain information on how the Contractors will coordinate overpayment issues. In order to earn award fee dollars for this metric, the Contractor shall provide a monthly report to the PSC listing all demand letters issued and overpayment dollars recouped, as a result of

PSC initiated activities, by the 10 th of the month for the prior month’s activities. The report shall contain at a minimum the following fields: provider number, date of the demand letter, amount of the demand letter, and amount paid by the provider.

Contractor Assessment: [Contractor] provided the monthly reports to the PSC on the dates listed below:

Month Date Submitted

January

February

March

April

May

June

July

August

September

Attachment J-6 Sample Award Fee Plan 19

Month Date Submitted

October

November

December

The [Contractor] submitted __ reports late to the PSC and therefore earned ___% of the available award fee dollars for this criterion. The Contractor’s self-assessment should also include documentation showing the transmission date of this information to the PSC

(e.g., a copy of the e-mail sent to the PSC). In addition, the MAC shall have copies of the reports sent to the PSC available to CMS upon request.

Evaluation Criterion #7: Program Integrity Support – Law Enforcement Support

Metric: This criterion measures the Contractor’s responsiveness to Program Safeguard

Contractor/Zone Program Integrity Contractor (PSC/ZPIC) requests for information. In order to earn award fee for this metric, the Contractor must furnish the PSC/ZPIC all requested information needed to support referrals to law enforcement and potential fraud case development in accordance with the timeframes and guidance established in its Joint

Operating Agreement with the PSCs/ZPIC.

Contractor Assessment: The [Contractor] submitted [ __%] of the reports late to the

PSC/ZPIC and therefore earned [___%] of the available award fee dollars for this criterion. The Contractor’s self-assessment shall contain a log of all PSC/ZPIC requests for information including the date the request was received by the Contractor, the agreed upon due date for the request, and the date they responded to the PSC’s/ZPIC’s request.

The Contractor’s self-assessment should also include documentation showing the transmission date of this information to the PSC/ZPIC (e.g., a copy of the e-mail sent to the PSC/ZPIC). In addition, the MAC shall have copies of the information sent to the

PSC/ZPIC available to CMS upon request.

Evaluation Criterion #8: System Security

Metric: This criterion measures the Contractor’s compliance with CMS’ system security standards. In order to earn the award fee dollars for the metric, the Medicare

Administrative Contractor shall receive no high risk electronic data processing (EDP) findings as a result of any applicable Chief Financial Officer (CFO) audits (including

CFO Desktop Reviews) or Section 912 evaluation. The scoring for this metric will be pass/fail.

Contractor Assessment: The [Contractor] received [___] high risk EDP findings and therefore [passed/failed] this award fee metric.

Attachment J-6 Sample Award Fee Plan 20

Where to obtain the proper calculations for this metric:

1. Go to the portal provided by ForeSee Results

Attachment J-6 Sample Award Fee Plan 21 a279 Text Box Attachment B

2. On the Results tab select “Scores with Impacts”

Attachment J-6 Sample Award Fee Plan 22

3. Make sure that the “Day” tab is selected on the left side of the screen

4. Follow instructions above.

Attachment J-6 Sample Award Fee Plan 23

ATTACHMENT C

Protocol for Award Fee Criterion 4: Accuracy of Written Redetermination Letters

(Unless otherwise noted, 0 points will be allowed if the accuracy component is not met.)

Accuracy Component

Points

A. Timely Acknowledgement of Appeal Request (5 Points)

Earn 5 points for timely acknowledgement of the redetermination request

B. Typographic or Grammar

(5 Points)

Earn 5 points for no typographic or grammar errors; earn

3 points if there is one typographic/grammar error; earn 1 point if there are two or more typographic/grammar errors

C. Copy Parties (5 Points) Earn 5 points for copying all parties to the appeal

D. Required Elements of

Medicare Redetermination

Notice (30 Points):

Clear Statement of

Decision Outcome (on st and 2 nd page of

MRN)

Summary of Facts

Decision Paragraph

(page 2)

What to Include in

Request for Appeal

(option 1 or 2), Information

Regarding Further

Appeal Rights

Other Required

Elements of the MRN

Model Letter

Earn up to 5 points if the appeal decision is clearly stated on page 1 of the MRN

Earn 8 points if summary of the facts is accurate and complete

Earn 5 points if summary of facts is incomplete

Earn 3 points if the summary of facts is completely inaccurate or missing

Earn up to 7 points if the decision paragraph is accurate and complete.

Earn up to 5 points if required (model notice) language for either Option 1 or Option 2 (as applicable) is included, and is accurate and complete. In order to earn 4 points, specific evidence/documentation missing at the redetermination level that will be required in order for a possible favorable outcome at the next level of appeal must be specifically mentioned either here, or in the explanation of decision (see below).

Earn up to 5 points if all other required elements of the

MRN not specifically broken out in this protocol are present, accurate, and complete

E. Explanation of Decision

(i.e., The Rationale for the

Decision) (40 Points)

Earn Up to 15 points if applicable coverage rules/criteria are clearly, accurately, and completely stated in the MRN, along with a clear statement of the specific coverage rule/criteria that was not met. Where relevant coverage

Attachment J-6 Sample Award Fee Plan 24

Statement of the

Relevant Coverage

Rules (i.e., The Rules), and How Those Rules

Apply to the Facts of the Case (i.e., The

Rules That Were Not

Met)

Explanation of Why

Facts of the Case Did

Not Support Coverage or Payment rules require specific documentation to support medical necessity, that portion of the coverage rule containing the documentation requirements must be included in the MRN.

Earn up to 10 points if the applicable coverage rules/criteria are only partially stated and/or specific documentation requirements are incomplete or missing.

Earn up to 5 points if the coverage rules/criteria contain inaccurate/irrelevant information;

Earn 0 points if the applicable coverage rules/criteria are not stated at all.

Earn up to 25 points if the explanation of the decision clearly, accurately, and completely elaborates on the reason why the facts of the case failed to meet the relevant coverage rules. In order to achieve full points: the facts of the case are clearly laid out; those facts have been applied to the relevant coverage rules as stated previously; and an explanation as to the specific reason(s) why the facts of the case failed to meet relevant coverage rules is included.

From a practical viewpoint, the explanation of the decision should serve as an educational paragraph for the appellant.

Earn up to 20 points if the written explanation does not clearly state why the facts of the case do not meet the relevant coverage rules/criteria.

Earn up to 15 points if the written explanation does not state why the facts of the case do not meet the relevant coverage rules/criteria.

F. Financial Liability

(15 Points)

Limitation on Liability

Under Section 1879

Refund Requirements under Section 1879(h) or

1834(j)(4)/1834(a)(18)

Earn up to 15 points for complete and accurate application of relevant/applicable financial liability provisions of the

Medicare law. These provisions include Limitation on

Liability under Section 1879, Refund Requirements under

Section 1879(h) or Section 1834(j)(4)/1834(a)(18), or

Waiver of Recovery on overpayment appeals under

Section 1870.

For Limitation on Liability, applicable guide language, including the indemnification procedures to be issued to

Attachment J-6 Sample Award Fee Plan 25

Waiver of Recovery

Provisions under

Section 1870 beneficiaries where the supplier is held liable, is available in IOM 100-4, chapter 30, Section 120.5.1.

For Refund Requirements, applicable guide language is available in IOM 100-4, chapter 30, Section 150.

For Waiver of Recovery, instructions are available in IOM

100-6, Chapter 70, Section 70.3

Earn up to 10 points if the required instructions and guide language were not completely followed, or otherwise incomplete.

Earn 0 points if the required instructions and guide language were missing completely from the MRN (i.e., Sections 1879, 1834(j)(4)/1834(a)(18), or 1870 for overpayments, should have been addressed in the MRN based on the facts of the case, but were missing completely.)

Attachment J-6 Sample Award Fee Plan 26

AFP 4 .pdf