J-06A Award Fee template.docx

RFP- RRB-11-R-001- Attachment J-06 A Attachment A

Contractor Name [insert] Award Fee Plan Self-Assessment RRB Specialty MAC 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:

This section of the report shall detail the Contractor’s assessment of its performance against the implementation-related 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. The implementation portion of the Contractor’s Self-Assessment should not exceed five (5) pages. The award fee self-assessment shall be submitted in MS Word.

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

Evaluation Criterion #1: Successful Claims Workload Cutover

Metric: The Contractor successfully implements the claims workload 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

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

Evaluation Criterion #2: Risk Mitigation

Metric: The Contractor appropriately mitigates and/or takes action when risks affect implementation and/or operations. In addition, the Contractor proactively communicates with RRB and CMS regarding any impending problems during the implementation period.

Contractor Assessment: The Contractor shall provide narrative, by workload, 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.

Evaluation Criterion #1: Contract Administration

Metric: This award fee criterion measures overall contract management. RRB and 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] performance was [excellent/very good good/average/] for this criterion during the award fee period. The Contractor shall include narrative to substantiate its evaluation for this area.

Evaluation Criterion #2.1: Provider Customer Service Program - Accuracy

Metric: 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 will respond to policy questions with a 90% 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. 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 ten business days of the inquiry. If the call is returned by a different CSR, unless demonstrated extenuating circumstances exist, the call will be scored as incorrect.

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

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

Evaluation Criterion #2.1: Provider Customer Service Program - Listserv

Metric: The Contractor shall actively market and promote the benefits of being a member of the provider listserv(s). No later than 15 days prior to the end of the operational award fee period, the total of unique, individual members of its provider listserv(s) shall be at 50% or higher of its active provider count for the entire jurisdiction, as supplied by the Contractor.

Contractor Assessment: The Contractor [did/did not meet] this award fee metric. The total of unique, individual members of the listserv(s) is ____% higher than the active provider count for the entire jurisdiction, as supplied by RRB/CMS. There are currently ____ unique Part B listserv subscribers and ____ billing providers in the jurisdiction.

Evaluation Criterion #2.2: Provider Customer Service Program – Self-Service Utilization Rate

Metric: This criterion measures the rate at which providers in the contractor’s jurisdiction use the Interactive Voice Response (IVR) system and the Provider Internet Portal (if the contractor has one). For this award fee metric, the utilization rate shall average at least 75% in the last two months of the evaluation period. If the contractor proposed an IVR handle rate greater than 75% during the procurement process, RRB/CMS will adjust this award fee metric to be greater than the proposed IVR handle rate. If the contractor does not have an Internet Portal, the utilization rate is the IVR handle rate. If the contractor has both an IVR and an Internet Portal, the utilization rate is the (# of Calls Handled in IVR + Internet Portal Sessions) / (IVR Only Completed Calls CSR Only Completed Calls + Internet Portal Sessions) *100. The data used to determine this metric will be taken from the data reported into the Provider Inquiries Evaluation System (PIES).

Contractor Assessment: The contractor’s utilization rate for the award fee period is _____. As a result, the contractor met/did not meet this award fee criterion.

Evaluation Criterion #3: Claims Processing Timeliness

This criterion measures the timeliness of processing clean, electronic claims within statutorily specified timeframes. Specifically, clean electronic claims are to be paid as early as the 14th day after receipt and must be paid by the 31st day of receipt. Part B CPT only will be evaluated for purposes of this award fee criterion.

In order to be eligible for participation in this criterion, the Contractor shall process at least 95.0% of clean, electronic claims within statutorily specified timeframes. If the Contractor has one or more months during the period in which the Contractor does not achieve the 95.0% performance threshold, then the Contractor is not eligible for participation in this criterion.

Award fee for this metric will be earned based on the number of months the Contractor achieves a 99.0% performance level for processing clean, electronic claims within statutorily specified timelines. The percentage of award fee earned will be calculated by dividing the number of months the Contractor achieved the 99.0% CPT rate by the number of months in the operational period. For example, if there are six (6) months in the operational period and the Contractor achieves the 99.0% Part B CPT rate for four (4) of the six (6) months, the Contractor would earn 67% of the award fee for this metric. The data source for this metric is the Contractor Reporting Operational Workload Data (CROWD) system which reflects monthly performance.

The RRB/CMS rounding convention for this metric is to one decimal place. Values of five (5) and above are rounded up and values of four (4) and below are rounded down. For example, a CPT score of 98.95% would be rounded to a 99.0% and a score of 98.94% would be rounded to 98.9%. Please note, because the data in CROWD is already rounded to one decimal place, a score of 98.9% in CROWD would NOT be rounded up to 99.0% for purposes of award fee evaluation.

The Part B results for the award fee period are as follows:

The Contractor [achieved/did not achieve] at least a 95.0% Part B CPT rate for each month of the award fee period and is therefore [eligible/ineligible] for this award fee criterion. Based on the data listed above, the [Contractor] met the 99.0% Part B CPT performance threshold for___ months of the award fee period and therefore, should earn ____% of the available award fee pool for this award fee criterion.

Evaluation Criterion #4: EMC Claims Increase

Metric: This criterion measures the contractor’s efforts to increase the number of electronic claims received. Specifically, in order to be eligible to receive this award fee, the Contractor must receive over 91% of its monthly claims electronically. The award fee will be earned by calculated by dividing the number of months that the metric was met by the total months in the evaluation period.

Contractor Assessment: The results for the award fee period are as follows:

Month

Based on the data listed above, the Contractor met the 91.0% performance standard for___ months of the award fee period and therefore, should earn ____% of the available award fee pool for this award fee criterion.

Evaluation Criterion #5: Appeals Redetermination Timeliness

Metric: This criterion measures the Contractor’s timeliness in processing and sending 100% of redetermination notices within 60 calendar days of receipt. In order to be eligible for participation in this criterion, the Contractor shall process at least 90% of redeterminations within 60 calendar days of receipt for all months of the period of performance.

The percentage of Award Fee earned will be calculated by dividing the number of months that the metric was met by the total number of months in the evaluation period.

The data source for this metric is the CROWD, CMS-2592 Appeals Workload Report and data submitted in the monthly report. Redetermination timeliness is calculated by dividing the sum of redeterminations cleared in 60 days (line 15) by the total cleared (lines 15 + 16). For validation purposes, the sum of lines 15 + 16 should equal line 6 (requests cleared) – line 7 (requested cleared where evidence is submitted after request). Redeterminations subject to the 74-day processing timeframe, because documentation is submitted later in the process (as reported on lines 7, 18, 19, and 20), are not to be included in the calculation for this metric. For this metric, timeliness is calculated to two (2) decimal places, with a hundredth value of five (5) and above rounded up, and hundredth value of four (4) and below rounded down. Therefore, a value of 99.95% or above would be rounded to 100%, and a value of 99.94% would be rounded to 99.9%.

The Part B redetermination timeliness results for the award fee period are as follows:

The Contractor [achieved/did not achieve] at least a 90.0% Part B redetermination timeliness for each month of the award fee period and is therefore [eligible/ineligible] for this award fee criterion. Based on the data listed above, the [Contractor] met the 100.0% Part B redetermination performance threshold for___ months of the award fee period and therefore, should earn ____% of the available award fee pool for this award fee criterion.

Evaluation Criterion #6.1: Beneficiary Customer Service- 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 and RRB 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 Part B results for the period of performance are as follows:

The [Contractor] is [eligible/not eligible] to earn award fee for this criterion because it [did/did not] respond to 75% of inquiries within 25 business days and 95% within 45 business days. Based on the performance data listed above, the Contractor earned [ %] of the available award fee pool for this criterion.

Evaluation Criterion #6.2: Beneficiary Customer Service – Average Speed to Answer (ASA) Metric: This criterion measures the average speed to answer beneficiary phone calls, currently 99% of the beneficiary phone calls are to be answered within 120 seconds. This data is summarized on monthly statistical phone data reports

The award fee for this criterion will be based on the number of months in the award fee period that the Contractor answers to 99% of beneficiary telephone calls within 120 seconds. The percentage of award fee earned will be calculated by dividing the number of months the Contractor achieved the 99 performance level by the number of months in the award fee period.

Contractor Assessment: The Contractor shall report the following:

Evaluation Criterion #6.3: – Beneficiary Customer Service - Call Completion Rate

Metric: This criterion measures the call completion rate; currently the call completion rate must equal or be less than 70%. This data is summarized on monthly statistical phone data reports.

In order to earn award fee dollars for this metric, the contractor shall provide in its monthly status report the call completion rate. The award fee for this criterion will be based on the number of months in the award fee period that the Contractor’s beneficiary call completion rate was equal to or greater than 70 percent.

Contractor Assessment: [Contractor] provided monthly phone reports reflecting the Call Completion Rates for the months listed below:

The number of months Contractor met this standard ( ) divided by total months ( ) = ( ) percent of Award fee earned.

Evaluation Criterion #7: Medical Review

Metric: This criterion measures the annual Medicare Review Strategy Report as outlined in the Medicare Program Integrity Manual, Chapter 7, MR Reports Annual MR Strategy with the goal of reducing the claims payment error rate.

Contractor Assessment: The Contractor shall provide a narrative summary, not to exceed 10 pages, to substantiate its rating in this area. The Contractor’s self-assessment shall contain documentation reflecting the results and accomplishments of completing its Medical Review Strategy Plan and goal of reducing claim payment error rates.

Evaluation Criterion #8: Decrease in the Number of Paper Remittances

Metric: This criterion measures the Contractor’s ability to decrease the number of paper remittance advices sent to providers in its jurisdiction. The contractor shall include the number of paper and electronic remittance advices sent in its monthly status reports.

Award fee earned will be based on the percentage decrease in the number of paper remittances sent during the last three months of the award fee period compared to the baseline. The baseline will be calculated based on the average number of remittances sent in the first three full months of the award fee period. The data source for this metric, for Part B, will be line 8 in the CROWD 3.2.19 5 List report Contractor Assessment: The [Contractor] achieved a ____% decrease in the number of paper remittances during the award fee period and therefore earned ___% of the award fee pool.

Evaluation Criterion #9: Increase in the Use of Electronic Funds Transfer (EFT)

Metric: This criterion measures the Contractor’s ability to increase the use of EFT payments to existing Medicare providers. The contractor shall include EFT statistics in its monthly status reports. Specifically, the contractor should include the number of EFT payments made to providers, as well as, the number of paper checks sent to providers by month. The data source for this metric will be line 9 in the CROWD 3.2.19 5 List report. Award fee earned will be based on the increase in the % of EFT transactions made in the last full month of the award fee period compared against the % of EFT transactions made in the first full month of the award fee period (baseline).

Contractor Assessment: The [Contractor’s] baseline for the percentage of EFT transitions is ____. The Contractor achieved a ____ increase and therefore earned __ % of the award fee pool.

Evaluation Criterion #10: Provider Enrollment - Calls

Metric: This award fee criterion measures the Contractor’s call completion rate for provider enrollment calls. Considering the significant size of the RRB active provider data base, a monthly call completion rate of 51% or higher is eligible for award participation based on the following:

This data is summarized on monthly statistical phone data reports.

Contractor Assessment: The award fee results are as follows:

Total Award Fee

Based on the above results, the Contractor earned ___% of the available award fee for this criterion.

RRB Specialty MAC Sample AFP Self-Assessment