Schedule N SLA Report Format.xlsx
XLSX spreadsheet 37 KB Posted
- Solicitation number
- RFP 171 260000002410 2
- Issued by
- Michigan
About this file
This is a Schedule N Service Level Agreement (SLA) Report Format template document for Michigan's Behavioral Health and Substance Use Disorder Benefits Administration contract. The document establishes the standardized reporting framework and metrics that the benefits administrator must track and report to the state regarding service delivery performance. The template specifies data collection categories, performance indicators, and reporting intervals required to monitor compliance with contractual service level obligations. The SLA report format serves as the mechanism for the contractor to demonstrate operational performance, quality standards, and adherence to state requirements throughout the contract term.
The Schedule N template does not contain pricing information, set-asides, or funding details within the document itself. Rather, it functions as a reporting tool that will be completed on an ongoing basis during contract performance to measure key performance indicators and service metrics specific to behavioral health and substance use disorder benefits administration. This document is a supporting exhibit that establishes accountability measures and performance visibility for the state to monitor contractor compliance with service delivery standards outlined in the primary contract terms and conditions.
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Sheet1
| Behavioral Health and Substance Use Disorder | BENEFIT CONTRACT PERIOD: | 01/01/2028-12/31/2031 | Quarterly Compliance Review Date: | |||||||||||||
| Account Representative: | Q1: | |||||||||||||||
| Contract Designee: | Bethany Beauchine | Q2: | ||||||||||||||
| Contract Value: | Q3: | |||||||||||||||
| Contract Options Remaining: | Annual review: | |||||||||||||||
| Contract Number: | ||||||||||||||||
| CY 2028 | Credit | Standard | JAN | FEB | MAR | APR | MAY | JUN | JUL | AUG | SEPT | OCT | NOV | DEC | Annual Total | |
| Weekly | Discrepancy reports | |||||||||||||||
| Monthly | See Reporting section below for due dates | |||||||||||||||
| Quarterly | See Reporting section below for due dates | |||||||||||||||
| Annual | See Reporting section below for due dates | |||||||||||||||
| Eligibility Files | SLA #1A: The Contractor must upload and accurately process eligibility files (i.e., additions, deletions, corrections of addresses, names, social security numbers, etc.) within one business day of receiving them from the State. |
Measured: Monthly and reported quarterly.
| Credit: 2% of the monthly admin fee. | 2% | 1 | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| SLA #1B: Discrepancies must be reported in the Contractor’s mutually agreed upon report format within two business days after the eligibility files have been uploaded. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the monthly admin fee. | 1% | 2 | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| SLA #1C: Discrepancies must be corrected in the Contractor’s system within one business day after the state has returned the discrepancy report to the Contractor with the requested clarifications. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the monthly admin fee. | 1% | 1 | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| Id Cards | SLA #2A: 100% of ID cards must be created and distributed through the U.S. Mail within 10 business days of receipt of the Plan Sponsor’s eligibility file. Performance must be substantiated by documentation providing proof of receipt date and mailing date. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the monthly admin fee. | 1% | 100% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| SLA #2B: ID Cards must have an accuracy rate of 99% or higher. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the monthly admin fee. | 1% | 99% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| Average | |||||||||||||||||
| Claims Turnaround | SLA #3A: 94% of all claims must be processed within 14 calendar days; assumes that the claims are filed completely and with valid information. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the monthly admin fee. | 1% | 94% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| SLA #3B: 99% of all claims must be processed within 30 calendar days; assumes that the claims are filed completely and with valid information. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the monthly admin fee. | 1% | 99% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| Claims | |||||||||||||||||
| Accuracy | SLA #4: Claims Processing Accuracy. The non-financial error rate (as defined as the number of claims with a non-financial error divided by the total number of claims) must not exceed 2.0%. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the monthly admin fee. | 1% | 2% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| SLA #5: Payment Incident Accuracy. The financial error (as defined as the number of claims containing a financial error divided by the total number of claims) must not exceed 3%. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the monthly admin fee. | 1% | 3% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| SLA #6: Financial Payment Accuracy. This measures the percentage of benefit dollars paid correctly. The financial accuracy rate calculation is the total dollars paid in the sample, less the absolute value of overpayments and underpayments, divided by the total dollars paid in the sample. The acceptable error rate for each year of the Contract will be 0.7%. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the monthly admin fee. | 1% | 0.7% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| Inquiry Handling | SLA #7A: Contractor must resolve 90% of all Written Inquiries within 14 calendar days of receipt. Written inquiries mean any inquiry other than telephonic. They include mail, email, fax, or web portal inquiries and include those submitted to the Contractor by the Plan Sponsor. The receipt date will be considered the date the Written Inquiry is received by the Contractor. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the Contractor's monthly admin fee. | 1% | 90% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| SLA #7B: 100% of all Written Inquiries must be resolved within 30 calendar days. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the Contractor's monthly admin fee. | 1% | 100% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| SLA #8: On a monthly basis, calls must be answered within an average of 30 seconds. The average speed of answer is the average length of time a caller waits in queue prior to the call being answered by a customer service representative |
Measured: Monthly and reported quarterly.
| Credit: 1% of the Contractor's monthly admin fee. | 1% | 30 | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| Inquiry Handling (cont.) | SLA #9: The monthly call abandonment rate must not exceed 2.0% (determined by the number of calls abandoned divided by the total number of calls). A call will be considered abandoned if the Member hangs up at any time after initiating a transfer out of the Interactive Voice Response (IVR) system. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the Contractor's monthly admin fee. | 1% | 2% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| Participating Provider List Audit | SLA #10: Contractor must perform a random audit of 3% of the Michigan based In-Network participating provider list to assure accuracy of identified providers accepting new patients and guaranteeing appointment availability. |
Measured: Monthly and reported quarterly.
| Credit: 1% of the Contractor's monthly admin fee. | 1% | 3% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| Network Accessibility | SLA #11: The Contractor must follow-up with each member to ensure that the provider access for an initial appointment meets contractual requirements, and the treatment setting is appropriate, eliminating any barriers in receiving care (e.g., travel distance, transportation issues, office hours, accessibility, etc.). |
97% of provider appointments must have been offered within the following timeframes:
• Immediate for Emergency (Life-threatening)
• 6 hours for Emergency (Non-Life-threatening)
• 48 hours for urgent
• 10 calendar days for routine Measured: Annually and reported annually.
| Credit: 4% of the Contractor's annual admin fee. | 4% | 97% | Actual | |||
| Credit | $0.00 | $0.00 | ||||
| Member Satisfaction Survey | SLA #12: One random sample survey of members who have received services under this Contract must be completed annually at no additional cost and must yield 85% satisfied or higher. Survey results must be available to the Plan Sponsor by December 31st within the Plan Year unless a different date is mutually agreed upon. |
The surveys must be completed within each Plan Year for the Plan Year. The acceptable timeframe for returned responses must not exceed four weeks. The respondent pool must be statistically valid based on the Plan Sponsor’s total population (randomly generated sample size sufficient to produce a 95.00% confidence interval with a margin of error not greater than +/- 3.00%). If the returned responses do not meet a sample size sufficient to produce a 95.00% confidence interval within the stated margin of error, upon agreement from the Plan Sponsor, the timeframe may be extended by two weeks.
Measured: Annually and reported annually.
| Credit: 2% of the Contractor's annual admin fee | 2% | 85% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| Network Access Standards | SLA #13: Network Access is at least 95% of the standards outlined in Schedule A Section 1.4.5.1; calculation of access will exclude any providers operating with income dependent access restriction (e.g., community mental health facilities/providers) or those not accepting new patients. |
The following is not subject to this SLA: Network Access in rural areas where there is a shortage of MD/DO specializing in child/adolescent psychiatry and where there is a shortage of ABA board certified providers.
Measured: Monthly and reported quarterly.
| Credit: 4% of the Contractor's monthly admin fee. | 4% | 95% | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| Timely Production of Complete Management Reports | SLA #14A: Contractor must provide complete monthly reports on the 15th of the second subsequent month. (i.e, October reporting is due December 15th). |
Measured: Monthly and reported monthly.
| Credit: 2% of the Contractor's monthly admin fee. | 2% | TRUE | Actual | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||
| SLA #14B: Contractor must provide complete quarterly reports on the following dates: |
Q1: (01/01-03/31) Due 05/15 of the current calendar year Q2: (04/01-06/30) Due 08/15 of the current calendar year Q3: (07/01-09/30) Due 011/15 of the current calendar year Q4: (10/1-12/31) Due 03/15 of the following calendar year.
Measured: Quarterly and reported quarterly.
| Credit: 2% quarterly admin fees. | 2% | TRUE | Actual | ||||||
| Timely Production of Complete Management Reports (cont.) | Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |||
| SLA #14C: Contractor must provide complete annual CY reports on March 15th of the following calendar year.. |
Measured: Annually and reported annually.
| Credit: 2% of the Contractor's annual admin fee. | 2% | TRUE | Actual | |||
| Credit | $0.00 | $0.00 | ||||
| Care Management | SLA #15: Contractor must provide care management services for behavioral health that includes the following services with at least 90% compliance: |
1. Pre-certification of all inpatient and higher level of care services.
2. Concurrent review of all in patient and higher level of care cases.
3. Discharge planning for all 24 hour care, including facilitation of ambulatory follow up appointments to be held within 7 days of discharge.
4. Follow up on all cases discharged from 24 hour care to improve attendance with post-discharge ambulatory appointments.
5. Individual case management (ICM) with high risk cases to identify and mitigate risk, reduce barriers to care and optimize recovery.
Measured: Monthly and reported quarterly.
| Credit: The credit for failure to meet this SLA is $1,000.00 per missed element quarterly. | $1,000 | 90.0% | Actual | ||||||||||||||
| $0.00 | $0.00 | $0.00 | $0.00 | ||||||||||||||
| Actual | |||||||||||||||||
| $0.00 | $0.00 | $0.00 | $0.00 | ||||||||||||||
| Actual | |||||||||||||||||
| $0.00 | $0.00 | $0.00 | $0.00 | ||||||||||||||
| Actual | |||||||||||||||||
| $0.00 | $0.00 | $0.00 | $0.00 | ||||||||||||||
| Actual | |||||||||||||||||
| $0.00 | $0.00 | $0.00 | $0.00 | ||||||||||||||
| Credit | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | ||||||||||||
| Admin Fees | Per Contract Per Month | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | $ - 0 | |||
| # of Active & Retiree Members | Monthly total of Active, Retiree, & COBRA members. | ||||||||||||||||
| Maximum At Risk | No more then 30% of the administration fees may be at risk. | $0.00 | |||||||||||||||
| Audit Timing | Status: New contract effective 04/01/2019 | ||||||||||||||||
| Penalty | Penalty due on XX. | Total Annual Credit Due: | $0.00 | Date Annual Credit Paid: | Amount Paid: | ||||||||||||
| Appeal Process | |||||||||||||||||
| HIPAA BAA | |||||||||||||||||
| Change Notices |
&"-,Bold"&K0070C0STATE OF MICHIGAN&K01+000 RFP No. &KFF0000XXX&K01+000 Schedule &KFF0000X&K01+000, Sample SLA Reporting Format
Prepared by Keri Rust on &D File Name: &Z&F Page &P of &N
File details come from the government source that posted it. Updated .