J6 MSPRC Performance Standards 12012010 DRAFT.pdf

MSPRC PERFORMANCE STANDARDS

1 Attachment J-6

SOW

Section

Performance

Standard

Evaluation

Methodology

Sampling

Methodology

Data

Source

Frequency

C.3.1 The infrastructure is available 98% of the time during all required hours of operation.

CMS receives a report of infrastructure hours of operation and any down-time.

Sampling MSPRC report and sampling report.

Annually

C.3.2.8 Supply 95% of requested case files and documentation to the PO within seven (7) calendar days of the request.

PO will track the date of request and receipt.

Sampling Report tracked by

PO.

Annually

C.3.3.1.1 The quality improvement plan is successful when the contractor makes improvements in its business process in accordance with the plan and can show the effectiveness of those changes.

CMS receives a report from the MSPRC to document quality actions and outcomes.

Sampling Report tracked by

PO.

Annually

C.3.3.1.1 Plan is successful when trends and their outcomes are captured and communicated to interrelated operational areas to improve the overall quality and efficiency of the recovery operations.

CMS receives a report from the MSPRC to document quality actions and outcomes.

Sampling Report tracked by

PO.

Annually

2 Attachment J-6

C.3.3.4.3 The MSPRC shall issue the RAR letter within fifteen (15) calendar days after the NGHP case is created in

ReMAS (SKL status).

CMS receives a report from

MSPRC of number of

RAR letters sent.

Report MSPReco very system.

Weekly

C.3.3.4.6

Standard 1

Ninety-five (95) percent of all newly created

NGHP cases out of SKL status by the 21st calendar day from the case creation date shall be filtered, and an interim

CPL/CPN/”No

Claims to Date”

Letter mailed to all authorized individuals/entitie s with valid addresses on file within fifty-five

(55) calendar days after the date of the RAR letter including scenario 5 for

ORM but excluding scenarios 1 through 4.

CMS receives a report from

MSPRC of conditional payment letters sent and the timeframes associated.

Report MSP

Recovery

System

Every other week

3 Attachment J-6

Standard 2

All complete

Proof of

Representation and/or Consent to

Release documentation received prior to the issuance of the initial

CPL/CPN shall be applied to ninety-eight (98) percent of the appropriate MSP

Recovery System cases prior to the issuance of the initial CPL or

CPN. If received after the issuance of the initial

CPL/CPN,

normal correspondence timeframes apply.

(“Applied” indicates that representative information is added to the case and the system will release documentation to the authorized parties with valid addresses on file.)

Compare

Receipts, CPL/CPN/”N o Claims to

Date” Letters mailed, and closures.

Sampling done during an On-site review

MSP

Recovery

System

4 Attachment J-6

Standard 3

Ninety-eight

(98) percent of all incomplete Proof of Representation and/or Consent to

Release documentation shall be resolved and applied to the appropriate MSP

Recovery System case within thirty

(45) calendar days. Any case that contains documentation of appropriate actions to obtain the needed information will be considered as meeting this standard.

(“Applied” indicates that representative information is added to the case and the system will release documentation to authorized parties)

(“Resolved” indicates the

MSPRC has proactively performed/docum ented its due diligence to obtain or has obtained appropriate and complete documentation

Compare

Receipts, CPL/CPN/”N o Claims to

Date” Letters mailed, closures, and case notes.

Sampling done during an On-site review

MSP

Recovery

5 Attachment J-6 for a case.)

Addresses and telephone numbers are not required to complete a Proof of Representation and/or Consent to

Release.

C.3.3.4.7

For an existing

MSP Recovery

System case where the initial

CPL has been sent, upon receiving notification of a settlement, judgment, award or other payment from the beneficiary or their representative, the MSPRC shall issue a recovery demand letter to the appropriate debtor and copy all authorized individuals with valid addresses on file within twenty (20) calendar days from the receipt of the notice of the settlement, judgment, award, 6 Attachment J-6 or other payment for 98% of these cases.

Ninety-five (95) percent of all newly created

ORM cases out of

SKL status by the

21st calendar day from the case creation date shall be filtered, and

Demand Letter mailed to the appropriate debtor and copy all authorized individuals with valid addresses on file within fifty-five (55) calendar days after the date of the RAR letter with the exception of

Scenario 5 for

ORM.

All complete

Proof of

Representation and/or Consent to

Release documentation received prior to the issuance of the demand, for

Scenarios 1 through 4 of

ORM, shall be applied to ninety-

PO receives report from

MSPRC for the number of status changes from CPL to

CPN.

Report MSP

Recovery

System

7 Attachment J-6 eight (98) percent of the appropriate

MSP Recovery

System ORM cases prior to the issuance of the demand. If received after the issuance of the demand, normal correspondence timeframes apply.

(“Applied” indicates that representative information is added to the case and the system will release documentation to authorized parties.)

Standard 4

Ninety-eight (98) percent of all incomplete Proof of Representation and/or Consent to

Release documentation shall be resolved and applied to the appropriate MSP

Recovery System

ORM case within forty-five (45) calendar days for

Scenarios 1 through 4 of

ORM. Any ORM case that contains documentation of appropriate actions to obtain the needed

Report MSP

Recovery

System

8 Attachment J-6 information will be considered as meeting this standard.

(“Applied” indicates that representative information is added to the case and the system will release documentation to authorized parties.)

(“Resolved” indicates the

MSPRC has proactively performed/docum ented its due diligence to obtain or has obtained appropriate and complete documentation for a case.)

Standard 5

MSP Recovery

System case, upon receiving notification of a settlement, judgment, award or other payment via Section 111 reporting and no settlement information has been provided by the beneficiary or their representative including

PO receives report from

MSPRC for the number of status changes from CPL to

CPN.

Report MSP

Recovery

System

9 Attachment J-6 scenario 5 for

ORM but excluding scenarios 1 through 4, the

MSPRC shall issue a CPN to all authorized parties with valid addresses on file within forty-five

(45) calendar days from the receipt of the

Section 111 notification for

98% of these

Standard 6

MSP Recovery

System case, upon receiving notification of a settlement, judgment, award or other payment via Section 111 reporting and/or settlement information has been provided by the beneficiary or their representative, including scenario 5 for

ORM but excluding scenarios 1 through 4, before the initial CPL has been issued, the MSPRC shall issue a CPN to all

PO receives report from

MSPRC for the number of status changes from CPL to

CPN.

Report MSP

Recovery

System

10 Attachment J-6 individuals with valid addresses on file within fifty-five (55) calendar days from the date of the RAR for 98% of these cases.

Standard 7

: For an existing

MSP Recovery

System case, upon receiving notification of

ORM Scenarios 1 through 4 via

Section 111 reporting, the

MSPRC shall issue a demand to the appropriate debtor and copy all authorized individuals with valid addresses on file within forty-five (45) calendar days from the date the lead associated to a case for 98% of these cases.

Standard 8

For cases identified as

MMSEA Section

111 and other settled cases not previously established in the

MSP Recovery

System, when the notice of the settlement, PO receives report from

MSPRC for the number of cases initially in CPN status.

11 Attachment J-6 judgment, award, or other payment is received, the

MSPRC shall:

a) Issue the

RAR letter to the beneficiary and any representative s/entities, as applicable, within fifteen

(15) calendar days after the

NGHP case is created in the

MSP

Recovery

System for

99% of such cases with the exception of non valid addresses.

This includes all scenarios for ORM reported via

Section 111.

b) Issue a

CPN to all authorized individuals/en tities within fifty-five (55) calendar days from the date of the RAR for 98% of these cases where claims have been retrieved.

This includes

a) CMS receives a report from

MSPRC of number of

RAR letters sent.

b) CMS report from

MSPRC of conditional payment notices sent and the timeframes associated.

c) CMS receives a report from

MSPRC of demands sent as a result of the CPN and the timeframes

12 Attachment J-6 scenario 5 for

ORM but excludes scenarios 1 through 4.

c) If a response to the CPN is received timely, issue a recovery demand letter to the appropriate debtor and copy all authorized individuals with valid addresses on file within forty-five (45) calendar days from the response due date printed on the notice plus five (5) calendar days, for 98% of these cases.

d) If no response to the CPN is received by the response due date plus five (5) calendar days, issue a recovery demand letter to the appropriate debtor and copy all associated.

d) CMS report from

MSPRC of demands sent as a result of the CPN and the timeframes associated.

13 Attachment J-6 individuals with valid addresses on file within twenty (20) calendar days from the response due date printed on the notice for 98% of the

C.3.3.4.8 The MSPRC shall close 100% of NON-GHP records upon settlement, judgment, award, or other payment at issuance of the demand, except for ORM reported pursuant to

Section 111.

Sampling Use

MSPRC

report above and compare with CWF updates.

C.3.3.4.13

The MSPRC mails 100% of all complete and assumed valid demand packages by the date printed on the demand letters.

Note: The AR-established date shall equal the date of the demand.

Sampling done during an On-site review

Compare a day’s mail- outs to dates on the letter.

For every PPN sent, including

PPNs that receive no response, the

MSPRC shall

PO receives

PPN Tracking report from the MSPRC.

Report MSP

Recovery

Monthly

14 Attachment J-6 determine if the debt is valid, based upon the

PPN responses or lack thereof, and issue a demand letter or send a letter to the responsible party closing the case for 98% of cases within ninety-five

(95) calendar days of the date of the PPN.

If a response is received, the

MSPRC has eighteen (18) calendar days from the response due date of the

PPN plus five (5) calendar days to enter any applicable ECRS requests for 98% of cases.

PO receives

PPN Tracking report from the MSPRC.

Report MSP

Recovery

System

Monthly

C.3.3.4.14 resolves ninety-five percent

(95%) of all correspondence, except checks, within forty-five calendar days

(unless directed otherwise, depending on the type of correspondence).

This includes misrouted

Sampling . Annually

15 Attachment J-6 correspondence, based upon the

MSPRC receipt date, that the

MSPRC transfers to the Medicare claims processing contractors including

Medicare

Administrative

Contractors

(MACs) and

/Durable Medical

Equipment

Medicare

Administrative

Contractors

(DME MACS).

The MSPRC shall accurately post one hundred percent 100% of all checks received with correspondence to a known debt within twenty

(20) calendar days (this does not affect the requirement that the MSPRC shall deposit all checks within twenty-four (24) hours of receipt; see

Section C.3.6, Banking

Relations).

MSPRC

supply a report of correspondenc e showing

Julian date.

Sampling done during an On-site review

Compare corr.

Report with actual action.

shall deposit voluntary/unsolici ted checks within

24 hours of

Sampling done during an On-site review

Compare check deposit logs with date of

16 Attachment J-6 receipt from a provider, physician or other supplier into its

Treasury General

Account (TGA;

see Section C.3.6, Banking

Relations). The

MSPRC shall reissue the deposited amount and all related correspondence to the appropriate

Medicare claims processing contractor via first class mail no later than seven

(7) calendar days after receiving the requested funds from the PO.

AR

posting.

All correspondence received, before the initial

CPL/CPN is issued, shall be worked and any responses shall be sent out simultaneously with the initial

CPL/CPN for

98% of all such cases. (Includes

Notice of

Settlement and excludes Appeals, Waivers, and

Compromises)

Compare

Receipts, CPL/CPN/”N o Claims to

Date” Letters mailed, closures, and case notes.

Sampling MSP

Recovery

17 Attachment J-6

Standard 5

For ORM scenarios 1 through 4, all correspondence received before the demand is issued shall be worked and any responses shall be sent out simultaneously with the demand for 98% of all such cases.

C.3.3.4.15 The MSPRC shall answer 98% of all voicemail messages and complete callbacks within one business day after the message was left.

Sampling done during

On-site review

Confirm call sheets are with the case file and the call sheet is dated.

C.3.3.4.16.

3.3.

Standard

14.16.

The MSPRC shall resolve seventy (70) percent of individual beneficiary GHP debts (with payment or valid documented defense) prior to the debts becoming 180 calendar days delinquent. This is a test standard for CY2010 after the inception of the PPN.90% of

Non- t.

Sampling done during

On-site review

Confirm call sheets are with the case file and the call

18 Attachment J-6

C,3.3.4.163

2.3.4.16 shall resolve ninety (90) percent of

NGHP debts prior to the debts becoming 180 calendar days delinquent. This is a test standard for CY2010 after the inception of the CPN.

Sampling done during

On-site review

Confirm call sheets are with the case file and the call

3.3.4.16 shall refer one hundred (100) percent of eligible delinquent

NGHP and GHP debts to Treasury before the 181st calendar day of delinquency

(241 calendar days after the date of the demand).

Sampling done during

On-site review

Confirm call sheets are with the case file and the call

MSPRC shall resolve debts deemed to be “in appeal” status within forty-five

(45) calendar days of that designation.

Sampling Annually

19 Attachment J-6

C.3.5.4 forwards all second-level appeal requests and all supporting documentation, including the case file, to the designated QIC within five (5) calendar days.

MSPRC

supply a Corr.

Tracking report with the appeal requests categorized outside of the general universe.

Sampling Obtain report showing date of referral and compare to the

MSPRC

corr.

Tracking.

Report.

Misrouted appeal requests are forwarded to the

QIC or OMHA within 5 calendar days of receipt.

MSPRC

supply a Corr.

Tracking report with the appeal requests categorized outside of the general universe.

Sampling Obtain report showing date of referral and compare to the

MSPRC

corr.

Tracking.

effectuates 95% of all appeal decisions, whether made at or above the QIC level or by a court, within the same monthly financial reporting period as the date(s) of the decisions or within thirty (30) calendar days, whichever is longer.

Sampling Obtain report showing date of referral and compare to the

MSPRC

corr.

Tracking.

C.3.5.5 The MSPRC shall deposit voluntary/unsolici ted checks within

Sampling MSP

Recovery

Systems

20 Attachment J-6

24 hours of receipt from a provider, physician or other supplier into its

Treasury General

Account (TGA;

see Section C.3.6, Banking

Relations). The

MSPRC shall reissue the deposited amount and all related correspondence to the appropriate

Medicare claims processing contractor via first class mail no later than seven

(7) calendar days after receiving the requested funds from the PO.

C.3.6 deposits funds into its TGA within twenty-four (24) hours of receipt.

On-site

Sampling

Obtain report showing date of referral for refund and compare to the

MSPRC

date of response.

C.3.6

Recording and reconciliations are accurate and timely. The TGA will allow for deposit through the U.S. Treasury into the Medicare

On-site

Sampling

Obtain report showing date of referral for refund and compare

21 Attachment J-6

Trust Funds.

These deposits will be categorized in

CMS’ cash link to the

MSPRC

date of response.

C.3.6.1 request 95% of refunds within fifteeen (15) calendar days of the identification of the situation requiring a refund and 100% within thirty (30) calendar days unless otherwise directed by the

SOW. (This standard excludes

Treasury refunds.)

On-site

Sampling

Obtain report showing date of referral for refund and compare to the

MSPRC

date of response.

C.3.7.4

Initial CAP reports are timely when submitted to CMS within 45 calendar days of receiving a final audit report.

Sampling Obtain and

Review all audit reports.-

C.3.7.4

The MSPRCs

CAPs are successful when its deficiencies have been corrected within one year of being identified.

Sampling CMS will confirm and obtain proof from

MSPRC

of completio n.

Annually

C.3.7.7 The MSPRCs deficiencies have been corrected within one year of being identified.

Sampling CMS will confirm and obtain proof from

MSPRC

of

22 Attachment J-6 completio n.

C.3.9.3 All MSPRC

A123 findings under the direct control of the

MSPRC shall be corrected within one (1) year (or less based on

CMS’

determination of criticality).

Sampling A123 auditors

Annually

C.3.9.6 The MSPRC (as a prime contractor together with any and all subcontractors, if any) shall deploy a Six Sigma and/or Lean Six

Sigma Quality

Program to drive continuous business process improvement.

Sampling A123

Auditors or Internal

C.3.10.3 correct its weaknesses, findings, gaps, or other deficiencies according to

CMS/OIS

required timeframes unless otherwise authorized by

CMS.

Sampling A123Audi tors or

Internal

Security auditors.

C.4.1.1

The implementation is successful when all Medicare MSP recovery

23 Attachment J-6 functions are performed by the new MSPRC beginning on the specified implementation date.

C.4.1.1

The workload transition is successful when all Medicare MSP recovery information, records, and data have been accepted from the current Medicare contractor and are performed by the new MSPRC beginning on the specified implementation date.