Contractor Performance Reference Checks

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					                                                                                       Core MMIS - Monitoring Contractual Performance Measurements V1.3


RFP                                                   Contractual Performance Measurement
          5.2 CORE MMIS COMPONENT

5.2.2.2          Provider Function

5.2.2.2.7        Performance Standards
                 If the State develops an automated interface for licensing and/or certification data, the Core MMIS contractor must
            1    meet these standards for update of this licensing/certification data.
          1.1    Update the Provider database with Occupational Licensing updates at least twice per month.
          1.2    Validate the licensing update process within two (2) business days of application of the update transmission.
          1.3    Resolve licensing transactions that fail the update process within two (2) business days of error detection.
                 Refer to the State all licensing transactions that fail the update process and cannot be resolved by contractor staff
                 pursuant to edit update rules or State-approved procedures within two (2) business days of attempted error
          1.4    resolution.
            2    Produce and mail provider 1099s by January 31st of each calendar year.
                 Produce and make provider mailing labels available for printing in the State data center within one (1) business
             3   day of request.

             4 Update and notify the State of provider data received electronically within one (1) business day of receipt of file.

5.2.2.3          Claims Processing Function

5.2.2.3.7      Performance Standards
             1 The performance standards for the claims processing functions are provided on the sections below.

5.2.2.3.4.1 Claims Entry and Control

5.2.2.3.7.1 Performance Standards
             Log, image and assign a unique control number to every claim, attachment, adjustment/void, prior authorization
           1 and other documents submitted by providers within one (1) business day of receipt.
             Data enter ninety-eight percent (98%) of all hard copy claims and adjustment/void requests within five (5)
           2 business days of receipt.
           3 Return hard copy claims that fail the prescreening process within one (1) business day of receipt.
           4 Maintain at least a ninety-five percent (95%) keying accuracy rate for data entered documents.
           5 Produce facsimiles of electronic claims within one (1) business day of receipt.
           6 Maintain a ninety-nine percent (99%) accuracy rate for electronic claims receipt and transmission.
             Produce and provide to DHS all daily, weekly and monthly claims entry statistics reports within one (1) business
           7 day of production of the reports.
             Provide access to imaged documents to all users within one (1) business day of completion of the imaging.
           8 Response time for accessing imaged documents at the desktop must not exceed ten (10) seconds.
             For claims submitted via modem-to-modem transmission or via the Internet, return an electronic receipt and/or
           9 notification within four (4) business hours of receipt

            10 All EMC claims, including Medicare crossover claims, must be processed in the next daily cycle after receipt.
               For claims submitted on tape or diskette, notify the provider within twenty-four (24) hours of receipt when claims
            11 cannot be processed and include the reason for the rejections in the notice.
            12 Resolve all rejected batches within three (3) business days of the rejection.

5.2.2.3.7.2 Claims Adjudication

File Name: Performance Measurements v1.3
Author: Barnett 7/22/2010

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                                                                                       Core MMIS - Monitoring Contractual Performance Measurements V1.3


RFP                                               Contractual Performance Measurement
5.2.2.3.7.2 Performance Standards
             Ninety percent (90%) of all clean claims must be adjudicated for payment, denial or budget relief within twenty-
           1 (20) calendar days of receipt.
             Ninety-nine percent (99%) of all clean claims must be adjudicated for payment, denial or budget relief within sixty-
           2 (60) calendar days of receipt.
             One hundred percent (100%) of all claims must be adjudicated for payment, denial or budget relief within one
           3 hundred and twenty- (120) calendar days of receipt.
             One hundred percent (100%) of all clean provider-initiated adjustment requests must be adjudicated within ten
           4 (10) business days of receipt.
             Claims processed in error must be reprocessed within ten- (10) business days of identification of the error or upon
           6 a schedule approved by the State.

5.2.2.3.7.3 Claims Financial and Reporting

5.2.2.3.7.3 Performance Standards
           1 Enter all financial transactions to the online financial file within one (1) business day of receipt.
             Produce and submit to the State, balancing and control reports that reconcile all claims input to the processing
           2 cycle to the output of the cycle by the next business day following the cycle.
           3 Produce the check-write accounting reports by 8:00AM after completion of payment cycle.
             Ninety-eight percent (98%) of client claim histories shall be provided within three- (3) business days of DHS
           4 request.
             Mail provider checks and remittance advices by the third (3rd) business day following the second (2nd) and fourth
           5 (4th) Monday of each month.

5.2.2.4          Recipient Function

5.2.2.4.7        Performance Standards
                 Update the member eligibility database with electronically received data and provide DHS with update and error
                 reports within twenty-four (24) hours of receipt of daily updates. For a batch-processing environment, updates
             1   must be done prior to daily claims processing.
                 Update month-end replacement files and provide DHS with update and error reports before the first day of the
             2   replacement month.
             3   Maintain a ninety-nine percent (99%) accuracy rate on electronic eligibility file updates.
             4   Resolve eligibility transactions that fail the update process within two (2) business days of error detection.

               Refer to the State all eligibility transactions that fail the update process and cannot be resolved by contractor staff
             5 pursuant to edit rules or State approved standards within two (2) business days of attempted error resolution.
               Perform online updates for hardcopy update transactions to member data, except presumptive eligibility records,
             6 within one (1) business day of receipt.
               Add records for presumptively eligible individuals to the member eligibility file the same day as the eligibility
             7 determination.
             8 Maintain a ninety-eight percent (98%) keying accuracy rate for online updates.
             9 Identify and correct keying errors in online updates within one (1) business day of the update.
               Produce and send notices to members based on adverse actions for denied ambulance and rehabilitation claims,
            10 and denied and modified prior authorizations within three (3) business days of decision on the claim.
               Provide a weekly report to DHS of all "Notices of Decision to Recipients" that were sent to members based on
               adverse actions for denied ambulance and rehabilitation claims, and denied and modified prior authorizations
            11 within five (5) business days.

File Name: Performance Measurements v1.3
Author: Barnett 7/22/2010

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                                                                                   Core MMIS - Monitoring Contractual Performance Measurements V1.3


RFP                                               Contractual Performance Measurement
               Issue Notices of Decision to members within twenty-four (24) hours of the determination of the denial of
               ambulance claims and rehabilitation therapy services claims for occupational therapy, physical therapy and
            12 speech therapy.

               Support the processing of nursing facility, ICF/MR, Home and Community Based Waiver and other long term care
            13 claims through the maintenance of member-specific LTC data and provider-specific certification and rate data.

5.2.2.5        Reference Function

5.2.2.5.7      Performance Standards
             1 Update the CLIA laboratory designations within one (1) business day of receipt of file
             2 Perform online updates to reference data within twenty-four (24) hours of receipt.
               Process procedure, diagnosis, and other electronic file updates to the reference databases within five (5) business
             3 days of receipt or upon a schedule approved by the State.
             4 Provide update error reports and audit trails to the State within 24 hours of completion of the update.
             5 Update edit adjudication documentation within three (3) business days of the request from DHS.
             6 Update error text file documentation within three (3) business days of DHS approval of the requested change.
             7 Maintain a 98% accuracy rate for all reference file updates.
             8 Identify and correct errors within one (1) business day of error detection.

5.2.2.6        Encounter Function

5.2.2.6.7      Performance Standards
               Process and report disposition of encounter file edit review to the submitting managed care organization within
             1 three (3) business days of receipt.
               Provide encounter data files, in acceptable format, to DHS-recognized contractors within five (5) business days of
             2 end of designated reporting period.
               Report findings from audits of HMO and Iowa Plan encounters to DHS within five (5) business days from the end
             3 of the reporting quarter.

5.2.2.7        Managed Care Function

5.2.2.7.7      Performance Standards
               Process capitation payments before the 15th of the month and report claim count and payment amount per rate
             1 cell to DHS within two (2) business days of processing the payment.
             2 Meet a ninety-eight percent (98%) accuracy rate for all capitation rate assignments.
               Meet a ninety-eight percent (98%) accuracy rate on appropriate payment, or denial, of fee for service claims for
             3 HMO members.

5.2.2.9        Medically Needy

5.2.2.9.7      Performance Standards
             1 All claims will be applied to the Medically Needy spend down accounts according to the following timelines:
           1.1 Within 24 hours of adjudication cycle for all Medicaid covered claims
           1.2 Within 48 hours of adjudication cycle for all Non-Medicaid covered claims
               Assure ninety-five percent (95%) accuracy in identifying all appropriate claims for the Medically Needy spend
             2 down account for approved Medically Needy clients.

5.2.2.10       Management and Administrative Reporting (MAR) Function
File Name: Performance Measurements v1.3
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                                                                                       Core MMIS - Monitoring Contractual Performance Measurements V1.3


RFP                                                   Contractual Performance Measurement

5.2.2.10.7       Performance Standards
                 All standard production reports must be available on line for review by DHS staff pursuant to the following
             1   schedule:
           1.1   Daily reports - by 10:00 AM of the following business day.
           1.2   Weekly reports - by 10:00 AM of the next business day after the scheduled production date.
           1.3   Monthly reports - by 10:00 AM of the third business day after month end cycle.
           1.4   Quarterly reports - by 10:00 AM of the fifth business day after quarterly cycle.
                 Annual reports - by 10:00 AM of the tenth (10th) business day after year end cycle (state fiscal year, federal fiscal
           1.5   year, waiver year, or calendar year)
                 Balancing reports are to be provided to DHS within two (2) business days after completion of the MARS
           1.6   production run.
                 Hard copy reports, when requested, must be delivered to DHS staff within two (2) business days of availability of
           1.7   online report.
                 Ninety-eight percent (98%) accuracy is required on all MMIS reports. The contractor will propose a means for
             3   calculating the 98% accuracy rate.

               When an error in a MAR report is identified either by the Core MMIS contractor or by DHS, provide an explanation
               as to the reason for the error within three (3) business days and correct the report within ten (10) business days
             4 following the date the error was identified unless DHS authorizes additional time for correction.
               Data files for all reports must be made available on the State data center servers and accessible online within 24
             5 hours of completion.

5.2.2.11         Surveillance and Utilization Review (SUR) Function

5.2.2.11.7     Performance Standards
             1 All required reports must be available online for review by DHS staff pursuant to the following schedule:
           1.1 Daily reports - by 10:00 AM of the following business day.
           1.2 Weekly reports - by 10:00AM of the next business day after the scheduled production date.
           1.3 Monthly reports - by 10:00 AM of the third (3rd) business day after month end cycle.
           1.4 Quarterly reports - by 10:00 AM of the fifth (5th) business day after quarterly cycle.
               Annual reports - by 10:00 AM of the tenth (10th) business day after year-end cycle (state fiscal year, federal fiscal
           1.5 year, waiver year, or calendar year).
           1.6 Special requests - by 10:00 AM on the agreed upon date.
             2 Produce and mail REOMBs by the 15th calendar day of the month.

5.2.2.12         Third Party Liability (TPL) Function

5.2.2.12.7     Performance Standards
               Once a month, within 5 calendar days of month end, produce and mail letters to members for claims with services
               exceeding $100 related to trauma resulting from an accident requesting additional information concerning the
             1 accident and whether any other third party is liable.
               Provide a monthly report to DHS identifying all payments avoided due to TPL in a format approved by the
             2 Department by the 10th calendar day of the following month.
               Provide a monthly report to DHS of terminated TPL coverage on HIPP members so DHS does not continue to pay
             3 premiums in a format approved by the Department by the 10th calendar day of the following month.

               Generate a weekly report from the data provided by the TPL Resource File, HIPP and Child Support Recovery
             4 unit so that the information can be keyed into the system by the end of the week in which the report is generated.
File Name: Performance Measurements v1.3
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                                                                                     Core MMIS - Monitoring Contractual Performance Measurements V1.3


RFP                                                 Contractual Performance Measurement

5.2.2.13       Prior Authorization Function

5.2.2.13.7     Performance Standards
             1 Complete all PA interface updates within one (1) business day of receipt of a file if there are no critical errors
             2 Generate all error reports within one (1) business day of the interface or file update.
               Ninety-five percent (95%) of prior authorization file updates received from outside entities/agencies will be applied
             3 no later than the next business day.

5.2.2.14       Early and Periodic Screening, Diagnosis, and Treatment

5.2.2.14.7     Performance Standards
             1 Accept and update EPSDT screening data from claims no less frequently than weekly.
               Hard copy reports, when requested, must be delivered to DHS staff within two (2) business days of availability of
             2 online report.
               All standard production reports must be available online for review by DHS staff pursuant to the following
             3 schedule:
           3.1 Daily reports - by 10:00 AM of the following business day.
           3.2 Weekly reports - by 10:00AM of the next business day after the scheduled production date.
           3.3 Monthly reports - by 10:00 AM of the third (3rd) business day after month end cycle.
           3.4 Quarterly reports - by 10:00 AM of the fifth (5th) business day after quarterly cycle.
               Annual reports - by 10:00 AM of the tenth (10th) business day after year-end cycle (state fiscal year, federal fiscal
           3.5 year, waiver year, or calendar year).
               Ninety-eight percent (98%) accuracy is required on all MMIS reports. The contractor will propose a means for
             4 calculating the 98 percent accuracy rate.


             5 SYSTEM COMPONENTS & OPERATIONAL REQUIREMENTS

5.1.4          Contract Management

5.1.4.3        Performance Standards

               Provide the monthly contract management reports within three (3) business days of the end of the reporting
             1 period.
               Provide monthly performance monitoring report card within ten (10) business days of the end of the reporting
             2 period.

             3 Provide new user training for State staff and other component contractor staff a minimum of one time per quarter.
             4 Provide refresher training to State users and other component contractor staff a minimum of twice a year.
               Provide training on system changes as a result of upgrades or other enhancements within two (2) weeks of the
             5 upgrade.
               Provide an acknowledgment of the receipt of a user support request by response to the requestor within twenty-
             6 four (24) hours and indicate the time frame for a resolution to the issue or question.
               Provide a response/resolution to State Project Management staff within forty-eight (48) hours of receipt to
             7 requests made in any form (e.g., e-mail, phone) on routine issues or questions.
               Provide a response within 24 hours to State Project Management staff on emergency requests, as defined by the
             8 State.

File Name: Performance Measurements v1.3
Author: Barnett 7/22/2010

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                                                                                  Core MMIS - Monitoring Contractual Performance Measurements V1.3


RFP                                        Contractual Performance Measurement
5.1.5         System Maintenance and Enhancement

5.1.5.3       Performance Standards
              Notify DHS of system problems identified by the contractor within twenty-four (24) hours of identification of the
          1   problem.
              Respond to system maintenance requests within five (5) business days except for emergency requests for which
          2   a response is due within twenty-four (24) hours of receipt of the request.
              Ninety percent (90%) of schedule and cost estimates for system enhancements must be submitted within ten (10)
              business days after receiving request, and one hundred percent (100%) must be submitted within thirty (30)
          3   business days
              Ninety-five percent (95%) of system changes must be completed on the date agreed to by DHS and the
          4   contractor. Completion dates may be extended with concurrence of the State.
              Provide monthly reports of programmer hours by the fifth (5th) calendar day of the month for activity completed in
          5   the previous month.
              Provide monthly reports of enhancement project progress and to-date cost report and time expended on each
          6   open project by the fifth (5th) calendar day of the month for activity in the previous month.

5.1.7         Internal Quality Assurance

5.1.7.3     Performance Standards
            Identify deficiencies and provide the State with a corrective action plan within ten (10) business days of discovery
          1 of a problem found through the internal quality control reviews.
          2 Meet ninety-five percent (95%) of the corrective action commitments within the agreed upon timeframe.




File Name: Performance Measurements v1.3
Author: Barnett 7/22/2010

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                                                                                           POS - Monitoring Contractual Performance Measurements V1.3


RFP or
Contract                           Contractual Performance Measurements

            5.3 PHARMACY POINT-OF-SALE (POS) COMPONENT

4.2.2.2          Claims Processing Function

4.2.2.2.7      Performance Standards
             1 No more than five percent (5%) of incoming calls to the Help Desk may ring
               Provide POS function availability twenty-three (23) hours a day, seven (7)
             2 days a week.
               Provide online response notifications to providers within ten (10) seconds of
             3 receipt of incoming claim transactions.
               Hold time must not exceed two (2) minutes for ninety-five percent (95%) of
             4 Help Desk calls.
             5 The average hold time for Help Desk shall not exceed thirty (30) seconds.
               Ninety-five percent (95%) of incoming Help Desk calls that do not ring busy
             6 must be answered by a live operator.
               Provide adjudicated claims and payment data to the Core MMIS contractor by
             7 10:00 pm on the day prior to the payment cycle.
               Update provider, member, and TPL data within one (1) business day of receipt
             8 of the data from the Core MMIS contractor.

4.2.2.3          Reference Function

4.2.2.3.7        Performance Standards
                 Update the formulary file within one (1) business day of receipt of the file from
             1   the drug update vendor or receipt of online updates from DHS.
                 Provide update, error reports, and audit trails to DHS within one (1) business
             2   day of completion of the update.
                 Identify and correct any errors on the formulary file within one (1) business day
             3   of error detection.
                 Provide the quarterly drug listings to DHS by 10:00 AM of the fifth (5th)
             4   business day after the end of the quarter.

4.2.2.4          Prospective Drug Utilization Review (ProDUR)

4.2.2.4.7        Performance Standards
                 Provide ProDUR criteria for new drugs within two (2) weeks of a drug's
             1   introduction.
                 Provide the ProDUR criteria update and error reports within one (1) business
             2   day of the update.
                 Provide the monthly ProDUR reports by 10:00 AM of the third business day
             3   after the end of the month.
                 Provide quarterly reports by 10:00 AM of the fifth (5th) business day after the
             4   end of the quarter.

4.2.2.5          Drug Rebates



File Name: Performance Measurements v1.3
Author: Barnett
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                                                                                          POS - Monitoring Contractual Performance Measurements V1.3


RFP or
Contract                             Contractual Performance Measurements
4.2.2.5.4.6       Performance Standards
                  Update the manufacturer rebate data within five (5) business days of receipt of
              1   the update from CMS.
                  Generate and mail invoices to manufacturers within five (5) business days of
                  the receipt of the CMS drug rebate tape & IME Pharmacy Medical Services
              2   contractor supplemental drug rebate data.
                  Generate initial collection letters or make phone calls to non-responding
                  manufacturers within thirty-eight (38) calendar days from the mailing date of
              3   the invoice.
                  Collect at least ninety percent (90%) of the total of accounts receivables
                  outstanding at the beginning of the quarter plus invoices issued during the
              4   current quarter by the end of the current quarter.
                  Deposit all payments from drug manufacturers into designated State accounts
              5   within one (1) business day of receipt.

              4 SERVICE REQUIREMENTS

4.1.4             Contract Management

4.1.4.3           Performance Standards

                Provide the monthly contract management reports within three (3) business
              1 days of the end of the reporting period.
                Provide monthly performance monitoring report card within ten (10) business
              2 days of the end of the reporting period.
                Provide new user training for State staff and other component contractor staff
              3 a minimum of one time per quarter.
                Provide refresher training to State users and other component contractor staff
              4 a minimum of twice a year.
                Provide training on system changes as a result of upgrades or other
              5 enhancements within two (2) weeks of the upgrade.
                Provide an acknowledgment of the receipt of a user support request by
                response to the requestor within twenty-four (24) hours and indicate the time
              6 frame for a resolution to the issue or question.
                Provide a response/resolution to POS Unit Manager within forty-eight (48)
                hours of receipt to requests made in any form (e.g., e-mail, phone) on routine
              7 issues or questions.
                Provide a response within 24 hours to the POS Unit Manager on emergency
              8 requests, as defined by the State.

4.1.5             System Maintenance and Enhancement

4.1.5.4         Performance Standards
                Notify POS Unit Manager of system problems identified by the contractor
              1 within twenty-four (24) hours of identification of the problem.




File Name: Performance Measurements v1.3
Author: Barnett
7/22/2010                                                                                                             8
                                                                                      POS - Monitoring Contractual Performance Measurements V1.3


RFP or
Contract                         Contractual Performance Measurements
               Respond to system maintenance requests within five (5) business days except
               for emergency requests for which a response is due within twenty-four (24)
           2   hours of receipt of the request.
               Ninety percent (90%) of schedule and cost estimates for system
               enhancements must be submitted within ten (10) business days after receiving
               request, and one hundred percent (100%) must be submitted within thirty (30)
           3   business days
               Ninety-five percent (95%) of system changes must be completed on the date
               agreed to by the POS Unit Manager and the contractor. Completion dates may
           4   be extended with concurrence of the State.
               Provide monthly reports of programmer hours by the fifth (5th) calendar day of
           5   the month for activity completed in the previous month.
               Provide monthly reports of enhancement project progress and to-date cost
               report and time expended on each open project by the fifth (5th) calendar day
           6   of the month for activity in the previous month.

4.1.7          Internal Quality Assurance

4.1.7.3      Performance Standards
             Identify deficiencies and provide the State with a corrective action plan within
             ten (10) business days of discovery of a problem found through the internal
           1 quality control reviews.
             Meet ninety-five percent (95%) of the corrective action commitments within the
           2 agreed upon timeframe.




File Name: Performance Measurements v1.3
Author: Barnett
7/22/2010                                                                                                         9
                                                                                Medical Services - Monitoring Contractual Performance Measurements v1.3


RFP                           Contractual Performance Measurement

         8 MEDICAL SERVICES COMPONENT


        8.2 Medical Support

8.2.9        Performance Standards
             Screen claims appeals and review for accuracy, validity, and completeness
         1   within two (2) business days of receipt from provider.
             Notify the provider within three (3) business days of receipt of a claims
         2   appeal of incomplete or missing information.
             Send the final determination letter on a claims appeal to the provider within
         3   ten (10) business days of receipt of complete documentation.
             Process requests for exceptions to policy within ten (10) business days of
         4   receipt unless additional information is requested.
             Complete retrospective reviews based on criteria developed by the
         5   Department


        8.3 Disease Management

8.3.9        Performance Standards
             Reduce the costs of care for members under disease management by 10%
             (or specify some other percentage) from the fee-for-service costs of care for
         1   the same condition.
             Enroll a minimum of 250 eligible members into the disease management
             program during the first year of the contract and increase that percentage by
         2   5% per year for each year of the contract.
             Retain ninety (90) percent of members in the program for at least one year,
         3   if that member maintains eligibility in Medicaid for that period.
             Complete initial health status assessments for each enrollee within 30 days
         4   of enrollment.
             Prepare annual (or quarterly or semi-annual) health status assessments on
         5   all members who have been enrolled for at least one year.
             Complete health status assessments on all members who have been
             enrolled for at least one year within 30 days of the anniversary date of the
         6   member's enrollment.


        8.4 Enhanced Primary Care Case Management

8.4.9      Performance Standards
           Upon referral, initial member contact for case management services shall be
           completed for ninety five percent (95%) of the members within five (5)
         1 working days.
           Update the case management manual within three (3) business days of
         2 State approval of a change or State request for a change.
           Identify and correct any errors with case management activities within three
         3 (3) business days of the error detection.

Performance Measurements v1.3
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                                                                                   Medical Services - Monitoring Contractual Performance Measurements v1.3


RFP                          Contractual Performance Measurement
           4 Complete required reports accurately and timely.


         8.5 Prevention Promotion (EPSDT)

8.5.9           Performance Standards
                All standard production reports must be available on line for review by DHS
           1    staff pursuant to the following schedule:
         1.1    Monthly reports - by 10:00 AM of the third business day after month end
                Monthly cost analysis summary of EPSDT screening services and exception
        1.1.1   to policy services to DHS
          1.2   Quarterly reports - by 10:00 AM of the fifth business day after quarterly
                Quarterly service analysis summary of EPSDT services including claim and
        1.2.1   encounter data
                Quarterly breakdown of screening center service costs by provider number
        1.2.2   and summary of informing and care coordination service costs
                Process requests from providers or the public for services under the EPSDT
                program that are outside the coverage for the regular Medicaid program
           2    within ten (10) days of receipt.
           3    Notify case managers that a PA is due within sixty (60) days of the due date.
                Make PA decisions within five (5) working days of receiving the completed
           4    PA and supporting documentation.
                Provide an alert to the case manager sixty (60) days prior to the end date of
                a PA and to the case manager twelve (12) months prior to a member turning
           5    21.
                Process new request for private duty nursing & personal care services with
                the case manager (using ISIS system to identify case manager) within 1
                business day of receipt & process all other new requests within 5 working
           6    days of receipt.


         8.7 Quality of Care

8.7.9           Performance Standards
                Provide quarterly reports within 10 business days of the end of the reporting
           1    quarter
         1.1    Quarterly QA/UR utilization reports to MediPASS providers
         1.2    Quarterly paid claims audits of MediPASS enrollees
         1.3    Quarterly report of the HMO's and their enrolled providers
                Quarterly report of all appeal hearings, including status, disposition of case
         1.4    and policy changes resulting from appeals


         8.8 Long Term Care Assessment

8.8.9        Performance Standards
             Onsite prescreening and reassessment shall be completed for ninety five
           1 percent (95%) of the members within five (5) working days.



Performance Measurements v1.3
Author: Barnett
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                                                                                  Medical Services - Monitoring Contractual Performance Measurements v1.3


RFP                               Contractual Performance Measurement
              Provide a Notice of Decision and results onsite to the member with one (1)
         2    business day of completion of the assessment.
              If an individual is determined medically eligible, make referral for service
              coordination, as needed by program, within two- (2) business days of initial
         4    assessment.
              Enter pre-screening and reassessment requests requiring a peer review, (as
              determined by DHS guidelines) into ISIS within three (3) business days of
         5    completion.
              Update the prescreening manual within three (3) business days of State
         6    approval of a change or State request for a change.
              Identify and correct any errors on the pre-screening assessment within three
         7    (3) business days of the error detection.
              Complete reports as required in Section 3.2.2.9.6 of RFP# MED-04-034A
         8    pursuant to DHS standard guidelines

        8.9 Lock-In

8.9.7      Performance Standards
           All reports will be filed with DHS pursuant to the general schedule for
         1 weekly, monthly, quarterly and annual reports
           Substantiate program saving of five percent (5%) for Lock-in members or
         2 substantiate the factors that prevented program savings
           Maintain level of lock-in participation at five thousand members or higher
         3 during the term of the Contract

        8.6 Medical Prior Authorization

              Performance Standards
              For complete PA requests not requiring Peer Review, approve or deny,
              enter into the system and send appropriate notices for ninety-five (95%)
         1    within five (5) business days of initial receipt.
              For complete PA requests requiring Peer Review, approve or deny, enter
              into the system and send appropriate notice for ninety-five percent (95%)
         2    within ten (10) business days of initial receipt.
              For PA requests that need additional information, ninety-five percent (95%)
              will be processed within sixty (60) business days of initial receipt but these
              requests cannot be denied prior to forty-five (45) working days from initial
         3    receipt.
              Resolve ninety-five percent (95%) of all Contractor errors (as identified on
              error reports) within five (5) business days of generation of the error report
        3.1   and the remaining five percent (5%) within ten (10) business days.
              Comply with all federal and state laws on prior authorization, protocols and
              standards regarding responsiveness, timeliness and availability of
         4    appropriate clinical staff 100% of the time.
              Type of authorization and number approved or denied by authorizer, units
        4.1   and dollar value of services used and not used
        4.2   Suspended PA's and duplicate suspends
        4.3   Frequency of service codes requested and authorized



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RFP                            Contractual Performance Measurement
            Utilization (including the number of times particular services were
        4.4 approved), by provider, provider type, and member
            Denials (including denial reason), approvals, pends (including pend reason),
        4.5 with year-to-date totals
            Timeliness of PA processing, including days from receipt of request to
        4.6 mailing notices; numbers of PA's in the system by type.

            PROFESSIONAL SERVICES COMPONENTS & OPERATIONAL
            REQUIREMENTS

         6 Contract Management

        6.3 Performance Standards
            Provide the monthly contract management reports within three (3) business
          1 days of the end of the reporting period.
            Provide monthly performance monitoring report card within ten (10)
          2 business days of the end of the reporting period.
            Provide training on operational procedure changes as a result of upgrades
          3 or other changes within two (2) weeks of the upgrade.
            Update operational procedure manuals within two (2) weeks of the
          4 implementation of a change.
            Provide a response/resolution to DHS Project Management Team within two
            (2) business days of receipt to requests made in any form (e.g., e-mail,
          5 phone) on routine issues or questions.
            Provide a response within one (1) business day to DHS Project
          6 Management Team on emergency requests, as defined by the State.

        7.4 Internal Quality Assurance

7.4.3      Performance Standards
           Identify deficiencies and provide DHS with a corrective action plan within ten
           (10) business days of discovery of a problem found through the internal
         1 quality control reviews.
           Meet ninety-five percent (95%) of the corrective action commitments within
         2 the agreed upon time frame.




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RFP or
Contract                                       Contractual Performance Measurement

           8 PHARMACY MEDICAL SERVICES (Including PDL) COMPONENT

        8.2 Retrospective Drug Utilization Review (Retro-DUR)

8.2.9        Performance Standards
           1 Provide annual reports within ninety (90) business days of the state fiscal year end

           2 Demonstrate annual savings in total outlays for prescription drugs as a result of Retro-DUR activities.

           3 Produce profiles for review eight (8) times each year at least two (2) weeks prior to the meeting date.

        8.3 Pharmacy Prior Authorization

8.3.9         Performance Standard


             The Contractor shall provide sufficient staff, facilities, and technology such that ninety-five percent (95%)
             of all call line inquiry attempts are answered. The total number of abandoned calls shall not exceed five
           1 percent (5%) in any calendar month.

              Calls must be answered within thirty (30) seconds. If an automated voice response system is used as an
              initial response to inquiries, an option must exist that allows the caller to speak directly with an operator.
              The Contractor shall provide sufficient staff such that average wait time on hold per calendar month shall
        1.1   not be in excess of thirty (30) seconds.
              All call line inquiries that require a call back, including general inquiries, shall be returned within 1
        1.2   business day of receipt one hundred percent (100%) of the time.
              Respond to one hundred percent (100%) of pharmacy prior authorization requests within twenty-four (24)
        1.3   hours of receipt
              Update the pharmacy prior authorization manual within three (3) business days of State approval of a
        1.4   change or State request for a change

        8.4 Preferred Drug List (PDL) & Supplemental Rebate Program

8.4.9         Performance Standards

             Complete required reports accurately and timely. Monthly reports are due five (5) business days
             following the end of the month. Quarterly reports are due five (5) business days following the end of the
             quarter. Annual reports are due the 10th business day following the end of the year whether Federal
           1 fiscal year, State fiscal year or other annual period.
           2 Be able to demonstrate annual savings in the total outlay for prescription drugs.
             Provide DHS with access to all supplemental rebate agreements and related documentation within twenty-
           3 four (24) hours of request.

           4 Provide the P&T Committee with required information a minimum of thirty (30) days prior to the meeting

           5 Provide notification to providers a minimum of thirty (30) days prior to implementation.



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RFP or
Contract                                     Contractual Performance Measurement

           6 All providers must receive a notification training a minimum of thirty (30) days prior to the training.
             Provide DHS with a detailed project work plan and timeline within five (5) business days of signing the
           7 contract

           8 Within ten (10) business days of signing the contract provide DHS with a PDL phase in schedule.
             Provide DHS with a written report of the P&T Committees recommendations within three (3) business
           9 days of the conclusion of the meeting

         8.4 PDL Member Inquiries/Relations

8.5.13       Performance Standards

             For calls in which a member has a person-to-person conversation, ninety-five percent (95%) of the
             inquiries whose answer is not immediately available to the Customer Service attendant will be researched
           1 and answered within forty-eight (48) hours of receipt of the inquiry.

             Maintain a service level of eighty percent (80%) for incoming calls. The service level (SL) will be
           2 calculated as follows: (refer to RFP# MED-04-034B, page 52 for the formula)

           3 Answer to at least ninety percent (90%) of telephone inquiries during the initial call from the member
             Respond, with a complete response, to ninety percent (90%) of written inquires from a member within five
           4 (5) business days of receipt



             PROFESSIONAL SERVICES COMPONENTS & OPERATIONAL REQUIREMENTS

           6 Contract Management

         6.3 Performance Standards
             Provide the monthly contract management reports within three (3) business days of the end of the
           1 reporting period.
             Provide monthly performance monitoring report card within ten (10) business days of the end of the
           2 reporting period.
             Provide training on operational procedure changes as a result of upgrades or other changes within two
           3 (2) weeks of the upgrade.
           4 Update operational procedure manuals within two (2) weeks of the implementation of a change.
             Provide a response/resolution to DHS Project Management Team within two (2) business days of receipt
           5 to requests made in any form (e.g., e-mail, phone) on routine issues or questions.
             Provide a response within one (1) business day to DHS Project Management Team on emergency
           6 requests, as defined by DHS.

         7.4 Internal Quality Assurance

7.4.3        Performance Standards
             Identify deficiencies and provide DHS with a corrective action plan within ten (10) business days of
           1 discovery of a problem found through the internal quality control reviews.

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RFP or
Contract                                    Contractual Performance Measurement

           2 Meet ninety-five percent (95%) of the corrective action commitments within the agreed upon time frame.




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RFP                                 Contractual Performance Measurement


          6.3 PROVIDER SERVICES COMPONENT

6.3.2.2         Provider Enrollment

6.3.2.2.7       Performance Standards
                In response to provider enrollment inquiries, send 95% of the provider enrollment
                packets to the provider no later than one business day following the receipt of the
            1   request from the provider.
                95% of the provider enrollment applications must be approved, assigned a
                provider number, entered in the provider file, denied, or returned to the provider
            2   for additional information within 5 business days of receipt of the application.
                100% of the provider enrollment applications will be verified against the
            3   appropriate licensing entity and against the additional specialty credentials.
                100% of the providers will have valid licensing criteria and the specialty
            4   credentials at the time of approval of the provider enrollment application.
                Perform online updates to provider data within one (1) business day of receipt of
            5   the update.
            6   Maintain a 98% accuracy rate for online update transactions.
            7   Identify and correct errors within one (1) business day of error detection

6.3.2.3         Provider Inquiry/Provider Relations
6.3.2.3.7       Performance Standards

              Screen and resolve 95% of pended and denied claims within fifteen (15) business
            1 days from identification of a provider requiring proactive support.
              Maintain a service level of eighty percent (80%) for incoming calls. The service
            2 level (SL) will be calculated as follows:
              Respond to at least ninety percent (90%) of telephone inquiries during the initial
            3 call from the provider.
              Respond with a complete response to ninety percent (90%) of written, faxed, or e-
              mailed inquiries within five (5) business days of receipt. If a complete response
              cannot be made within five (5) days, an interim response must be provided with
            4 the five (5) business days.

6.3.2.4         Provider Publications

6.3.2.4.7       Performance Standards
                Print new or updated provider manuals and make them available for distribution
            1   within ten (10) business days of written approval by the State.
                Print and distribute newsletters, bulletins, inserts or other special mailings within
            2   five (5) business days of written approval by the State.
                Incorporate all provider manual revisions and updates into current and future
            3   stock within twenty-two (22) business days of issuance of the revision.
                Distribute supplies of claim forms and other provider forms to providers within two
            4   (2) business days after request.
                Distribute provider manuals to newly enrolled providers within three (3) business
            5   days of receipt of the request.

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RFP                                 Contractual Performance Measurement
              The website for disseminating provider publication online will be updated within
            6 two (2) business days of approval of information by DHS.
              In emergency situations, print and distribute any manuals, manual updates, and
              informational letters and bulletins within three (3) business days following
            7 approval by DHS.
              Maintain informational letters, bulletins, manual updates on the provider website
            8 until replaced, or the directive has expired.

6.3.2.5         Provider Training

6.3.2.5.7     Performance Standards
              Provide the annual training plan to DHS by July 15th of each calendar year of the
              contract. Provide requested corrections within ten (10) business days of receipt of
              comments by DHS. Provide quarterly updates within ten (10) business days from
            1 the end of the quarter.
              For each training session or individual provider visit, present a report to DHS
            2 within ten (10) business days of the session or provider visit.

6.3.2.6         Managed Care Function

6.3.2.6.7     Performance Standards
              Increase MediPASS provider participation by five percent (5%) per year for each
              contract year, from base year. The base year is the 12-month period prior to the
            1 effective date of Iowa Medicaid Enterprise contract.


              PROFESSIONAL SERVICES COMPONENTS & OPERATIONAL
            6 REQUIREMENTS

6.1.5           Contract Management

6.1.5.3         Performance Standards
                Provide the monthly contract management reports within three (3) business days
            1   of the end of the reporting period.
                Provide monthly performance monitoring report card within ten (10) business
            2   days of the end of the reporting period.
                Provide training on operational procedure changes as a result of upgrades or
            3   other changes within two (2) weeks of the upgrade.
                Update operational procedure manuals within two (2) weeks of the
            4   implementation of a change (10 business days).
                Provide a response/resolution to DHS Project Management Team within two (2)
                business days of receipt to requests made in any form (e.g., e-mail, phone) on
            5   routine issues or questions.
                Provide a response within one (1) business day to DHS Project Management
            6   Team on emergency requests, as defined by the State.

6.1.7           Internal Quality Assurance

6.1.7.3         Performance Standards

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RFP                            Contractual Performance Measurement
          Identify deficiencies and provide DHS with a corrective action plan within ten (10)
          business days of discovery of a problem found through the internal quality control
        1 reviews.
          Meet ninety-five percent (95%) of the corrective action commitments within the
        2 agreed upon time frame.




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RFP or
Contract                                Contractual Performance Measurement


            6.4 MEMBER SERVICES COMPONENT

6.4.2.2           MHC Enrollment Broker

6.4.2.2.7         Performance Standards
                  Distribute enrollment packets to eligible managed health care participants within two
             1    (2) business days from receipt of eligibility alert from Title XIX system.
                  Meet a ninety-eight percent (98%) accuracy rate for all enrollment assignment for
             2    both HMO and MediPASS participation.
                  All standard reports must be online for review by DHS staff pursuant to the following
             3    schedule:
                  Daily reports - by 10:00 AM of the next business day after the scheduled production
            3.1   date.
                  Weekly reports - by 10:00 AM of the next business day after the scheduled
            3.2   production date.

            3.3 Monthly reports - by 10:00 AM of the third (3rd) business day after month end cycle.

            3.4 Quarterly reports - by 10:00 AM of the fifth (5th) business day after quarterly cycle.

6.4.2.3           Member Inquiry / Member Relations

6.4.2.3.7         Performance Standards

                  For calls in which a member has a person-to-person conversation, ninety-five
                  percent (95%) of the inquiries (with the exception of bill inquiries) whose answer is
                  not immediately available to the Customer Service attendant will be researched and
                  forwarded to DHS within forty-eight (48) hours of receipt of the inquiry.
                  One hundred percent (100%) of bill inquiries will be responded to in writing within
                  thirty (30) days of the initial inquiry.
             1
                  For each Member Hotline bill inquiry, issue written notices of decision to the
                  member, as directed by DHS, within thirty- (30) days of initial inquiry by the
             2    member.
                  Maintain a service level of eighty percent (80%) for incoming calls. The service level
             3    (SL) will be calculated as follows: (refer to page 409 for formula)
                  Respond to at least ninety percent (90%) of telephone inquiries, excluding bill
             4    inquiries, during the initial call from the member.
                  Respond, with a complete response, to ninety percent (90%) of written, faxed, or e-
                  mailed inquiries within five (5) business days of receipt excluding bill inquiries. If a
                  complete response cannot be made within five (5) business days, an interim
             5    response must be provided within the five (5) business days.

6.4.2.4           Member Publications and Education

6.4.2.4.7         Performance Standards

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RFP or
Contract                             Contractual Performance Measurement
            1 Provide monthly reports by the fifth business day following the end of the month.
              Update the website with approved information by the third (3rd) business day
            2 following receipt of the approval.

6.4.2.6         Member Quality Assurance

6.4.2.6.7       Performance Standards
                Submit the first annual Member Satisfaction Assessment Plan within one month
            1   from the operations start date.
                Submit annual Member Satisfaction Assessment Plans by the end of January of
            2   each calendar year.
                Submit the quarterly Member Quality Assurance Activity reports within five business
            3   days of the end of the quarter.
                Submit the Annual Member Quality Assurance Assessment Report by the end of
            4   January of each calendar year
                Meet monthly with DHS staff to review assessment activity and issues identified
            5   during the assessment activities.


              PROFESSIONAL SERVICES COMPONENTS & OPERATIONAL
            6 REQUIREMENTS

6.1.5           Contract Management

6.1.5.3         Performance Standards
                Provide the monthly contract management reports within three (3) business days of
            1   the end of the reporting period.
                Provide monthly performance monitoring report card within ten (10) business days
            2   of the end of the reporting period.
                Provide training on operational procedure changes as a result of upgrades or other
            3   changes within two (2) weeks of the upgrade.
                Update operational procedure manuals within two (2) weeks of the implementation
            4   of a change (10 business days).
                Provide a response/resolution to DHS Project Management Team within two (2)
                business days of receipt to requests made in any form (e.g., e-mail, phone) on
            5   routine issues or questions.
                Provide a response within one (1) business day to DHS Project Management Team
            6   on emergency requests, as defined by the State.

6.1.7           Internal Quality Assurance

6.1.7.3       Performance Standards
              Identify deficiencies and provide DHS with a corrective action plan within ten (10)
              business days of discovery of a problem found through the internal quality control
            1 reviews.
              Meet ninety-five percent (95%) of the corrective action commitments within the
            2 agreed upon time frame.


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RFP or
Contract              Contractual Performance Measurement


          6.5 REVENUE COLLECTION COMPONENT

6.5.2.2         Third Party Liability

6.5.2.2.7       Performance Standards
                Post TPL recovery amounts and denial information to
                the benefit recovery and tracking database within two
            1   (2) business days of receipt of the recovery data.
                Deposit all TPL recoveries in the designated state bank
            2   account within two (2) banking days of receipt.
                Initiate follow-up activities on unpaid post-payment
                carrier billings within forty-five (45) days from
          3.1   submission if no response has been received.
                Initiate follow-up activities on denied post-payment
                billings within two (2) business days of receipt of the
          3.2   denial notice.
                Complete the verification or validation of TPL and
                update MMIS with the data within ten (10) business
                days of receiving the TPL leads from the DHS Income
            4   Maintenance Workers.
                Increase the third party insurance collections under
                contractor's jurisdiction, and cost avoided, by five
            5   percent (5%) each year.
                Ensure ninety-five percent (95%) accuracy of TPL data
                in MMIS files based on the monthly quality assurance
            6   audit of the data.
                Maintain a ten percent (10%) benefit to cost ratio for
                the TPL function. (The revenue collected is at least
                ten percent (10%) greater than the cost to staff and
            7   maintain the contractor's TPL unit).

6.5.2.3         Estate Recovery

6.5.2.3.7     Performance Standards
              Provide monthly reports to DHS by the 10th of each
            1 month for the preceding month.
              Provide the annual report to DHS no later than August
            2 15th of each Contract year
              Return phone calls within two (2) to four (4) working
(PCR) 3       days.




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RFP or
Contract              Contractual Performance Measurement
              Initiate recoveries within one (1) month of determining
              that a Medicaid member is deceased and that the
              member's assets are subject to recovery. The
              Revenue Collection contractor must wait at least four
              (4) months after the death of the member before
              establishing the amount of Medicaid debt. This time
              allows most providers to bill Medicaid, be paid, and
            4 allow these payments to be updated in the MMIS.

              Within thirty- (30) days of receiving the report of death,
              notify the representative of the deceased that there is
            5 an amount due DHS as a result of estate recovery.
              BENDEX tapes received by the Revenue Collection
              contractor that contain information from the Social
              Security Administration must be returned to DHS within
(PCR) 6       forty-five (45) days of receipt.

6.5.2.4       Lien Recovery

6.5.2.4.7     Performance Standards
              Post lien recovery amounts and denial information to
              the benefit recovery and tracking database within two
            1 (2) business days of receipt of the recovery data.
              Deposit all lien recoveries in the designated state bank
            2 account within two (2) banking days of receipt.
              Provide weekly reports of lien recovery activity by the
              5th business day of the week for the previous week's
(PCR) 3       activity.
              Provide monthly reports of lien recovery activity by the
              10th business day of the month for the previous
            4 month's activity.

6.5.2.5       Provider Overpayment

6.5.2.5.7     Performance Standards
              Deposit refund checks to the designated State bank
            1 account within two (2) banking days of receipt.

              Provide deposit receipt and check log to DHS within
            2 twenty-four (24) hours of depositing the refund checks.

              Prepare and process adjustments/voids against
              refunds and returned warrants within ten (10) business
            3 days of receipt of the refund or returned warrant.




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RFP or
Contract                Contractual Performance Measurement
                For refunds and returned warrants requiring additional
                information from the provider, enter claim adjustments
                within five (5) business days of receipt of additional
(PCR) 4         information from the provider.

6.5.2.6         Interface With DAS (Tax Offset)

6.5.2.6.7     Performance Standards
              Process the Department of Administrative Services
            1 Offset Program file within 1 business day of receipt.
              Validate the processing of liens within one (1) business
            2 day after each payment cycle.

6.5.2.7         Miller Trust and Special Needs Trust Recovery

6.5.2.7.7     Performance Standards
              Provide monthly reports to DHS by the 10th calendar
            1 day of each month for the preceding month.
              Within two months of the initial notification of the
              amount due DHS, send at least two follow-up letters to
            2 the representative/attorney in two month intervals.


              PROFESSIONAL SERVICES COMPONENTS &
            6 OPERATIONAL REQUIREMENTS

6.1.5           Contract Management

6.1.5.3         Performance Standards
                Provide the quarterly contract management reports
                within three (3) business days of the end of the
            1   reporting period.
                Provide quarterly performance monitoring report card
                within ten (10) business days of the end of the reporting
            2   period.
                Provide training on operational procedure changes as a
                result of upgrades or other changes within two (2)
            3   weeks of the upgrade.
                Update operational procedure manuals within two (2)
                weeks of the implementation of a change (10 business
            4   days).
                Provide a response/resolution to DHS Project
                Management Team within two (2) business days of
                receipt to requests made in any form (e.g., e-mail,
            5   phone) on routine issues or questions.



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RFP or
Contract            Contractual Performance Measurement
             Provide a response within one (1) business day to DHS
             Project Management Team on emergency requests, as
           6 defined by the State.

6.1.7        Internal Quality Assurance

6.1.7.3      Performance Standards
             Identify deficiencies and provide DHS with a corrective
             action plan within ten (10) business days of discovery
             of a problem found through the internal quality control
           1 reviews.

             Meet ninety-five percent (95%) of the corrective action
           2 commitments within the agreed upon time frame.




             Third Party Liability, Performance Measurement #5
Note 1:       is connected to 6.2 Contract.
             Miller Trust and Special Needs Trust Recovery,
             6.5.2.7.7, Performance Measurement #1. Cannot
Note 2:      count cost avoidance on anything but 115%.

             6.2 Contract, 6.2.1.4, Performance Standards #1. Cost
Note 3:      avoidance data will be obtained from Data Warehouse.
Note 4:      SIQ = Supplemental Insurance Questionnaire
Note 5:      The column heading "Other"= Phone or Email




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RFP or
Contract                             Contractual Performance Measurement


          6.7 PROVIDER COST AUDITS AND RATE SETTING COMPONENT

6.7.2.2          Rate Setting, Cost Settlements, and Cost Audits

6.7.2.2.7        Performance Standards
                 Settle cost reports for all institutional providers within three (3) months after
                 receipt of the final Title XVIII Medicare cost report or, if no Title XVIII Medicare
                 cost report is submitted, within twelve (12) months after receipt of the submitted
            1    Medicaid report.
                 Response to Questions - The Contractor shall respond to questions from
            2    Department staff within three (3) working days of the request.
                 For ICFs/MR, RCF and HCBS providers, the Contractor shall notify the provider
                 and the Department of the new payment rate by sending a "rate sheet" within two
                 (2) months of the end of the month after receipt of the financial and statistical
            3    report.
                 For NFs, a "rate sheet" shall be sent to each NF on a quarterly basis based on the
            4    Case Mix Index.
                 The Contractor shall complete all compilation reports required in 6.7.2.2.4 within
                 two (2) weeks of the end of the provider's fiscal year, which ends December 31 or
            5    June 30.
                 The Acuity Analysis Report for Accountability Measures shall be provided to the
          6.1    Department semiannually by February 1 and August 1 of each Contract year.
                 The Accountability Measures report shall be provided to the Department annually
          6.2    by June 15 of each Contract year.
                 Knowledge of Federal Requirements. The Contractor shall maintain sufficient
                 knowledge about Federal requirements for funds used for the services for which
                 costs are being reported to: 1) Know what cost are allowable and 2) To be
                 familiar with any reporting that may be required for receipt of those funds in order
             7   to assist the Department in complying with Federal requirements.
             8   Complete required reports accurately and timely.
             9   Complete all duties in an accurate, complete, timely and professional manner.
            10   Be knowledgeable of and apply all State and Federal requirements.

6.7.2.3          State Maximum Allowable Cost (SMAC) Program Rate Setting

6.7.2.3.7     Performance Standards
            1 Complete required reports accurately and timely.
            2 Complete all duties in an accurate, complete, timely and professional manner.
            3 Be knowledgeable of and apply all State and Federal requirements.
              Demonstrate annual savings in total outlays for prescription drugs associated with
            4 the SMAC program.
              Provide notification to the POS contractor a minimum of thirty (30) days prior to
            5 implementation of changes to the SMAC fee schedules.



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RFP or
Contract                           Contractual Performance Measurement
              Provide notification to pharmacy providers a minimum of thirty (30) days prior to
              the effective date of any new drug(s) being added to the SMAC fee schedule and
              notify providers of any changes in reimbursement rates and any deletion(s) of
            6 drug product(s) from the SMAC fee schedule on a regular basis.

6.7.2.4         Rebasing and DRG and APG Recalibration

6.7.2.4.7     Performance Standards
              Ensure a ninety-five percent (95%) accuracy rate in calculations to apportion
              costs to Medicaid for each hospital submitting Form CMS 2552, Hospital and
              Healthcare Complex Cost Report, for use in calculating the base, capital cost,
            1 direct and indirect medical education, and disproportionate share rates.
              Ensure a ninety-five (95%) accuracy rate in calculating hospital case-mix indices,
              inpatient base, capital cost, direct and indirect medical education, and
              disproportionate share rates and outpatient base and direct medical education
            2 rates.
              Ensure a ninety-five (95%) accuracy rate in calculating DRG and APG weights
              when determined using Iowa Medicaid paid claims data or when determined
            3 based on other negotiated or manually calculated means.

6.7.2.5         Revenue Maximization

6.7.2.5.7       Performance Standards
                Provide annual reports of upper payment limit test results and preliminary fiscal
                analyses for hospital and nursing facility services within 30 days after the
                beginning of each state fiscal year, applicable (prospectively) for that state fiscal
            1   year.
                Provide final fiscal analyses for hospital and nursing facility services within 30
            2   days after the end of each state fiscal year.
                Provide preliminary reimbursement rate calculations for services delivered by
                faculty at academic institutions or physicians or other medical professionals
                employed by government-owned or operated institutions within 30 days after the
                beginning of each state fiscal year, applicable (prospectively) for that state fiscal
            3   year.
                Provide final fiscal analyses for reimbursement rate calculations for services
                delivered by faculty at academic institutions or physicians or other medical
                professionals employed by government-owned or operated institutions within 30
            4   days after the end of each state fiscal year.
                Respond to requests and inquiries from the Department regarding all Federal
            5   Medicaid maximization work within 24 hours of the request.
                Draft all policy changes to the Medicaid State Plan, state administrative rules, and
                provider or employee manuals according to the timeframe required by the
            6   Department.

6.7.2.6         Reimbursement Technical Assistance and Support



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RFP or
 Contract                         Contractual Performance Measurement
6.7.2.6.7     Performance Standards
            1 Complete required reports accurately and timely.
            2 Complete all duties in an accurate, complete, timely and professional manner.
            3 Be knowledgeable of and apply all State and Federal requirements.


              PROFESSIONAL SERVICES COMPONENTS & OPERATIONAL
            6 REQUIREMENTS

6.1.5           Contract Management

6.1.5.3         Performance Standards
                Provide the quarterly contract management reports within three (3) business
            1   days of the end of the reporting period.
                Provide quarterly performance monitoring report card within ten (10) business
            2   days of the end of the reporting period.
                Provide training on operational procedure changes as a result of upgrades or
            3   other changes within two (2) weeks of the upgrade.
                Update operational procedure manuals within two (2) weeks of the implementation
            4   of a change (10 business days).
                Provide a response/resolution to DHS Project Management Team within two (2)
                business days of receipt to requests made in any form (e.g., e-mail, phone) on
            5   routine issues or questions.
                Provide a response within one (1) business day to DHS Project Management
            6   Team on emergency requests, as defined by the State.

6.1.7           Internal Quality Assurance

6.1.7.3       Performance Standards
              Identify deficiencies and provide DHS with a corrective action plan within ten (10)
              business days of discovery of a problem found through the internal quality control
            1 reviews.
              Meet ninety-five percent (95%) of the corrective action commitments within the
            2 agreed upon time frame.

                Bold type, within a performance measurement, indicates that the word(s) have
Note 1:         been changed because the phrasing in the RFP was not applicable.
                Under "Rate Setting, Cost Settlements, and Cost Audits", the Acuity Analysis
Note 2:         Report/Log Letter is distributed to Policy.
                Under "Rate Setting, Cost Settlements, and Cost Audits", the Accountability
Note 3:         Measures Log Letter is distributed to Policy.




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RFP or
Contract                          Contractual Performance Measurement

             PROFESSIONAL SERVICES COMPONENTS & OPERATIONAL
           6 REQUIREMENTS

6.1.5          Contract Management

6.1.5.3        Performance Standards
               Provide the quarterly contract management report within three (3) business
           1   days of the end of the reporting period.
               Provide quarterly performance monitoring report card within ten (10) business
           2   days of the end of the reporting period.
               Provide training on operational procedure changes as a result of upgrades or
           3   other changes within two (2) weeks of the upgrade.
               Update operational procedure manuals within two (2) weeks of the
           4   implementation of a change (10 business days).
               Provide a response/resolution to DHS Project Management Team within two (2)
               business days of receipt to requests made in any form (e.g., e-mail, phone) on
           5   routine issues or questions.
               Provide a response within one (1) business day to DHS Project Management
           6   Team on emergency requests, as defined by the State.

6.1.7          Internal Quality Assurance

6.1.7.3      Performance Standards
             Identify deficiencies and provide DHS with a corrective action plan within ten
             (10) business days of discovery of a problem found through the internal quality
           1 control reviews.
             Meet ninety-five percent (95%) of the corrective action commitments within the
           2 agreed upon time frame.



               Bold type, within a performance measurement, indicates that the word(s) have
Note 1:        been changed because the phrasing in the RFP was not applicable.
               Actual Recoupment: Is money in the door. Use an "Access" Recoupment
Note2:         Database.
               Cost Avoidance: Recommend an edit in place that will recommend savings.
               Report of an analysis of what it would have been without the edit and what it is
Note 3:        with the edit. Report of analysis of cost avoidance.
               Revenue Enhancement: Analysis with tracking of actual increased revenue as a
Note 4:        result of their work.

               Performance Measurement 3 under Contract Management should be included
               in the Operational Procedures. "Provide training on operational procedure
               changes as a result of upgrades or other changes within two (2) weeks of the
Note 5:        upgrade."
Note 6:        Who is the DHS Project Management Team?
Note 7:        SFY = State Fiscal Year

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MOU or
RFP                                          Contractual Performance Measurement v1.1


          3 DATA WAREHOUSE / DECISION SUPPORT COMPONENT

              Data Warehouse

3.2.8         Performance Standards

            Complete complex ad hoc requests within two (2) business days of receipt of the request unless an
          1 alternate timeframe is approved by IME


            Complete data warehouse updates from MMIS data within twelve hours of completion of the payment cycle.
            Any extraordinary updates will be performed in a timely and accurate manner at time intervals determined
          2 by the IME and DDM

          3 Resolve all data warehouse load errors within one (1) business day of identification of the error.

          4 Complete updates from non-MMIS data sources within twelve (12) hours of receipt of the valid data

          5 Resolve all DW/DS system functionality errors within five (5) business days of identification of the error.


          5 SYSTEM COMPONENTS & OPERATIONAL REQUIREMENTS

5.1.4         Contract Management

5.1.4.3       Performance Standards

            Provide the monthly contract management reports within three (3) business days of the end of the reporting
          1 period.
            Provide monthly performance monitoring report card within ten (10) business days of the end of the
          2 reporting period.
            Provide new user training for State staff and other component contractor staff a minimum of one time per
          3 quarter.

          4 Provide refresher training to State users and other component contractor staff a minimum of twice a year.
            Provide training on system changes as a result of upgrades or other enhancements within two (2) weeks of
          5 the upgrade.
            Provide an acknowledgment of the receipt of a user support request by response to the requestor within
          6 twenty-four (24) hours and indicate the time frame for a resolution to the issue or question.
            Provide a response/resolution to State Project Management staff within forty-eight (48) hours of receipt to
          7 requests made in any form (e.g., e-mail, phone) on routine issues or questions.
            Provide a response within 24 hours to State Project Management staff on emergency requests, as defined
          8 by the State.

5.1.5         System Maintenance and Enhancement

5.1.5.3       Performance Standards
              Notify DHS of system problems identified by the contractor within twenty-four (24) hours of identification of
          1   the problem.
              Respond to system maintenance requests within five (5) business days except for emergency requests for
          2   which a response is due within twenty-four (24) hours of receipt of the request.
              Ninety percent (90%) of schedule and cost estimates for system enhancements must be submitted within
              ten (10) business days after receiving request, and one hundred percent (100%) must be submitted within
          3   thirty (30) business days
              Ninety-five percent (95%) of system changes must be completed on the date agreed to by DHS and the
          4   contractor. Completion dates may be extended with concurrence of the State.


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MOU or
RFP                                          Contractual Performance Measurement v1.1
             Provide monthly reports of programmer hours by the fifth (5th) calendar day of the month for activity
           5 completed in the previous month.
             Provide monthly reports of enhancement project progress and to-date cost report and time expended on
           6 each open project by the fifth (5th) calendar day of the month for activity in the previous month.

5.1.7        Internal Quality Assurance

5.1.7.3      Performance Standards
             Identify deficiencies and provide the State with a corrective action plan within ten (10) business days of
           1 discovery of a problem found through the internal quality control reviews.

           2 Meet ninety-five percent (95%) of the corrective action commitments within the agreed upon timeframe.

          3.3 Contract

             On a Monthly basis, the Bureau Chief of Medical Services and Data Warehousing will conduct face-to-face
             review sessions with the IME Unit Managers to review work performed, reports generated, and progress
             towards reaching expectations and Performance Goals/Performance Measures as set forth in the Scope of
           1 Services Section.
             The Bureau Chief of Medical Systems and Data Warehousing will also conduct a Quarterly Face to Face
             Review of the work performed, to establish whether goals were met and to establish any corrective actions
           2 deemed necessary to meet future performance goals/performance measures.




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DOCUMENT INFO
Description: Contractor Performance Reference Checks document sample