Common use of General Reporting Requirements Clause in Contracts

General Reporting Requirements. The Contractor shall: Submit to EOHHS all applicable MassHealth reporting requirements in compliance with 42 C.F.R. § 438.602-606; Submit to CMS applicable reporting requirements in compliance with 42 C.F.R. § 422.516, 42 C.F.R. § 423.514 and 42 C.F.R. § 438 et. seq.; Submit to EOHHS all applicable MMP reporting requirements; Submit to CMS and EOHHS all required reports and data in accordance with the specifications, templates and time frames described in this Contract; In accordance with the timelines, definitions, formats and instructions contained herein or as specified by EOHHS, provide the following information. Where practicable, EOHHS shall consult with the Contractor to establish time frames and formats and detailed specifications reasonably acceptable to both parties; Provide all information required under this Contract, including but not limited to, the requirements of this section, Appendix D, or other information related to the performance of its or its first-tier, downstream, or related entities’ responsibilities hereunder or under the subcontracts as reasonably requested by CMS or EOHHS; Provide any information in its or its First Tier, Downstream or Related Entities’ possession sufficient to permit EOHHS to comply with 42 C.F.R. § 438; and Provide any data from its or its first-tier, downstream or related entities’ clinical systems, authorization systems, claims systems, medical record reviews, Network Management visits, and Enrollee and family input. Upon request, participate in work groups led by EOHHS to develop reporting specifications and to adopt the reporting models formulated by these work groups and approved by EOHHS, pursuant to the timeline established by EOHHS; Upon request, provide EOHHS with the original data sets used by the Contractor in the development of any required reporting or ad-hoc reporting in accordance with the time frames and formats established by EOHHS; Upon request, submit to CMS and EOHHS any internal reports that the Contractor uses for internal management. Such reports shall include, but not be limited to, internal reports that analyze the medical/ loss ratio, financial stability, or other areas where standard compliance reports indicate a problem in performance; Report HEDIS, HOS, and CAHPS data, as well as measures related to Long-Term Services and Supports. HEDIS, HOS, and CAHPS measures will be reported consistent with Medicare requirements for HEDIS, plus additional Medicaid measures required by EOHHS. All existing Part D metrics will be collected as well. Such measures shall include a combined set of core measures that the Contractor must report to CMS and EOHHS; Pursuant to 42 C.F.R. § 438.6(f)(2)(ii), comply with any reporting requirements on Provider Preventable Conditions in the form and frequency as may be specified by EOHHS; The Contractor shall, at the direction of EOHHS, require its PCPs who are not MassHealth Primary Care Clinicians (PCCs) to complete a practice infrastructure survey provided by EOHHS; and Provide to CMS and EOHHS, in a form and format approved by CMS and EOHHS and in accordance with the timeframes established by CMS and EOHHS, all reports, data or other information CMS and EOHHS determine are necessary for compliance with the provisions of the Affordable Care Act of 2010, Subtitle F, Medicaid Prescription Drug Coverage, and applicable implementing regulations and interpretive guidance. Information Management and Information Systems General The Contractor shall: a. Maintain Information Systems (Systems) that will enable the Contractor to meet all of EOHHS’ requirements as outlined in this Contract. The Contractor’s Systems shall be able to support current EOHHS requirements, and any future IT architecture or program changes. Such requirements include, but are not limited to, the following EOHHS standards: (1) The EOHHS Unified Process Methodology User Guide; (2) The User Experience and Style Guide Version 2.0; (3) Information Technology Architecture Version 2.0; and (4) Enterprise Web Accessibility Standards 2.0. b. Ensure a secure, HIPAA-compliant exchange of Member information between the Contractor and EOHHS and any other entity deemed appropriate by EOHHS. Such files shall be transmitted to EOHHS through secure FTP, HTS, or a similar secure data exchange as determined by EOHHS; c. For the purposes of quality management and Rating Category determination, accept, process, and report to CMS and the EOHHS uniform person-level Enrollee data, based upon a Comprehensive Assessment process that includes ICD-9 (or, as applicable ICD-10) diagnosis codes, the Minimum Data Set (MDS-HC or MDS 2.0 or 3.0), and any other data elements deemed necessary by CMS and the EOHHS; d. Develop and maintain a website that is accurate and up-to-date, and that is designed in a way that enables Enrollees and Providers to quickly and easily locate all relevant information. If directed by EOHHS, establish appropriate links on the Contractor’s website that direct users back to the EOHHS website portal; e. Cooperate with EOHHS in its efforts to verify the accuracy of all Contractor data submissions to EOHHS; and f. Actively participate in any EOHHS Systems Workgroup, as directed by EOHHS. The Workgroup shall meet in the location and on a schedule determined by EOHHS. Design Requirements The Contractor shall comply with EOHHS requirements, policies, and standards in the design and maintenance of its Systems in order to successfully meet the requirements of this Contract. The Contractor’s Systems shall interface with EOHHS’s Legacy MMIS system, EOHHS’s MMIS system, the EOHHS Virtual Gateway, and other EOHHS IT architecture. The Contractor shall have adequate resources to support the MMIS interfaces. The Contractor shall demonstrate the capability to successfully send and receive interface files. Interface files, which include, but are not limited to: (1) Inbound Interfaces (A) Daily Inbound Demographic Change File; (B) HIPAA 834 History Request File; (C) Inbound Co-pay Data File (daily); and (D) Monthly ICO Provider Directory. (2) Outbound Interfaces (A) HIPAA 834 Outbound Daily File;

General Reporting Requirements. The Contractor shall provide the reports described in Appendix N according to the specified timeframes. Furthermore, the Contractor shall: Submit to EOHHS all applicable MassHealth reporting requirements in compliance with 42 C.F.R. § 438.602-606438.602‑606; Submit to CMS applicable reporting requirements in compliance with 42 C.F.R. § 422.516, 42 C.F.R. § 423.514 and 42 C.F.R. § 438 et. seq.; Submit to CMS, and EOHHS as directed, all applicable MMP reporting requirements; Submit to CMS and EOHHS all required reports and data in accordance with the specifications, templates and time frames described in this Contract; In accordance with the timelines, definitions, formats and instructions contained herein or as specified by EOHHS, provide the following information. Where practicable, EOHHS shall consult with the Contractor to establish time frames and formats and detailed specifications reasonably acceptable to both parties; Provide all information required under this Contract, including but not limited to, the requirements of this section, Appendix D, or other information related to the performance of its or its first-tierfirst‑tier, downstream, or related entities’ responsibilities hereunder or under the subcontracts as reasonably requested by CMS or EOHHS; Provide any information in its or its First Tier, Downstream Downstream, or Related Entities’ possession sufficient to permit EOHHS to comply with 42 C.F.R. § 438; and Provide any data from its or its first-tierfirst‑tier, downstream or related entities’ clinical systems, authorization systems, claims systems, medical record reviews, Network Management visits, and Enrollee and family input. Upon request, participate in work groups led by EOHHS to develop reporting specifications and to adopt the reporting models formulated by these work groups and approved by EOHHS, pursuant to the timeline established by EOHHS; Upon request, provide EOHHS with the original data sets used by the Contractor in the development of any required reporting or ad-hoc ad‑hoc reporting in accordance with the time frames and formats established by EOHHS; Upon request, submit to CMS and EOHHS any internal reports that the Contractor uses for internal management. Such reports shall include, but not be limited to, internal reports that analyze the medical/ loss ratio, financial stability, or other areas where standard compliance reports indicate a problem in performance; Report HEDIS, HOS, and CAHPS data, as well as measures related to Long-Term Services and SupportsLTSS. HEDIS, HOS, and CAHPS measures will be reported consistent with Medicare requirements for HEDISrequirements, plus additional Medicaid measures required by EOHHS. All existing Part D metrics will be collected This includes, but is not limited to, reporting data for certain HEDIS measures, such as well. Such measures shall Breast Cancer Screening and Controlling High Blood Pressure, in accordance with additional stratification requirements as directed by EOHHS, minimally to include a combined set of core measures that the Contractor must report to CMS race, ethnicity, and EOHHSlanguage; Pursuant to 42 C.F.R. § 438.6(f)(2)(ii438.3(g), comply with any reporting requirements on Provider Preventable Conditions in the form and frequency as may be specified by EOHHS; The Contractor shall, at the direction of EOHHS, require its PCPs who are not MassHealth Primary Care Clinicians (PCCs) to complete a practice infrastructure survey provided by EOHHS; and Provide to CMS and EOHHS, in a form and format approved by CMS and EOHHS and in accordance with the timeframes established by CMS and EOHHS, all reports, data or other information CMS and EOHHS determine are necessary for compliance with the provisions of the Affordable Care Act of 2010, Subtitle F, Medicaid Prescription Drug Coverage, and applicable implementing regulations and interpretive guidance. Information Management and Information Systems General The Contractor shall: a. Maintain Information Systems (Systems) that will enable Data, documentation, or information the Contractor submits to meet all of EOHHS’ requirements as outlined in this Contract. The Contractor’s Systems shall the State must be able to support current EOHHS requirements, and any future IT architecture or program changes. Such requirements include, but are not limited to, the following EOHHS standards: (1) The EOHHS Unified Process Methodology User Guide; (2) The User Experience and Style Guide Version 2.0; (3) Information Technology Architecture Version 2.0; and (4) Enterprise Web Accessibility Standards 2.0. b. Ensure a secure, HIPAA-compliant exchange of Member information between the Contractor and EOHHS and any other entity deemed appropriate certified by EOHHS. Such files shall be transmitted to EOHHS through secure FTP, HTS, or a similar secure data exchange as determined by EOHHS; c. For the purposes of quality management and Rating Category determination, accept, process, and report to CMS and the EOHHS uniform person-level Enrollee data, based upon a Comprehensive Assessment process that includes ICD-9 (or, as applicable ICD-10) diagnosis codes, the Minimum Data Set (MDS-HC or MDS 2.0 or 3.0), and any other data elements deemed necessary by CMS and the EOHHS; d. Develop and maintain a website that is accurate and up-to-date, and that is designed in a way that enables Enrollees and Providers to quickly and easily locate all relevant information. If directed by EOHHS, establish appropriate links on either the Contractor’s website that direct users back Chief Executive Officer (CEO), Chief Financial Officer (CFO) or an individual who reports directly to the EOHHS website portal; e. Cooperate CEO or CFO with EOHHS delegated authority to sign so the CEO or CFO is ultimately responsible for the certification. The certification, pursuant to 42 C.F.R. §§ 438.604(a), 438.606, and 438.608(d)(3), must be submitted concurrently with the submission of data, and must attest that, based on best information, knowledge, and belief, the data are accurate, complete, and truthful. The Contractor must provide and require its First Tier, Downstream, and Related Entities to provide any information required for the implementation and operation of Electronic Visit Verification (EVV) to ensure that the Contractor’s EVV systems comply with the requirements outlined in its efforts to verify Section 12006 of the accuracy of all Contractor data submissions to EOHHS; and f. Actively participate in any EOHHS Systems Workgroup, 21st Century Cures Act (codified as 42 USC 1396b(l)) and as directed by EOHHS. The Workgroup shall meet in the location EOHHS and on a schedule determined by EOHHS. Design Requirements The Contractor shall comply with EOHHS requirements, policies, and standards in the design and maintenance of its Systems in order to successfully meet the requirements of this Contract. The Contractor’s Systems shall interface with EOHHS’s Legacy MMIS system, EOHHS’s MMIS system, the EOHHS Virtual Gateway, and other EOHHS IT architecture. The Contractor shall have adequate resources to support the MMIS interfaces. The Contractor shall demonstrate the capability to successfully send and receive interface files. Interface files, which include, but are not limited to: (1) Inbound Interfaces (A) Daily Inbound Demographic Change File; (B) HIPAA 834 History Request File; (C) Inbound Co-pay Data File (daily); and (D) Monthly ICO Provider DirectoryCMS. (2) Outbound Interfaces (A) HIPAA 834 Outbound Daily File;

General Reporting Requirements. The Contractor shallmust: Submit to EOHHS Be responsible for all applicable MassHealth reporting requirements in compliance administrative costs associated with 42 C.F.R. § 438.602-606the development, production, mailing, and delivery of all reports required under the Contract; Submit to CMS applicable reporting requirements in compliance with 42 C.F.R. § 422.516, 42 C.F.R. § 423.514 and 42 C.F.R. § 438 et. seq.; Submit to EOHHS all applicable MMP reporting requirements; Submit to CMS and EOHHS all required reports and data in accordance with the specifications, templates templates, and time frames described in this Contract; In accordance with the timelinesContract and Appendix D, definitions, formats and instructions contained herein unless otherwise directed or as specified agreed to by EOHHS. The Contractor must submit all proposed modifications, revisions, or enhancements to any reports to EOHHS for approval prior to making such changes; If EOHHS does not approve any report the Contractor submits, correct or modify the report as directed by EOHHS and resubmit it to EOHHS for final acceptance and approval within time frames prescribed by EOHHS; At request of EOHHS provide additional ad hoc or periodic reports or analyses of data related to the Contract, according to a schedule and format specified and prescribed by EOHHS; Have the capacity to display data graphically, in tables, and in charts, as directed by EOHHS; Apply generally accepted principles of statistical analysis and tests for statistical significance, as appropriate, to data contained in reports; Ensure that all reports are identified with a cover page that includes at least the following information. Where practicable, EOHHS shall consult with : Title of the Contractor report; Production date of the report; Contact person for questions regarding the report; Data sources for the report; Reporting interval; Date range covered by the report; and Methodology employed to establish time frames and formats and detailed specifications reasonably acceptable to both partiesdevelop the information for the report; Provide all information required under this Contractwith each report a narrative summary of the findings contained in the report, including but not limited toanalyses, the requirements of this section, Appendix D, and actions taken or other information planned next steps related to those findings; Submit each report electronically in a format and media compatible with EOHHS software and hardware requirements. At the performance of its or its first-tier, downstream, or related entities’ responsibilities hereunder or under the subcontracts as reasonably requested by CMS or EOHHS; Provide any information in its or its First Tier, Downstream or Related Entities’ possession sufficient to permit EOHHS to comply with 42 C.F.R. § 438; and Provide any data from its or its first-tier, downstream or related entities’ clinical systems, authorization systems, claims systems, medical record reviews, Network Management visits, and Enrollee and family input. Upon request, participate in work groups led by EOHHS to develop reporting specifications and to adopt the reporting models formulated by these work groups and approved by EOHHS, pursuant to the timeline established by EOHHS; Upon request, provide EOHHS with the original data sets used by the Contractor in the development of any required reporting or ad-hoc reporting in accordance with the time frames and formats established by EOHHS; Upon request, submit to CMS and EOHHS any internal reports that the Contractor uses for internal management. Such reports shall include, but not be limited to, internal reports that analyze the medical/ loss ratio, financial stability, or other areas where standard compliance reports indicate a problem in performance; Report HEDIS, HOS, and CAHPS data, as well as measures related to Long-Term Services and Supports. HEDIS, HOS, and CAHPS measures will be reported consistent with Medicare requirements for HEDIS, plus additional Medicaid measures required by EOHHS. All existing Part D metrics will be collected as well. Such measures shall include a combined set of core measures that the Contractor must report to CMS and EOHHS; Pursuant to 42 C.F.R. § 438.6(f)(2)(ii), comply with any reporting requirements on Provider Preventable Conditions in the form and frequency as may be specified by EOHHS; The Contractor shall, at the direction request of EOHHS, require its PCPs who are not MassHealth Primary Care Clinicians (PCCs) to complete also provide an original and printed copy of each report that is: In a practice infrastructure survey provided by EOHHSloose-leaf binder; Clearly labeled with the titles of the reports it contains; and Has clear separations between reports when more than one report is contained in one binder. Provide EOHHS with reports and necessary data to meet all applicable federal and State reporting requirements within the legally required time frames; Provide to CMS and EOHHS, in a form and format approved by CMS and EOHHS and in accordance with the timeframes established and other requirements specified by CMS and EOHHS, all reports, data or other information CMS and EOHHS determine are determines necessary for compliance with program report requirements set forth in 42 CFR 438.66(e); and Provide reports to EOHHS according to the provisions following timetable, unless otherwise specified or approved by EOHHS. All references to “annual” or “year-to-date” reports or data refer to the Contract Year, unless otherwise specified. EOHHS may at its sole discretion assess financial penalties as described in Section 5.5.Q for failure to perform any reporting requirements. Incident Reports – deliver incident reports to EOHHS by 5:00 p.m. (Eastern Time) on the next business day after the Contractor receives incident notification, in accordance with the established protocol. Monthly Reports – no later than 5:00 p.m. on the 20th day of the Affordable Care Act month immediately following the month reported, if the 20th of 2010the month falls on a non-business day, Subtitle Fthe next business day; except for October, Medicaid Prescription Drug CoverageJanuary, April, and applicable implementing regulations July, when monthly reports may be submitted with quarterly reports. Quarterly Reports – no later than 5:00 p.m. on the 30th day of the month following the end of the quarter reported, that is, October 30, January 30, April 30, and interpretive guidanceJuly 30; or, if the 30th of the month falls on a non-business day, the next business day. Quarterly reports due January 30 and July 30 may be submitted with semiannual reports. Semiannual Reports – no later than 5:00 p.m. on the 30th day following the end of the semiannual period reported, that is, January 30 and July 30; or, if the 30th of the month falls on a non-business day, the next business day. Annual Reports – April 30 or, if April 30 falls on a non-business day, the next business day. One-time, Periodic, and Ad Hoc Reports – no later than the time stated, or as directed by EOHHS. Participation in Surveys The Contractor agrees to participate in any surveys required by EOHHS and to submit all information requested by EOHHS to administer and evaluate the program. This survey information regarding the Contractor must include, but not be limited to: Plan quality and performance indicators, including: Information on Enrollee satisfaction; The availability, accessibility, and acceptability of services; and Information on health outcomes and other performance measures. Information Management about Enrollee Appeals and their disposition; and Information Systems General The Contractor regarding formal actions, reviews, findings, or other similar actions by any governmental body, or any certifying or accrediting organization. Certification Requirements In accordance with 42 CFR 438.600 et seq., the Contractor’s Chief Executive or Chief Financial Officer shall: a. Maintain Information Systems (Systems) , at the time of submission of the types of information, data, and documentation listed below, sign and submit a certification to EOHHS, certifying that will enable the information, data and documentation being submitted by the Contractor is true, accurate, and complete to meet all the best of EOHHS’ his or her knowledge, information and belief, after reasonable inquiry: Data on which payments to the Contractor are based, including data on the basis of which the State certifies the actuarial soundness of capitation rates paid to the Contractor; All enrollment information, encounter data, and measurement data; Data related to medical loss ratio requirements; Data or information related to protection against the risk of insolvency, including the data on the basis of which the State determines that the Contractor has made adequate provision against the risk of insolvency; Documentation related to requirements around Availability and Accessibility of services, including adequacy of the Contractor’s Provider Network; Information on ownership and control, such as outlined that pursuant to Section 5.1.F; Reports related to overpayments; and Data and other information required by EOHHS including, but not limited to, reports and data described in this Contract. The Contractor’s Systems Contractor must submit the certification concurrently with the certified data. Required Program Reports Clinical Indicator Data The Contractor must report clinical indicator data for all Enrollees in accordance with the specific HEDIS measures developed for Medicare Advantage Special Needs Plans (SNPs) by the National Commission on Quality Assurance (NCQA). The Contractor must comply with, and report to EOHHS, the HEDIS SNP Measures as required and approved by NCQA and CMS and report to EOHHS on the same time schedule required by CMS. The HEDIS measures in Appendix L, Exhibit 1 must be collected according to HEDIS specifications, and reported to EOHHS on the same time schedule required by CMS. Encounter Data The Contractor shall meet any diagnosis and/or encounter reporting requirements that are mandated by federal or state law, or by EOHHS. This includes the requirements set forth in 42 CFR 438.242(c)(1)-(4), 42 CFR 438.604(a)(1) and 42 CFR 438.818. This also includes the diagnosis and/or encounter reporting requirements that apply to Medicare Advantage plans and Medicaid managed care organizations, as well as the EOHHS Encounter data specifications set forth in Appendix I, as may be amended from time to time. The Contractor shall maintain processes to ensure the validity, accuracy and completeness of the Encounter Data in accordance with the standards specified in this section. The Contractor shall collect and maintain 100% Encounter Data for all Covered Services provided to Enrollees, including from any subcapitated sources. Such data must be able to support current EOHHS requirementsbe linked to MassHealth eligibility data. The Contractor shall participate in site visits and other reviews and assessments by EOHHS, or its designee, for the purpose of evaluating the Contractor's collection and maintenance of Encounter Data. Upon request by EOHHS, or its designee, the Contractor shall provide medical records of Enrollees and a report from administrative databases of the Encounters of such Enrollees in order to conduct validation assessments. Such validation assessments may be conducted annually. The Contractor shall produce Encounter Data according to the specifications, format, and any future IT architecture mode of transfer reasonably established by EOHHS, or program changesits designee, in consultation with the Contractor. Such requirements Encounter Data shall include, but are is not limited to, the following EOHHS standards: (1) The EOHHS Unified Process Methodology User Guide; (2) The User Experience data elements described in Appendix I, the delivering physician, and Style Guide Version 2.0; (3) Information Technology Architecture Version 2.0; and (4) Enterprise Web Accessibility Standards 2.0. b. Ensure a secure, HIPAA-compliant exchange elements and level of Member information between the Contractor and EOHHS and any other entity deemed appropriate detail determined necessary by EOHHS. Such files shall be transmitted to EOHHS through secure FTP, HTS, or a similar secure data exchange as determined by EOHHS; c. For the purposes of quality management and Rating Category determination, accept, process, and report to CMS and the EOHHS uniform person-level Enrollee data, based upon a Comprehensive Assessment process that includes ICD-9 (or, as applicable ICD-10) diagnosis codes, the Minimum Data Set (MDS-HC or MDS 2.0 or 3.0), and any other data elements deemed necessary by CMS and the EOHHS; d. Develop and maintain a website that is accurate and up-to-date, and that is designed in a way that enables Enrollees and Providers to quickly and easily locate all relevant information. If As directed by EOHHS, establish appropriate links such Encounter Data shall also include the National Provider Identifier (NPI) of the servicing/rendering, referring, prescribing and primary care Provider and any National Drug Code (NDC) information on drug claims. As directed by EOHHS, such Encounter Data shall also include information related to denied claims and 340B Drug Rebate indicators. The Contractor shall provide Encounter Data to EOHHS on a monthly basis or within time frames specified by EOHHS in consultation with the Contractor, including at a frequency determined necessary by EOHHS to comply with any and all applicable statutes, rules, regulations and guidance. The Contractor shall submit Encounter data to EOHHS by the last calendar day of the month following the month of the claim payment. Such submission shall be consistent with all Encounter data specifications set forth in Appendix I. The Contractor shall submit Encounter Data that is at a minimum compliant with the standards specified in Appendix O, including but not limited to standards for completeness and accuracy. To meet the completeness standard, all critical fields in the data must contain, at a minimum, valid values. To meet the accuracy standard, the Contractor must have systems in place to monitor and audit claims. The Contractor must also correct and resubmit voided and denied encounters as necessary. If EOHHS, or the Contractor, determines at any time that the Contractor’s Encounter Data is not compliant with the benchmarks described in Appendix O, the Contractor shall: Notify EOHHS, prior to Encounter Data submission, that the data is not complete or accurate, and provide an action plan and timeline for resolution; Submit for EOHHS approval, within a time frame established by EOHHS which shall in no event exceed 30 days from the day the Contractor identifies or is notified that it is not in compliance with the Encounter Data requirements, a corrective action plan to implement improvements or enhancements to bring the accuracy and/or completeness to an acceptable level; Implement the EOHHS-approved corrective action plan within a time frame approved by EOHHS which shall in no event exceed 30 days from the date that the Contractor submits the corrective action plan to EOHHS for approval; and Participate in a validation study to be performed by EOHHS, or its designee, following the end of a twelve-month period after the implementation of the corrective action plan to assess whether the Encounter Data is compliant with the benchmarks described in Appendix O. The Contractor may be financially liable for such validation study. The Contractor shall report as a voided claim in the monthly Encounter Data submission any claims that the Contractor pays, and then later determines should not have paid. The Contractor shall submit any correction/manual override file within 10 business days from the date EOHHS places the error report on the Contractor’s website that direct users back 's server. Such submission shall be consistent with all Encounter data specifications set forth in Appendix I. EOHHS may, at any time, modify the specifications required for submission of Encounter Data, including but not limited to requiring the EOHHS website portal; e. Cooperate Contractor to submit additional data fields to support the identification of Enrollees’ affiliation with EOHHS in its efforts to verify their Primary Care Provider. At EOHHS’ request, the accuracy of all Contractor data submissions to EOHHS; and f. Actively participate in any EOHHS Systems Workgroupshall submit denied claims, as directed further specified by EOHHS. The Workgroup shall meet EOHHS may impose intermediate sanctions in accordance with Section 5.5.Q based on the location completeness, accuracy, timeliness, form, format, and on other standards described in this Section. At a schedule determined time specified by EOHHS. Design Requirements The , the Contractor shall comply with all Encounter Data submission requirements related to HIPAA and the ASCX12N 837 format. This may include submitting Encounter Data to include professional, institutional and dental claims and submitting pharmacy claims using NCPDP standards. This submission may require the Contractor to re-submit Encounter Data previously submitted to EOHHS requirementsin alternative formats. Consumer Assessment of Healthcare Providers and Services (CAHPS) data The Contractor must submit the Consumer Assessment of Healthcare Providers and Services (CAHPS) data to EOHHS annually, policies, and standards in on the design and maintenance anniversary of its Systems in order to successfully meet the requirements start date of this the Contract. The Contractor’s Systems shall interface with EOHHS’s Legacy MMIS system, EOHHS’s MMIS systemGrievances and Appeals On a monthly basis, the EOHHS Virtual GatewayContractor must report the number and types of Grievances filed by Enrollees and received by the Contractor, specifying how and other EOHHS IT architecturein what time frames they were resolved (see Section 2.8). The Contractor shall have adequate resources must cooperate with EOHHS to support implement improvements based on the MMIS interfacesfindings of these reports. The Contractor shall demonstrate must report the capability to successfully send number, types, and receive interface filesresolutions of Appeals filed, including, for external Appeals, whether the external review was by the CMS Independent Review Entity or by the MassHealth Board of Hearings. Interface files, which include, but are not Functional Data The Contractor must report the need for assistance with Activities of Daily Living (ADLs) annually for all Enrollees by age and gender. This data will be collected in accordance with the Comprehensive Assessment and will include the number of Enrollees per 1,000 needing limited to: (1) Inbound Interfaces (A) Daily Inbound Demographic Change File; (B) HIPAA 834 History Request File; (C) Inbound Co-pay Data File (daily)assistance and number of Enrollees per 1,000 needing extensive or total assistance with: Mobility; Transfer; Dressing; Eating; Toilet use; Personal hygiene; and (D) Monthly ICO Provider Directory. (2) Outbound Interfaces (A) HIPAA 834 Outbound Daily File;

General Reporting Requirements. The Contractor shall provide the reports described in Appendix N according to the specified timeframes. Furthermore, the Contractor shall: Submit to EOHHS all applicable MassHealth reporting requirements in compliance with 42 C.F.R. § 438.602-606438.602‑606; Submit to CMS applicable reporting requirements in compliance with 42 C.F.R. § 422.516, 42 C.F.R. § 423.514 and 42 C.F.R. § 438 et. seq.; Submit to EOHHS all applicable MMP reporting requirements; Submit to CMS and EOHHS all required reports and data in accordance with the specifications, templates and time frames described in this Contract; In accordance with the timelines, definitions, formats and instructions contained herein or as specified by EOHHS, provide the following information. Where practicable, EOHHS shall consult with the Contractor to establish time frames and formats and detailed specifications reasonably acceptable to both parties; Provide all information required under this Contract, including but not limited to, the requirements of this section, Appendix D, or other information related to the performance of its or its first-tierfirst‑tier, downstream, or related entities’ responsibilities hereunder or under the subcontracts as reasonably requested by CMS or EOHHS; Provide any information in its or its First Tier, Downstream Downstream, or Related Entities’ possession sufficient to permit EOHHS to comply with 42 C.F.R. § 438; and Provide any data from its or its first-tierfirst‑tier, downstream or related entities’ clinical systems, authorization systems, claims systems, medical record reviews, Network Management visits, and Enrollee and family input. Upon request, participate in work groups led by EOHHS to develop reporting specifications and to adopt the reporting models formulated by these work groups and approved by EOHHS, pursuant to the timeline established by EOHHS; Upon request, provide EOHHS with the original data sets used by the Contractor in the development of any required reporting or ad-hoc ad‑hoc reporting in accordance with the time frames and formats established by EOHHS; Upon request, submit to CMS and EOHHS any internal reports that the Contractor uses for internal management. Such reports shall include, but not be limited to, internal reports that analyze the medical/ loss ratio, financial stability, or other areas where standard compliance reports indicate a problem in performance; Report HEDIS, HOS, and CAHPS data, as well as measures related to Long-Term Services and SupportsLTSS. HEDIS, HOS, and CAHPS measures will be reported consistent with Medicare requirements for HEDIS, plus additional Medicaid measures required by EOHHS. All existing Part D metrics will be collected as well. Such measures shall include a combined set of core measures that the Contractor must report to CMS and EOHHS; Pursuant to 42 C.F.R. § 438.6(f)(2)(ii438.3(g), comply with any reporting requirements on Provider Preventable Conditions in the form and frequency as may be specified by EOHHS; The Contractor shall, at the direction of EOHHS, require its PCPs who are not MassHealth Primary Care Clinicians (PCCs) to complete a practice infrastructure survey provided by EOHHS; and Provide to CMS and EOHHS, in a form and format approved by CMS and EOHHS and in accordance with the timeframes established by CMS and EOHHS, all reports, data or other information CMS and EOHHS determine are necessary for compliance with the provisions of the Affordable Care Act of 2010, Subtitle F, Medicaid Prescription Drug Coverage, and applicable implementing regulations and interpretive guidance. Information Management and Information Systems General The Contractor shall: a. Maintain Information Systems (Systems) that will enable Data, documentation, or information the Contractor submits to meet all of EOHHS’ requirements as outlined in this Contract. The Contractor’s Systems shall the State must be able to support current EOHHS requirements, and any future IT architecture or program changes. Such requirements include, but are not limited to, the following EOHHS standards: (1) The EOHHS Unified Process Methodology User Guide; (2) The User Experience and Style Guide Version 2.0; (3) Information Technology Architecture Version 2.0; and (4) Enterprise Web Accessibility Standards 2.0. b. Ensure a secure, HIPAA-compliant exchange of Member information between the Contractor and EOHHS and any other entity deemed appropriate certified by EOHHS. Such files shall be transmitted to EOHHS through secure FTP, HTS, or a similar secure data exchange as determined by EOHHS; c. For the purposes of quality management and Rating Category determination, accept, process, and report to CMS and the EOHHS uniform person-level Enrollee data, based upon a Comprehensive Assessment process that includes ICD-9 (or, as applicable ICD-10) diagnosis codes, the Minimum Data Set (MDS-HC or MDS 2.0 or 3.0), and any other data elements deemed necessary by CMS and the EOHHS; d. Develop and maintain a website that is accurate and up-to-date, and that is designed in a way that enables Enrollees and Providers to quickly and easily locate all relevant information. If directed by EOHHS, establish appropriate links on either the Contractor’s website that direct users back Chief Executive Officer (CEO), Chief Financial Officer (CFO) or an individual who reports directly to the EOHHS website portal; e. Cooperate CEO or CFO with EOHHS delegated authority to sign so the CEO or CFO is ultimately responsible for the certification. The certification, pursuant to 42 C.F.R. §§ 438.604(a), 438.606, and 438.608(d)(3), must be submitted concurrently with the submission of data, and must attest that, based on best information, knowledge, and belief, the data are accurate, complete, and truthful. The Contractor must provide and require its First Tier, Downstream, and Related Entities to provide any information required for the implementation and operation of Electronic Visit Verification (EVV) to ensure that the Contractor’s EVV systems comply with the requirements outlined in its efforts to verify Section 12006 of the accuracy of all Contractor data submissions to EOHHS; and f. Actively participate in any EOHHS Systems Workgroup, 21st Century Cures Act (codified as 42 USC 1396b(l)) and as directed by EOHHS. The Workgroup shall meet in the location EOHHS and on a schedule determined by EOHHS. Design Requirements The Contractor shall comply with EOHHS requirements, policies, and standards in the design and maintenance of its Systems in order to successfully meet the requirements of this Contract. The Contractor’s Systems shall interface with EOHHS’s Legacy MMIS system, EOHHS’s MMIS system, the EOHHS Virtual Gateway, and other EOHHS IT architecture. The Contractor shall have adequate resources to support the MMIS interfaces. The Contractor shall demonstrate the capability to successfully send and receive interface files. Interface files, which include, but are not limited to: (1) Inbound Interfaces (A) Daily Inbound Demographic Change File; (B) HIPAA 834 History Request File; (C) Inbound Co-pay Data File (daily); and (D) Monthly ICO Provider DirectoryCMS. (2) Outbound Interfaces (A) HIPAA 834 Outbound Daily File;