Common use of Performance Outcome Measures Clause in Contracts

Performance Outcome Measures. 1. CONTRACTOR shall maintain an ongoing performance outcomes monitoring program using information in its provider database, Beneficiary and Network Providers satisfaction surveys, and documentation completed by providers, including but not limited to monitoring of claims utilization patterns, assessment and screening tools, direct peer review and medical record audits. CONTRACTOR shall include in the outcomes monitoring program items required or recommended by the DHCS, as communicated by the ADMINISTRATOR and specified in the Reports Paragraph of this Exhibit A to the Agreement. a. Objective 1: CONTRACTOR shall achieve, track and evaluate timeliness of access for Beneficiaries and Network Providers calling the Access Line. Timeliness measurements should include, but are not limited to, percentage and number of abandoned member calls to be no more than five percent (5%) of total monthly member calls, percentage and number of member calls answered within thirty (30) seconds to be no less than eighty-five percent (85%) and track call volume, service verification, and timeframe for routine calls from point of authorization to provider appointment. b. Objective 2: CONTRACTOR shall achieve, track and evaluate utilization trends from claims-based data, identifying quality of care concerns related to over and underutilization patterns. CONTRACTOR will report on the number and outcomes for cases exceeding utilization criteria approved by ADMINISTRATOR and conduct clinical reviews including but not limited to provider-peer consultation, beneficiary rescreening, Level of Care (LOC) reassignment and transition and Medical Director review for no less than twenty percent (20%) of identified outliers within thirty (30) calendar days of each monthly report. c. Objective 3: CONTRACTOR shall achieve, track and evaluate no less than ninety percent (90%) satisfactory Beneficiary survey results with the customer service provided on the twenty-four (24) hour-seven (7) days a week Access Line. Measurement of satisfaction shall be determined by, but not be limited to; overall satisfaction with informing Beneficiaries of grievance and appeals, State Fair Hearings, accessing services, brief screening for services, and providing referral processes.”

Performance Outcome Measures. 1. CONTRACTOR shall maintain an ongoing performance outcomes monitoring program using information in its provider database, Concurrent Review database, Beneficiary and Network Providers satisfaction surveys, and documentation completed by providers, including but not limited to monitoring of claims utilization patterns, assessment and screening tools, direct peer review and medical record audits. CONTRACTOR shall include in the outcomes monitoring program items required or recommended by the DHCS, as communicated by the ADMINISTRATOR ADMINISTRATOR, and specified in the Reports Paragraph of this Exhibit A to the AgreementContract. a. Objective 1: CONTRACTOR shall achieve, track and evaluate timeliness of access to benefit services for Beneficiaries and Network Providers calling the Access Line. Timeliness measurements should will include, but are not limited to, percentage and number of abandoned member calls to be no more than five percent (5%) of total monthly member calls, percentage and number of member calls answered within thirty (30) seconds to be no less than eighty-five percent (85%) and track call volume, service verification, and timeframe for routine calls from point of authorization to provider appointment. b. Objective 2: CONTRACTOR shall achieve, track and evaluate utilization trends from claims-based datadata for outpatient and inpatient network provider mental health claims, identifying quality of care concerns related to over over- and underutilization patternspatterns as established within clinical program guidelines. CONTRACTOR will shall report on the number and outcomes for cases exceeding utilization criteria approved by ADMINISTRATOR and conduct clinical reviews including including, but not limited to to, provider-peer consultation, beneficiary rescreening, Level of Care (LOC) reassignment and transition and Medical Director review for no less than twenty percent (20%) of identified outliers within thirty (30) calendar days of each monthly reportreview. c. Objective 3: CONTRACTOR shall achieve, track and evaluate no less than ninety percent (90%) satisfactory Beneficiary survey results with the customer service provided on the twenty-four (24) hour-seven (7) days a week Access Line. Measurement of satisfaction shall be determined by, but not be limited to; overall satisfaction with informing Beneficiaries of grievance and appeals, State Fair Hearingsbenefit information, accessing services, brief screening for services, and providing referral processes.” 2. ADMINISTRATOR may identify contracted Network Providers to be reviewed. CONTRACTOR shall initiate review within thirty (30) calendar days of notification from ADMINISTRATOR and shall advise contracted Network Providers of reason(s) for the review. CONTRACTOR shall adhere to its standard treatment audits as deemed necessary or shall provide ADMINISTRATOR with claims and/or treatment-related data. Treatment-related data may be obtained from clinical or legacy systems in the same manner that treatment-related data is gathered during claims processing and provider assessment reports. 3. XXXXXXXXXX agrees to comply with the state requirements and standards for

Performance Outcome Measures. 1. CONTRACTOR shall maintain an ongoing performance outcomes monitoring program using information in its provider database, Beneficiary and Network Providers Concurrent Review database, Client satisfaction surveys, and documentation completed by providers, including but not limited to monitoring of claims utilization patterns, assessment and screening tools, direct peer review and medical record audits. CONTRACTOR shall include in the outcomes monitoring program items required or recommended by the DHCS, as communicated by the ADMINISTRATOR ADMINISTRATOR, and specified in the Reports Paragraph of this Exhibit A to the AgreementContract. a. Objective 1: CONTRACTOR shall achieve, track and evaluate timeliness of access to benefit services for Beneficiaries Clients and Network Providers calling the Access Line. Timeliness measurements should shall include, but are not limited to, percentage and number of abandoned member calls to be no more than five percent (5%) of total monthly member calls, percentage and number of member calls answered within thirty (30) seconds to be no less than eightyninety-five percent (8595%) and track call volume, service verification, and timeframe for routine calls from point of authorization to provider appointment. b. Objective 2: CONTRACTOR shall achieve, track and evaluate utilization trends from claims-based datadata for outpatient and inpatient network provider mental health claims, identifying quality of care concerns related to over over- and underutilization patternspatterns as established within clinical program guidelines. CONTRACTOR will shall report on the number and outcomes for cases exceeding utilization criteria approved by ADMINISTRATOR and conduct clinical reviews including including, but not limited to to, provider-peer consultation, beneficiary Client rescreening, Level of Care (LOC) reassignment and transition and Medical Director review for no less than twenty percent (20%) of identified outliers within thirty (30) calendar days of each monthly reportreview. c. Objective 3: CONTRACTOR shall achieve, track and evaluate no less than ninety percent (90%) satisfactory Beneficiary Client survey results with the customer service provided on the twenty-four (24) hour-seven (7) days a week Access Line. Measurement of satisfaction shall be determined by, but not be limited to; overall satisfaction with informing Beneficiaries Clients of grievance and appeals, State Fair Hearingsbenefit information, accessing services, brief screening for services, and providing referral processes.” 2. ADMINISTRATOR may identify contracted Network Providers to be reviewed. CONTRACTOR shall initiate review within thirty (30) calendar days of notification from ADMINISTRATOR and shall advise contracted Network Providers of reason(s) for the review. CONTRACTOR shall adhere to its standard treatment audits as deemed necessary or shall provide ADMINISTRATOR with claims and/or treatment-related data. Treatment-related data may be obtained from clinical or legacy systems in the same manner that treatment-related data is gathered during claims processing and provider assessment reports. 3. CONTRACTOR agrees to comply with the state requirements and standards for performance outcome measures, which may be implemented by the State at any time during the term of the Contract.