Contract between the board of regents of the unversity system of georgia and

Data Reporting. Contractor shall provide data reports in accordance with the requirements of the RFP and the Performance Guarantees in Attachment I. Contractor shall provide weekly, monthly, quarterly, and annual reports as well as ad hoc reports as requested by the BOR. Such reports may contain individual identifiable claim information and other information for Members enrolled in Plan Options.

5. Performance Guarantees. Contractor shall meet the specific Performance Guarantees as shown on Attachment G, as well as any reporting requirements related to the Performance Guarantees. The actions described in Attachment I will be Deliverables.

9. Private Review Agent Laws and Regulations. Contractor shall comply with the provisions of O.C.G.A. § 33-46-1 et seq. regarding private review agents and shall remain in compliance with all applicable State and federal laws and regulations.

9. Member Identification Cards. Contractor shall arrange for the issuance of an identification card for each Member, which shall contain appropriate information to denote selection of the MSA INO Plan by each Member.

1. 
   The Identification Cards shall contain appropriate contact and benefit information, including (i) Member name and date of birth, (ii) the Member’s identification number, and (iii) Contractor’s twenty-four (24) hours, seven (7) day/week toll-free Member Services telephone number(s).
   

2. 
   In accordance with the Performance Guarantees set forth in Attachment G, Contractor will send, via first class mail to Member’s home address, an Identification Card within ten (10) Business Days of receiving enrollment information from the BOR as a result of the annual enrollment period for Employees. Contractor shall mail two Identification Cards when a spouse is enrolled. For enrollments that occur outside of the annual enrollment periods, Contractor shall mail Identification Cards to newly enrolled Members within five (5) Business Days of receiving notice of enrollment from the BOR. Upon request, additional or replacement Identification Cards will be provided promptly to the Member.
   

3. 
   Contractor shall make temporary, replacement Identification Cards directly available to Members through its web portals.
   

4. 
   Contractor shall submit a front and back sample of the Identification Cards at least sixty (60) Calendar Days prior to the Effective Date for review and approval by the BOR.
   

5. 
   Contractor shall produce weekly and monthly reports on the number of Identification Cards produced and the number of Identification Cards rejected during the abstraction process.
   

6. 
   The Member ID Card will apply for medical and pharmacy services under the MSA INO Plan.
   

7. 
   The Identification Card will contain any other information required by applicable law.
   

1. 
   Healthcare Information Exchange. Contractor shall have in place or develop initiatives towards Health Information Exchange (HIE) and Health Care Transparency (HCT) that would encourage the use of electronic health records, make available to Members increased information on cost and quality of care, and offer provider incentives that reward high quality at low cost. Contractor shall demonstrate to the BOR its strategies and development toward improving HCT and HIE activities on an annual basis.
   

1. 
   Any provider in a specific specialty where another provider in-network of equal services is not available within 10 miles in an Urban market, 20 miles in a Suburban market and 30 miles in a Rural market;
   

2. 
   Loss of a hospital in an area where another provider of equal service is not available within 10 miles in an Urban market, 20 miles in a Suburban market and 30 miles in a Rural market;
   

3. 
   Other changes to the composition of the networks which impair or deny the Member’s adequate access to Network Providers; or
   

4. 
   Provider Minimum Access Requirements falling below the established threshold of 90% for Primary Care Physicians, Pediatricians, and OB/ GYN in tandem with a 75% threshold for Hospital access.
   

1. 
   Provide for the expected utilization of services and conduct trend analysis periodically to identify and track changes in Member population both by volume and demographic of a geographical area;
   

2. 
   Provide the numbers and types (in terms of training, experience, and specialization) of Providers required to furnish Covered Services;
   

3. 
   Provide the number of Network Providers who are not accepting new patients;
   

4. 
   Meet the Geo Access requirements stated in the RFP and Contractor’s Proposal and the Performance Guarantees in Attachment G; and
   

5. 
   Audit Network Providers periodically to ensure compliance with the Network Provider contract requirements, including but not limited to the contract requirements set forth in Section 5.19.
   

17. 
    System Access. Contractor grants the BOR the nonexclusive, nontransferable right to access and use the functionalities contained within the Systems, under the terms set forth in this Contract. The BOR agrees that all rights, title, and interests in the Systems and all rights in patents, copyrights, trademarks, and trade secrets encompassed in the Systems will remain Contractor’s. In order to obtain access to the Systems, the BOR shall obtain, and be responsible for maintaining at no expense to Contractor, the hardware, Software, and Internet browser requirements Contractor provides to the BOR. The BOR shall be responsible for obtaining an Internet Service Provider or other access to the Internet. The BOR shall not (i) access Systems or use, copy, reproduce, modify, or excerpt any of the Systems documentation provided by Contractor in order to access or utilize Systems, for purposed other than as expressly permitted under this Contract; or (ii) share, transfer or lease the BOR’s right to access and use Systems, to any other person or entity which is not a party to this Contract. The BOR may designate any third party to access Systems on the BOR’s behalf, provided the third party agrees to these terms and conditions of Systems access.
    

17. 
    Network Provider Communication. Contractor must provide training to all Network Providers and their staff regarding the requirements of the BOR Health Plan and the MSA INO Plan within thirty (30) Calendar Days of placing a newly contracted Network Provider on active status and must monitor Network Provider knowledge and understanding of Network Provider requirements, and take corrective actions to ensure compliance with the MSA INO Plan.
    

11. 
    Network Providers shall report to Contractor when they (1) refer Members to Out-of-Network Providers for services related to the services provided to the Member by the Out-of-Network Provider; (2) order services for Members from Out-of-Network Providers, or (3) otherwise engage an Out-of-Network Provider on behalf of a Member who is seeking treatment from the Network Provider.
    

12. 
    Network Providers may be excluded from the Network for failure to properly refer to other Network Providers.
    

20. 
    Electronic Data Processing (EDP) Environment and Software. The EDP environment, Software, security features and the internal controls used by Contractor must meet the minimum internal accounting control standards outlined in the current edition of the Auditor’s Study and Evaluation of Internal Control in EDP Systems, published by the American Institute of Certified Public Accountants.
    

1. 
   EDP System Audits. Contractor shall agree to authorize the BOR and the State Department of Audits personnel to have access to detailed EDP system documentation and all subsystems relevant to services provided for the BOR at Contractor’s facilities. Access must be granted within a reasonable time of the request. Documentation must include, but not be limited to file structures, program libraries, program logic, program edits, establishment of fee schedules, and interface programs or subsystems.
   

2. 
   System Security. Contractor shall utilize a state-of-the-art and secure EDP/telecommunications facility with hardware, etc., sufficient to process, store and access the volume of submitted transactions on behalf of Members and handle any projected and actual growth in membership over the Term of the Contract. Moreover, Contractor must maintain documented, state-of-the-art Software to accurately process transactions submitted on behalf of Members and must provide a state-of-the-art secure EDP system that authorizes different levels of access and prevents and records attempts of unauthorized access to information (Software, data, or media of any kind). Contractor shall provide for sufficient information technology staff to customize the Software to meet the BOR’s business needs.
   

Contractor is responsible for the creation of a firewall to secure information about utilization, pricing information or other information that is useful to Contractor in marketing or expanding non-State business relationships.

3. 
   HIPAA-Compliant System. Contractor must utilize a Claims system that is HIPAA-compliant and that conforms to all security, EDI, and privacy rules as required under federal and State laws. In order to assure compliance with privacy and confidentiality laws, Contractor must seek the BOR’s approval for any release of data regarding Claim and membership information not specifically authorized.
   

4. 
   Date-Stamp Capacity. Contractor shall maintain a Claims management system that can identify the date of receipt (the date Contractor receives the Claim as indicated by the date-stamp), real-time-accurate history of actions taken on each Provider Claim (i.e. paid, denied, suspended, appealed, etc.), and date of payment (the date of the check or other form of payment).
   

5. 
   Electronic Data Transfer. Contractor shall provide all requirements for electronic transfers of data to and from the BOR and make provisions for other BOR vendors to use electronic transfers of data for interfaces as required in the RFP. Contractor shall submit its proposed plan to the BOR for review and approval.
   

6. 
   On-Line Processing. Contractor shall process Claims “on-line” or process Claims in “real time” for manually keyed initial Claims and adjustments. Contractor’s Claims process will include imaging, scanning, or other EDI media, an appropriate balance of on-line and batch processing applications is required. Contractor must also utilize an on-line system able to retain and display Claims information in detail for a period of twenty-four (24) months from the date of Claim payment. The system must be able to retain and display Claims information in an off-line report for a minimum of an additional five years. Contractor will make use of on-line help screens and user manuals to increase the number of questions/problems that can be resolved without reference to paper manuals.
   

7. 
   Enterprise Data Warehouse (EDW). Contractor will maintain a sophisticated enterprise data warehouse (EDW) for ease in generating user-defined reports and ad hoc reports for the BOR. The process of transferring data to the warehouse and using the BOR Health Plan data must be subject to the confidentiality and data security policies of the BOR. The EDW or stand-alone Software must be capable of analyzing and producing reports for the physician and hospital profiling. The EDW shall be capable or producing utilization and pricing information in various categories.
   

8. 
   Absorption of Costs. Contractor shall absorb all costs related to the change in Systems or due to changes in State or federal law, rules, and/or regulations as provided for in Section 13.5 of this Contract.
   

21. 
    Fraud and Abuse. Contractor shall have written program integrity policies and procedures, including a mandatory compliance plan designed to guard against fraud and abuse. This program shall include policies, procedures, and standards of conduct for the prevention, detection, reporting, and corrective action for suspected, reported and investigated cases of fraud and abuse in the administration and delivery of services under this Contract and shall otherwise meet the requirements of the RFP. Contractor shall submit its program integrity policies and procedures, which include the compliance plan described below, to the BOR for review and approval.
    

1. 
   Compliance Plan. Contractor must establish a compliance plan that must include, but not be limited to, the following:
   

(a) Provision for internal monitoring and auditing of suspected, reported and investigated fraud and abuse violations, including specific methodologies for such monitoring and auditing;

2. 
   Compliance Officer and Staff Training. As a part of its compliance plan, Contractor shall designate a Compliance Officer who is accountable to Contractor’s senior management and is responsible for ensuring that policies to establish effective lines of communication between the Compliance Officer and Contractor’s staff, and between the Compliance Officer and the BOR staff, are followed. Contractor shall be responsible for ensuring the effective training and education for the Compliance Officer and the organization’s employees, management, board members, and Subcontractors.
   

3. 
   Policies and Procedures. At a minimum, Contractor’s policies and procedures shall consist of the following:
   

1. 
   Policies to ensure that all officers, directors, managers and employees know and understand the provisions of Contractor’s fraud and abuse compliance plan;
   

2. 
   Policies to establish a compliance committee that periodically meets and reviews fraud and abuse compliance issues;
   

3. 
   Policies to ensure that any individual who reports BOR Health Plan violations or suspected fraud and abuse will not be retaliated against;
   

4. 
   Polices of enforcement of standards through well-publicized disciplinary standards;
   

5. 
   Procedures for reporting suspected, investigated and reported fraud and abuse cases to the BOR, including timelines and use of BOR approved forms, as outlined in the RFP;
   

6. 
   Policies to ensure that Member Services representatives and other staff who have access to highly confidential information will be subject to appropriate background checks.
   

7. 
   Procedures for the detection of improper payments, waste, fraud, and abuse that includes, at a minimum, the following:
   

• 
  Claims edits;
  
• 
  Post-processing review of Claims;
  
• 
  Provider profiling and credentialing;
  
• 
  Detection of fraud, waste, abuse, and improper payments by customer service representatives;
  
• 
  Monitoring of Claims processing;
  
• 
  Quality control;
  
• 
  Utilization management; and
  
• 
  Pre-payment review of Claims;
  

8. 
   A well publicized toll-free telephone hot line and user-friendly email arrangement for anyone to report improper payments, waste, fraud, and abuse; and
   

9. 
   Any other policies and procedures necessary for Contractor to comply with Contractor’s Proposal
   

4. 
   Cooperation and Coordination with the BOR and Other Agencies. Contractor shall cooperate and assist any State or federal agency charged with the duty of identifying, investigating, or prosecuting suspected improper payments, waste, fraud, and abuse cases, including permitting access to Contractor’s place of business during normal business hours, providing requested information, permitting access to personnel, financial and medical records, and providing internal reports of investigative, corrective and legal actions taken relative to the suspected case of fraud and abuse directly or indirectly related to services under this Contract. This access to Contractor’s place of business and requested information will be provided at not charge to the BOR.
   

5. 
   Meetings, Notification, and Reports. Contractor shall work closely, including attending regular meetings, with the BOR’s staff to ensure that the activities of one entity do not interfere with an ongoing investigation being conducted by the other entity. The BOR must be informed immediately about known or suspected cases and Contractor shall not investigate or resolve the suspicion without making the BOR aware of, and if appropriate involved in, the investigation, as determined by the BOR.
   

6. 
   Notification and Reports. As permitted by applicable law, the BOR must be informed about known or suspected cases of fraud and Contractor shall not investigate or resolve the suspicion without making the BOR aware of, and if appropriate, as determined by the BOR, other State and federal agencies, involved in the investigation. Fraud, improper payments, waste, and abuse reports must be submitted to the BOR Program Manager on a monthly, quarterly, and annual basis.
   

7. 
   Detailed Process, Recovery and Investigations.
   

1. 
   Contractor shall not settle any identified overpayment for less than 90% of the total identified overpayment without written authority of the BOR.
   

2. 
   Contractor shall meet annual recovery targets that are consistent with industry standards.
   

3. 
   Contractor shall track and report actual recoveries against targets, benchmarks, and actual recovery dollars requested.
   

4. 
   Contractor shall implement technology and/or software to prevent and detect overpayments, which shall, at a minimum, automatically trigger a recovery review of transactions that are at a higher risk for overpayment, fraud, or waste.
   

5. 
   Contractor shall follow the guidelines for payment plans and settlement that are approved in the final version of the Implementation Plan.
   

6. 
   Contractor shall notify the BOR of any fraud, waste, or abuse overpayment investigation that impacts, or is reasonably expected to impact, the BOR Health Plan and shall provide details of the investigation to the BOR.
   

7. 
   Contractor shall provide the BOR copies of demand letters, settlement agreements, or other documents related to investigations upon request.
   

8. 
   Contractor shall cooperate with the BOR and the Georgia Attorney General’s office in litigation against those suspected of committing fraud.
   

9. 
   Except as expressly authorized in the final Implementation Plan approved by the BOR, Contractor will not agree to a settlement or program payment on the Plan’s behalf without first obtaining written approval form the BOR.
   

8. 
   Ongoing Services, Recovery, and Investigations. On a monthly basis:
   

1. 
   Contractor shall share the root cause analysis of recoveries required because of Contractor error.
   

2. 
   Contractor shall provide requested workflow, data, and other materials needed to review Contractor’s process.
   

3. 
   Contractor shall address root causes uncovered as a result of recovery discovery.
   

4. 
   Contractor shall support the BOR’s recovery and investigation vendors by providing data, adjusting claims, and posting payments as needed.
   

5. 
   Contractor will report on its process for prioritizing and addressing process and system gaps uncovered through routine analysis of processing and system errors.
   

6. 
   Contractor will report total recovery dollars requested and received as a result of Contractor error for each Plan Option.
   

7. 
   Contractor will provide benchmark and book of business results in addition to Plan specific results when reporting recoveries.
   

8. 
   Contractor will provide Plan specific recovery reports that include, but are not limited to, the following data elements:
   

• 
  Recovery types (e.g., COB, duplicate Claims, pricing, etc.);
  

• 
  Total requested, by recovery type and recovery vendor;
  

• 
  Total received, by recovery type and recovery vendor;
  

• 
  Total by vendor, less vendor fees, recouped by Plan Option;
  

• 
  Quarter and year to date results;
  

• 
  Trends;
  

• 
  Benchmark data; and
  

• 
  Book of business data.
  

Upon the BOR’s request:

9. 
   Contractor will provide customized recovery reports.
   

10. 
    Contractor will provide Plan specific investigation reports on a monthly basis that include, but are not limited to the following data elements:
    

• 
  Date case opened;
  

• 
  Basis for review;
  

• 
  Summary of case;
  

• 
  Status of case;
  

• 
  Total projected Plan claims dollars associated with the case; and
  

• 
  Upon final resolution, dollars to be recovered and any projected savings from future avoidance of similar claims.
  

21. 
    Member Services. Contractor shall have a Designated Member Services unit with sufficient personnel to adequately handle the BOR call volume. During the initial term of this Contract, Contractor shall use diligent good faith efforts to ensure that a minimum of seventy-five percent (75%) of all designated core team members have a minimum of one (1) year customer service experience within Contractor’s call center, and a minimum of two (2) years experience each of general customer service experience; all other designated core team shall have a minimum of one (1) year general customer service experience. For each renewal term of this Contract, Contractor shall use diligent good faith efforts to ensure that a minimum of eighty-five percent (85%) of the designated core team members meet the requirements set fort in this Section. Contractor shall operate a toll-free general Member Services telephone line to respond to Member questions, comments and inquiries. If Contractor does not have a dedicated Provider services line, the Member Services telephone lines must be able to handle Provider questions, comments and inquiries. This Member Services telephone line shall be available 24 hours a day, 7 days a week (including weekends and holidays, but excluding minimal periods for maintenance) through staff or an interactive voice recognition system.
    

1. 
   Member Services Policies and Procedures. Contractor shall develop Member Services and telephone policies and procedures that address staffing, personnel, hours of operation, access and response standards, monitoring of calls via recording or other means, and compliance with standards. Contactor shall submit these telephone policies and procedures, including performance standards pursuant to this Contract to the BOR for review and approval, within sixty (60) Calendar Days after the Effective Date.
   

2. 
   Non-English Speaking Calls and Hearing Impaired Callers. Contractor shall provide a Member Services helpline that handle calls from Spanish speaking callers, as well as calls from Members who are hearing impaired. Contractor shall also provide a Member Services helpline that handles calls from other non-English speaking callers through a translation service.
   

3. 
   Other Minimum Requirements. At a minimum, the BOR requires that Contractor’s Member Services:
   

1. 
   Have the capability to track call management metrics (as outlined in Attachment I, Performance Guarantees) and shall be fully staffed between the hours of 8:00 a.m. and 6:00 p.m. Eastern Time, Monday through Friday, excluding State holidays;
   

2. 
   Consist of Member Services staff trained to respond to Member questions in all areas, including, but not limited to, Covered Services, the Provider Network, and any prior approval or pre-certification requirements;
   

3. 
   Ensure the Member Services staff have specialized training in assisting the needs of a retired population who have no access to employer assistance and have Medicare coordination of benefits and procedures;
   

4. 
   Provide warm transfer of Members to other service areas, the PBM Vendor, or BOR staff, if necessary;
   

5. 
   Provide Members with the choice to opt-out of the interactive voice response to speak with a live Member Services staff member;
   

6. 
   Record all calls and keep recordings for a period of twenty-four (24) months;
   

7. 
   Report to the BOR Member Services call statistics on a weekly, monthly and quarterly basis;
   

8. 
   Maintain throughout the term of the Contract at a minimum the ratio of Member Services staff per 1,000 Members and ratio of supervisors to staff identified in Contractor’s Proposal; and
   

9. 
   Provide BOR staff with access to live (real time) and recorded calls monthly and onsite for monitoring and plan administration purposes. The BOR Program Manager will provide Contractor with a list of BOR staff authorized to access live or recorded calls on Contractor’s Member Services system for the purpose of quality monitoring or other Plan administration purposes.
   

4. 
   Web Tools. As part of its Member Services, Contractor agrees to make available to Members and the BOR the web tools described in Contractor’s Proposal in response to the RFP and in this Contract.
   

5. 
   Resolution of Complaints. Contractor agrees to cooperate in activities with the BOR in responding to and resolving complaints from any Member. Complaints may include but are not limited to dissatisfaction with Member Services or Network Pharmacy issues.
   

6. 
   Tracking of Complaints. Contractor shall administer a tracking, monitoring, and response system for addressing the complaints or issues of Members and a reporting system for providing data to the BOR on a monthly and quarterly basis, as well as otherwise requested by the BOR.
   

21. 
    Member Communication Materials. Contractor shall develop proposed collateral materials, marketing materials, program descriptions, and other materials necessary to adequately inform and educate Members concerning utilization of the Plan Options and any changes to the terms or conditions of the MSA INO Plan. Contractor shall provide these materials to the BOR in electronic format for review, revision and approval by the BOR at least forty-five (45) Calendar Days before the desired date of use or publication for the materials. Before submitting Member communication materials to the BOR, Contractor’s materials shall be reviewed and approved by the appropriate Account Directors, with consultation by Contractor’s legal counsel if the materials describe benefits or actions Members must take in order to obtain benefits. Contractor’s materials shall be accompanied by an affirmation that the materials are accurate, grammatically correct, and do not conflict with the current EOC or any other Plan Documents or materials posted on Contractor’s websites or otherwise being made available to Members. Contractor shall make all BOR approved Member communication materials available to Members electronically and, upon request by any Member, shall mail the materials to the Member in paper format.
    

21. 
    Account Management Services. Contractor shall assign a Dedicated Account Manager and Dedicated service representatives (the “account management team”), which must be approved in advance by the BOR for purposes of working directly with the BOR. The account management team shall be located in metropolitan Atlanta and devote the necessary time to the account, including being available for frequent telephone and on-site consultations with the BOR staff during regular business hours. The Account Director/Account Manager will be available after business hours for emergency situations. Contractor shall be proactive in developing innovative solutions and recommendations to reduce healthcare costs and increase quality and Member satisfaction. Contractor’s account management team shall be comprised of individuals with specialized knowledge of Contractor’s corporate operations, Claims and eligibility Systems, Systems reporting capabilities, and Claims adjudication policies and procedures. Contractor shall be thoroughly familiar with all Contractor’s services that relate directly and indirectly to the BOR and shall act on behalf of the BOR in minimizing administrative delay. The account management team shall conduct quarterly meetings to review and analyze Claims data utilization, review strategy to enhance effectiveness of Member information, interventions, and services, discuss Member relation issues, and customer service statistics with the BOR.
    

21. 
    Resolution of Complaints. Contractor agrees to cooperate in activities with the BOR in responding to and resolving complaints or issues from any Member related to services Contractor is administering under the MSA INO Plan. Furthermore, Contractor agrees to cooperate with the BOR in resolving any Provider access issues, including but not limited to Providers not accepting new patients, lengthy waits for appointments, or lack of specialty care physician coverage.
    

Contractor shall acknowledge any and all complaints from Members related to services under this Contract within five (5) Business Days of the complaint. Resolution of all complaints shall be completed within ninety (90) Calendar Days and if not Contractor must provide a written status of the delay to the Member. Contractor shall administer a tracking, monitoring, and response system for addressing complaints and a reporting system for providing data to the BOR on a monthly and quarterly basis and upon request by the BOR.

21. 
    Open Enrollment. Upon request of the BOR, Contractor agrees to participate in the BOR Health Plan open enrollment period by attending benefit fairs, open enrollment and retiree meetings, and train-the-trainer programs throughout the State at each institution of the University System of Georgia as well as the University System Office and Employing Entities. Contractor must submit copies of all marketing materials (written and oral) that it and any of its subcontractors may distribute during open enrollment to the BOR for review and approval as determined by the BOR and outlined in the RFP. Additionally, Contractor shall pay the expenses for design, printing, mailing, and delivery of the Health Plan Decision Guides to each Member to be used in the open enrollment period.
    

21. 
    Provider Directory. Without cost to the BOR or Members, Contractor shall publish or cause to be published a Network Provider directory. The Network Provider directory must include the following information about Network Providers: names, addresses, contact information, services, including types and levels of specialties, whether Network Providers are accepting new patients, age and gender limitations, available language services offered by those Network Providers, and whether (or the extent to which) the Network Provider engages Out-of-Network Providers to perform services related to the Network Provider’s treatment, so that Members can make an informed decision to choose a Network Provider that engages other Network Providers to perform related services. Contractor shall make the Network Provider directories available for viewing, searching, and printing via Contractor’s website. Contractor shall mail the appropriate Network Provider directory upon request to Members within ten (10) Business Days of receiving the request for the directory.
    

21. 
    Internet Presence/Web Site. Contractor shall provide an integrated, robust website that will allow Members to actively manage their Plan benefits encourage Plan utilization, and provide information/tools to help the Member obtain healthier outcomes. At a minimum, the website must provide the Provider Network, information on how to reach Member Services, information about Claims appeal process, and fraud and abuse notification information. The Member should have secure access to Member specific information, including but not limited to, processed Claims information (EOB), accruals towards deductibles, Copayments, Coinsurance, in and out of network maximums, total out of pocket spend by the Member, and HRA balances and/or HRA spend.
    

21. 
    Adequate Provision of Services; Non-Discrimination. Contractor shall require Network Providers to provide Covered Services to Members within the scope of the Provider’s license and in accordance with the terms and conditions of the Plan, which are set forth in the Plan Documents. At all times throughout the term of this Contract, Contractor shall require Network Providers to maintain adequate facilities, equipment, personnel and administrative services to perform their obligations under and as prescribed for the MSA INO Plan of this Contract and under the Plan. Network Providers shall render Covered Services to Members in the same manner, in accordance with the same standards and with the same time availability as offered to other patients enrolled in large employer group health plans. Network Providers shall not differentiate or discriminate unlawfully in the treatment of any Member on account of race, color, national origin, religion, sex, marital status, sexual orientation, age, disability, health status, or source of payment and shall comply with Title VII of the Civil Rights Act of 1964 as well as applicable state laws regarding discrimination.
    

21. 
    Cost Avoidance Recovery, Coordination of Benefits, Subrogation. Contractor must have procedures and processes in place for cost avoidance to the BOR Health Plan to identify, investigate, track, and recover third party and workers’ compensation liabilities, including coordinating coverage through cross-over with Medicare and other coordination of benefits (“COB”).
    

21. 
    Surveys. As established in the Performance Guarantees, Contractor shall conduct regular surveys of Members served under this Contract, in a format and under a methodology approved by the BOR, with respect to quality, access, utilization and service levels of Network Providers and Member Services. Contractor shall investigate and provide the BOR with a written report of all quality problems identified by the BOR in conducting these surveys, as requested by the BOR in writing on a quarterly basis. Furthermore, Contractor shall implement measures to correct quality problems identified by the BOR pursuant to this section. Contractor agrees that it will conduct an annual customized Member satisfaction survey of the Members served by Contractor.
    

21. 
    COB with Medicare. Contractor shall administer COB and subrogation of Medicare claims according to standard Medicare rules and regulations and pursuant to, and also consistent with, Plans’ policies and procedures for Medicare eligible employees.
    

1. 
   Pro-ration of HRA for mid-year new hires.
   

2. 
   Caps on rollovers and end of year rollovers, including if a Member opts out of an In-Network Only or MA Plan Option.
   

3. 
   Health promotion incentive credits to the HRA, including credits that may vary throughout the year based on the Member’s participation in wellness programs.
   

4. 
   Individual deductibles in instances of family coverage.
   

5. 
   Acceptance and loading of current Member balances maintained by previous HRA administrators.
   

34. 
    Readiness Review. Contractor shall participate in all readiness review activities conducted by BOR staff to ensure Contractor’s operational readiness. Contractor will review and address all issues identified in the summary of findings document provided by the BOR after each readiness review activity and resolve all issues identified within the agreed upon time frames.
    

34. 
    Health Information Technology. Contractor shall commit to developing improvements in its technology as outlined in Contractor’s Proposal (e.g., access to confidential personal health information online for Members, web-based health information for Members, electronic and more efficient communication among and between Providers and Pharmacies as well as among Members, Pharmacies, and Providers).
    

34. 
    Independent Relationship. It is understood and agreed that Contractor has no responsibility to the BOR or any other person or entity, for the following:
    

1. 
   The propriety, necessity or advisability of any recommended treatment, medicine, drug, prescription, or other matter relating to the rendition of any medical or other health care services by any Network Provider; or
   

2. 
   Payment of any Members’ bills, debts, obligations or other liabilities of any kind relating to or arising out of any health care services other than as set forth in the Plan Documents.
   

34. 
    Quality of the Services. Contractor represents and warrants that the Services performed by the Contractor shall be performed in a professional and workmanlike manner.
    

34. 
    Truth and Correctness. No representation or warranty by Contractor herein, nor any written statement or certificate or other instrument furnished to the BOR by Contractor pursuant to this Contract or in connection with the transactions contemplated by this Contract, (i) contains, or will contain, any untrue statement of a material fact or (ii) omits, or will omit, to state a material fact necessary to make the statements contained herein or therein, in light of the circumstances under which such statements are made, not misleading.
    

34. 
    Executive Order on Transparency. The BOR supports the President’s Executive Order on Transparency (Order Number 13410), which call for:
    

1. 
   Standards for connecting health information technology, making it possible to share patient health information securely and seamlessly among healthcare providers;
   
2. 
   Quality of care reporting, so that healthcare providers as well as the public can learn how well each provider measures up in delivering care;
   
3. 
   Providing costs of health services in advance, so that when patients choose routine and elective care, they can make comparisons on the basis of both quality and how much of the total cost they will have to pay under their health plan; and
   
4. 
   Providing incentives for quality care at competitive prices, as in payments to providers based on the quality of their services, or insurance options that reward consumers for choosing on the basis of quality and costs.
   

Consequently, Contractor agrees to the following provisions.

1. 
   Agreement by Contractor. Contractor agrees to
   

1. 
   Provide the following data to the BOR in a format specified or approved by the BOR
   

• 
  Claims (including utilization and financial metrics);
  
• 
  Capitation (including financials and encounter records) as appropriate;
  
• 
  Prescription drug rebate information, if applicable;
  
• 
  Eligibility, as required;
  
• 
  Health Risk Assessment information (including person-level results);
  
• 
  Disease Management participation (including person-level results); and
  
• 
  Lab results information (including person level results).
  

2. 
   Recognize that the data is owned by the BOR;
   

3. 
   Provide data electronically within a time-frame specified or approved by the BOR but in any event no later than the fifteenth (15^th) Calendar Day following the close of the time period of data provided;
   

4. 
   Provide accurate data (accuracy being measured and determined by the BOR);
   

5. 
   Provide data in compliance with HIPAA requirements regarding the transmission of Personal Health Information;
   

6. 
   Place no restraints on the use of data, provided the BOR has in place procedures to protect the confidentiality of the data consistent with HIPAA requirements.
   

2. 
   BOR’s Information Vendor. The BOR has or will retain an information vendor to receive the data from Contractor and to store the data on behalf of the BOR. Contractor agrees to cooperate with the BOR and its information vendor in the fulfillment of the Contractor’s duties under this Section 5.34.
   

3. 
   Cooperation with the BOR’s Information Vendor. Contractor agrees to cooperate with the BOR and its information vendor in fulfillment of any third party contract validation or auditing support using the BOR’s data.
   

1. 
   Once each year, or more frequently as reasonably determined by the BOR, as well as following termination of this Contract, the BOR and the State Auditor may inspect and verify Claim data, billing records, pricing discounts and terms, claims adjudication systems, healthcare benefits, clinical programs, and other compensation from any party directly related to Member utilization and services, Performance Guarantees, and operational processes relating to the Services to ensure Contractor’s compliance with the terms and conditions of this Contract, including but not limited to, 100% of the Claims data for such time period the BOR determines.
   

2. 
   Any requests by the BOR or any party acting on behalf the BOR (including the State Auditor) shall constitute the BOR’s direction and authorization to Contractor to disclose Member information subject to the terms of this Contract.
   

3. 
   Any audits may be based on either a 100% review of Claims or a statistically representative sample thereof. Any findings from a statistically representative sample of claims will be extrapolated to the total claims population. All findings will be shared with Contractor. In the event the BOR or any party acting on its behalf has reviewed 100% of Claims and identified suspect Claims, Contractor may elect to review a mutually-agreed upon representative sample of the suspect claims.
   

4. 
   The audit may include an onsite review of the sample Claims at Contractor’s office. The BOR will provide Contractor with a list of the sample Claims for review not less than thirty (30) Calendar Days in advance of the onsite review. Any onsite review will not exceed five (5) Business Days.
   

5. 
   The scope of any audit may include up to three (3) benefit years as determined by the BOR.
   

6. 
   Any and all costs and expenses of each party associated with an audit under this Section 5.39 will be borne by the party incurring the cost. The parties agree that the scope of audits under this Section 5.39 will not be duplicative of the SSAE-16 audit required under this Contract but may include inspection and/or verification of certain information provided in the SSAE-16 audits to the extent necessary to give the BOR a more thorough understanding of and support for such information. Audit materials or documentation provided by Contractor under this Section 5.39 will be confined to BOR specific information.
   

7. 
   If an audit under this Section 5.39 discloses an overpayment of fees or claim payments by the BOR or an underpayment of guarantees or performance standard penalties to the BOR by Contractor, or other economic benefits received by Contractor in excess of what Contractor is entitled to under this Contract, Contractor shall pay the amount owed to the BOR following completion of the audit. Payment of any reconciliation or reversal of amounts owed by Contractor to the BOR will not be contingent upon Contractor’s ability to recover from Providers paid in error.
   

4. 
   Costs. Contractor shall include all costs for programming and delivery of required data to the BOR’s information vendor as directed by the BOR as part of the Administrative Services Fees. In addition, Contractor shall pay applicable fees associated with data format changes (due to vendor-initiated or regulatory compliance requirements) late data, or unusable data.
   

5. 
   Support of BOR’s Analyses. Contractor shall work with the BOR’s information vendor to ensure that data quality is sufficient to support the BOR’s analyses. At a minimum, Contractor shall provide:
   

1. 
   Financial fields including but not limited to submitted charge, denied amount, allowed amount, out of pocket amounts (copayments, coinsurance, deductibles), coordination of benefit (i.e. third-party) amount, discount, net payment, and prescription drug rebates;
   

2. 
   Clinical fields including but not limited to ICD diagnosis and procedure codes, CPT codes, HCPCS codes, UB Revenue Codes; and
   

3. 
   Service fields including but not limited to place of service, provider type, provider specialty, provider name, provider address (including 5-digit ZIP code), provider tax ID, National Provider ID (NPI), and network provider indicator.
   

5. 
   
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