3.13.1 The Contractor shall participate in Fair Hearings related to the determinations of prior authorization. Fair Hearings must be requested of DMAHS within twenty (20) days of the date of an adverse action. Requests by beneficiaries or providers on their behalf must be received in writing by the DMAHS Fair Hearing Unit, P.O. Box 712, Quakerbridge Plaza, Trenton, N.J. 08625. The Contractor shall print this statement regarding a beneficiary’s right to a Fair Hearing and the time limitation on adverse action letters and send them to the beneficiary.
NOTE #1: Whenever the Contractor denies a Beneficiary a transport, it must send the Beneficiary a letter that states their appeal rights, for both internal appeals and the Office of Administrative
Law (OAL) fair hearing process. The twenty (20) day clock begins when the Beneficiary receives the notification in writing. The notification will be sent by registered mail.
3.13.2 The Contractor shall monitor utilization and claims payments to detect and report fraud and abuse and the Contractor shall report such findings to the DMAHS and MFD.
3.13.3 The Contractor shall participate in meetings to prepare for the auditing of their functions by State and Federal agencies.
3.13.4 The Contractor shall participate in various other proceedings, such as testifying at proceedings arising from, but not limited to, audit/review activity.
3.13.5 The Contractor shall submit accurate and complete management reports to the State Contract Manager no later than twenty (20) days after the close of the month so that fully reconciled data is provided to the State. The Contractor shall provide the following management reports to the State Contract Manager on the frequency and in the format specified for each report. All reports must be submitted in electronic format. Informational data reports must be provided on a CD in Microsoft Excel format. In addition, all narrative reports must be provided on a CD in Microsoft Word or Adobe PDF format.
A. Transportation Summary Report summarizing all authorizations and denials of transportation services by type of transportation. The data elements must include beneficiary’s name, ID number, date of service, transportation service provider, service type, pick-up point, and destination. Other data elements may be specified by the State Contract Manager;
B. Call Center Report and ACD Report summarizing call volume, nature of calls and other information, as designated by the State Contract Manager;
C. Complaint Log summarizing the complaints received and their resolutions including any corrective action taken;
D. Annual Transportation Report describing the contracted services, major problems and issues, and how they were addressed, future plans, as well as, a statistical summary of services. A draft of the report shall be submitted to the State Contract Manager within forty (40) business days after the close of each year of operation, and the final report shall be submitted to the State Contract Manager within twenty (20) business days of receipt of DMAHS comments that were submitted to the Contractor by the State Contract Manager. The Contractor shall provide to State Contract Manager other operational, management and/or ad hoc reports required by the State Contract Manager, including, but not be limited to, the following:
E. Monthly On-Time Performance Report identifying those trips in which the waiting time for pickup and delivery exceeded thirty (30) minutes. Output must include, but not be limited to, the name of the network provider, waiting time, and service date/time;
F. Monthly Bariatric Completion Report that includes trip date, trip status, rider number, pick up and drop office facility, transportation provider and cancellation reason;
G. Monthly report of staffing changes that includes, but is not limited to: name(s) of staff, position(s) under change, date of change, reason for change, impact on organizational profile and recommend substitutions, if available;
H. Monthly Rider No-Show Report identifying recipients who were “no shows”, and which includes, but is not limited to: recipient name, recipient ID number, provider name, date of service/time, scheduled pick-up/delivery destination;
I. Upon Commencement of Operations, as part of the credentialing/re-credentialing process, the Contractor shall provide a list to DMAHS that includes the name, address and social security number of all escorts authorized by the Contractor to accompany any beneficiary under twenty-one (21) years of age. As part of the credentialing/re-credentialing process,
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the Contractor shall demonstrate that all BLS-FFS providers are Medicare approved. The list shall be updated monthly;
J. The Contractor shall perform a monthly audit of at least thirty percent (30%) of the network provider maintenance and related vehicular records, and report its summarized findings to the State Contract Manager within twenty (20) days after the close of the reported-upon calendar month. The report format shall be mutually agreed to by the Contractor and the State Contract Manager;
K. The Contractor shall provide the State Contract Manager a quarterly report summarizing the outcome of annual provider network inspections. This report must be submitted to the State Contract Manager within thirty (30) days after the close of the inspection period. The report format shall be mutually agreed to by the Contractor and the State Contract Manager;
L. Monthly Prompt Payment report identifying all clean claims not fully adjudicated within thirty (30) days of receipt by the Contractor;
M. Monthly Prompt Payment report identifying all claims not fully adjudicated thirty-one to sixty (31-60) days following receipt by the Contractor;
N. A monthly No Vehicle Available (NVA) report identifying transportation requests not responded to by the Contractor within one (1) business day, and that includes, but is not limited to, date of requested services, requested service, and reasons for failure to meet standards;
O. A Monthly Denial Report identifying all transportation service authorizations denied by the Contractor, and which includes, but is not limited to, recipient name, recipient ID number, date of requested service, requested service, reason for denial;
P. Monthly Exception Report identifying beneficiary evaluation not conducted within seventy- two (72) hours of a transportation request being received by the Contractor, and which includes, but is not limited to, provider name, recipient name, recipient ID number, requested service, reason(s) for the delay in conducting beneficiary evaluation;
Q. Upon request by the State Contract Manager, Exception Report identifying MNFs not responded to within five (5) business days of receipt by the Contractor, and which includes, but is not limited to, provider name, recipient name, recipient ID number, requested service, reason(s) for the delay in not responding to MNFs;
R. Upon request by the State Contract Manager, MNF Tracking report that identifies the responsiveness of the Contractor to MNFs that have not been returned timely. Output must include, but shall not be limited to, prescriber name, recipient name, recipient ID number, MNF tracking number, date of request(s), type of service, and reasons for failure to follow up; and
S. The Contractor shall provide monthly encounter claims using the current version of the Health Insurance Portability and Accountability Act (HIPAA) electronic transaction standards for health care professionals and suppliers (currently Version 5010A1 837P). 3.13.6 Timely receipt of these reports shall be a prerequisite for authorization of monthly payment to the Contractor. Failure to provide accurate and complete management reports by reporting deadlines may result in a delay or suspension of payment to the Contractor, pursuant to RFP Section 5.15 (Retainage), until the reports are received and approved by the State Contract Manager.
3.13.7 The Contractor shall have arrangements and policies and procedures that comply with all State and Federal statutes and regulations, including 42 C.F.R. 438.608, 42 C.F.R. 438.610 and Section 6032 of the Federal Deficit Reduction Act of 2005, governing fraud, waste and abuse requirements. The Contractor shall monitor network provider employees, utilization and claims payments to detect and report fraud, waste and abuse and the Contractor shall report such findings to the State Contract Manager and MFD. This includes all allegations of fraud, waste or abuse stemming from complaints, whistleblowers or any other types of disclosures made to the
Contractor. A policies and procedures section that outlines the logistics of how the Contractor is required to report allegations of fraud, waste and abuse to the State Contract Manager and MFD. 3.13.8 The Contractor shall provide quarterly profit and loss statements to the State Contract Manager in order to monitor that the capitation pricing is in-line with the operational costs of the program. The direct transportation expenses of the program must be at a minimum, eighty (80%) of the capitated payments received. In order to monitor this expense ratio, the State will audit the profit and loss statements semi-annually. The Contractor will be required to resubmit income statements for the June 30 and December 31 periods ninety (90) days after those dates to allow for run out of the IBNR (Incurred but Not Reported) estimate. From these revised profit and loss statements, DMAHS must be able to reconcile paid amounts from the encounter records submitted through the State’s fiscal agent, to within one-hundred percent (100%) of the paid claim amounts in the profit and loss statements. The State reserves the right to collect as damages any unreconciled amount representing the difference between the paid claims on the profit and loss statement and the encounter data. Once each year, DMAHS will prepare an Agreed Upon Procedures for the Contractor’s external auditors to complete and return to the State one-hundred and twenty (120) days after the completion of the Contractors fiscal year. DMAHS will prepare and deliver to the contractor the Agreed Upon Procedures thirty (30) days in advance of the end of the fiscal year. Failure to complete and return the Agreed Upon Procedures may result in penalties or fines recovered from the Contractors capitated premiums.