seven (7) days a week. The TPA has averaged handling nearly 200,000 provider calls per year on behalf of the Plan. The TPA is responsible for maintaining an automatic call distribution system capable of tracking and reporting phone activity for both participant and provider customer service toll-free numbers. The TPA is required to participate in activities with the Board in responding to participant or provider inquiries or complaints relating to TPA services. The TPA must cooperate with the Board and with all other contractors of the Board with respect to ongoing coordination and delivery of health care services and in any transition of responsibilities. The TPA is responsible for responding to inquiries from employer units concerning administrative procedures and benefits. Participant Mobile App The TPA should have a mobile app that enables participants to obtain important information from a mobile device. Information available through this app must include, but is not limited to, locating a provider, accessing a virtual ID Card, viewing benefit information, viewing claim formation, viewing prescription drug information, viewing articles on various health topics, updating phone number, and updating email address. Electronic Payment to Providers The TPA must provide a system capable of electronic deposit of funds for health care providers. Enrollment and Eligibility The TPA must provide a system for employer to view and maintain enrollment and eligibility information for the health insurance component of the Plan, as well as for the group term life insurance program provided by the Plan (See 3.27 below), for the more than 116,000 participating employees and their covered dependents. The 335+ employer units are primarily responsible for entering and maintaining enrollment changes in the TPA electronic system for their respective employees and dependents. The TPA is responsible for processing any allowed changes for the nearly 25,000 COBRA and retiree participants and any covered dependents. The TPA is responsible for verifying the eligibility for participants for benefits under the Plan based on the information provided by the employer units, participants, and DFA. The TPA will receive (primarily in electronic format) enrollment and eligibility information from the following unique groups: All Employer Units (approximately 335 State agencies, universities, community/junior colleges, libraries, and school districts) DFA-Office of Insurance (some initial retiree applications only) Mississippi Public Employees' Retirement System (PERS) Retirees (primarily paper format) COBRA participants (primarily paper format)
Standard 90% of all claims processed in 30 calendar days Threshold 90.00% - 100.00% 85.00% - 89.99% 85.00% Total Annual Liquidated Damages None 2.0% of TPA Fees 4.0% of TPA Fees Claim Financial Accuracy Mathematically, the financial accuracy of a universe of claims is the dollars paid correctly divided by the total dollars paid, stated as a percentage. Standard 99.00% Accuracy Threshold 99.00% - 100.00% 98.00% - 98.99% 97.00% - 97.99% 97.00% Total Annual Liquidated Damages None 2.0% of TPA Fees 3.0% of TPA Fees 4.0% of TPA Fees Claim Payment Accuracy The Payment Accuracy of a universe of claims is the number of claims paid correctly divided by the total number of claims, stated as a percentage. Payment accuracy reflects the percentage of claims that are paid correctly. Standard 97% Accuracy Threshold 97.00% - 100.00% 95.00% - 96.99% 95.00% Annual Liquidated Damages None 2.0% of TPA Fees 3.0% of TPA Fees Processing Accuracy The Processing Accuracy of a universe of claims is the number of claims processed correctly divided by the number of claims. Claims with payment errors will not be considered in the calculation of processing accuracy. Standard 95% Accuracy Threshold 95.00% - 100.00% 93.50% - 94.99% Below 93.50% Annual Liquidated Damages None 2.0% of TPA Fees 3.0% of TPA Fees
Telephone Call Answer Time The amount of time once a person is first connected to a phone system to the time the call is answered by a live person. Standard 100% Answered live within average of 30 seconds or less Threshold 100.00% 95.00% - 99.99% 95.00% Total Annual Liquidated Damages None 2.0% of TPA Fees 3.0% of TPA Fees Telephone Drop Rate A call “drop rate” is defined as an individual hanging up once in the que. Standard Less than 5% Threshold Less than 5% 5.00% - 8.00% Above 8.00% Annual Liquidated Damages None 2.0% of TPA Fees 3.0% of TPA Fees Data Transfer Standard All error transactions from the data transfer sent to the Board’s vendors will be corrected and returned to the Board’s vendors via data transfer within two (2) business days of receipt of the error report. Total Annual Liquidated Damages Total of 2% of annual TPA Fees to be assessed at the end of each 12-month period Standard Reports TPA is to produce and provide the Board with reports. The final reporting format and elements are to be agreed upon between the Board and the TPA following contract award. All reports are due by the last day of the month following the close of the reporting period. Compliance with this standard will be evaluated by the Board at the end of each contract year. Liquidated damages will be assessed for failure to meet the reporting requirements for the performance standard if a required report is late, incomplete, or inaccurate. All information supplied by the TPA is subject to audit by the Board or its designee. The Board, at its discretion, may also conduct an independent audit of the TPA’s performance and if such audit is conducted, the results of the audit will be used to assess any liquidated damages. The TPA will be provided the opportunity to review and discuss the audit results before the application of liquidated damages.