Network Auditing Program Services

The vendor is required to provide network auditing (EPNA) program for statewide medicaid managed care (SMMC) plans.
- Medicaid recipients through managed care arrangements must not only establish certain provider network standards ensuring access to services but must also monitor and enforce those standards.
- Continuously audit and test the provider networks reported and maintained by the Managed Care Plans. Special emphasis shall be given to onsite reviews.
- Receive network access complaints from the Agency’s Recipient and Provider Assistance (RPA) bureau and research/audit the alleged network deficiency to determine potential findings.
-  Address and monitor identified network deficiencies with the Managed Care Plans to ensure appropriate remediation.
- Provide reports including analytics, dashboards, and reports of Vendor findings and activities.
- Provide access to data from the health track, system, enterprise data warehouse (EDW) and any state health care connections module that replaces or enhances the health track and system functions that enables the vendor to receive electronic files, and exchange data with the agency and managed care plans as required by this contract; the information and data transferred or made available to the vendor by the agency includes, at a minimum:
• Medicaid recipient files
• Managed care plan provider network files
• Medicaid claims/encounter files
- Monitor and evaluate the vendor’s compliance with the requirements of this contract.
- The agency reserves the right to request additional information in support of monitoring the vendor’s performance to ensure compliance with the requirements of this contract.
- Determine whether the vendor has violated a contractual obligation and assess liquidated damages or sanctions when necessary.
- Provide information related to federal and state requirements that are related to the provision of services under this contract and expectations of the vendor, including the provider network standards specified in the managed medical assistance, long-term care, and specialty care provider network services sections of the SMMC model contracts as well as the prepaid dental model contract.
- Update and provide to the vendor and managed care plans quarterly which provider types (facilities/groups/organizations) have been granted waivers of the two per county provider network standard based on the availability of the provider type in each county.
- Notify managed care plans and other interested stakeholders regarding the implementation of the EPNA program.
- Meet with the vendor in person or virtually after contract execution to discuss the vendor’s proposed implementation plan and anticipated time frames, and to determine information and other resources needed to complete the final implementation plan.
- Review all deliverables (e.g., sampling methodology plan, reports, invoices, and documents) submitted by the vendor in a timely manner that adheres to the deadlines as required in this contract; the agency reserves the right to approve, deny or require revision to any submitted deliverables.
- Provide training in the appropriate use of the health track and system data as well as training to support the vendor’s transition from health track and system to the agency’s replacement systems on a timeline to be provided by the agency.
- Direct the vendor to provide additional training to the agency and/or the managed care plans via in-person and/or webinars at no additional cost to the agency.
- Reproduce and distribute, at its discretion, any of the vendor’s training materials.
- Provide the vendor with at least thirty (30) calendar days advance notice if the specifications of any of the reports required by the agency need to be amended after the implementation date.
- The Vendor shall provide the Agency with analytics and other reports as determined by the Agency.
- The Vendor shall develop, manage, and maintain both internal and external facing dashboards to report data elements specified by the Agency.
- The Vendor shall furnish an IT user manual to authorized Agency staff on the Vendor’s web-based reporting system at no additional cost to the Agency.
- The user manual shall include, at a minimum:
• System Overview
• Authorized Use Permission Guidelines
• Points of Contact for:
oInformation
oCoordination
oHelp Desk
• Acronyms and Abbreviations
• System Restrictions
• Interfaces with Other Systems
• Security
• Error Messages
- The Vendor shall provide updates to the user manual; the agency may provide, in writing, recommendations for modifications to the user manual consistent with the requirements of this contract.
- Contract Period/Term: 3 years