External Quality Review Organization (EQRO) ? RFP # 20260731/ RFx # 3160008164 ? 7/31/2026 RFP # 20260731 ? Word RFP # 20260731 ? PDF Business Associate Agreement EQRO ? Amendment 1 ? 8/10/2026

	Request for Proposal
	RFP # 20260731/ RFx # 3160008164
	External Quality Review Organization (EQRO) Services

DOM Procurement Officer:

Sharon Clark, Procurement Officer

Email: procurement@medicaid.ms.gov

601.359.6153

RFP PROCESS DESCRIPTION	ANTICIPATED DUE DATE
Questions Due Submit all questions using the designated Q&A form, per RFP instructions. Responses will be published as an RFP amendment to ensure all potential Offerors have access to the same information.	August 18, 2026 2:00 PM, CT
SharePoint Access Request Offerors must submit the required information on the attached form to obtain access to the secure file share.	September 9, 2026 2:00 PM, CT
Proposal Submission Deadline Proposals shall be submitted in accordance with the RFP submission instructions prior to the time and date indicated here, or as may be amended through an RFP Amendment	September 18, 2026 2:00 PM, CT

OFFERORS ARE STRONGLY ENCOURAGED TO CAREFULLY READ THE ENTIRE SOLICITATION

DOM WELCOMES PARTICIPATION OF MINORITY BUSINESSES

1.0 PROCUREMENT OVERVIEW

1.1 Purpose

The Mississippi Division of Medicaid (DOM) is seeking to contract with a qualified and responsible Offeror to conduct External Quality Review (EQR) activities in compliance with applicable federal regulations. These activities are intended to support the Mississippi Coordinated Access Network (MississippiCAN) and the Mississippi Children’s Health Insurance Program (CHIP). The selected External Quality Review Organization (EQRO) will be responsible for analyzing and evaluating aggregated data concerning the quality, timeliness, and accessibility of services covered under Medicaid and CHIP, as delivered by Managed Care Organizations (MCOs).

Pursuant to 42 CFR § 438.350, as amended, each state’s Medicaid managed care program must undergo an annual external quality evaluation by an EQRO to identify performance improvement opportunities and assess progress over time. This review must be conducted by an independent entity that meets the qualifications set forth under 42 CFR Part 438, Subpart E, and must utilize information obtained through EQR activities consistent with federally approved protocols.

The Centers for Medicare and Medicaid Services (CMS) have established detailed protocols to guide EQROs in the execution of both mandatory and optional review activities. Mandatory EQR activities are federally required evaluations that state Medicaid agencies must conduct annually on their contracted Managed Care Organizations (MCOs), while Optional EQR activities are additional oversight evaluations that state Medicaid agencies can choose to have an External Quality Review Organization (EQRO) conduct. Offerors must demonstrate a thorough understanding of these federal regulations and protocols, including the most recent CMS guidance titled Monitoring Medicaid Managed Care Organizations (MCOs) and Prepaid Inpatient Health Plans (PIHPs): A Protocol for Determining Compliance with Medicaid Managed Care Proposed Regulations at 42 CFR Part 400, 430, et al., as amended.

Any contract awarded pursuant to this Request for Proposal (RFP) will be contingent upon approval by the Public Procurement Review Board (PPRB). In the event that PPRB approval is not obtained, the contract shall be deemed null and void, and no compensation will be paid.

1.2 Authority

1.2.1 Legal and Regulatory Mandate

This Request for Proposal (RFP) is issued under the authority of Title XIX and Title XXI of the Social Security Act, as amended, and its implementing federal regulations. As the single state agency designated to administer Medicaid and CHIP programs, the Mississippi Division of Medicaid (DOM) is authorized under the Mississippi Code of 1972, as amended, to procure services necessary to ensure compliance with federal managed care oversight and quality assurance requirements.

In accordance with Section 1902(a)(30)(A) of the Social Security Act, DOM maintains procedures to safeguard against unnecessary utilization of care and to ensure efficiency, economy, and quality of care across its programs.

1.2.2 External Quality Review (EQR) Requirements

Pursuant to 42 CFR § 438.350 and Section 1932(c)(2) of the Social Security Act, DOM is required to contract with an independent External Quality Review Organization (EQRO) to perform annual external quality reviews of managed care organizations (MCOs). These reviews assess the quality, timeliness, and accessibility of services to support the State in monitoring and improving managed care program performance.

The EQR program shall be managed in full compliance with state and federal standards, including:

• 42 CFR Part 438, Subpart E: Governing EQR requirements for Medicaid managed care.

• 42 CFR §§ 438.350, 438.354, 438.358, 438.360, and 438.364: Establishing standards for independence and mandatory/optional EQR activities.

• 42 CFR § 457.1250: Incorporating EQR requirements for the Children’s Health Insurance Program (CHIP).

• Mississippi Administrative Code: Title 23, Part 100.

1.2.3 Programs Subject to Oversight

DOM operates the following managed care programs subject to EQR oversight:

• MississippiCAN: A coordinated care program for eligible Medicaid beneficiaries, currently served by three (3) Managed Care Organizations (MCOs).

• CHIP: The State’s Children’s Health Insurance Program, administered by DOM and currently served by the same three (3) MCOs listed above.

1.2.4 Contractor Compliance and Standards

DOM is conducting this procurement to secure an EQRO that meets all federal qualifications and independence standards. The selected Contractor shall perform required and optional EQR activities in accordance with:

• Federal regulations and the most current or superseding guidance issued by the CMS;

• All applicable state laws and regulations and State Plan Amendments (SPAs); and

• The specific requirements and standards outlined in this RFP.

Submission of a proposal constitutes the Offeror’s acknowledgment of these authorities. The selected Contractor must comply with all such requirements as a condition of contract award and performance. DOM reserves the right to interpret and apply these authorities in the best interest of the State.

1.3 Organizations Eligible to Submit Proposals

1.3.1 Minimum Qualifications

Offerors must certify that they meet the following minimum qualification requirements:

1. Must have a minimum of three (3) years of experience within the last five (5) years conducting External Quality Review (EQR) activities, or substantially similar quality oversight activities, for Medicaid and/or CHIP managed care programs. For purposes of this solicitation, substantially similar quality oversight activities are those performed under contract with a state Medicaid agency or other governmental entity and must include quality oversight of risk-based Medicaid and/or CHIP managed care programs that align with one or more External Quality Review (EQR) activities described in 42 CFR Part 438, Subpart E, including validation of performance improvement projects, performance measure validation, compliance reviews, or quality systems assessments. Such experience must have involved oversight of at least one (1) Medicaid and/or CHIP managed care organization (MCO) operating under a risk-based managed care delivery system and serving a comparable Medicaid and/or CHIP population. (Offeror’s submission of References (Section 5.3.5.(2)) shall satisfy this eligibility requirement)

2. Must meet all requirements to serve as an External Quality Review Organization (EQRO) as defined in 42 CFR Part 438, Subpart E, including independence standards (at minimum the EQRO cannot be the state agency, a managed care plan, or a competitor of a plan it is reviewing). (Offeror’s response to this statement in the Transmittal Letter (Section 5.3.1) shall satisfy this eligibility requirement)

3. The Offeror has the capacity to fulfill all required components and deliverables as outlined in the Scope of Services. (Offeror’s response to this statement in the Transmittal Letter (Section 5.3.1) shall satisfy this eligibility requirement)

1.4 Request for Reconsideration of the Terms of the Submission

Prospective Offerors are hereby informed that they may request reconsideration of the terms outlined in this solicitation. The procedures and requirements for submitting such a request are detailed in Section 6.5.4 of the Mississippi Public Procurement Review Board (PPRB) Office of Personal Service Contract Review (OPSCR) Rules and Regulations.

1.5 Procurement Timetable

The following schedule represents DOM’s anticipated timeline for the RFP and procurement process. Please note that DOM reserves the right to modify the Procurement Timetable at its discretion.

Procurement Timetable
Date	Time	Process
7/31/2026		Request for Proposal (RFP) Release
8/18/2026	2:00 p.m. CT	Deadline for Written Questions
9/3/2026	5:00 p.m. CT	Anticipated Date of Response to Questions Posted
9/9/2026	2:00 p.m. CT	SharePoint Access Request Deadline
9/18/2026	2:00 p.m. CT	Proposal Submission Deadline
10/22/2026		Anticipated Date of Notice of Intent to Award
12/2/2026		Public Procurement Review Board Meeting (Proposed)
12/3/2026		Operational Period

1.6 Pre-Submission Requirements

1.6.1 RFP Questions and Answers

Potential offerors may submit multiple questions related to this RFP no later than Tuesday, August 18, 2026, by 2:00 p.m. CT, using the designated Question-and-Answer template available at: https://medicaid.ms.gov/resources/procurement

All questions must be submitted using the required template and emailed to:
procurement@medicaid.ms.gov .

Subject Line: EQRO – Questions

The Offeror bears all risks and responsibility for ensuring timely delivery. Questions received after the deadline and Questions submitted by Offerors who do not submit a timely Mandatory Letter of Intent will not be addressed by the DOM.

DOM anticipates that the written answers will be available on or about Thursday, September 3, 2026, by 5:00 p.m. CT, via DOM’s procurement website:

https://medicaid.ms.gov/resources/procurement/

and the Mississippi Contract/Procurement Opportunity Search portal website:

https://www.ms.gov/dfa/contract_bid_search/Bid?autoloadGrid=False

The Division of Medicaid (DOM) will compile a register of all questions received, presented exactly as submitted, along with the corresponding responses. This register will be issued as an official Amendment to the Request for Proposal (RFP). DOM’s responses will be considered formal amendments to the RFP and will require acknowledgment by all Offerors.

All written responses provided by DOM are binding. The complete set of questions and answers will be included as an attachment to the final executed contract.

1.6.2 Receipt of Acknowledgement of Amendments

Offerors shall acknowledge receipt of any amendment to the RFP, in writing, by signing and returning as part of the proposal submission following the format as described in the Proposal Submission Format (Section 5.1). This includes receipt of the Question-and-Answer Document. Each Offeror shall submit a written acknowledgement of every amendment to DOM with the proposal submission.

1.6.3 Proposal Submission Method and Access Requirements

Proposals for this solicitation must be submitted electronically via DOM’s secure SharePoint platform. No physical, emailed, or faxed proposals will be accepted.

To gain access to DOM’s SharePoint site for proposal submission, the Offeror must complete the SharePoint Access Request Form (Attachment L) and submit it via email to procurement@medicaid.ms.gov , with the subject line:

EQRO 2026 – SharePoint Access Request

Within the request form, the Offeror may provide email addresses for up to two (2) designated individuals responsible for uploading the proposal. Please ensure that email addresses are clearly typed or printed to ensure legibility. Shared email addresses are not permitted; they must be individual email accounts.

The SharePoint Access Request form must be received no later than Wednesday, September 9, 2026, by 2:00 p.m. CT, and must be signed by an individual authorized to commit the Offeror to the proposed work. Submitting a SharePoint Access Request form does not obligate an Offeror to submit a proposal. However, proposals will not be accepted from vendors who fail to submit their designated upload contacts by the SharePoint Access Request deadline.

Offerors are solely responsible for ensuring timely delivery of the Access Request Form and assume all associated risks of delivery. To ensure timely technical support before proposal upload, any assistance with SharePoint access or submission must be requested no later than two (2) business days before the proposal’s due date.

1.7 Expenses Incurred in the Procurement Process

All parties participating in the procurement process with regard to this solicitation shall bear their own costs of participation, pursuant to Section 1.4.4 of the Mississippi Public Procurement Review Board Office of Personal Service Contract Review Rules and Regulations.

1.8 Type of Contract

The resulting contract will be a firm, fixed-rate agreement. Compensation will be based on a set rate that will not be adjusted, regardless of changes in the Contractor’s costs to perform the specified services.

1.9 Written Proposals

All proposals shall be submitted in writing.

1.10 Accuracy of Statistical Data

When applicable, any statistical data provided by the Division of Medicaid (DOM) in relation to this RFP represents the most accurate and current data available from DOM records at the time of publication. Although DOM endeavors to ensure the accuracy of this information, it does not assume responsibility for any potential discrepancies. Should any inaccuracies be discovered following the release of this RFP, such findings shall not constitute a basis for renegotiation of any payment rate after contract award. Additional statistical details concerning DOM operations are available on the DOM website.

1.11 Security Requirements

1.11.1 Data Location

The Contractor shall not store or transfer DOM data outside of the continental United States. This includes backup data and disaster recovery locations.  The Contractor will permit its personnel and contractors who are located within the continental United States (CONUS) to access DOM data remotely from within the CONUS only as required to provide technical support. Such access must be fully-encrypted in transit as per Section 1.11.2.

1.11.2 Data Encryption

The Contractor must encrypt all non-public data in transit regardless of the transit mechanism, using encryption that meets current industry standard and is updated as standards evolve. For engagements where the Contractor stores non-public data, the data shall be encrypted at rest.  The key location and other key management details will be discussed and negotiated by both parties.

1.11.3 Breach Notification and Recovery

Unauthorized access or disclosure of non-public data is considered to be a security breach. The Contractor will provide notification within 24 hours of the incident and all communication shall be coordinated with DOM. At a minimum, the current DOM Privacy Officer and current DOM Chief Information Security Officer must be notified and included in such communication. When the Contractor or their sub-contractors are liable for the loss, the Contractor shall bear all costs associated with the investigation, response and recovery from the breach, including but not limited to, credit monitoring services with a term of at least three years, mailing costs, website and toll-free telephone call center services. DOM shall not agree to any limitation on liability that relieves a Contractor from its own negligence or to the extent that it creates an obligation on the part of DOM to hold a Contractor harmless.

1.11.4 Notification of Legal Requests

Contractor shall contact DOM immediately upon receipt of any electronic discovery, litigation holds, discovery searches, and expert testimony related to, or which in any way might reasonably require access to the data of DOM. At a minimum, the current DOM Privacy Officer and current DOM Chief Information Security Officer must be notified and included in such communication. The Contractor shall not respond to subpoenas, service of process, and other legal requests related to DOM without first notifying DOM unless prohibited by law from providing such notice.

1.11.5 Termination and Suspension of Service

1. In the event of termination of the contract, the Contractor shall implement an orderly return of DOM data in CSV, XML or another mutually agreeable format. The Contractor shall guarantee the subsequent secure disposal of DOM data. At a minimum, the current National Institute of Standards and Technology (NIST) standards/guidance must be followed.

2. Suspension of services: During any period of suspension of this Agreement, for whatever reason, the Contractor shall not take any action to intentionally erase any DOM data.

3. Termination of any services or agreement in entirety: In the event of termination of any services or of the agreement in its entirety, the Contractor shall not take any action to intentionally erase any DOM data for a period of 90 days after the effective date of the termination. After such 90-day period, the Contractor shall have no obligation to maintain or provide any DOM data and shall thereafter, unless legally prohibited, dispose of all DOM data in its systems or otherwise in its possession or under its control. Such disposal shall be performed using secure purge methods that render the data permanently unrecoverable and incapable of being reconstructed or reconstituted. At a minimum, the Contractor shall perform the secure purge in accordance with applicable NIST guidance and standards. Upon completion, the Contractor shall provide DOM with a written certification identifying the date the secure purge was completed, the method(s) used, and confirming that all DOM data was securely destroyed in accordance with the applicable NIST standards. The secure purge shall include all copies of DOM data, including primary storage, backup media, disaster recovery systems, archived data, and any other copies maintained by the Contractor or its subcontractors. Within this 90-day timeframe, Contractor will continue to secure and back up DOM data covered under the contract.

4. Post-Termination Assistance: DOM shall be entitled to any post-termination assistance generally made available with respect to the Services unless a unique data retrieval arrangement has been established as part of the contract.

5. Secure Data Disposal: When requested by DOM, the provider shall destroy all requested data in all its forms, for example, disk, CD/DVD, backup tape, and paper. Data shall be permanently deleted and shall not be recoverable, according to NIST approved methods. Certificates of destruction shall be provided to DOM.

1.11.6 Security Logs and Reports

Contractor shall maintain and, upon request, provide DOM with access to or reports from all audit and security logs relevant to the services performed under this Agreement, its data and its processes. At a minimum, audit logs shall record the user or administrator identifier, date and time of the event, system or resource accessed, action performed, success or failure of the event, and, where available, the originating device or IP address. The Contractor shall provide DOM with the ability to request reports of activities performed by a specific user or administrator over a specified period. The logging mechanisms shall be defined up-front and documented, and available throughout the term of the Agreement.

1.11.7 Processes and Procedures

Contractor shall disclose its security processes and technical limitations to DOM so that DOM can determine if and how adequate protection and flexibility can be attained between DOM and the Contractor.  For example: virus checking and port scanning. DOM and the Contractor shall work together to understand each other’s roles and responsibilities.

1.11.8 Background Checks

Contractor warrants that it will not utilize any staff members, including sub-contractors, to fulfill the obligations of the contract who have been convicted of any crime of dishonesty. The Contractor shall promote and maintain an awareness of the importance of securing DOM's information among the Contractor's employees and agents.

1.12 Incorporation of Documents by Reference

The Request for Proposal (RFP) may incorporate certain documents by reference to provide additional details, specifications, or requirements relevant to this solicitation. Such incorporated documents become an official part of the RFP, and Offerors are expected to review and comply with their contents. To ensure ease of access, this solicitation will clearly specify where and how these referenced documents can be obtained. It is the responsibility of each Offeror to acquire and thoroughly review all incorporated documents to prepare a complete and compliant proposal.

1.13 Electronic Access to Materials

The following resources are available online to support the procurement process; however, they are provided solely for informational purposes and do not replace the official requirements set forth in this RFP.

The RFP, any amendments, and RFP Questions and Answers (following official release) will be posted on the Procurement page of DOM’s website at:

http://www.medicaid.ms.gov/resources/procurement/

Additional details about services offered through Mississippi Medicaid, along with information about the Division of Medicaid's structure and operations, can also be found on the DOM’s website.

The DOM website, www.medicaid.ms.gov , contains useful resources such as annual reports, provider manuals, and bulletins. The Annual Report Summary includes data on member enrollment, program funding, and expenditures by service type for each fiscal year.

Other helpful links include:

• Mississippi Administrative Code: Title 23, Part 100: https://medicaid.ms.gov/providers/administrative-code/

• State of Mississippi website: www.mississippi.gov

• MAGIC system information: portal.magic.ms.gov
Mississippi’s Accountability System for Government Information and Collaboration (MAGIC) can be used by businesses to register as suppliers, receive RFX notifications based on selected categories, submit electronic responses to solicitations, and receive purchase orders. Supplier registration is available at: https://www.dfa.ms.gov/mmrs-vendors

• MS ITS Enterprise Security Policy:
https://www.sos.ms.gov/adminsearch/ACProposed/00020006b.pdf

• MS ITS Enterprise Cloud and Offsite Hosting Security Policy:
https://www.its.ms.gov/sites/default/files/Enteprise%20Cloud-Offsite%20Hosting%20Security%20Policy%202.1.pdf

• Public Procurement Review Board Rules and Regulations:
https://www.dfa.ms.gov/dfa-offices/personal-service-contract-review/

• Mississippi Code of 1972:
https://www.sos.ms.gov/communications-publications/mississippi-law

2.0 SCOPE OF SERVICES

2.1 General Overview and Responsibilities

The Contractor shall provide all services, activities, reports, and deliverables necessary to perform EQRO functions for DOM in accordance with all applicable federal and state requirements, including but not limited to 42 CFR §§ 438.350-364 and 457.1250.

The Contractor shall:

1. Conduct all EQR activities under the direction and oversight of DOM and in accordance with standards of quality, accuracy, completeness, and timeliness acceptable to DOM.

2. Conduct EQR activities that require a site visit by the Contractor onsite or virtually to obtain the required information, at the discretion of DOM. Contractor shall seek prior approval from DOM before initiating the EQR activity.

3. Perform all scope of services and deliverables within the timelines established by DOM and this Contract. Unless otherwise specified, the deliverable dates apply to all contract years following the first year.

Note: Deliverables for the first contract year shall be adjusted as necessary to ensure compliance with the April 2027 CMS submission deadline. Also, submission date of any first annual reporting requirements will be decided after contract execution.

4. Perform all other EQR activities not otherwise designated as DOM responsibilities, which are necessary for optimal operation of the EQRO functions.

5. Acknowledge that DOM reserves the right to make appropriate adjustments in the Scope of Services as necessary, from year to year, to address Medicaid program changes in federal regulations, state requirements, CMS guidance, managed care operations, or program priorities, by written agreement between DOM and the Contractor on an as-needed basis.

6. Receive timely notifications from DOM of all changes and/or amendments in the contract, which can reasonably be expected to affect the Contractor’s performance of this contract.

7. Request an interpretation of any laws, regulations, and/or policies from DOM if such a need arises.

8. Maintain, on a current and ongoing basis, a full and detailed knowledge of applicable Federal and State laws, regulations, policies, the State Medicaid Plan, State CHIP Plan, Federal EQR regulations (42 CFR §§ 438.350-364 and 457.1250) and protocols for Medicaid MCOs and specific DOM requirements.

9. Be responsible for conducting all reviews effective July 1, 2025, and producing all regularly scheduled monthly, quarterly, and annual reports.

10. As directed by DOM and at no additional cost, coordinate with, facilitate the prompt exchange of information between, and work collaboratively with all other DOM contractors and DOM agents for the purpose of fulfilling the obligations set forth in this Contract. If any part of the Scope of Services involves sharing or obtaining information of a confidential, proprietary, or otherwise valuable nature with or from another DOM contractor, the Contractor may be requested to sign mutually agreeable documents, including but not limited to, Non-Disclosure Agreements (Non-Disclosure Documents), which are reasonably necessary to maintain cooperation and collaboration among and with any and all other DOM contractors and DOM agents in the performance of the Contract.

11. Not invoice DOM for any coordination services other than those submitted on the Proposal Submission Form, nor shall DOM be liable for payment of such services, without the prior written consent of DOM.

2.2 Proposal Requirements

2.2.1 General Obligations

The Contractor shall meet the EQRO qualification requirements for competence and independence of external quality review organizations as set forth in 42 CFR § 438.354.

2.2.2 Objectives

The Contractor shall review, assess, and validate the performance of DOM’s contracted Medicaid and CHIP managed care organizations and issue findings in compliance with 42 CFR § 438.364.

The Contractor shall identify opportunities for quality improvement and provide recommendations designed to improve access, quality, timeliness, and outcomes of care.

2.3 Federally Defined Protocols

The Contractor shall adhere to all current CMS External Quality Review (EQR) protocols and guidance relevant to Medicaid and CHIP managed care programs. Throughout the duration of the Contract, the Contractor is required to stay up to date with all CMS-issued protocols, updates, technical guidance, and reporting requirements. Additionally, the Contractor must use the most current CMS EQR protocols available at the time the work is performed.

MississippiCAN and CHIP completed procurements can be found on the DOM website at https://medicaid.ms.gov/programs/managed-care/11081-2/ .

CMS’ most current Validating Performance Improvement Project protocols are located at https://www.medicaid.gov/medicaid/quality-of-care/downloads/2023-eqr-protocols.pdf .

The CMS website provides a step-by-step overview for each protocol’s compliance. The Contractor is responsible for maintaining compliance with subsequent guidance from CMS on these protocols.

2.4 Protocol 1 – Validation of Performance Improvement Projects

42 CFR § 438.358(b)(1)(i)

States must require their Medicaid and CHIP managed care organizations (MCOs) to conduct performance improvement projects (PIPs) that focus on both clinical and non-clinical areas each year as part of the MCO’s Quality Assessment and Performance Improvement (QAPI) program.

A PIP is a project conducted by the MCO that is designed to achieve significant improvement, sustained over time, in health outcomes and enrollee experience.  A PIP may be designed to change behavior at a member, provider, and/or MCO/system level. The topic should target improvement in relevant areas of clinical and non-clinical services.

Note: Submission date of any first annual reporting requirements in this section will be decided after contract execution.

2.4.1 PIP Technical Papers

The Contractor shall:

1. Review and validate clinical and non-clinical PIPs;

2. Provide the PIP Technical Papers (by MCO, by PIP), for each MCO, that includes a section for each region of the state;

3. Prepare a comprehensive report to analyze PIP results by MCO and, where applicable, by geographic region. This report shall include, but not be limited to:

a. Assessment of the appropriateness of each PIP by examining factors such as the methodology used and the adequacy of supporting data in justifying the need for the PIP. This analysis must integrate and cross-reference findings from other relevant surveys and audits completed;

b. Identification of strengths, deficiencies, trends and opportunities for improvement based on the documents and processes reviewed; and

c. In instances of identified non-compliance, the Contractor shall be responsible for the development, implementation, and monitoring of the MCO’s Corrective Action Plan (CAP) related to the PIP. Additionally, the Contractor must provide regular status updates regarding CAP progress to DOM. (Deliverable)

4. Submit the PIP Technical Papers (by MCO, by PIP) to DOM by September 1st each year of the term. (Deliverable)

2.4.2 Annual PIP Summary Report

The Contractor shall submit the Annual PIP Summary Report, that provides a comprehensive summary of all PIPs conducted by the MCOs, by October 31st each year of the term.   (Deliverable)

The Contractor shall:

1. Ensure that the Annual PIP Summary Report includes the methodology used for each type of activity;

2. Ensure that the PIP Summary Report includes a table that lists all PIPs by MCO;

3. Ensure that the table clearly identifies the PIP topic, measurement year, PIP aim statement, PIP goals and objectives (including any national benchmarks or State performance targets) and improvement strategies to achieve performance goals; and

4. Ensure that the Annual PIP Summary Report includes results of the activity across MCOs, highlighting any trends identified and a timeline for any CAP activities, as well as comparative charts, and is prepared with input from DOM.

2.4.3 PIP Validation and HEDIS Performance Monitoring

The Contractor is responsible for the validation and technical oversight of MCO quality initiatives. By integrating audited Healthcare Effectiveness Data and Information Set (HEDIS) data and on-site performance measure validations, the Contractor shall ensure that all PIP activities are grounded in accurate data and align with the DOM’s quality improvement goals.

The Contractor shall:

1. Provide technical assistance to the MCOs as directed by DOM regarding performance improvement, including at minimum but not limited to, facilitating quarterly performance improvement/quality improvement calls with each MCO and a separate call for the joint PIP with MCOs each quarter.

2. Evaluate the annual audited Healthcare Effectiveness Data and Information Set (HEDIS) data provided by the MCOs in comparison to the Decision Support System (DSS) – Fiscal Agent HEDIS data for discrepancies and outliers, as well as comparison to the Fee for Service population data.

3. Use the MCOs completed audit reports and findings to fulfill the requirements for HEDIS review.

4. Ensure that MCOs have met the requirement of contracting with the National Committee on Quality Assurance (NCQA) Certified Audit Firm to validate the MCOs’ annual HEDIS rates.

5. Be responsible for conducting the validation of non-HEDIS performance measures in alignment with CMS Protocols, including an on-site visit.

6. Submit EQRO annual review requests and subsequent requests to the MCOs.

2.5 Protocol 2 – Validation of Performance Measures

42 CFR § 438.358(b)(1)(ii)

All CMS Adult and Child Core Set Measures will require validation for MississippiCAN and CHIP, in addition to the Annual Audited HEDIS data.

Note: Submission date of any first annual reporting requirements in this section will be decided after contract execution.

The Contractor shall:

1. Validate MCO performance measures in accordance with 42 CFR § 438.330(b)(2) during the preceding twelve (12) months. These measures may be initially calculated by MCOs or by DOM;

2. Use national standards to validate and report findings on performance measures and outcomes. The Contractor shall work with DOM to determine the performance measure(s) that will be evaluated each year of the contract term;

3. Define the scope of the validation by confirming DOM-required technical specifications for each of the performance measures and DOM requirements for performance measure reporting; assess the integrity of the information system; initiate review of medical record data collection, if applicable; and prepare for the site visit;

4. Conduct individual site visits to include follow-up on findings from the pre-site information system assessment and validation of the production and reporting of performance measures through document review or direct observation, such as: review the information system underlying performance measurement; assess data integration and control for performance measure calculation; review performance measurement production; conduct a detailed review of selected measures; assess the sampling process; and review preliminary findings and outstanding items;

5. Evaluate other national quality standards or quality improvement frameworks to recommend additional performance measures, as needed, to DOM and in accordance with 42 CFR § 438.358(c)(3); and

6. Submit the Annual Performance Measure Validation report, to DOM by September 1st each year of the term of the contract. (Deliverable)

2.6 Protocol 3 – Review of Compliance with Medicaid and CHIP Managed Care Regulations – Annual Quality Survey (AQS)

42 CFR § 438.358(b)(1)(iii)

The Contractor shall conduct a review of compliance with Medicaid and CHIP Managed Care regulations via what DOM refers to as an Annual Quality Survey (AQS), which shall be conducted annually for MCOs, or at DOM’s discretion.

Note: Submission date of any first annual reporting requirements in this section will be decided after contract execution.

2.6.1 AQS Criteria Tools

The Contractor shall develop AQS Criteria Tools, as required, to assess contract compliance and adherence to current industry, federal, and state requirements for Medicaid and CHIP managed care.  These criteria must include a review of the standards contained in 42 CFR Part 438, Subparts D and E, in addition to other standards as defined by DOM.

The Contractor shall:

1. Submit AQS Criteria Tools to DOM for approval within 30 days of the contract effective date for the initial AQS reviews and by October 31st each year of the term for the subsequent reviews (Deliverable); and

2. Ensure that any major changes or deletions from the survey must be clearly identified and approved by DOM.

2.6.2 AQS Deeming Table

The Contractor shall complete and submit the AQS Deeming Table, as required, that provides a detailed comparison of state/federal requirements and the National Committee on Quality Assurance (NCQA) Health Plan Accreditation standards.

The Contractor shall:

1. Use the NCQA Health Plan Accreditation standards for the year that MCOs receive their accreditation. The Contractor shall obtain proof of accreditation from the MCOs;

2. Ensure the tool identifies which elements of the AQS survey may be potentially deemable; and

3. Submit the AQS Deeming Table to DOM for approval within 30 calendar days of the contract effective date for the AQS reviews and by October 31st each year of the term for the subsequent reviews. The Contractor shall ensure that any major changes or deletions from the Deeming Table are clearly identified and approved by DOM. (Deliverable)

2.6.3 Scope of the Annual Quality Survey

The Contractor shall conduct a review for the AQS that incorporates, at a minimum, the following:

1. Availability of services and assurances of adequate capacity and services;

2. Coordination and continuity of care;

3. Coverage and authorization of services;

4. Provider selection and sub-contractual relationships/delegation;

5. Grievance and appeal process and confidentiality;

6. Practice guidelines and health information systems; and

7. Quality assessment and performance improvement program.

2.6.4 AQS Technical Papers and Performance Assessment

The Contractor shall submit a draft of the AQS Technical Papers, as required, within 30 days following the completion of each MCO’s site review with the final report due no later than 60 days from the last review. (Deliverable)

Contractor shall ensure that the report assesses MCO compliance with contractual requirements and all EQR-related mandatory and optional activities, including, but not limited to, the methodology of how data was collected, aggregated, and analyzed, as well as conclusions drawn on quality, timeliness, effectiveness and access to the care furnished by the MCO and their alignment to the Mississippi Medicaid Quality Strategy, see also Section 2.14.6.

The Contractor shall ensure that the report of the quality survey includes, at minimum, the following components:

1. A detailed assessment of the strengths and weaknesses of each MCO based on findings in each MCO’s AQS review.

2. Recommendations for improving the quality of care by each MCO, including specific information the MCOs can utilize to make appropriate changes.

3. Recommendations for best practices from other states and national best practices, when appropriate.

4. Comparative charts on all MCOs, to include a contrast of each MCO to other MCOs in the state; MCO rates in relation to Fee for Service rates, as determined by DOM; and MCO rates compared to state and national benchmarks.

5. An assessment of the degree to which each MCO effectively addressed the recommendations for Quality Improvement (QI) made during the previous year’s EQR.

6. An assessment of each MCO’s compliance with EPSDT requirements and non-discrimination requirements.

2.6.5 AQS Timeline and Scheduling

The Contractor shall maintain the following timeline for the AQS:

1. Within 30 days of the contract effective date for the AQS reviews and by October 31st each year of the term, the Contractor shall submit the proposed AQS Criteria Tools to DOM for approval. (Deliverable);

2. By January 1st each year of the term, the Contractor shall present the proposed AQS schedule to DOM, as required, for approval. (Deliverable); and

3. Appointments with the MCOs shall be scheduled thirty (30) days in advance of the visit, with notification to DOM of intended dates thirty (30) days in advance of the visit.

The Contractor shall ensure that the proposed schedule indicates if the AQS will take place onsite or virtually. The schedule shall be decided jointly between DOM, MCOs, and the Contractor.  DOM shall be notified in writing of any changes to the approved appointment schedule immediately.

2.6.6 AQS Summary Report

By September 1st of each year, the Contractor shall submit a separate, comprehensive AQS Summary Report. (Deliverable)

The Contractor shall:

1. Ensure that the AQS Summary Report includes an executive summary of results of the activity across MCOs, as well as comparative charts, and shall be prepared with input from DOM;

2. Ensure that the report includes an outline and rating of each MCO based on quality process standards as outlined in Protocol 10 – Assist with Quality Rating of Medicaid and CHIP Managed Care Organizations;

3. Ensure that the report includes strengths and noncompliance of each MCO based on the AQS; and

4. Ensure that the report includes clear documentation of the methodology used for each type of activity.

2.7 Protocol 4 – Validation of Network Adequacy

42 CFR § 438.358(b)(1)(iv)

2.7.1 Regulatory Compliance and Protocol Alignment

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