MCO Performance Clause Samples
The MCO Performance clause defines the standards and expectations for the performance of a Managed Care Organization (MCO) under a contract. It typically outlines specific metrics, benchmarks, or service levels that the MCO must meet, such as timely claims processing, quality of care, or member satisfaction targets. This clause ensures that the MCO is held accountable for delivering agreed-upon services and provides a basis for monitoring, evaluating, and enforcing performance, thereby protecting the interests of the contracting party and ensuring quality outcomes for beneficiaries.
MCO Performance. The MCO is expected to meet or exceed all the Department’s objectives and standards, as set forth in the Contract. All areas of responsibility and all Contract requirements will be subject to performance evaluation by the Department. A designated representative of the MCO and a designated representative of the Department may meet as requested by either party, to review the performance of the MCO under this Contract. Written minutes of such meetings will be kept. In the event of any disagreement regarding the performance of services by the MCO under this Contract, the designated representatives must discuss the performance problem and negotiate in good faith in an effort to resolve the disagreement. For purposes of this Contract, an item of non-compliance/non-performance means a specific action of the MCO or its Subcontractor, agent and/or consultant that: • Violates a provision of this Contract including Appendices; • Fails to meet an agreed measure of performance and/or standard; or • Represents a failure of the MCO to be reasonably responsive to a reasonable request of the Department for information, assistance, or support within the timeframe specified by the Department. Non-performance of this Contract includes, but is not limited to: • Failing substantially to provide Medically Necessary covered services that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Failing substantially to provide covered SNS that the MCO is required to provide, under law or under its Contract with the Department, to an enrollee covered under the Contract; • Imposing premiums, copays, or charges that are in excess of the premiums, copays, or charges permitted under the Medicaid program; • Acting to discriminate among enrollees on the basis of their health status or need for health care services, including terminating of enrollment or refusal to reenroll an individual, except as permitted under the Medicaid program, or any practice that would reasonably be expected to discourage enrollment by individuals whose medical condition or history indicates probable need for substantial future medical services; • Misrepresenting or falsifying information that the MCO furnishes to CMS, ACF, or to the State; • Misrepresenting or falsifying of information that the MCO furnishes to an enrollee, potential enrollee, health care provider or SNS provider; • Distributing directly, or indirectly through any agent or...