AMENDED AND RESTATED MASTER SERVICES AGREEMENT Between Health Net, Inc. and Cognizant Healthcare Services, LLC Dated November 21, 2014

AMENDED AND RESTATED MASTER SERVICES AGREEMENT Between Health Net, Inc. and Cognizant Healthcare Services, LLC Dated November 21, 2014

Document Metadata

Document Metadata

Table of Contents

Exhibit 10.81

Final

AMENDED AND RESTATED

MASTER SERVICES AGREEMENT

Between

Health Net, Inc.

and

Cognizant Healthcare Services, LLC

Dated

November 21, 2014

“***” = CONFIDENTIAL PORTIONS OF THIS DOCUMENT HAVE BEEN OMITTED AND HAVE BEEN SEPARATELY FILED WITH THE SECURITIES AND EXCHANGE COMMISSION PURSUANT TO AN APPLICATION FOR CONFIDENTIAL TREATMENT UNDER RULE 24B-2 UNDER THE SECURITIES EXCHANGE ACT OF 1934, AS AMENDED.


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TABLE OF CONTENTS


			Page
1.	PREAMBLE			1
	1.1	Background and Purpose		1
	1.2	Goals and Objectives		3
	1.3	Structure of Agreement		4
	1.4	Construction of Preamble		7

2.	DEFINITIONS			7
	2.1	Defined Terms		7
	2.2	Other Terms		16

3.	SERVICES			17
	3.1	Provision of the Services		17
	3.2	Implied Services		18
	3.3	Evolution of the Services		18
	3.4	Users of the Services		18
	3.5	Non-Exclusive; Variability		19
	3.6	Cooperation and Coordination with Other Parties		19
	3.7	“Master” Nature of the Terms and Conditions		20
	3.8	New Services		20
	3.9	Joinder Agreements		21
	3.10	Contract documents to be completed after Effective Date		22

4.	TERM AND REGULATORY APPROVALS			22
	4.1	Initial Term		22
	4.2	Renewal Terms		23
	4.3	Regulatory and Customer Approvals		23

5.	PERFORMANCE			24
	5.1	Performance, Generally		24
	5.2	Place of Performance		24
	5.3	Time of Performance		25
	5.4	Manner of Performance		26
	5.5	Quality Assurance and Continuous Improvement		27
	5.6	Critical Deliverables		27

6.	SERVICE LEVELS			27
	6.1	General		27
	6.2	Failure to Perform		27
	6.3	Removal of Performance Group Guarantee Customers		28


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7.	SUPPLIER PERSONNEL		28
	7.1	Provision of Suitable Personnel	28
	7.2	Screening and Background Checks	28
	7.3	Responsibility for Supplier Personnel, Generally	29
	7.4	Key Supplier Positions	29
	7.5	Removal and Replacement of Supplier Personnel	30
	7.6	Controlling Turnover of Supplier Personnel	30
	7.7	Subcontracting	31
	7.8	Supplier Personnel No Longer on Health Net Account	32
	7.9	Training	33

8.	HEALTH NET RESPONSIBILITIES		33
	8.1	Appointment of Health Net Program Management Office (PMO) Personnel	33
	8.2	Health Net Cooperation Duties	33
	8.3	Savings Clause	34
	8.4	Minimum Revenue Commitment.	34

9.	CHARGES		34
	9.1	Pass-Through Expenses	34
	9.2	Incidental Expenses	35
	9.3	Taxes	35
	9.4	Estimating Model	37
	9.5	Most Favored Customer	37

10.	INVOICING AND PAYMENT		37
	10.1	Invoicing	37
	10.2	Payment Due	38
	10.3	Accountability	38
	10.4	Proration	38
	10.5	Refundable Items	38
	10.6	Deductions	38
	10.7	Disputed Charges	38

11.	TRANSFER OR USE OF RESOURCES		39
	11.1	Transfer of Resources	39
	11.2	Use of Health Net Resources	39
	11.3	Required Consents	44
	11.4	Health Net Resources Provided to Supplier Personnel Working On-site	45
	11.5	Service Description Update	46


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12.	RESOURCE ACQUISITIONS DURING THE TERM		47
	12.1	General Responsibility and Compatibility	47
	12.2	Software Used to Provide the Services	48
	12.3	Health Net Rights to Certain Software	48
	12.4	Colocation Facilities.	53

13.	TRANSITION		54
	13.1	Overview	54
	13.2	“Transition” Defined	54
	13.3	Transition Changes	55
	13.4	Transition Documents	56
	13.5	Conduct of the Transition	57
	13.6	Health Net Cooperation and Support	57
	13.7	In Flight Projects	57
	13.8	Completion of Transition Projects	57

14.	DATA SECURITY AND PROTECTION		58
	14.1	[Reserved.]	58
	14.2	Health Net Data, Generally	58
	14.3	Data Security	58
	14.4	Intrusion Detection/Interception	60
	14.5	Litigation and Investigation Requests	61
	14.6	Compliance with Data Privacy and Data Protection Laws, Regulations and Policies	62
	14.7	Security Breach	62
	14.8	Import/Export Controls	64
	14.9	Compliance with ▇▇▇▇▇-▇▇▇▇▇-▇▇▇▇▇▇	64

15.	INTELLECTUAL PROPERTY RIGHTS		65
	15.1	Certain IP-related Definitions	65
	15.2	Independent IP, Generally	66
	15.3	Rights in Deliverables	66
	15.4	Incorporation of Third-Party Independent IP in a Deliverable	68
	15.5	Work Products	69
	15.6	Delivery of Deliverables and Other Materials	69
	15.7	Use of Material Subject to Open Source Licenses	69
	15.8	Intellectual Property Rights Agreements with Supplier Personnel	69
	15.9	Bankruptcy	70
	15.10	Mental Impressions	70


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16.	TERMINATION		70
	16.1	Termination By Health Net	70
	16.2	Termination Related Payments.	73
	16.3	Termination By Supplier	74
	16.4	Extension of Termination/Expiration Date	74
	16.5	Partial Termination	74
	16.6	Disengagement Assistance	75
	16.7	Survival	76
	16.8	Bid Assistance	77

17.	GOVERNANCE AND MANAGEMENT		78
	17.1	Contract Governance Structure and Processes	78
	17.2	Procedures Manual	78
	17.3	Technology Plans	79
	17.4	Action Plans and Step In Rights	80
	17.5	Change Control	82

18.	AUDITS AND RECORDS		84
	18.1	Audit Rights	84
	18.2	Supplier Audits	85
	18.3	Supplier’s Internal Controls	87
	18.4	Audit Follow-up	87
	18.5	Confidentiality of Audits	87
	18.6	Records Retention	87
	18.7	Financial Reports	88
	18.8	Overcharges	88

19.	REPRESENTATIONS, WARRANTIES AND COVENANTS OF SUPPLIER		88
	19.1	Work Standards	88
	19.2	Maintenance	89
	19.3	Efficiency and Cost-Effectiveness	89
	19.4	Deliverable	89
	19.5	Documentation	89
	19.6	Compatibility	89
	19.7	Non-Infringement	90
	19.8	Viruses	91
	19.9	Disabling Code	91


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	19.10	Date and Currency Compliance	91
	19.11	Corporate Social Responsibility	91
	19.12	Subcontractor Confidentiality and Data Protection	92
	19.13	No Improper Inducements	92
	19.14	Foreign Corrupt Practices Act	92
	19.15	Claims Procedures, Appeals and External Review	93
	19.16	ABS Platform	93

20.	MUTUAL REPRESENTATIONS AND WARRANTIES; DISCLAIMER		93
	20.1	Mutual Representations and Warranties	93
	20.2	Disclaimer	94

21.	CONFIDENTIALITY		94
	21.1	“Confidential Information” Defined	94
	21.2	Obligations of Confidentiality	95
	21.3	No Implied Rights	96
	21.4	Compelled Disclosure	96
	21.5	Confidential Treatment of this Agreement	96
	21.6	Disclosure of Information Concerning Tax Treatment	96
	21.7	Return or Destruction	97
	21.8	Duration of Confidentiality Obligations	97

22.	INSURANCE		98

23.	INDEMNIFICATION		98
	23.1	Indemnification By Supplier	98
	23.2	Infringement Indemnity Claims	100
	23.3	Indemnification By Health Net	100
	23.4	Indemnification Procedures	102
	24.1	General Intent	106
	24.2	Limitations of Liability	106
	24.3	Force Majeure	110

25.	RULES OF CONSTRUCTION		111
	25.1	Entire Agreement	111
	25.2	Contracting Parties; No Third Party Beneficiaries	111
	25.3	Contract Amendments and Modifications	111
	25.4	Governing Law	112
	25.5	Relationship of the Parties	112
	25.6	Consents and Approvals	112


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	25.7	Waiver	112
	25.8	Remedies Cumulative	112
	25.9	References	112
	25.10	Rules of Interpretation	113
	25.11	Order of Precedence	113
	25.12	Severability	113
	25.13	Counterparts	113
	25.14	Reading Down	114

26.	DISPUTE RESOLUTION		114
	26.1	Informal Dispute Resolution	114
	26.2	Litigation	115
	26.3	Continued Performance	115
	26.4	Equitable Remedies	115
	26.5	Waiver of Jury Trial	116
	26.6	Disclaimer of Uniform Computer Information Transactions Act	116

27.	GENERAL		116
	27.1	Binding Nature and Assignment	116
	27.2	Ethics Hotline	117
	27.3	Nondiscrimination	117
	27.4	Beneficiary Hold Harmless	117
	27.5	Notices	118
	27.6	Non-solicitation of Employees	118
	27.7	Compliance with Laws	119
	27.8	Covenant of Good Faith	120
	27.9	Public Disclosures	120
	27.10	Service Marks	120
	27.11	Guaranty	120
	27.12	Mutually Negotiated	121


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Master Services Agreement

This Master Service Agreement, dated November 21, 2014, but effective as of November 2, 2014 (the “Effective Date”), is between Health Net, Inc., a Delaware corporation with its principal place of business located at ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇ (“Health Net”), and Cognizant Healthcare Services, LLC (“Supplier”), a Delaware limited liability company having an office at ▇▇▇ ▇▇▇▇▇ ▇. ▇▇▇▇ ▇▇▇▇., ▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ (each, a “Party” and collectively, the “Parties”). The Parties agree that the following terms and conditions shall apply to the services to be provided by Supplier to Health Net under this Agreement, in consideration of certain payments to be made by Health Net, all as more specifically described below.

References to “Supplier” in this Agreement may include Supplier Personnel where such interpretation is required by the context of the particular clause or provision in question. The interpretation will be adopted which best preserves the Parties’ mutual intention that certain Supplier obligations to Health Net pursuant to the Agreement are to be executed by Supplier Personnel performing such actions.

1.	PREAMBLE

1.1

Background and Purpose

This Agreement is made and entered into with reference to the following:

(a)

Health Net is among the nation’s largest publicly traded managed health care companies. Its mission is to help people be healthy, secure and comfortable. The company’s health plans and government contracts subsidiaries provide health benefits to individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as “Part D”), Medicaid, Department of Defense, including TRICARE, and Veterans Affairs programs. Health Net’s behavioral health services subsidiary, Managed Health Network, Inc., provides behavioral health, substance abuse and employee assistance programs to individuals, including Health Net’s own health plan members. Health Net’s subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs.

(b)

Supplier and its Affiliates are providers of business process and information technology outsourcing services and have provided various business process and information technology services to Health Net since 2006.

(c)

Health Net and Cognizant Technology Solutions U.S. Corporation (CTSUS) are parties to the following existing agreements (collectively, the “Existing Agreements”):

(i)

that certain Master Staff Augmentation and Application Development Services Agreement dated May 3, 2006, as amended (the “SA/AD Agreement”);

(ii)

that certain Master Services Agreement dated September 30, 2008, as amended (the “AO Agreement”); and

(iii)

that certain Master Services Agreement dated January 23, 2009, as amended (the “Original BPO Agreement”).


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(d)

Supplier is a wholly owned subsidiary of CTSUS, which is a wholly owned subsidiary of Cognizant Technology Solutions Corporation.

(e)

Supplier is interested in expanding its existing business process outsourcing offerings and establishing a business process as a service (“BPaaS”) service offering for health insurance companies, including to Health Net. Supplier plans to launch its BPaaS offering with Health Net (utilizing certain assets to be conveyed by Health Net to Supplier) to attract and engage BPaaS customers in the health care industry.

(f)

Supplier is also interested in providing IT and perhaps other types of services to Health Net, andHealth Net is interested in procuring such BPaaS services, IT services and perhaps other services from Supplier. After a comprehensive evaluation and negotiation process, Health Net selected Supplier to provide the Services described in this Agreement, during the Term of this Agreement and pursuant to the terms and conditions of this Agreement.

(g)

The Parties reached agreement on contract terms and entered into that certain Master Services Agreement effective as of November 2, 2014 (the “Original Agreement”). Concurrently with the execution of the Original Agreement, Supplier and Health Net entered into an Asset Purchase Agreement (“APA”) for the sale by Health Net to Supplier of the Acquired Assets, including the ABS Platform, for Supplier’s use in providing BPaaS Services under this Master Services Agreement.

(h)

After entering into the Original Agreement, the Parties agreed to make certain modifications to certain of the contract documents. The Parties are entering into this Amended and Restated Master Services Agreement to implement such modifications. The Parties further agree that:

(i)

the Effective Date of the Original Agreement (i.e., November 2, 2014) shall be the Effective Date of this Amended and Restated Master Services Agreement;

(ii)

this Amended and Restated Master Services Agreement replaces and supersedes in all respects the Original Agreement, and any remaining references herein to the Original Agreement (including references to the Master Services Agreement) shall be deemed to be a reference to this Amended and Restated Master Services Agreement;

(iii)

references in the following agreements relating to the Master Services Agreement dated as of November 2, 2014 shall be understood to refer to this Amended and Restated Master Services Agreement, as it may be amended from time to time in accordance with this Agreement: (A) Schedule V (Guaranty)(including the actual signed version of this agreement), (B) Schedule 1-A to the Supplemental Terms and Conditions for BPaaS Services (Escrow Agreement)(including the actual signed version of this agreement), (C) the Initial SOWs, (D) the APA, (E) the Business Associate Agreement, (F) the Transition Manual, and (G) Amendment #5 to Master Services Agreement (the AO Amendment); and

(iv)

the term “Amended and Restated Master Services Agreement” is interchangeable with the term “Agreement” as used throughout this Agreement.


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1.2

Goals and Objectives

(a)

Health Net and Supplier have the following over-arching goals and objectives associated with the execution of this Agreement and their performance hereunder:

(i)

Expand the Parties’ existing long term strategic relationship;

(ii)

A seamless transition of functions from Health Net and its vendors to Supplier in a manner that is designed to ensure minimal business disruption and business risk to both Parties;

(iii)

Convert Health Net’s existing BPO services model into an outcome-based service delivery model;

(iv)

Establish a relationship that could provide the basis for Supplier to create an industry-leading BPaaS delivery model for Supplier to then deliver BPaaS Services to Health Net as well as additional Supplier customers;

(v)

Through Supplier’s provision of the Services to Health Net, allow Health Net to focus its efforts on creating membership growth for its existing products and plans as well as driving business expansion into new service offerings (which may include dual eligibility and TRICARE);

(vi)

Improve the quality, effectiveness and efficiency of Health Net’s operations, including through Supplier’s modernization of the Acquired Assets, ABS Platform and the overall solution and service delivery method so as to:

(A)

more accurately track activities related to the compliance with Laws, including compliance with the Patient Protection Affordable Care Act (PPACA) and compliance of reporting Quality Improvement expenses; and

(B)

generally permit Health Net to focus on providing higher quality of care to its Beneficiaries.

(vii)

Improve customer service and stakeholder satisfaction including consistent repeatable process models to reduce compliance risk;

(viii)

Where applicable, provide Health Net with a predictable and inclusive pricing model based on Health Net business metrics;

(ix)

Redesign and streamline existing complex service level agreements to simplify service level administration while continuing to provide a quantifiable means by which Health Net can measure the accuracy, timeliness and quality of Supplier’s delivery of services;

(x)

A mutually beneficial relationship with a professional service provider;


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(xi)

Implement a smooth and timely Transition and Transformation of personnel, systems, suppliers and processes (including the transfer to Supplier of Health Net’s strategic information technology assets and process delivery knowledge) with no disruption in Supplier’s provision of service to Health Net and no disruption to Health Net in its general conduct of its business; and

(xii)

Support Supplier’s strategic goal of leveraging this industry leading delivery model developed by Supplier from Health Net’s existing delivery solution and the Acquired Assets to provide like services to other Supplier customers.

(b)

The goals and objectives set out in this Section 1.2 are intended to be a general introduction to, and statement of the spirit of, this Agreement. Although this Section 1.2 does not expand or reduce the scope of the Parties’ obligations under this Agreement, other portions of this Agreement may measure Supplier’s performance, in part, based on the extent to which Supplier achieves certain objectives.

1.3

Structure of Agreement

This document (the “Terms and Conditions”) sets out the basic terms and conditions under which the Parties will conduct the transactions contemplated by this Agreement. In addition, there will be a number of schedules attached to the Terms and Conditions, including:

Schedule A (Cross Functional Services)

Schedule A-1 (Cross Functional Solution Description)

Schedule A-2 [Reserved]

Schedule A-3 (Future SOW Template)

Schedule A-4 (IT Continuity and Disaster Recovery Services)

Schedule B (Service Levels)

Schedule B-1 (Certain Service Levels)

Schedule B-2 (Compliance Service Level Metrics)

Schedule B-3 (Performance Guarantee Group Service Level Metrics)

Schedule B-4 (Stakeholder Satisfaction Survey)

Schedule C (Charges)

Schedule C-1 (BPaaS—PMPM Variable Rates)

Schedule C-2 (BPaaS—Detailed LOB Structure and Tower-Level PMPM Variable Rates)

Schedule C-3 (Forecasted Supplier-Procured IT Assets Charge)


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Schedule C-4 (BPaaS Membership Baseline)

Schedule C-5 (AD Projects—Examples)

Schedule C-6 (IT SOW – Resource Categories)

Schedule C-7 (IT SOW – Annual Services Charge)

Schedule C-8 (IT SOW – Resource Baselines)

Schedule C-9 (IT SOW – ARC/RRC Rates)

Schedule C-10 (IT SOW – Supplier-Procured Assets)

Schedule C-10-1 (BOM with Pricing)

Schedule C-11 (Financial Responsibility Matrix)

Schedule C-12 (Termination Charges)

Schedule C-13 (BPO T&M Rates)

Schedule C-14 (IO T&M Rates)

Schedule C-15 (T&M Time Codes)

Schedule C-16 (Medical Management Rates)

Schedule C-17 (Pass-Through Expenses)

Schedule D (Key Supplier Positions)

Schedule E (Transitioned Employees)

Schedule F (Supplier Facilities)

Schedule G (Governance)

Schedule G-1 (Supplier Organization)

Schedule G-2 (Meeting Framework)

Schedule G-3 (Management Reports)

Schedule H (Change Control Process)

Schedule H-1 (Change Control Notice)

Schedule I (Insurance)

Schedule J (Project Framework)


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Schedule J-1 (Deliverable Acceptance Procedures)

Schedule J-2 (Form of Work Order)

Schedule J-3 (Project Estimation Model)

Schedule K (Regulatory Compliance Addendum)

Schedule K-1 (Supplemental Regulatory Detail)

Schedule K-2 (CMS Offshore Attestation Requirements)

Schedule K-3 (AHCCS Subcontract)

Schedule L (Disengagement Assistance)

Schedule M (Supplier Competitors)

Schedule N (Non-Disclosure Agreement)

Schedule O (Health Net Provided Resources)

Schedule P (Health Net Policies)

Schedule Q (Security Requirements)

Schedule R (Critical Deliverables)

Schedule S (Procedures Manual TOC)

Schedule T (Joinder Agreement)

Schedule U (Aspect Assignment and Assumption Agreement)

Schedule V (Guaranty)

Schedule W (Glossary)

Schedule X (In-Flight and Accelerated Projects)

Schedule X-1 (In-Flight Project List)

Schedule X-2 (Accelerated Project List)

Schedule Y (Offshore Prohibitions and Requirements)

Schedule Z (Transition)

Schedule Z-1 (Acceptance of Transition Deliverables and Milestones)

Schedule Z-2 (Summary of Onshore and Offshore Counts and Ratios)


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Schedule Z-3 (Health Net Transition Support Role Descriptions)

Schedule Z-4 (Health Net Transition Support Personnel Levels)

Schedule Z-5 (Health Net Provided Transition Work Space)

Schedule Z-6 (Ramp-Down Plan)

Schedule Z-7 (Offshore Ramp-Up Plan)

Schedule Z-8 (Required Onshore Positions)

Schedule Z-9 (Staff Augmentation Plan)

Schedule Z-10 (Consolidated BPaaS Transition Plans)

Schedule Z-11 (IT Transition Plan)

Schedule Z-12 (Call Center Transition Plan)

Annex 1 (Supplemental Terms and Conditions for BPaaS Services)

Schedule 1-A (Escrow Agreement)

1.4

Construction of Preamble

The provisions of this Section 1 (Preamble) are intended to provide a general introduction to this Agreement and a context in which to interpret this Agreement’s terms and conditions in circumstances where their meanings are unclear or ambiguous. It is not intended to alter the plain meaning of this Agreement or to alter the scope of the Parties’ express obligations under it.

2.	DEFINITIONS

2.1

Defined Terms

The following capitalized terms, when used in this Agreement, will have the meanings given them below:

(a)

“ABS Platform” has the meaning given to it in the APA.

(b)

“Accelerated Projects” has the meaning given in Schedule C (Charges).

(c)

“Adverse Change in Supplier’s Financial Circumstances” means if Supplier (i) files a petition in bankruptcy; (ii) has an involuntary petition in bankruptcy filed against it which is not challenged within twenty (20) days and dismissed within sixty (60) days; (iii) becomes insolvent; (iv) makes a general assignment for the benefit of creditors; (v) admits in writing its inability to pay its debts as they mature; or (vi) has a receiver appointed for its assets.

(d)

“Affected Employees” has the meaning given in Schedule E (Transitioned Employees).


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(e)

“Affected Services” mean Services for which Health Net is requesting Disengagement Assistance.

(f)

“Affiliate” means, with respect to an entity, any other entity or person Controlling, Controlled by or under common Control with such entity.

(g)

“Agreement” means this Terms and Conditions document as well as all Schedules, Annexes and attachments attached hereto, and any SOWs entered into pursuant to this Agreement as well as all Exhibits thereto, the Transition Manual, all as may be amended by the Parties from time to time in accordance with Section 27.5 (Contract Amendments & Modifications) or as otherwise provided in the Agreement.

(h)

“APA” has the meaning given in Section 1.1(g).

(i)

“Application” or “Application Software” means Software that performs specific End User-related data processing, data management and telecommunications tasks.

(j)

“Acquired Assets” will have the meaning set forth in the APA.

(k)

“Auditor” has the meaning set forth in Section 18.1 of the Agreement.

(l)

“Beneficiary” means a person who has enrolled in and/or is eligible to receive services under a Benefit Program at the time services are rendered. The Parties acknowledge that the term “member,” “enrollee” and “insured” may be used by Health Net, and for purposes of this Agreement, the term Beneficiary includes the term “member,” “enrollee” and “insured” wherever used.

(m)

“Benefit Program” means a plan offered or administered by Health Net, its Affiliates or any of their respective customers whereby any of the foregoing are obligated to provide or arrange for health care services, or compensation therefore, to Beneficiaries in accordance with the provisions contained in such plans.

(n)

“BPaaS Discretionary Projects” has the meaning given in Schedule C (Charges).

(o)

“BPaaS Non-Discretionary Projects” has the meaning given in Schedule C (Charges).

(p)

“BPaaS Roadmap Projects” has the meaning given in Schedule C (Charges).

(q)

“BPaaS Services Commencement Date” shall mean the later to occur of (i) the date that is ten (10) Business Days after the date that Health Net receives the last required approval from the Regulators to proceed with the transactions contemplated by this Agreement, and (ii) March 1, 2015.

(r)

“BPaaS Services” means collectively the Services to be provided by Supplier under this Agreement, excluding the Non-BPaaS IT Services and any other Services that may be expressly designated as not part of the BPaaS Services in any Future SOWs.

(s)

“Breakup Fee” means a fee in the amount of *** to be paid by Health Net if Health Net exercises its right to terminate this Agreement pursuant to Section 16.1(n).

(t)

“Business Day” has the meaning given in Schedule B (Service Levels).


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(u)

“Business Hours” means 08:00 – 17:00, local time (from the perspective of the applicable Service Recipient), during a Business Day, provided that the foregoing shall not supersede any business, operational or similar hours set forth in a SOW (including Solution documents attached thereto).

(v)

“Commercially Available” means Software that is routinely licensed to the general public by Supplier or a third party, as applicable, through separately established standard terms and conditions and standard charges, and for which such Software Supplier or the third party (as applicable) provides ongoing maintenance, support and Software Updates.

(w)

“Commercially Reasonable Efforts” means taking all such steps and performing in such a manner as a well-managed company would undertake where it was acting in a determined, prudent and reasonable manner to achieve a particular desired result for its own benefit.

(x)

“Control” and its derivatives, such as “Controlling” means with regard to any entity the legal, beneficial or equitable ownership, directly or indirectly, of: (i) fifty percent (50%) or more of the capital stock (or other ownership interest if not a stock corporation) of such entity ordinarily having voting rights; or (ii) (A) twenty percent (20%) or more of the capital stock (or other ownership interest if not a stock corporation) and (B) either (1) a greater percentage than any other juridical person or (2) management control in fact or by agreement.

(y)

“Disengagement Assistance” means, collectively, the Functions that Health Net requests from Supplier to enable an orderly transfer of Services from Supplier to Health Net or its designees without interruption or adverse effect to Health Net in connection with the reduction or cessation of any Services (in whole or in part), or the expiration or earlier termination (for any reason) of this Agreement (in whole or in part) or any SOW (in whole or in part), including (i) the Functions described in Section 16.5 (Disengagement Assistance) and Schedule L (Disengagement Assistance), and (ii) as requested by Health Net, any or all of the Affected Services provided by Supplier prior to the effective date of reduction, cessation, termination or expiration of the Affected Services, which for clarity Health Net may require Supplier to perform after expiration or termination of the Agreement with respect to such Affected Services.

(z)

“Disengagement Assistance Period” means, for each request by Health Net for Disengagement Assistance, the period of time requested by Health Net for Supplier to provide Disengagement Assistance pursuant to Section 16.6 (Disengagement Assistance), provided that in no event shall any Disengagement Assistance Period extend beyond the date that is *** following the effective date of expiration or termination of this Agreement in whole, as such effective date may be extended pursuant to Section 16.4.

(aa)

“DMHC” means the Department of Managed Health Care of the State of California.

(bb)

“Documentation” means written materials (including materials published on an Internet or Intranet site or otherwise online) that are available or necessary to instruct or assist End Users, operators or systems personnel in the installation, development, maintenance, operation, use or modification of any Equipment, Software, system, or Deliverable (including applicable functional and technical specifications), as such documentation is updated from time to time.


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(cc)

“Effective Date” has the meaning set forth in the first paragraph of the Terms and Conditions of this Agreement.

(dd)

“Employee Transfer Date” has the meaning given in Schedule E (Transitioned Employees).

(ee)

“End Users” means direct users of the Services provided under this Agreement.

(ff)

“Equipment” means any computer and telecommunications machines or other hardware (without regard to the entity owning or leasing it), including all associated attachments, features, accessories and peripheral devices and related services (e.g., maintenance and support services, upgrades, and subscriptions services). For purposes of allocating financial, operational, management, or other responsibilities with respect to Equipment, references to Equipment shall also include any associated maintenance and services agreements relating to such Equipment that are in effect and disclosed by the contracting Party to the other Party.

(gg)

“Exchange” shall mean the California Health Benefit Exchange (“Covered California”) and any Laws applicable to such entity, and any other comparable entity operating in a state in which Health Net or a Health Net Affiliate conducts business.

(hh)

“Exchange Agreement” shall mean the agreement between Health Net and the Exchange in California that establishes the terms under which Health Net shall participate in the Exchange’s Covered California program, and any comparable agreement between Health Net or a Health Net Affiliate and an Exchange in a state in which Health Net or a Health Net Affiliate conducts business.

(ii)

“Financial Responsibility” means having responsibility for furnishing, maintaining and paying for resources (or certain services related to such resources) without seeking reimbursement from the other Party.

(jj)

“Former Health Net Affiliate” means: (i) any entity Affiliated with Health Net at any time during the Term (such designation expiring at the end of the twenty-fourth (24th) month after the date that such entity ceases to Control, be Controlled by, or be under common Control with, Health Net); or (ii) the purchaser of all or substantially all of the assets and/or customers of any line of business of Health Net or any of its Affiliates (such designation (A) applying only with respect to the business or customers so acquired; and (B) expiring at the end of the twenty-fourth (24th) month after the date of such purchase.) At Health Net’s option, each Former Health Net Affiliate shall be deemed to be an Affiliate of Health Net.

(kk)

“Functions” has the meaning given in Section 3.1(a) (Services, Defined).

(ll)

“Health Insurance Portability and Accountability Act” or “HIPAA” means Public Law 104-191 and its implementing regulations.

(mm)

“Health Net Data” means all data and information in any form (and all Derivative Works thereof), including Confidential Information, payment card information, Protected Health Information and Personally Identifiable Information, belonging to or concerning any of Health Net; its Affiliates; its Service Recipients; and each of their respective and prospective members, customers, employees, providers or other suppliers that (i) is present in Software or Equipment operated by Supplier for the benefit of Health Net, a Health Net


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Affiliate or another Service Recipient, or (ii) is directly or indirectly accessed or obtained by Supplier from, in connection with, or as a result of the Services, or is derived therefrom. For the avoidance of doubt, “Health Net Data” does not include publicly available information or Supplier Confidential Information.

(nn)

“Health Net Facilities” means facilities that are owned or leased by Health Net (or a Health Net Affiliate).

(oo)

“Health Net Leased Equipment” means Equipment leased by Health Net (or a Health Net Affiliate).

(pp)

“Health Net Licensed Software” means Software owned (i.e., in which the copyright is owned) by a party other than Health Net (or a Health Net Affiliate) that is licensed by Health Net (or a Health Net Affiliate).

(qq)

“Health Net Owned Equipment” means Equipment owned by Health Net (or a Health Net Affiliate).

(rr)

“Health Net Owned Software” means Software owned (i.e., in which the copyright is owned) by Health Net (or a Health Net Affiliate).

(ss)

“Health Net Policies” means the applicable standards, policies and procedures of Health Net (and its Affiliates) provided to Supplier in connection with this Agreement (including by Health Net providing Supplier a link to an online repository where they may be accessed), whether existing as of the Effective Date (including those policies identified in Schedule P (Health Net Policies) or in any SOW) or adopted by Health Net during the Term, and in each case as may be modified by Health Net during the Term.

(tt)

“Health Net Third Party Service Contracts” means third party service contracts of Health Net (or a Health Net Affiliate). For clarity, maintenance and support and services agreements relating to Software that are in effect and that are disclosed by Health Net to Supplier shall be deemed to be part of the Software and not Health Net Third Party Service Contracts.

(uu)

“Identity-Related Costs” means the following costs that are reasonable and incurred by Health Net relating to a Security Breach: ***

(vv)

“Indemnity Claim” means any demand, or any civil, criminal, administrative or investigative notice, inquiry, claim, action, or proceeding (including arbitration) sent to, or commenced or threatened against, an entity or person.

(ww)

“Initial SOWs” shall mean collectively the following Statements of Work:

(i)

Statement of Work # 1 (Claims Management Services),

(ii)

Statement of Work # 2 (Membership and Configuration Services),

(iii)

Statement of Work # 3 (Contact Center Services),

(iv)

Statement of Work # 4 (IT Services),


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(v)

Statement of Work # 5 (Quality Assurance Services),

(vi)

Statement of Work # 6 (Appeals and Grievances Services), and

(vii)

Statement of Work # 7 (Medical Management Services).

(xx)

“IPRs” or “Intellectual Property Rights” means all intellectual and industrial property rights recognized in any jurisdiction, including copyrights, mask work rights, moral rights, trade secrets, patent rights, rights in inventions, trademarks, trade names and service marks (including applications for, and registrations, extensions, renewals, and re-issuances of, the foregoing).

(yy)

“Law” means, if and to the extent applicable: (i) any law, statute, regulation, ordinance or subordinate legislation in force from time to time, including any such item that relates to TRICARE, the Veteran’s Administration, and the Centers for Medicare and Medicaid (“CMS”); (ii) the common law; (iii) any binding court order, judgement or decree (including consent agreements); (iv) any directive, policy, rule, order, corrective action plan, communication, standards or other mandate that is made or given by any government, an agency thereof, or any regulatory body (including an Exchange, the DMHC and the U.S. Department of Health and Human Services), of any country, the European Union, or other national, federal, commonwealth, state, provincial or local jurisdiction, and of any exchange or association (including the New York Stock Exchange, the National Association of Securities Dealers whose regulations are binding on either Party pursuant to a self-regulating mechanism approved by a governmental entity; and (v) any communication from a Regulator to Health Net or Supplier indicating a course of action be taken or not taken that, if disclosed by the Regulator to Health Net is thereafter disclosed by Health Net to Supplier.

(zz)

“Line of Business” means the lines of business established by Health Net into which its operations relevant to the scope of the Services are organized for certain purposes. As of the Effective Date, there are five (5) such Lines of Business, as follows: (i) Individual – Commercial; (ii) Group – Commercial; (iii) Medicare; (iv) State Health Programs; and (v) Duals. The Lines of Business shall also include any additional Lines of Business for which pricing is developed pursuant to Schedule C (Charges).

(aaa)

“Losses” means all losses, liabilities, damages, liens, claims and costs, and all related expenses and other charges suffered or reasonably incurred as a result of or in connection with an Indemnity Claim, including reasonable attorneys’ fees and disbursements, costs of investigation, litigation, settlement, and judgment, and any taxes, interest, penalties, and fines.

(bbb)

“Minimum Revenue Commitment” or “MRC” has the meaning given in Schedule C (Charges).

(ccc)

“Non-BPaaS IT Projects” has the meaning given in Schedule C (Charges).

(ddd)

“Non-BPaaS IT Services” has the meaning in SOW #4 (IT Services).

(eee)

“Non-Commercially Available” means, with respect to Software, Software that is not Commercially Available.


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(fff)

“Object Code” shall mean Software code resulting from the translation or processing of Software in Source Code form by a computer into machine language, which is a form that is not convenient to human understanding of the Software.

(ggg)

“Open Source Code” means any Software that requires as a condition of its use, modification or distribution that it be disclosed or distributed in source code form or made available at no charge. Open Source Code includes software licensed under the GNU General Public License (GPL) or the GNU Lesser/Library GPL.

(hhh)

“Open Source License” means a license to Software that complies with the Open Source Initiative’s definition of “Open Source.”

(iii)

“Out-of-Pocket Expenses” means reasonable, demonstrable and actual out-of-pocket expenses incurred by Supplier for Equipment, materials, supplies, or services provided to or for Health Net that are expressly subject to reimbursement by Health Net pursuant this Agreement, but not including Supplier’s actual or allocated overhead costs, administrative expenses or other ▇▇▇▇-ups.

(jjj)

“Protected Health Information” and “PHI” shall have the meaning given to such term at 45 C.F.R. § 160.103, as may be amended by Law from time to time.

(kkk)

“Personally Identifiable Information” means any information about an individual including any information that could be used to identify an individual such as Protected Health Information.

(lll)

“Proprietary Business Rules” shall have the definition in the APA.

(mmm)

“Regulator” means any governmental or quasi-governmental entity (i) with investigatory or oversight capability regarding Health Net, a Health Net Affiliate, or a Former Health Net Affiliate, or of any Services under this Agreement, including CMS, DMHC and Arizona Health Care Cost Containment System (“AHCCCS”), or (ii) that is party to a Regulatory Contract.

(nnn)

“Regulatory Contract” means any contract between Health Net and a governmental or quasi-governmental entity under which the governmental or quasi-governmental entity is paying for services provided to Beneficiaries (e.g., Medicaid, Medi-Cal, CHIPs), but excluding contracts in which the governmental or quasi-governmental entity is merely acting as the employer paying for health insurance coverage for its employees.

(ooo)

“Related SOW” shall mean a SOW that is impacted by the event that gives rise to the right to terminate under Section 16, such as the SOW under which the breach or Service Level Failure occurred. Related SOW shall also include any SOW which Health Net, in its reasonable discretion, determines should also be terminated because of business, operational or financial reasons, including that the Services provided under the immediately impacted SOW should be grouped with Services under other SOWs in order to achieve a desired business, operational or financial result.

(ppp)

“Required Consents” means such consents as may be required for (i) the assignment to a Party, or the grant to a Party of rights of access and use, of resources otherwise provided to or licensed by the other Party, and (ii) with respect to any resource (e.g., Software, Equipment, third party services) for which the corresponding contract is to be assigned to


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Health Net or its designee pursuant to Disengagement Assistance (including any resource utilized or introduced after the Effective Date during the Term), the disclosure of the corresponding contract terms to Health Net or its designee, or the assignment of such contract to Health Net or it designee, as part of Disengagement Assistance.

(qqq)

“Security Breach” means (i) any actual circumstance that compromises the privacy and/or security of any Health Net Data or Health Net Software or systems which are possessed or operated by (or for) or are under the control of Supplier or a third party that received such Health Net Data (directly or indirectly) through Supplier (with the exception of a third party to which Health Net directs Supplier in writing to provide Health Net Data, including auditors, regulators and contractors but excluding Subcontractors); or (ii) any loss or unauthorized acquisition, access, destruction, alteration, disclosure or use (in all cases whether intentional or not) of, or the inability to locate, Health Net Data which was delivered to, created, maintained or accessed by, Supplier or a third party that received such Health Net Data (directly or indirectly) through Supplier (with the exception of a third party to which Health Net directs Supplier in writing to provide Health Net Data, but excluding Subcontractors). For purposes of defining “in control” as that term is used in clause (i) of this definition, Supplier shall be deemed to be in control of Health Net Data, Health Net Software or systems in the IBM data center to the extent (A) Supplier provides or is required to provide systems monitoring or related management or other Services that affect the security of such Health Net Data, Health Net Software or systems, (B) Supplier is obligated to manage IBM or any other third party under this Agreement, (C) the provisions set forth in Schedule Q (Security) are applicable to the Services to be provided by Supplier with respect to such Health Net Data, Health Net Software or systems, or (D) any other circumstance in which Supplier’s acts or omissions could have prevented the Security Breach if Supplier had exercised due care and complied with is obligations under this Agreement.

(rrr)

“Service Tower” means the Services to be provided by Supplier under each Statement of Work, as well as the Cross Functional Services to support such Service Tower. The Service Towers as of the Effective Date are:

(i)

Cross Functional Services Tower means the Cross Functional Services as defined in Schedule A (Cross Functional Services);

(ii)

Claims Service Tower means the Claims Services as defined in Statement of Work # 1 (Claims Management Services);

(iii)

Membership Service Tower means the Membership and Configuration Services as defined in Statement of Work # 2 (Membership and Configuration Services);

(iv)

Contact Center Service Tower means the Contact Center Services as defined in Statement of Work # 3 (Contact Center Services);

(v)

Non-BPaaS IT Service Tower means the IT Services as defined in Statement of Work # 4 ( IT Services);

(vi)

Quality Assurance Service Tower means the Quality Assurance Services as defined in Statement of Work # 5 (Quality Assurance Services);


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(vii)

Appeals and Grievances Service Tower means the Appeals and Grievances Services as defined in Statement of Work # 6 (Appeals and Grievances Services); and

(viii)

Medical Management Service Tower means the Medical Management Services as defined in Statement of Work # 7 (Medical Management Services).

(sss)

“Software” means (i) program code (in Object Code and Source Code forms) and all supporting documentation, media, on-line help facilities and tutorials, including any Software Updates, (ii) frameworks, utilities, macros, software configurations, templates and tools used to deliver services or enhance the productivity or quality of services, and (iii) Derivative Work of any item described in clauses (i) and (ii). For purposes of allocating financial, operational, management, or other responsibilities with respect to Software, references to Software shall also include any associated maintenance and support agreements relating to such Software that are in effect and are disclosed by the contracting Party to the other Party.

(ttt)

“Software Update” means any modification, enhancement, upgrade, update, new version or release, or Derivative Work of Software.

(uuu)

“SOW Effective Date” means, (i) with respect to the Initial SOWs, the Effective Date of this Agreement, and (ii) with respect to any Future SOW, the effective date set forth in the applicable SOW.

(vvv)

“SOW Service Commencement Date” means, with respect to Future SOWs, the date set forth in the applicable SOW that Supplier Personnel shall commence performing the applicable SOW Services in a live production environment.

(www)

“SOW Services” means, for each SOW, (i) the Services described in such SOW, and (ii) the Services described in Schedule A (Cross Functional Services) and elsewhere in the Agreement as they apply to the Services described in such SOW.

(xxx)

“SOW Term” has the meaning given in Section 4.1 (Initial Term).

(yyy)

“Source Code” means the computer code of Software in programming languages, including all comments and procedural code, and all related development documents (e.g., flow charts, schematics, statements of principles of operations, End User manuals, architectural standards, documentation, and any other specification that are used to create or that comprise the computer code, of the Software concerned).

(zzz)

“Statement of Work” or “SOW” has the meaning given in Section 3.7(a).

(aaaa)

“Subcontractor” means (i) a third party engaged by Supplier to provide any portion of the Services, (ii) any entity to which a Subcontractor further subcontracts (or otherwise sub-delegates) any of its subcontracted duties or obligations, and (iii) any other entity to which any such subcontracted duties or obligations are further subcontracted (or otherwise sub-delegated), below the level of the agreement between Supplier and a Subcontractor.

(bbbb)

“Supplier Competitor” means those entities listed in Schedule M (Supplier Competitor).


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(cccc)

“Supplier Personnel” means, collectively, any and all personnel furnished or engaged by Supplier to perform any part of the Services, including: (i) the employees of Supplier; (ii) Subcontractors; and (iii) the employees of such Subcontractors.

(dddd)

“Supplier Provided Software” means Software that is used by Supplier to provide the Services that is either (i) made available by Supplier to Health Net, its Affiliates, Former Health Net Affiliates and Service Recipients to receive or use the Services, or (ii) reasonably necessary for Health Net and its Affiliates’ and their respective service providers to provide and deliver, and for Health Net, its Affiliates, Former Health Net Affiliates and Service Recipients to receive and use, services that are substantially similar to the Services, during the Disengagement Assistance Periods and for two years thereafter as contemplated by Section 12.3.

(eeee)

“Supplier Software” means any Software that is owned by Supplier or its Affiliates.

(ffff)

“Technology Platform” has the meaning given in Annex 1 (Supplemental Terms and Conditions for BPaaS Services).

(gggg)

“Terms and Conditions” means this document, which is identified in the footer as the Terms and Conditions.

(hhhh)

“Third Party Software” means any Software that is owned by a third party (i.e., not Health Net or its Affiliates or Supplier or its Affiliates).

(iiii)

“Transition Documents” has the meaning given in Section 13.4(a).

(jjjj)

“Transition Manual” shall mean that certain manual containing Transition-related plans and material agreed to by the Parties on or about the Effective Date.

(kkkk)

“Transitioned Employees” has the meaning given in Schedule E (Transitioned Employees).

(llll)

“Use” means to access, use, execute, display, copy, perform, distribute copies of, maintain, modify, enhance, and create Derivative Works of the subject material(s).

2.2

Other Terms

(a)

Other Capitalized Terms. Other capitalized terms used in this Agreement but not defined above are defined where they are used and have the meanings there indicated, and in the Glossary attached hereto as Schedule W (Glossary). Those terms, acronyms, and phrases utilized in the business process outsourcing or health and wellness industries which are not otherwise defined in this Agreement shall be interpreted in accordance with their generally understood meaning in such industry or business context.

(b)

References to Schedules. References to a Schedule include such Schedules at the Terms and Conditions level and the corresponding Exhibit covering the same topic at the SOW level. For example, a reference to Schedule P (Health Net Policies) also includes Exhibit F (Health Net Policies) to any SOW.


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3.	SERVICES

3.1

Provision of the Services

(a)

Services, Defined. Supplier will provide the following services, functions, obligations, responsibilities, activities and tasks (collectively, “Functions”) as they may be supplemented, enhanced, modified or replaced pursuant to this Agreement (collectively, the “Services”):

(i)

the Functions described in Schedule A (Services), each SOW, and elsewhere in this Agreement, other than (1) those expressly designated as Functions for which Health Net is responsible, and (2) those prohibited by Law to be delegated by Health Net to a third party for performance;

(ii)

any Functions performed during the twelve (12) months preceding the applicable SOW Effective Date:

(A)

by Supplier pursuant to any of the Existing Agreements, excluding the SA/AD Agreement; or

(B)

by Health Net’s or its Affiliates’ personnel (including employees and contractors) performing in a Service Tower who were displaced pursuant to this Agreement, or whose Functions were displaced pursuant to this Agreement;

(iii)

any other Functions required in order for Supplier to be in compliance with the requirements of each Health Plan, product and provider network (collectively, “Health Net Plans”), whether existing as of the Effective Date or created by Health Net during the Term, and in each case as same may be modified by Health Net during the Term.

(b)

Services Commencement.

(i)

Initial SOWs. For the Initial SOWs, Supplier shall commence performance of the applicable SOW Services on the BPaaS Services Commencement Date.

(ii)

Future SOWs. For each Future SOW, Supplier shall commence performance of the applicable SOW Services on the applicable SOW Service Commencement Date.

(c)

Relationship to the BPO Agreement.

For clarity, the BPO Agreement shall remain in effect until the BPaaS Services Commencement Date, at which time the BPO Agreement shall be automatically terminated and of no further force or effect, at no charge or cost to Health Net; provided, however, that such termination shall be without prejudice to any rights and remedies that may have accrued prior to the effective date of such termination.


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3.2

Implied Services

If any Functions (other than those Functions either (i) expressly retained as a Function to be performed by Health Net under this Agreement or (ii) prohibited by Law to be delegated by Health

Net to a third party for performance thereof), are reasonably required for, and incidental to or inherent in, the proper performance and provision of the Services (regardless of whether they are specifically described in this Agreement) they shall be deemed to be implied by and included within the scope of the Services to be provided by Supplier to the same extent and in the same manner as if specifically described in this Agreement.

3.3

Evolution of the Services

Throughout the Term, Supplier will seek to improve the quality, efficiency and effectiveness of the Services to keep pace with technological, business process outsourcing and Medicare Part D advances and support Health Net’s (and its Affiliates’) evolving business needs and efforts to maintain competitiveness in the markets in which it (and they) competes. Without limiting the generality of the foregoing, Supplier will: (i) identify and apply ‘best practice’ techniques and methodologies in performing and delivering the Services; and (ii) train Supplier Personnel in new techniques and technologies used generally within Supplier’s organization or the business process outsourcing services industry, and (ii) make investments to maintain the currency of Supplier’s tools, infrastructure and other resources used by Supplier to render the Services. Changes in the Services pursuant to this Section 3.3 will not be considered New Services (as defined in Section 3.8(a)).

3.4

Users of the Services

(a)

Supplier will provide the Services to Health Net and, as designated by Health Net from time to time, its Affiliates, Former Health Net Affiliates, licensees, customers, providers (e.g., physicians, medical groups, hospitals., etc), contractors and other entities with which Health Net has a business relationship (each such entity a “Service Recipient”). For purposes of this Agreement, Services provided to such entities shall be deemed to be Services provided to Health Net. The following apply with respect to all Service Recipients:

(i)

Health Net shall be directly responsible for (A) the payment of all Charges associated with Supplier’s provision of Services to Service Recipients under this Agreement and (B) as and to the extent related to any Service Recipient’s use of the Services, the performance, breach or other wrongful conduct of any such Service Recipient; and

(ii)

notice provided by Supplier to Health Net under this Agreement will constitute notice to Service Recipients, and Service Recipients will send notices required by this Agreement to Supplier only through Health Net.

(b)

With respect to Former Health Net Affiliates, Supplier will continue to provide the Services being provided as of the date of divestiture as is requested by Health Net for as long as such entity continues to meet the definition of “Former Health Net Affiliate” (or such shorter period of time designated by Health Net). There shall be no additional charge or fee (i.e., in addition to the charges for the actual Services as provided in this Agreement) for the provision of Services to Former Health Net Affiliates.

(c)

The Services provided to Health Net, Health Net Affiliates and Former Health Net Affiliates under this Agreement may be utilized by Health Net, Health Net Affiliates and Former Health Net Affiliates for the benefit of members of health plans owned by Health Net, a Health Net Affiliate, a Former Health Net Affiliate or any third party (including any


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third party which may have purchased such health plan from Health Net, a Health Net Affiliate or a Former Health Net Affiliate), or to meet its obligations under any contract that Health Net, a Health Net Affiliate or a Former Health Net Affiliate has with a third party to provide services of the type provided under this Agreement (including administrative services only (ASO) arrangements).

3.5

Non-Exclusive; Variability

(a)

This Agreement is non-exclusive. Subject to the minimum revenue commitment requirements set forth in Schedule C (Charges), nothing in this Agreement shall be construed to limit in any way Health Net’s ability to reduce the volumes of the Services being provided by Supplier, or to provide itself, or have other third parties provide (or propose to provide), services that are the same as or similar to the Services, including with respect to any in-scope Functions. Nothing in this Agreement shall limit Supplier’s ability to provide, or propose to provide, services to third parties that are the same as or similar to the Services, including with respect to any in-scope outsourcing Functions. Health Net (and its Affiliates) may contract with other suppliers for any products and services, including products and services that are similar to or competitive with the Services or that are part of the Services. In the case of Health Net’s withdrawal of portions of the Services from Supplier (including a withdrawal by Health Net of any volumes of Services or in-scope Functions from the scope of this Agreement), the charges shall be adjusted in accordance with the terms provided in Schedule C (Charges) and the unit rates set forth therein.

(b)

The Services are variable in volume. Such variations are provided for in the charging mechanisms set forth in Schedule C (Charges). Supplier shall be responsible for adjusting the resources used to provide the Services to accommodate the changes in volume (regardless of the amount of time remaining in the Term) in such a manner as to comply with all Service Levels. In the case of Health Net’s addition of Services to Supplier (including an increase by Health Net of any volumes of Services or in-scope Functions to the scope of this Agreement), the charges shall be adjusted in accordance with the terms provided in Schedule C (Charges) and the unit rate set forth therein. Supplier shall not be entitled to receive an adjustment to the Charges resulting from such variations in volume except as set forth in the applicable SOWs or Schedule C (Charges).

(c)

Except as set forth in Schedule C (Charges) regarding the minimum revenue commitment, Health Net (and its Affiliates) makes no commitment for any minimum or maximum volume, scope, or value of the Services under this Agreement or to any minimum or maximum payments to be made to Supplier.

3.6

Cooperation and Coordination with Other Parties

(a)

If Health Net performs itself, or retains a third party other than Supplier to perform, any services that interface or interact with the Services, or that formerly were part of the Services, Supplier will, in accordance with and subject to Section 3.6(b), cooperate and coordinate with Health Net or such third party as reasonably required for Health Net or the third party to perform such services subject in each case to the applicable requirements of Section 21.2 that pertain to the third party entering into a Non-Disclosure Agreement relating to Supplier’s Confidential Information. Supplier’s cooperation and coordination will include, as applicable: (i) providing reasonable access to the facilities being used by Supplier to provide the Services as necessary for Health Net or the third party to perform its


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work; (ii) providing reasonable access to the Equipment and Software used in providing the Services except to the extent prohibited under any applicable agreements with third parties; provided that this clause (ii) shall not limit Health Net’s rights under Sections 12 and 15; and (iii) providing such information regarding the operating environment, system constraints and other operating parameters as a person with reasonable commercial skills and expertise would find reasonably necessary for Health Net or the third party to perform its work.

(b)

Health Net shall require that third parties retained by Health Net who utilize Supplier’s resources comply with Supplier’s reasonable security and confidentiality requirements and, as relevant, with Supplier’s reasonable work standards, methodologies and procedures, if provided in writing by Supplier to Health Net and such third parties. Supplier shall immediately notify Health Net if an act or omission of such a third party may cause a problem or delay in providing the Services and shall work with Health Net to prevent or circumvent such problem or delay.

3.7

“Master” Nature of the Terms and Conditions

(a)

The Parties intend that these Terms and Conditions serve as a “master” agreement which will govern the Services and any additional services which the Parties agree will be provided by Supplier to Health Net under this Agreement. The Parties shall enter into statements of work (each a “Statement of Work” or “SOW”) that will reflect the terms under which Services shall be provided by Supplier to Health Net.

(i)

As of the Effective Date, the Parties are entering into the Initial SOWs.

(ii)

If, after the Effective Date, the Parties agree upon additional services that they desire to be governed by these Terms and Conditions, they shall enter into additional SOWs (“Future SOWs”) each in substantially the same format and containing the same information as in the Initial SOWs and required by Schedule A-3 (SOW Template).

(A)

Upon execution of any Future SOW, such Future SOW shall be governed by and subject to these Terms and Conditions and the other terms of this Agreement; provided, however, that a Future SOW may override any provision of these Terms and Conditions or any such other term of this Agreement only if, and to the extent that: (i) such Future SOW expressly identifies the provision(s) the Parties intend to override, (ii) such change applies solely to such SOW; and (iii) the executed version of such Future SOW has been approved by legal counsel for both Parties, as evidenced in writing on the executed version of it.

(B)

With respect to each Future SOW, Health Net and Supplier will jointly determine whether it is necessary or desirable to update any schedule(s) to the Terms and Conditions.

3.8

New Services

(a)

“New Services” means Functions Health Net requests Supplier to perform under this Agreement

(i)

that are materially different from, and in addition to, the Services; and


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(ii)

for which there is no existing charging mechanism in this Agreement.

(b)

Supplier will not perform any additional Functions that would constitute New Services prior to informing Health Net what the additional charges would be for performing them, and receiving Health Net’s prior written authorization to proceed, all in accordance with Section 17.5 and the Change Control Process. If Supplier does perform the additional Functions without Health Net’s prior written authorization, they will be deemed to have been performed as part of the Services at no charge.

3.9

Joinder Agreements

(a)

General.

(i)

The Parties acknowledge and agree that certain Health Net Affiliates desire to contract directly with Supplier for the Services to be provided to such Health Net Affiliates. The Parties agree that any such Health Net Affiliate that wishes to do so may enter into a joinder agreement with Supplier in the form attached hereto as Schedule T (Joinder Agreement) (each such agreement a “Joinder Agreement”, and each party to a Joinder Agreement, a “Joinder Party”).

(ii)

Except as provided in Section 3.9(d), any such Health Net Affiliate that enters into a Joinder Agreement (each, a “Health Net Joinder Party”) shall be solely responsible for the Charges with respect to such Services provided to such Health Net Joinder Party by Supplier, and the Joinder Parties shall comply with the terms of such Joinder Agreement. For the avoidance of doubt, in no event shall a Health Net Joinder Party be responsible for any Charges for Services provided by Supplier to Health Net or any other Health Net Affiliate.

(iii)

Except as otherwise expressly provided in a Joinder Agreement, all applicable provisions of this Agreement, as the same may be amended or modified from time to time in accordance with Section 25.3, shall be binding on the Joinder Parties to such Joinder Agreement. Any such amendment or modification to this Agreement shall be binding on such Joinder Parties without any further action by the Parties or such Joinder Parties.

(b)

Resolution of Joinder Disputes.

Unless otherwise required by Law, any claim or dispute arising out of or related to a Joinder Agreement (“Joinder Disputes”) may be brought pursuant to Section 26 by the applicable Joinder Party against the corresponding Joinder Party under such Joinder Agreement.

(c)

Relationship of this Agreement and Joinder Agreements.

This Agreement and any Joinder Agreements are separate, but related agreements. In no event shall this Agreement or any Joinder Agreement be or form the basis for an agreement, directly or indirectly, between Health Net and any Health Net Joinder Party. All Joinder Agreements shall expire upon termination (for any reason) or expiration of this Agreement. This Agreement shall remain in effect notwithstanding the termination (for any reason) or expiration of a Joinder Agreement.


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(d)

Guaranty.

Health Net hereby guarantees the payment of all sums payable by Health Net Joinder Party to Supplier under the Joinder Agreement and shall cause the due and punctual performance and observance by Health Net Joinder Party of all acts and obligations to be performed or observed by Health Net Joinder Party under the Joinder Agreement.

3.10

Contract documents to be completed after Effective Date

The Parties agree that they will work in good faith and cooperate with each other to complete the following documents within thirty (30) days after the Effective Date:

(a)

Schedule A-3 (Future SOW Template);

(b)

Schedule J (Project Framework);

(i)

Schedule J-1 (Deliverable Acceptance Procedures);

(ii)

Schedule J-2 (Form of Work Order Project);

(iii)

and Schedule J-3 (Project Estimation Model); and

(c)

Schedule W (Glossary);

(d)

Schedule U (Aspect Assignment and Assumption Agreement).

Upon agreement in writing by the Parties to any such Schedule, it shall be deemed to be attached to this Agreement without the need for an amendment.

4.	TERM AND REGULATORY APPROVALS

4.1

Initial Term

(a)

The term of this Agreement shall commence on the Effective Date and expire on the date that is seven (7) years after the BPaaS Services Commencement Date, unless it is terminated earlier or is extended pursuant to the terms of this Agreement (such period, together with all extensions thereof, the “Term”).

(b)

The term of each SOW shall commence on the SOW Effective Date for such SOW. The Initial SOWs shall expire on the date that this Agreement expires, unless this Agreement or such Initial SOW is terminated earlier or is extended pursuant to the terms of this Agreement. The Future SOWs shall expire on the date set forth in such Future SOWs, unless such Future SOW is terminated earlier or is extended pursuant to the terms of this Agreement. The foregoing period, together with all extensions thereof, is known as the “SOW Term”; provided, however, that no SOW Term will extend beyond the Term of this Agreement.


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4.2

Renewal Terms

(a)

By giving notice to Supplier no less than three (3) months prior to the then-existing expiration date of this Agreement, Health Net may extend the Term for a period designated by Health Net of up to one (1) year (“Renewal Period”)on the terms and conditions (including any productivity improvements) then in effect, provided however, that the Parties agree that the charges in effect during any such renewal period shall be subject to the mutual agreement of the Parties.

(b)

Health Net shall have two (2) such extension options of up to one (1) year each. With respect to each SOW, Health Net shall have the same rights to extend the applicable SOW Term that it has to extend this Agreement under this Section; provided, however, that no SOW Term will extend beyond the Term of this Agreement.

(c)

Supplier shall follow the following process in connection with establishing the charges during the Renewal Periods.***

4.3

Regulatory and Customer Approvals

(a)

The Parties acknowledge that Health Net must obtain both regulatory approvals and customer consents in order for the Functions that the Parties contemplate to be included in the scope of this Agreement to be actually included in the scope of this Agreement after the Effective Date. Health Net will keep Supplier informed of progress in obtaining such approvals Health Net will notify Supplier of any regulatory filing or information request, prior to filing or disclosure, in which any Confidential Information of Supplier (not including this Agreement or the terms hereof) may be disclosed. In the event that any Confidential Information of Supplier will be disclosed, Health Net will request and use reasonable efforts to obtain confidential treatment of such information, if requested by Supplier.

(b)

In the event that Health Net is not able to obtain such a consent or approval, or in the event that Health Net obtains a regulatory approval or customer consent that is later revoked, (i) Health Net will notify Supplier and provide such information regarding such denial or revocation as is reasonably requested by Supplier (which information will be deemed Health Net Confidential Information), (ii) Health Net shall have the right to remove any impacted Services, reduce any volumes associated with such Services, reduce the number of Supplier Personnel associated with such Services (and otherwise modify their skill mix) and remove any impacted Functions from the scope of this Agreement, and (iii) Health Net shall have the right to terminate this Agreement (in whole or in part) or any SOW (in whole or in part) as of a date specified by Health Net by giving Supplier at least ninety (90) days prior written notice of such termination.

(c)

The Parties hereby agree that if any Regulator sends to Health Net an email, letter, or other written statement which indicates, in effect, that such Regulator considers the outsourcing of the Services which the Parties have added or may add after the Effective Date, the volumes associated with such Services, the business process Functions associated with such Services, or Supplier’s solution to provide such Services (e.g., location from which such Services will be performed), to make Health Net out of compliance with such Regulator, then (i) Health Net shall provide copies of such notices to Supplier, and (ii) in order to maintain compliance with such Regulator, Health Net shall have the right to remove any impacted Services, reduce any volumes associated with such Services, reduce


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the number of Supplier Personnel associated with such Services and otherwise modify their skill mix, and remove any impacted Functions associated with such Services, from the scope of this Agreement, and (iii) terminate this Agreement (in whole or in part) or any SOW (in whole or in part) as of a date specified by Health Net by giving Supplier at least ninety (90) days prior written notice of such termination.

(d)

***

(ii)

If Health Net provides Supplier with notice that Health Net is exercising its right under clauses 4.3(b)(ii) or 4.3(c)(ii) after the BPaaS Services Commencement Date, then such modification shall be addressed via the Change Control Process and any Charges associated with such Change Order shall be governed by Section 19.1(a) of Schedule C (Charges).

(iii)

If Health Net provides Supplier with notice that Health Net is exercising its right under clauses 4.3(b)(iii) or 4.3(c)(iii) after the BPaaS Services Commencement Date, then Section 18.1 of Schedule C (Charges) shall govern.

(e)

To the extent relevant to the performance of the Services or any of Supplier’s other obligations under this Agreement, Supplier shall comply with provisions arising out of Health Net’s contracts for federal business, including restrictions against providing services from offshore and audit requirements, as such provisions are set forth in this Agreement, included in the Health Net Policies, or otherwise communicated to Supplier.

5.	PERFORMANCE

5.1

Performance, Generally

Supplier is responsible for managing and successfully performing, completing, and delivering the Services, subject to the overall direction of Health Net and with the cooperation and support of Health Net as specified in this Agreement.

5.2

Place of Performance

(a)

Schedule F (Supplier Facilities) sets forth the Supplier and Approved Subcontractor facilities from which Supplier will perform the Services (collectively, the “Supplier Facilities”). Section 1 of Schedule F (Supplier Facilities) sets forth the offshore Supplier Facilities. Section 2 of Schedule F (Supplier Facilities) sets forth the onshore Supplier Facilities. Schedule F (Supplier Facilities) also sets forth the type of Services that Supplier is permitted to provide from each such Supplier Facility.

(i)

Supplier may not provide Services from a Supplier Facility unless (A) such Service is expressly permitted to be provided from such Supplier Facility as described in Schedule F (Supplier Facilities), or (B) Supplier has received Health Net’s prior written consent for such Services to be provided from such Supplier Facility.

(ii)

Health Net may specify, upon prior written notice to Supplier from time to time during the Term, which (if any) Services must be performed on-shore, and Supplier shall comply with any such notice; provided, that any cost impact from such request, including the costs of performing the Services that are relocated, shall be addressed through the Change Control Process.


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(iii)

Supplier shall perform the Services at (i) offshore Supplier Facilities in space that is dedicated to Health Net and with secure access; and (ii) at onshore Supplier Facilities in space that has secure access.

(iv)

Supplier may also perform certain of the Services from Health Net Facilities, as described in Section 11.2(f).

(b)

During the Term, Supplier will not change any location from which it provides Services to Health Net, or materially reallocate the volume or nature of work processed between locations from which it provides Services to Health Net, without Health Net’s prior written approval, which approval (i) may be granted or withheld in Health Net’s discretion and (ii) may be conditioned upon Health Net (or the applicable Health Net Affiliate or Health Net lines of business) providing prior notification to, and receiving approval from, applicable Regulator(s) and customers.

(c)

Supplier will manage any approved relocations in accordance with this Agreement and provide a migration plan to be prepared by Supplier and approved in writing by Health Net. Prior to seeking Health Net’s approval of any proposed relocation, Supplier will fully examine and evaluate the risks and anticipated effects of the contemplated relocation on the Services and Health Net, including the operational, technical, security, regulatory, and other effects, and will prepare and submit to Health Net an analysis of such effects. Supplier will be responsible for all costs, taxes and other expenses incurred by Supplier. Supplier will also be responsible for any new or additional costs, taxes and other expenses incurred by Health Net and reasonably demonstrated to Supplier that are related to any Supplier-initiated relocation of an operational facility from which the Services are provided, except such new or additional costs, taxes and other expenses incurred by Health Net, if any, that Health Net has expressly agreed in writing in its discretion to bear and not seek reimbursement from Supplier in connection with such Supplier proposed relocation.

5.3

Time of Performance

(a)

Supplier will (and will provide the resources necessary to) perform and complete the Services diligently and in a timely manner and in accordance with any applicable time schedules set forth in this Agreement. The Parties agree that any “hard coded” dates set forth in this Agreement (i.e., references to specific calendar dates (such as a reference to “April 1, 2015” rather than a reference to “thirty (30) days after the BPaaS Services Commencement Date”), shall be extended on a day-for-day basis reflecting the number of days after March 1, 2015 that the BPaaS Services Commencement Date actually occurs unless and to the extent that the Parties agree otherwise in writing.

(b)

Supplier will promptly notify Health Net upon becoming aware of any circumstances that may reasonably be expected to jeopardize the timely and successful completion (or delivery) of any Service or other obligation of Supplier. Supplier will use Commercially Reasonable Efforts to avoid or minimize any delays in performance and will inform Health Net of the steps Supplier is taking or will take to do so, and the projected actual completion (or delivery) time.


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(c)

If Supplier believes a delay in performance by Health Net (or a third party service provider engaged by or on behalf of Health Net other than Supplier, Supplier’s Affiliates or subcontractors, or a Supplier Managed Third Party) has caused or will cause Supplier to be unable to perform its obligations on time, Supplier will promptly so notify Health Net and use Commercially Reasonable Efforts to perform its obligations on time notwithstanding Health Net’s (or such third party service provider’s) failure to perform. If Supplier’s use of Commercially Reasonable Efforts to perform on time in such a circumstance would cause Supplier to incur Out-of-Pocket Expenses, Supplier will so notify Health Net. In that case, Supplier’s obligation to continue its efforts to work around the Health Net-caused delay will be subject to Health Net agreeing to reimburse Supplier for its additional Out-of-Pocket Expenses incurred in the course of such efforts.

5.4

Manner of Performance

(a)

Except as this Agreement expressly provides otherwise, Supplier will perform the Services and cause the Technology Platform to operate in compliance with the following:

(i)

all applicable Service Levels, whether existing as of the Effective Date or added during the Term in accordance with the methodologies and processes set forth in Schedule B (Service Levels),

(ii)

the Procedures Manual;

(iii)

the Health Net Policies, provided that:

(A)

Supplier’s obligation to comply with any Health Net Policy that is not listed in Schedule P (Health Net Policies) on the Effective Date (including the link to the on line repository for Health Net Policies as of the Effective Date) or is not listed in the applicable SOW as of the SOW Effective Date or with respect to any change to any Health Net Policy whether listed in Schedule P (Health Net Policies) or in an SOW, will commence ten (10) Business Days after the new Health Net Policy is disclosed to Supplier, or such shorter period of time as required by the circumstances;

(B)

Health Net will deliver to Supplier copies of any changes made by Health Net (excluding changes proposed by Supplier) to Health Net Policies with which Supplier will be expected to comply, sufficiently in advance of the date such changes are to be effective to allow Supplier to plan for and implement changes in its procedures or performance to comply with the changes in the Health Net Policies; and

(C)

Health Net shall utilize the Change Control Procedure to implement any modified or new Health Net Policy that can reasonably be expected to increase the expenses or obligations of Supplier in any non-de minimis way, provided that financial responsibility for modified and new Health Net Policies relating to a change in or a new Law shall be governed by Section 17.5(e)(ii)(B);

(iv)

all other compliance obligations of Supplier under this Agreement, including compliance with data security requirements in Section 14 and compliance with Law obligations in Section 27.7;


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(v)

the terms of Annex 1 (Supplemental Terms and Conditions for BPaaS Services), and Schedule Y (Offshore Prohibitions and Requirements); and

(vi)

in cases where this Agreement does not prescribe or otherwise regulate the manner of Supplier’s performance of the Services, proven best practices followed by the leading providers of similar services.

(b)

In cases where this Agreement does not prescribe or otherwise regulate the manner or quality of Supplier’s performance, Supplier will render the Services with at least the same degree of accuracy, quality, timeliness, responsiveness and efficiency as was generally achieved or obtained by (or for) Health Net (and its Affiliates) prior to Supplier assuming responsibility under this Agreement for the affected Functions.

(c)

Supplier shall conduct a risk assessment, no less than annually, that is consistent with and that supports Health Net’s Enterprise Risk Assessment program and processes, which identifies risks to the proper performance of the Services and report on the results of such risk assessment to Health Net, along Supplier’s plans to monitor and mitigate any identified risks.

5.5

Quality Assurance and Continuous Improvement

In performing the Services, Supplier will follow commercially reasonable quality assurance procedures designed to ensure that the Services are performed with a high degree of professional quality and reliability. Such procedures shall include checkpoint reviews, testing, acceptance, and other procedures for Health Net to confirm the quality of Supplier’s performance. Supplier, as part of its total quality management process, will provide continuous quality assurance and quality improvement through: (i) the identification and application of proven techniques and tools from other installations within its operations; and (ii) the implementation of concrete programs, practices and measures designed to improve performance (including the Service Levels). Supplier will utilize project management tools, including productivity aids and project management systems, as appropriate in performing the Services.

5.6

Critical Deliverables

Supplier shall provide the Critical Deliverables to Health Net in accordance with Schedule R (Critical Deliverables).

6.	SERVICE LEVELS

6.1

General

Quantitative performance standards for certain of the Services (“Service Levels”) are set forth in Schedule B (Service Levels). Supplier’s obligation to pay Service Level Credits is further described in Schedule B (Service Levels).

6.2

Failure to Perform

Supplier will place the Amount at Risk (as defined in Schedule B (Service Levels)) at risk each month for Service Level Credits. Health Net may allocate the Pool Percentage Available for Allocation among Critical Service Levels for the purpose of calculating Service Level Credits, as further described in Schedule B (Service Levels).


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6.3

Removal of Performance Group Guarantee Customers.

(a)

If Supplier fails to meet the annual Performance Guarantee Group Service Levels with respect to a Performance Guarantee Group such that the failure for such Performance Guarantee Group is *** Health Net shall have the right to withdraw such Performance Guarantee Group from this Agreement. ***

(b)

***

(c)

A withdrawal under this Section 6.3 shall be implemented via the Change Control Process.

7.	SUPPLIER PERSONNEL

7.1

Provision of Suitable Personnel

Subject to any lesser qualifications of any Transitioned Employees, Supplier will assign an adequate number of Supplier Personnel to perform the Services who are properly educated, trained, familiar with and fully qualified for the Services they are assigned to perform, and Supplier shall ensure (to the extent reasonably possible) that any outgoing Supplier Personnel leaving the Health Net account spend a reasonable period of time training the new Supplier Personnel who will be replacing such outgoing personnel. Supplier is responsible for taking action at its own expense such that Supplier Personnel assigned to perform Services have the legal right to work in the countries in which they are assigned to work.

7.2

Screening and Background Checks

(a)

Supplier shall, at no additional expense to Health Net, and prior to placing any Supplier Personnel (other than a Transferred Personnel) at Health Net or on the Health Net account, complete background checks for all such personnel (“Background Checks”). Background Checks shall include, without limitation, verification of work history, I-9 completion (to the extent required by the laws of the United States), verification of passports, reference checks from at least three (3) prior employers (if such personnel have had three prior employers, and if not then from such personnel’s prior employers), drug testing and such other background checks as Health Net may request. Background Checks shall also identify State, county, federal and other applicable jurisdictions felonies and misdemeanor convictions and verify the social security number of such personnel, if applicable to such personnel. The personnel will be asked for education and, with respect to United States resident personnel, the last seven (7) years of residences. Background Checks shall also include a determination as to whether the person has been identified by the Department of Treasury Office of Foreign Assets Control (“OFAC”) as an individual with whom U.S. persons are prohibited from engaging in transactions. Also, all Supplier Personnel’s background checks will be done by an external agency that is contracted with Supplier.

(b)

Unless otherwise prohibited by applicable Law, Supplier Personnel may be tested for drugs and/or alcohol whenever Supplier or Health Net has reasonable suspicion that the personnel is under the influence of drugs and/or alcohol in the workplace or has violated the Health Net Policy on substance abuse. Such personnel have the right to refuse to submit to drug or alcohol testing; however, any personnel who do so will be subject to removal from the Health Net account. Results of Background Checks and drug testing will remain Supplier’s Confidential Information and will not be provided to Health Net, but any negative or questionable Background Check or drug test of personnel will require Supplier


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to remove or not assign such personnel. Supplier shall hire all Supplier Personnel and other personnel involved in the Health Net account strictly in accordance with all Laws applicable to the hiring and employment of individuals including, without limitation, the Fair Labor Standards Act, Immigration Reform and Control Act and all equal employment opportunity Laws.

7.3

Responsibility for Supplier Personnel, Generally

Supplier will manage, supervise and provide direction to Supplier Personnel and cause them to comply with the obligations and restrictions applicable to Supplier under this Agreement. Supplier will make Supplier Personnel aware of, and cause them to comply with, Health Net Policies, including those pertaining to safety and security. As between Supplier and Health Net, Supplier is responsible for all wages, salaries and other amounts due Supplier Personnel, and for all tax withholdings, unemployment insurance premiums, pension and social welfare plan contributions, and other employer obligations with respect to Supplier Personnel. Supplier is responsible for the acts and omissions of Supplier Personnel under or relating to this Agreement.

7.4

Key Supplier Positions

(a)

“Key Supplier Positions” means the Supplier positions identified in Schedule D (Key Supplier Personnel—Account Level) and in each SOW. The Supplier Personnel approved by Health Net as of the Effective Date to fill the Key Supplier Positions are identified, as applicable, in Schedule D (Key Supplier Personnel—Account Level) and in each SOW. Notwithstanding anything to the contrary in Section 25.3, the Parties agree that such Supplier Personnel approved to fill Key Supplier Positions may be changed by either (i) amendment to the Agreement or the applicable SOW or (ii) an email exchange between the Parties. If any individual designated to fill a Key Supplier Position as of the Effective Date turns out to be out of scope before the BPaaS Services Commencement Date and therefore is not hired by Supplier, and (1) if such designated individual was a not a Transitioned Personnel, then the Parties will backfill that position and Health Net shall have the right to recommend a replacement for such person and Supplier shall give priority to such recommended replacement, or (2) if such designated individual was a Transitioned Personnel, then Health Net shall have the right to designate a replacement for such person from other rebadged personnel, provided Health Net engages in good faith discussions with Supplier as to such selection.

(b)

Supplier will cause each of the Supplier Personnel filling the Key Supplier Positions (whether as of the Effective Date, or replacement personnel filling such Key Supplier Position during the Term) to devote full time and effort to the provision of the Services, except as otherwise indicated in Schedule D (Key Supplier Personnel—Account Level).

(c)

Before the initial and each subsequent assignment of an individual to a Key Supplier Position, Supplier will notify Health Net of the proposed assignment, introduce the individual to appropriate Health Net representatives and, consistent with Supplier’s personnel practices, provide Health Net a curriculum vitae and other information about the individual reasonably requested by Health Net. Upon request, Supplier will provide Health Net representatives an opportunity to meet with the individual. If Health Net in good faith objects to the proposed assignment, the Parties will attempt to resolve Health Net’s concerns on a mutually agreeable basis. If the Parties have not been able to resolve Health Net’s concerns within five (5) Business Days, Supplier may not assign the individual to that position and must propose the assignment of another suitably qualified individual.


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(d)

Health Net may from time to time change the positions designated as Key Supplier Positions under this Agreement. However, without Supplier’s consent, the number of Key Supplier Positions may not exceed the then-current total number of Key Supplier Positions.

(e)

Without prior written approval by Health Net, Supplier will not reassign or replace any person assigned to a Key Supplier Position until (i) in the case of the Supplier Personnel initially assigned to a Key Supplier Position, one year after the completion of the Transition of the Functions for which such Key Supplier Position is responsible, and (ii) in the case of replacements of Supplier Personnel assigned to a Key Supplier Position, one year after the individual’s assignment to the Key Supplier Position. Subject to the preceding sentence, Supplier will give Health Net, where reasonably possible, at least sixty (60) days advance notice of a proposed change in personnel filling a Key Supplier Position, and will discuss with Health Net any objections Health Net may have. Supplier will arrange, at no charge for the proposed replacement to work side-by-side with the individual being replaced during the notice period to effectuate a seamless transfer of knowledge prior to the incumbent leaving the Key Supplier Position. Individuals filling Key Supplier Positions may not be transferred or re-assigned until a suitable replacement has been approved by Health Net, and no such re-assignment or transfer may occur at a time or in a manner that would have an adverse impact on delivery of the Services or Health Net’s operations. Supplier will establish and maintain an up-to-date succession plan for the individuals serving in Key Supplier Positions. Supplier may remove an individual filling a Key Supplier Position after notification to Health Net for reasons of death, disability, resignation or termination from employment by Supplier, or otherwise as mutually agreed by the Parties. In addition, Supplier may suspend an individual filling a Key Supplier Position after notification to Health Net if the individual is under investigation in connection with a Security Breach.

7.5

Removal and Replacement of Supplier Personnel

(a)

Health Net may immediately remove any Supplier Personnel from any Health Net Facilities if the person is threatening or abusive, commits a crime, engages in an act of dishonesty while performing Services for Health Net or violates any Health Net Policy pertaining to safety, security or use of Health Net Facilities. If Health Net determines in good faith that the continued assignment to Health Net’s account of any of the Supplier Personnel is not in the best interests of Health Net, then, at Health Net’s request, Supplier shall promptly remove such Supplier Personnel from the Health Net account.

(b)

Supplier shall not reassign any Supplier Personnel providing services under the AO Agreement to work on the TriZetto platform or provide services to a Supplier customer utilizing the TriZetto platform for two (2) years after the Effective Date without first obtaining Health Net’s prior written consent. No Supplier Personnel performing services under the AO Agreement shall be removed until there has been proper and sufficient knowledge transfer to his or her designated replacement.

7.6

Controlling Turnover of Supplier Personnel

Health Net and Supplier agree that it is in their mutual best interests to keep the turnover rate of Supplier Personnel to a reasonably low level. Accordingly, if Health Net believes that Supplier’s turnover rate is excessive, and so notifies Supplier, Supplier will provide data concerning its turnover rate and meet with Health Net to discuss the reasons for, and impact of, the turnover rate.If appropriate, Supplier will submit to Health Net its proposals for reducing the turnover rate and the


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Parties will mutually agree on a program to bring the turnover rate down to an acceptable level. In any event, Supplier will use Commercially Reasonable Efforts to keep the turnover rate to a reasonably low level. Notwithstanding any turnover of Supplier Personnel, Supplier remains obligated to perform the Services in compliance with the requirements of this Agreement.

7.7

Subcontracting

Supplier may subcontract or delegate the performance of Services only in accordance with the following:

(a)

Supplier may subcontract the performance of Services to any of its wholly-owned Affiliates.

(b)

Supplier shall enter into and maintain a subcontract with TPUSA, Inc. (“TPUSA”) for the performance of the Contact Center Services provided to Health Net by TPUSA as of the Effective Date. Except in cases of TPUSA’s gross negligence, willful misconduct or material breach of a material provision, or significant liability or financial risk to either Health Net or Supplier, Supplier shall not terminate or allow such subcontract to expire without Health Net’s prior written consent. If Supplier terminates the TPUSA subcontract, Supplier shall provide Health Net with written notice of such termination within forty eight (48) hours of sending such termination notice. Any replacement of TPUSA shall be subject to Health Net’s prior written consent in accordance with Section 7.7(d) and carried out pursuant to a transition plan developed by Supplier and approved by Health Net. Health Net’s consents and approvals required under this paragraph shall not be unreasonably withheld or delayed.

(c)

Supplier may, in the ordinary course of business, subcontract for third party services or products (which include services and products from non-wholly owned Supplier Affiliates) that satisfy each of the following conditions: (i) are not dedicated to performance of Services for Health Net, (ii) are not material to a Function constituting a part of the Services, (iii) do not result in a material change in the way Supplier conducts its business, and (iv) any such third party does not have access to Health Net’s Confidential Information (including Protected Health Information); provided (1) such subcontract does not adversely affect Health Net; and (2) in each case Supplier provides at least forty-five (45) days prior written notice of the same to Health Net. If Health Net expresses concerns to Supplier about a subcontract covered by this paragraph, Supplier will discuss such concerns with Health Net and work to resolve Health Net’s concerns on a mutually acceptable basis.

(d)

Except as provided in Sections 7.7(a), 7.7(b) and 7.7(c), Supplier shall not subcontract for performance of, or delegate any of its responsibilities under this Agreement without first obtaining the prior written approval of Health Net, which approval (i) may be granted or withheld in Health Net’s discretion, (ii) may be conditioned upon Health Net (or the applicable Health Net Affiliate or Health Net lines of business) providing prior notification to, and receiving approval from, applicable Regulator(s) and customers, and (iii) may be conditioned on Supplier’s obtaining the right from the proposed Subcontractor to assign the related subcontract to Health Net upon the expiration or any earlier termination of the Services being provided by such Subcontractor, and at such time and upon Health Net’s request, Supplier shall so assign the subcontract to Health Net. When seeking such approval, Supplier will (i) give Health Net forty-five (45) days prior written notice specifying the components of the Services affected, the scope of the proposed subcontract,


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the identity and qualifications of the proposed Subcontractor and the results of any due diligence carried out with regard to the proposed Subcontractor; and (ii) at Health Net’s request, provide Health Net a description of the scope and material terms (other than financial) of the proposed subcontract. Health Net may require Supplier to replace any previously approved Subcontractor found, in the reasonable judgment of Health Net, to be unacceptable. Any Subcontractor authorized by this Section 7.7 or approved by Health Net, in its discretion, shall be an “Approved Subcontractor” hereunder.

(e)

Approved Subcontractors for each SOW as of the SOW Effective Date are listed in the applicable SOW. Notwithstanding anything to the contrary in Section 25.3, after the SOW Effective Date, the Parties may add additional Approved Subcontractors, or remove previously approved Approved Subcontractors, by an amendment or by execution of a letter or other informal written document with a signed counter-signature by the receiving Party.

(f)

Supplier will require (i) all Subcontractors with whom Supplier enters into a subcontracting agreement after the Effective Date for performance of any Services to be bound to Supplier by all applicable terms of this Agreement and to assume toward Supplier all of the applicable obligations and responsibilities that Supplier, by this Agreement, has assumed toward Health Net, and (ii) all Subcontractors (other than those covered by subsection (i)) with whom Supplier entered into a subcontracting agreement for performance of the services provided to Health Net under the Original BPO Agreement to be bound to Supplier as required by the Original BPO Agreement.

(g)

Supplier may use Approved Subcontractors to perform the Services to the extent permitted by Health Net’s approval. Supplier is responsible for managing all Subcontractors. Supplier remains responsible for all Functions delegated to Subcontractors to the same extent as if such Functions were to be performed by Supplier acting through its officers, directors, employees, and agents and, for purposes of this Agreement, such Functions will be deemed Functions performed by Supplier. Supplier will be Health Net’s sole point of contact regarding the Services, including with respect to payment.

(h)

Supplier may disclose Health Net Confidential Information only to Approved Subcontractors who have agreed in writing to protect the confidentiality of such Confidential Information in a manner substantially equivalent to that required of Supplier under this Agreement and to permit both Supplier and Health Net, or both, to enforce such terms directly against such Subcontractor. As between the Parties, Supplier shall be responsible for all acts and omissions of (i) Supplier’s independent contractors and other Subcontractors as if they were Supplier’s employees and (ii) any third party to whom Supplier permits access to Health Net Data or Health Net Confidential Information.

(i)

Supplier shall not restrict or prevent (including by contract) any Subcontractor from entering into an agreement with Health Net to perform services directly for Health Net.

7.8

Supplier Personnel No Longer on Health Net Account

Subject to Section 7.4(e), in the event any one of the Supplier Personnel in a Key Supplier Position leaves the Health Net account for any reason (e.g., termination, voluntary departure from Supplier, etc.), Supplier will use commercially reasonable efforts to notify Health Net of such occurrence within seventy-two (72) hours.


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7.9

Training

(a)

Health Net Required Training. In addition to the training required by Schedule K (Regulatory Compliance Addendum), Supplier Personnel are required to take the then-current Health Net-provided training (administered online via Health Net’s HR link). As of the Effective Date, the required Health Net training, for which Health Net will provide the content and materials at its own cost, includes:

(i)

HIPAA: An Overview;

(ii)

Business Code of Conduct at Health Net (Ethics);

(iii)

The Painful Price of Healthcare Fraud;

(iv)

Getting the Records Straight;

(v)

Health Net General Compliance;

(vi)

Medicare Part D: Fraud, Waste and Abuse (for all associates whose job functions cover or may cover Medicare Part D); and

(vii)

Other training courses related to the Functions that Health Net requires its employees or contractors to take.

(b)

Each Supplier Personnel shall complete the above training within sixty (60) days after being assigned to the Health Net account, and annually thereafter.

(c)

Health Net Customer Required Training. Supplier Personnel are also required to take any training that a customer of Health Net (e.g., LAUSD) would ordinarily require Health Net personnel to take if Health Net personnel were performing the Services.

8.	HEALTH NET RESPONSIBILITIES

8.1

Appointment of Health Net Program Management Office (PMO) Personnel

Health Net will designate an individual to serve as Health Net’s “Program Manager”, who will be Supplier’s principal point of contact for obtaining decisions, information, approvals and acceptances required from Health Net.

8.2

Health Net Cooperation Duties

(a)

In support of Supplier’s performance of the Services and subject to Section 8.3, Health Net will perform the Functions expressly identified in this Agreement, including in each SOW, as retained Health Net Functions and provide or make available to Supplier the Equipment, Software, and other resources specified in (i) for the Initial SOWs, Schedule O (Health Net Provided Resources), and (ii) each Future SOW, as applicable.

(b)

Health Net will cooperate with Supplier, including by making available management decisions, information, approvals and acceptances, as reasonably requested by Supplier so that Supplier may accomplish its obligations and responsibilities under this Agreement.


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8.3

Savings Clause

Health Net’s failure to perform its responsibilities set forth in this Agreement (or cause them to be performed) will not constitute grounds for termination by Supplier except as provided in Section16.3 (Termination by Supplier). Supplier’s nonperformance of its obligations under this Agreement will be excused if and to the extent (a) such Supplier nonperformance results from (i) the failure by Health Net (including failure by a Health Net contractor, agent or other party for which Health Net is responsible, but excluding Supplier) to perform an express obligation of Health Net under this Agreement, (ii) the failure of a Health Net Provided Resource provided that such failure shall not be an excuse if it arises out of Supplier’s failure to perform its obligations to manage and provide other Services with respect to such Health Net Provided Resource and the related third party from which Health Net procures such Health Net Provided Resource, and/or (iii) a breach by Health Net of its obligations under this Agreement that prevents Supplier from performing in accordance with this Agreement, and (b) Supplier provides Health Net with reasonable notice of such nonperformance and uses Commercially Reasonable Efforts to perform notwithstanding Health Net’s failure to perform or breach. If Supplier’s use of Commercially Reasonable Efforts to perform in such a circumstance would cause Supplier to incur Out-of-Pocket Expenses, Supplier may so notify Health Net. If it does, Supplier’s obligation to continue its efforts to work around Health Net’s failure to perform will be subject to Health Net agreeing to reimburse Supplier for its Out-of-Pocket Expenses incurred in the course of such efforts. SUPPLIER ACKNOWLEDGES THAT HEALTH NET WOULD NOT BE WILLING TO ENTER INTO THIS AGREEMENT WITHOUT ASSURANCE THAT THIS AGREEMENT MAY NOT BE TERMINATED BY SUPPLIER AND THAT SUPPLIER SHALL NOT HAVE THE RIGHT TO SUSPEND PERFORMANCE OF THE SERVICES EXCEPT, AND ONLY TO THE EXTENT, EXPLICITLY PROVIDED HEREIN.

8.4

Minimum Revenue Commitment.

Schedule C (Charges) sets out the terms and conditions of Health Net’s obligation to satisfy the Minimum Revenue Commitment.

9.	CHARGES

Schedule C (Charges) sets forth all the charges payable to Supplier for performing the Services applicable to such SOW. Health Net will not be required to pay Supplier any amounts for or in connection with performing the Services and fulfilling Supplier’s obligations under this Agreement other than those amounts expressly payable to Supplier under this Agreement.

9.1

Pass-Through Expenses

(a)

“Pass-Through Expenses” means third party charges that are to be both (i) paid by Health Net (either (A) directly to the third party or (B) to Supplier, which, in turn, pays the third party) on an Out-of-Pocket Expenses basis, and (ii) administered by Supplier. Any Pass-Through Expenses shall be agreed upon in accordance with Section 19.4 of Schedule C (Charges). Supplier shall arrange for delivery by third parties to Supplier of invoices for Pass-Through Expenses, and Supplier promptly shall review such invoices and provide Health Net with the original invoice together with a statement identifying which charges are proper and valid and should be paid by Health Net.


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(b)

Supplier shall use Commercially Reasonable Efforts to minimize the amount of Pass-Through Expenses. With respect to services or materials paid for on a Pass-Through Expenses basis, Health Net reserves the right to: (i) obtain such services or materials directly from a third party; (ii) designate the third party source for such services or materials; (iii) designate the particular services or materials (e.g., equipment make and model) Supplier shall obtain; (iv) designate the terms for obtaining such services or materials (e.g., purchase or lease and lump sum payment or payment over time); (v) require Supplier to identify and consider multiple sources for such services or materials or to conduct a competitive procurement; and (vi) review and approve the applicable Pass-Through Expenses before entering into a contract for particular services or materials.

9.2

Incidental Expenses

Supplier acknowledges that, except as may be otherwise provided in this Agreement, expenses that Supplier expects to incur in performing the Services (including travel and lodging, document reproduction and shipping, and long-distance telephone) are included in Supplier’s Charges and rates set forth in this Agreement. Accordingly, such Supplier expenses are not separately reimbursable by Health Net unless, on a case-by-case basis for unusual expenses, Health Net has agreed in advance and in writing to reimburse Supplier for the expense.

9.3

Taxes

The Parties’ respective responsibilities for taxes arising under or in connection with this Agreement shall be as follows:

(a)

Each Party shall be responsible for any personal property taxes on property it owns or leases, for franchise and privilege taxes on its business, and for taxes based on its net income or gross receipts.

(b)

Supplier shall be responsible for any sales, use, excise, value-added, services, consumption and other taxes and duties payable by Supplier on the goods or services used or consumed by Supplier in providing the Services where the tax is imposed on Supplier’s acquisition or use of such goods or services and the amount of tax is measured by Supplier’s costs in acquiring such goods or services.

(c)

Health Net shall be responsible for any applicable sales, use, excise, value-added, services, consumption or other tax that is assessed on the provision of the Services as a whole, or on any particular Service by any governmental or taxing authority within the United States; provided, however, that (i) Supplier invoices reflect on a current basis (and in any event before any such tax becomes due and payable) the amount of any such tax in each jurisdiction and the taxable Services to which such tax relates, (ii) if Supplier fails to reflect on its invoice any such tax on a current basis, Supplier shall be financially responsible for any penalties and interest assessed by the taxing authority with respect to such tax, and (iii) if Supplier fails to reflect any such tax on a Supplier invoice within twelve (12) months after the date that such tax is due and payable, Supplier shall be financially responsible for the full amount of such tax, including any penalties and interest.

(d)

Supplier shall be responsible for any sales, use, excise, value-added, services, consumption or other tax that is assessed on the provision of the Services as a whole, or on any particular Service, by any governmental or taxing authority outside the United States as of the Effective Date or during the Term, except (i) where the Parties agree in writing that a Supplier Affiliate located in a jurisdiction outside of the United States may invoice Health Net or a Health Net Affiliate directly or (ii) where the Parties agree in writing that Supplier


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will provide centralized billing, wherein a Health Net Affiliate located in a jurisdiction outside of the United States will receive Services from a Supplier Affiliate located in a jurisdiction outside of the United States and invoicing for such Services is between a Health Net Affiliate located in the United States and a Supplier Affiliate located in the United States.

(e)

Supplier shall be responsible for any payments required to compensate Supplier Personnel for compensatory tax treatment resulting from Supplier Personnel traveling to perform services, subject to the remainder of this paragraph. In the event that the assignment (or potential assignment) of particular Supplier Personnel to perform Services for Health Net has reached a point such that the continued assignment of such particular personnel is likely to trigger compensatory tax treatment of the travel related expenses reimbursed to such particular Supplier Personnel, Supplier may inform Health Net in writing that Supplier is close to becoming subject to compensatory tax treatment as a result of such assignment, and shall provide an estimate of the amount of such compensatory tax liability. If Supplier fails to so notify Health Net, Supplier shall remain responsible for any amounts resulting from compensatory tax treatment of such particular Supplier Personnel. Following such notice by Supplier, Health Net may then elect by sending written notice to Supplier to be financially responsible for any payments required to compensate Supplier with respect to such particular Supplier Personnel in an amount equal to the compensatory taxes assessed to such particular Supplier Personnel as the result of such assignment to the Health Net account. If Health Net does not so elect, Supplier shall remain responsible for any amounts resulting from compensatory tax treatment of such particular Supplier Personnel, provided, however, Supplier may then relocate such Supplier Personnel to avoid such taxes, and the Parties shall cooperate to make other arrangements so that the Services will be performed without interruption.

(f)

In the event that a sales, use, excise, value added, services, consumption or other tax is assessed on the provision of any of the Services, the Parties shall work together to segregate the payments under this Agreement into three (3) payment streams:

(i)

those for taxable Services;

(ii)

those for which Supplier functions merely as a payment agent for Health Net in receiving goods, supplies, or services (including leasing and licensing arrangements); and

(iii)

those for other nontaxable Services.

(g)

The Parties agree to cooperate with each other to enable each to more accurately determine its own tax liability and to minimize such liability to the extent legally permissible, provided however, where the Parties have made a joint assessment in writing as contemplated in this sentence and a taxing authority subsequently determines that a tax should have been collected and/or paid, the limitation in Section 9.3(c)(iii) will not apply. Supplier’s invoices shall separately state the amounts of any taxes Supplier is collecting from Health Net, and Supplier shall remit such taxes to the appropriate authorities. Each Party shall provide and make available to the other any resale certificates, information regarding out-of-state or out-of-country sales or use of equipment, materials or services, and other exemption certificates or information reasonably requested by the other Party.


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(h)

Supplier shall promptly notify Health Net of, and coordinate with Health Net the response to and settlement of, any claim for taxes asserted by applicable taxing authorities for which Health Net is responsible hereunder, it being understood that with respect to any claim arising out of a form or return signed by a Party to this Agreement, such Party shall have the right to elect to control the response to and settlement of the claim, but the other Party shall have all rights, at its sole cost and expense, to participate in the responses and settlements that are appropriate to its potential responsibilities or liabilities. If Health Net requests Supplier to challenge the imposition of any tax, Supplier shall do so in a timely manner and Health Net shall reimburse Supplier for the reasonable legal fees and expenses it incurs. Health Net shall be entitled to any tax refunds or rebates granted to the extent such refunds or rebates are of taxes that were paid by Health Net.

9.4

Estimating Model

Schedule J (Project Framework) sets forth the project estimation model Supplier will use for the Non-BPaaS IT Services (the “PEM”). The Parties will baseline and assess the PEM annually to address accuracy and institute improvements in Q2 of each calendar year.

9.5

***

(a)

***.

(b)

***.

(c)

***.

(d)

***.

10.

INVOICING AND PAYMENT

10.1

Invoicing

(a)

Supplier shall invoice Health Net for all amounts due under this Agreement on a monthly basis in arrears (i.e., Charges for Services delivered in August will be invoiced on the invoice delivered to Health Net in September), or as otherwise agreed by the Parties in writing. Each invoice shall provide, for each Charge, information regarding the Services to which such Charge relate which is sufficient to enable Health Net to determine the contractual basis for such Charge. Supplier shall include the calculations utilized to establish the Charges.

(b)

To the extent a credit may be due Health Net pursuant to this Agreement, Supplier shall provide Health Net with an appropriate credit against amounts then due and owing. If no further payments are due to Supplier, Supplier shall pay such amounts to Health Net within *** days of the date of request for such credit by Health Net.

(c)

Supplier shall render a single consolidated invoice for each month’s Charges showing such details as reasonably specified by Health Net, including as necessary to satisfy Health Net’s internal accounting and chargeback requirements (such as allocating Charges among Service components, locations and departments). The form of invoice shall be mutually agreed by the Parties during Transition and any changes to such form invoice during the Term must be approved by Health Net.


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(d)

Supplier shall use good faith efforts to submit complete invoices that include all Charges incurred in the applicable month, and may include additional Charges on a later invoice, provided that in no event shall Charges be billed more than *** days after the month during which the invoice for such Charges should have been provided to Health Net pursuant to Section 10.1(a).

10.2

Payment Due

Subject to the other provisions of this Section 10.2, invoices provided under Section 10.1 and properly submitted to Health Net pursuant to this Agreement shall be paid by Health Net within *** days after receipt thereof. Any amount due under this Agreement for which a time for payment is not otherwise specified shall be paid within *** days after receipt of a proper invoice for such amount.

10.3

Accountability

Supplier shall maintain complete and accurate records of and supporting documentation for the amounts billable to and payments made by Health Net hereunder in accordance with generally accepted accounting principles applied on a consistent basis. Supplier agrees to provide Health Net with documentation and other information with respect to each invoice as may be reasonably requested by Health Net to verify accuracy and compliance with the provisions of this Agreement.

10.4

Proration

Except as may be otherwise provided in this Agreement, periodic Charges under this Agreement are to be computed on a calendar month basis, and shall be prorated for any partial month.

10.5

Refundable Items

(a)

Prepaid Amounts. Where Health Net has prepaid for a service or function for which Supplier is assuming Financial Responsibility under this Agreement, Supplier shall refund to Health Net, upon either Party identifying the prepayment, that portion of such prepaid expense which is attributable to periods on and after the Effective Date.

(b)

Refunds and Credits. If Supplier should receive a refund, credit or other rebate for goods or services previously paid for by Health Net, Supplier shall promptly notify Health Net of such refund, credit or rebate and shall promptly pay the full amount of such refund, credit or rebate, as the case may be, to Health Net.

10.6

Deductions

With respect to any amount to be paid by Health Net hereunder, Health Net may deduct from such amount any amount that Supplier is obligated to pay Health Net hereunder.

10.7

Disputed Charges

Subject to Section10.6, Health Net shall pay undisputed Charges when such payments are due under this Section 10.7. Health Net may withhold and/or set off payment of particular Charges that Health Net disputes in good faith, and may set off amounts due and owing to Health Net as credits against Charges payable to Supplier under this Agreement. If any such disputed Charges have already been paid, Health Net may deduct such disputed Charges or amounts due from future


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amounts owed by Health Net to Supplier. If an invoiced amount is disputed in good faith by Health Net, then Health Net shall provide written notification to Supplier of the dispute and the basis for such dispute, and the Parties shall utilize the procedures in Section 26.1 to resolve the issue. In the event that Charges cover both disputed and undisputed items, then subject to the above in this Section 10.7, Health Net shall pay all undisputed items in accordance with this Agreement. If, after following the procedures in Section 26.1, it is determined that Health Net should have paid all or a portion of the disputed amounts, (a) Supplier shall submit to Health Net an invoice for an amount equal to the amount of disputed charges that Health Net should have paid, and (b) Health Net will endeavor to remit payment for such invoice as promptly as possible, but in no event more than *** days from receipt of such invoice.

11.

TRANSFER OR USE OF RESOURCES

This Section 11 sets forth the processes by which certain resources used by Health Net prior to the Effective Date will be transferred or otherwise made available to Supplier for use in providing the Services. For avoidance of doubt, this Section 11 does not address Acquired Assets which are being transferred by Health Net to Supplier pursuant to the APA. RIGHTS OF USE GRANTED BY HEALTH NET TO SUPPLIER UNDER THIS SECTION 11 ARE GRANTED ON AN ‘AS-IS, WHERE-IS’ BASIS, WITHOUT WARRANTIES OF ANY KIND.

11.1

Transfer of Resources

Schedule E (Transitioned Employees) sets forth the terms and conditions governing the recruitment and transition of Health Net personnel to Supplier. If Supplier is obligated to make employment offers to any Health Net personnel in connection with Services to be provided by Supplier under this Agreement, such personnel shall be the Affected Employees as defined in Schedule E (Transitioned Employees), and the terms of Schedule E (Transitioned Employees) shall govern.

11.2

Use of Health Net Resources

(a)

General. Health Net’s obligation to provide the Health Net Third Party Service Contracts, the Health Net Owned Software, the Health Net Licensed Software, the Health Net Owned Equipment and the Health Net Leased Equipment pursuant to Sections 11.2(b), (c) and (d) below (collectively, “Health Net Provided Resources”) and Supplier’s right to use such Health Net Provided Resources, shall be subject to the terms of Section 11.2(e) below.

(b)

Health Net Third Party Service Contracts.

(i)

The Health Net Third Party Service Contracts that are to be made available to Supplier for use in providing the Services are listed in Schedules ▇-▇-▇, ▇-▇-▇ and O-5-3 (Health Net Provided Resources). Health Net (and each of its Affiliates) retains all of its right, title and interest in and to the referenced Health Net Third Party Service Contracts, subject to Supplier’s rights in this Agreement.

(ii)

As of the applicable SOW Effective Date, Health Net grants to Supplier, without assignment of any such Health Net Third Party Service Contract, but subject to the Parties obtaining any Required Consents pursuant to Section 11.3 (Required Consents), the right to use the services provided to Health Net under such Health Net Third Party Service Contracts relevant to such SOW, if any, until such time as determined in accordance with Section 11.2(e) below.


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(iii)

In the event Health Net or any Health Net Affiliate (e.g., Health Net of California, Inc.) enters into any third party contracts that are designated “Health Net Third Party Service Contracts” made available to Supplier under this Section 11.2(a), Health Net and/or such Health Net Affiliate will file a list of them with the applicable Regulator. The filing by Health Net and/or such Health Net Affiliate is intended to demonstrate that the availability of such contracts to Supplier will not prevent Health Net and/or such Health Net Affiliate from complying with the requirements of any applicable Law (e.g., the ▇▇▇▇-▇▇▇▇▇ Act of California).

(c)

Health Net Owned Software and Health Net Licensed Software.

(i)

For purposes of this Section 11, Health Net Owned Software includes Health Net proprietary configurations of third party Software other than the Configurations acquired by Supplier from Health Net pursuant to the APA.

(ii)

The Health Net Owned Software and Health Net Licensed Software that are to be made available to Supplier for use in providing the Services, are listed in Schedules O-1 and O-2, respectively (Health Net Provided Resources). Health Net (and each of its Affiliates) retains all of its right, title and interest in and to the referenced Health Net Owned Software and Health Net Licensed Software.

(iii)

As of the applicable SOW Effective Date, Health Net grants to Supplier until such time as determined in accordance with Section 11.2(e) below and except as provided in Section 5.1(a) of Schedule C (Charges):

(A)

a fully paid-up, nonexclusive, worldwide license to Use the referenced Health Net Owned Software relevant to such SOW, if any, in both object and Source Code versions, and

(B)

subject to the Parties having obtained any Required Consents pursuant to Section 11.3 (Required Consents) with respect to the referenced Health Net Licensed Software, and without assignment of the license, such rights as Health Net has (or later obtains) to use the referenced Health Net Licensed Software relevant to such SOW except as in object and, if permissible within the terms of the applicable Required Consent and if approved in writing by Health Net, the right to modify and adapt the Health Net Licensed Software and access to the Source Code,

in each case, via Citrix or other similar method of remote access.

(iv)

The rights granted in clause (ii) above shall be in effect until such time as determined in accordance with Section 11.2(e) below.

(d)

Health Net Owned Equipment and Health Net Leased Equipment.

(i)

The Health Net Owned Equipment and Health Net Leased Equipment that are to be made available to Supplier for use in providing the Services, are listed in Schedules O-3 and O-4 (Health Net Provided Resources). Additionally terms relating to provision of desktop computers, laptops, cell phones and similar devices are set forth in and governed by Section 11.4(b). Health Net (and each of its Affiliates) retains all of its right, title and interest in and to the referenced Health Net Owned Equipment and Health Net Leased Equipment.


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(ii)

As of the applicable SOW Effective Date, Health Net grants to Supplier:

(A)

a fully paid-up, nonexclusive, license to use the referenced Health Net Owned Equipment relevant to such SOW, and

(B)

subject to the Parties having obtained any Required Consents pursuant to Section 11.3 (Required Consents) with respect to the referenced Health Net Leased Equipment, and without assignment of the leases, such rights as Health Net has (or later obtains) to use the referenced Health Net Leased Equipment relevant to such SOW.

(iii)

The rights granted in clause (ii) above shall be in effect until such time as determined in accordance with Section 11.2(e) below. After such time, Supplier will return such Equipment to Health Net in substantially the same condition as it was when Supplier began use of it, subject to reasonable wear and tear.

(e)

Terms Regarding Supplier’s use of Health Net Provided Resources. The following shall apply to the Health Net Provided Resources:

(i)

Supplier shall utilize the Health Net Provided Resources solely to provide Services to Health Net (and other Service Recipients) under this Agreement. Supplier is not permitted to use the Health Net Provided Resources for the benefit of any entity other than Health Net (and other Service Recipients under this Agreement) without the prior written consent of Health Net, which may be withheld in Health Net’s discretion.

(ii)

Supplier will comply with the duties and obligations imposed on Health Net by the Health Net Third Party Service Contracts, software licenses (and related maintenance, support and service agreements), and equipment leases (and related maintenance and service agreements) related to the Health Net Provided Resources, as promptly as practicable after such Health Net Third Party Service Contracts and related agreements have been disclosed to Supplier (but in no event later than thirty (30) days after such contracts and agreements have been provided to Supplier), provided that Health Net provides to Supplier any commercially reasonable support necessary from Health Net if available for Supplier to so comply. Supplier shall not seek to revoke or modify the terms of any such agreement. Health Net may revoke or modify the terms of any such agreement, which revocation or modification may give rise to a Change, in which case the Change Control Process will apply.

(iii)

Health Net shall make the Health Net Provided Resources available to Supplier commencing on the BPaaS Services Commencement Date and continuing through Phase 2, provided that (i) it is permitted under the existing terms of any applicable third party agreements as of the Effective Date, and (ii) Supplier shall be responsible for providing Managed Third Party Contract Services (as defined in Schedule A (Cross Functional) with respect to the Health Net Provided Resources after the BPaaS Services Commencement Date, even though Health Net is retaining (subject to Schedule C (Charges), including the Financial Responsibility Matrix attached as Schedule C-11 to Schedule C (Charges)) Financial Responsibility through Phase 2. After Phase 2, Health Net shall have no further obligation to provide such Health Net Provided Resources, subject to clause (iv) below.


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(iv)

Terms for making resources available beyond Phase 2.

(A)

If Supplier desires Health Net to continue to provide any of the Health Net Provided Resources after Phase 2, Supplier shall give written notice of such fact to Health Net as soon as reasonably possible, but not less than ninety (90) days prior to the date by which Health Net would need to (i) notify the applicable contract counter-party in order to effect a renewal or extension of the affected contract beyond Phase 2, or (ii) in order to avoid the payment of license, maintenance, support, service or other fees extending after Phase 2 if Supplier does not intend to utilize the applicable resource during such period after Phase 2 (a “Resource Extension Notice”).

(B)

Provided that Health Net is permitted under the existing terms of any applicable third party agreements, Health Net shall make the Health Net Provided Resources identified in the Resource Extension Notice available after Phase 2, provided that Supplier shall be financially responsible for any and all costs incurred by Health Net relating to such Health Net Provided Resources with respect to the period after Phase 2 (“Health Net Resources Costs”), and Supplier shall reimburse Health Net for any and all such costs, such costs to include:

(1)

Any costs incurred by Health Net under any of the Health Net Provided Resources, including fees under the third party Software license fees and fees for maintenance, support and services agreements related to such resources;

(2)

Any reasonable internal costs to maintain and support any of such resources; and

(3)

The reasonable internal administrative and personnel costs incurred by Health Net relating to any such resources.

(C)

Notwithstanding the foregoing, in no event shall (i) Health Net be obligated to make available the contracts identified in Schedule O-5-1 after Phase 2, and (ii) Health Net be obligated to make any Health Net Provided Resource available to Supplier after the date that is two years after the end of Phase 2.

(D)

Health Net shall invoice Supplier for the Health Net Provided Resources Costs to be reimbursed by Supplier pursuant to this Section 11.2(e). Such invoices shall be paid by Supplier to Health Net within forty-five (45) days after receipt thereof.

(E)

Section 5.1 of Schedule C (Charges) contains additional terms relating to the Health Net Provided Resources.


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(v)

Supplier will return any such Health Net Provide Resource to Health Net or, at Health Net’s election, destroy it and certify the destruction of all copies in Supplier’s (or any of its Subcontractor’s) possession or control, at such time as Health Net is no longer obligated to provide such Health Net Provided Resource pursuant to this Section 11.2(e).

(vi)

In the event that Health Net makes any additional Health Net Provided Resources available after the Effective Date, any such additional item shall be subject to the applicable Section 11.2(b), (c) or (d) above, as well as this Section 11.2(e).

(vii)

Supplier shall create a list of the dates by which Supplier must provide the Resource Extension Notice with respect to each Health Net Provided Resource in order to comply with the requirements of Section 11.2(e)(iv)(A). Supplier shall provide such list to Health Net on or before the date that is forty-five (45) days after the BPaaS Services Commencement Date provided that with respect to any contract that is not provided to Supplier as of the BPaaS Services Commencement Date, Supplier shall have an additional forty-five (45) days after being provided such contract to update the list with the date for such contract in order to be in compliance with Section 11.2(e)(iv)(A). Any inaccuracies in such list shall not relieve Supplier of its obligations under this Section 11.

(f)

Health Net Facilities.

(i)

Subject to the Parties having obtained any Required Consents pursuant to Section 11.3, Health Net grants to Supplier the right, to access the Health Net Facilities, to the extent permitted by applicable lease agreements, solely to perform the Services. Such space to be made available is described on Schedule O (Health Net Provided Resources).

(ii)

Such facilities shall be provided from the BPaaS Services Commencement Date until the end of Phase 2. If Supplier desires to occupy the Health Net facilities after Phase 2, Supplier shall pay Health Net for such space in accordance with the following. Supplier shall provide written notice to Health Net that it desires to occupy such space after Phase 2 not less than six (6) months prior to the end of Phase 2. The Parties shall discuss and determine a fair market rent for such space.

(iii)

Supplier will comply with the duties imposed on Health Net (or its Affiliate) by each lease for the Health Net Facilities, commencing ten (10) Business Days after such duties have been disclosed to Supplier in writing.

(g)

Terms Applicable to Health Net Facilities, Generally.

(i)

The following provisions are applicable with respect to the Health Net Facilities: Health Net retains responsibility for management and maintenance of the building and property electrical systems, water, sewer, lights, heating, ventilation and air conditioning (“HVAC”) systems, physical security services and general custodial/landscape services (including monitoring and maintaining the uninterruptible power supply (“UPS”) system, air handlers and water chillers that are primary support for the raised-floor environment in Health Net Facilities).


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(ii)

Supplier is responsible for providing all other the facilities and facilities-related support it needs to provide the Services.

(iii)

Health Net will inform Supplier of any plans or determination to relocate the Health Net Facilities so that Supplier will have a reasonable amount of time to prepare for and implement such relocation as it affects Supplier.

(iv)

Supplier’s use of the Health Net Facilities shall be for the sole and exclusive purpose of providing the Services and shall be subject to the terms set forth in this Section 11.2(f). Any other uses are subject to the prior approval of Health Net in its discretion. Supplier’s use of Health Net Facilities does not constitute a leasehold or other property interest in favor of Supplier.

(v)

Supplier will use the Health Net Facilities in an efficient manner and in a manner that is coordinated and does not interfere with Health Net’s business operations. Supplier is responsible for any damage to Health Net Facilities resulting from the negligent or intentional misconduct of Supplier (or its Subcontractors or other guests) or other failure to comply with its obligations under this Agreement respecting the Health Net Facilities.

(vi)

Supplier will keep the Health Net Facilities in good order, not commit or permit waste or damage to them or use them for any unlawful purpose or act. Supplier will comply with Health Net Policies and with applicable leases made available to Supplier regarding access to and use of the Health Net Facilities, including procedures for the physical security of the Health Net Facilities.

(vii)

Supplier will permit Health Net and its agents and representatives to enter any portions of the Health Net Facilities occupied by Supplier Personnel.

(viii)

Supplier may not make improvements or changes involving structural, mechanical or electrical alterations to the Health Net Facilities without Health Net’s prior written approval. Any improvements to the Health Net Facilities will become the property of Health Net.

(ix)

When Health Net Facilities are no longer required for performance of the Services, or in any event upon expiration or termination of this Agreement (or the applicable lease term, if shorter), Supplier will return them to Health Net in substantially the same condition as when Supplier began use of them, subject to reasonable wear and tear.

11.3

Required Consents

(a)

Health Net, with the cooperation of Supplier, is responsible for obtaining Required Consents under any of the leases, contracts and licenses referred to in this Section 11 (Transfer or Use of Resources) (the “Used Resources”). Health Net will work diligently to obtain such Required Consents as soon as practicable after:

(i)

the Effective Date with respect to the Used Resources known as of the Effective Date, or

(ii)

such later date as agreed by the Parties with respect to new Used Resources agreed to by the Parties after the Effective Date, if any.


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(b)

To the extent a Required Consent under this Section 11 has not been obtained prior to the Transfer Date of the applicable Health Net Personnel who have a role in obtaining a given Required Consent, then once such Health Net Personnel are Transitioned Employees, Supplier will utilize such Transitioned Employee to obtain such Required Consents, provided that this shall not relieve Health Net from any legal obligation (including the obligations Health Net may have to the third parties from which such Required Consents are sought) to obtain their consent to the transactions contemplated by this Agreement.

(c)

The Parties will equally bear any fees (such as transfer or upgrade fees) required to obtain a Required Consent relating to the Used Resources. Unless and until each such Required Consent has been obtained, to the extent practical Supplier will determine and adopt, subject to Health Net’s prior written approval, such alternative approaches to provide the Services without the Required Consent. The Parties shall equally bear the costs to implement such alternative approaches.

(d)

If either Party is not able to obtain any such Required Consent, or if it elects not to obtain a Required Consent because of the cost or other terms required to obtain such Required Consent, Health Net reserves the right to remove from the scope of this Agreement any affected Services (or reduce the volume of any affected Services). If the failure to obtain the Required Consent has a material impact on Supplier’s ability to provide the remaining Services or its Charges, Supplier may remove from the scope of this Agreement any affected Services (or reduce the volume of any affected Services). In either such event (i) the Charges shall be reduced using the charging methodologies provided in Schedule C (Charges) and unit rates set forth in the applicable SOW, or otherwise in an equitable manner to the extent such unit rates and charging methodologies do not provide a means to determine what the reduction of Supplier’s Charges should be, and (ii) Health Net shall have the right to rehire Transitioned Employees that are performing or will perform the Services removed from the scope of this Agreement. Health Net’s right in such case to remove or reduce Services (and the corresponding adjustment to charges and right to rehire Transitioned Personnel) shall extend to other Services that relate to Services for which a Required Consent is not obtained if, in Health Net’s reasonable determination, such other Services should be grouped together for operational, maintenance or other reasons. The removal or reduction of Services pursuant to this Section 11.3(d) will be subject to the Change Control Process and Schedule G (Governance).

11.4

Health Net Resources Provided to Supplier Personnel Working On-site

(a)

“On-site Health Net Resources” means the reasonable office space, furniture, fixtures, telephones, office supplies, and other mutually agreed resources to be provided or made available by Health Net (or its Affiliates) to Supplier Personnel assigned by mutual agreement of the Parties to work on-site at facilities of Health Net (or its Affiliates).

(b)

Except as otherwise provided in this Agreement, Health Net will provide to Supplier Personnel located and authorized to work on-site at Health Net Facilities the On-site Health Net Resources reasonably necessary for the Transitioned Employees to continue to perform the Functions that they were providing prior to the Transfer Date; provided however, that:


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(i)

For those Transitioned Employees utilizing a Health Net-provided cell phone, Health Net will continue to provide such cell phones until the earlier of (A) the date the lease or contract for each phone expires or terminates, or (B) the end of Phase 2, after which Supplier shall provide same;

(ii)

With respect to laptops and desktops, Health Net will provide such PCs for the Transitioned Employees until the earlier of (A) the date the lease on such PC expires or terminates, or (B) the end of Phase 2, after which Supplier shall provide same.

(iii)

Health Net will not be responsible for providing any other portable computing or communications devices to Supplier Personnel.

(c)

Supplier shall comply and cause Supplier Personnel to comply with Health Net’s Policies regarding access to and use of the On-site Health Net Resources to Supplier, including procedures for the physical and logical security. Health Net may conduct periodic compliance inspections and audits to confirm that Supplier’s use of the On-site Health Net Resources complies with the terms of this Agreement.

(d)

Supplier will use the On-site Health Net Resources in an efficient manner and for the sole purpose of providing the Services. Supplier will be responsible for damage to the On-site Health Net Resources caused by the negligence or intentional misconduct of Supplier Personnel. When the On-site Health Net Resources are no longer required for performance of the Services, Supplier will return them to Health Net in substantially the same condition as they were in when Supplier began use of them, subject to reasonable wear and tear.

11.5

Service Description Update

(a)

On or before the date that is forty-five (45) days after the Effective Date, Supplier shall provide a plan to Health Net describing Supplier’s proposed approach for conducting a true-up of the Services descriptions to determine if there are any additional Functions that were being performed by the Affected Employees during the twelve (12) months prior to the Effective Date that are not described in the Initial SOWs. Such plan shall be subject to Health Net’s review and approval.

(b)

Promptly after the BPaaS Services Commencement Date, Supplier shall implement the approved plan described in Section 11.5(a) above. Supplier shall create a list and description of any Functions that are not covered in the Initial SOWs and provide same to Health Net on or before the date that is forty-five (45) days after the BPaaS Services Commencement Date. In assembling such list of omitted Functions, Supplier shall not exclude or delete any Function identified by a Transitioned Employee in connection with such effort. The Initial SOWs shall be updated with any additional Functions and descriptions that the Parties agree were not described in the applicable Initial SOW. There shall be no increase in the Charges as a result of the updating process described in this Section.


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12.

RESOURCE ACQUISITIONS DURING THE TERM

12.1

General Responsibility and Compatibility

(a)

Except for (i) any resources set forth in Schedule O (Health Net Provided Resources), for which Health Net has Financial Responsibility and (ii) items which are shown as Health Net Retained Expenses in the Financial Responsibility Matrix attached as Schedule C-11 to Schedule C (Charges), Supplier is solely responsible (and has Financial Responsibility) for providing all Equipment, Software, connectivity, facilities, personnel, third party services and other resources required to perform and render the Services in accordance with this Agreement, including modifications, upgrades, enhancements, additions and replacements of Equipment, Software, and other resources as necessary or appropriate to render the Services in compliance with this Agreement.

(b)

Without limiting the generality of the foregoing, unless otherwise provided in Schedule O (Health Net Provided Resources), Supplier is also responsible (and has Financial Responsibility) for:

(i)

providing network connectivity between facilities necessary to provide the Services, including connectivity from Health Net Facilities or Health Net’s outsourcing vendor facilities to Supplier’s facilities, onshore and offshore. The Parties shall work together to determine the bandwidth, access, security and other requirements for such network connectivity;

(ii)

acquiring additional third party services as necessary or appropriate to render the Services in compliance with this Agreement;

(iii)

providing personal computers for Supplier Personnel and any additional Equipment (including modifications, upgrades, enhancements, additions and replacements of Equipment) as necessary or appropriate to render the Services in compliance with this Agreement, and the installation, operation, maintenance and refresh of such Equipment; and

(iv)

providing or acquiring all Software as necessary or appropriate to render the Services in compliance with this Agreement, including any office productivity Software for Supplier Personnel.

(c)

Supplier shall provide the Services using tools and processes that are compatible with those used by Health Net and its other service providers to provide other services within the Health Net environment. This includes implementing and maintaining interfaces with Health Net and other service provider problem management, change control, and configuration management systems to the extent required to maintain such compatibility.

(d)

Notwithstanding anything to the contrary in Section 25.3, the Parties agree that Schedule O (Health Net Provided Resources) may be changed through the Change Control Process without the need for a formal amendment to this Agreement.


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12.2

Software Used to Provide the Services

(a)

Upon Health Net’s request (made not more than twice per annum) Supplier will provide to Health Net a list of all Supplier Provided Software. Supplier Provided Software excludes any Health Net Software or third party Software to be provided by Health Net for Supplier’s use under this Agreement. Each list of Supplier Provided Software required under this Section 12.2(a) will separately identify:

(i)

Supplier Software that is Commercially Available,

(ii)

Supplier Software that is Non-Commercially Available,

(iii)

Third Party Software that is Commercially Available, and

(iv)

Third Party Software that is Non-Commercially Available.

(b)

If, after the Effective Date, Supplier intends to use any Supplier Software or Third Party Software that would constitute Supplier Provided Software, Supplier may do so without obtaining Health Net’s prior written consent (except as provided in Section 12.3(b)(ii)(B)(1)) provided that (i) Supplier’s implementation and use of such Software does not constitute a Change (and if it does, Supplier’s implementation and use of it will be subject to the Change Control Process), and (ii) Supplier has all necessary rights and agrees to provide to Health Net at the end of the Term the applicable license rights set forth in Section 12.3 with respect to such Software.

(c)

Notwithstanding anything else in this Section 12.2 to the contrary, if Supplier makes available to Health Net, or otherwise makes receipt of the Services dependent upon, any Software and fails to follow the process set forth in this Section 12.2, such use shall not limit Supplier’s obligations or Health Net’s rights set forth in Section 12.3 below.

(d)

Any Software and associated contracts acquired by Supplier for which Health Net is financially responsible shall be acquired in the name of Health Net unless Health Net otherwise agrees in writing.

12.3

Health Net Rights to Certain Software

The intent of this Section 12.3 is to provide the means for Health Net to have the ability to access and Use, both during the Term and Disengagement Assistance Period and thereafter as Health Net may require as contemplated herein, all Supplier Provided Software, it being the mutual intent of the Parties to provide Health Net a means to acquire licenses to whichever of the Supplier Provided Software that Health Net may desire to continue using after the Term and any Disengagement Assistance Period as outlined herein.

(a)

License During Term.

(i)

Supplier hereby grants to Health Net during the Term and any Disengagement Assistance Period, the right to use Software made available by Supplier to Health Net during the Term (including any updates and upgrades to such Software provided by Supplier), solely for Health Net (and its Affiliates and Service Recipients) to receive and use the Services.


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(ii)

Supplier hereby grants to Health Net, its Affiliates and the Service Recipients during the Term and any Disengagement Assistance Period, the right to access and Use—appropriate to their designated roles for Health Net and its Affiliates and consistent with Health Net’s and its Affiliates’ practices prior to the execution of this Agreement—the systems used by Supplier to provide the Services (and Health Net Data stored or processed in such systems) solely for Health Net, its Affiliates and the Service Recipients to perform their designated roles for Health Net and its Affiliates as reasonably required to receive and use the Services and otherwise reasonably required to carry on Health Net’s and its Affiliates business operations. By way of example and not limitation, Health Net’s rights include the right to access the systems used by Supplier to provide the Services in order to access Health Net Data, generate queries, run reports and perform retained Functions.

(b)

Additional Licenses to Use Certain Software.

This Section 12.3(b) shall apply to the Initial SOWs and any Future SOWs entered into by the Parties, provided that with respect to any Future SOW, the Parties may mutually agree in writing that this Section 12.3(b) shall not apply to such SOW, provided further that such agreement shall require the written agreement of the Health Net Legal Department.

(i)

Supplier Software

(A)

Commercially Available Supplier Software

(1)

With respect to Supplier Provided Software that is Commercially Available Supplier Software, Supplier (on behalf of itself and those Supplier Affiliates that own any such Software) grants to Health Net and its Affiliates (and for the sole purpose of providing services to Health Net, its Affiliates, Former Health Net Affiliates and Service Recipients, to Health Net’s and its Affiliates’ service providers), a license to Use such Software under the then-current license terms made available by Supplier to commercial customers comparable to Health Net in terms of use of the Software, during all Disengagement Assistance Periods for any Service for which such Software is used, and continuing thereafter, provided however that:

if such then-current terms do not grant Health Net rights to Use such Software in the same manner and for the same purposes it was used under this Agreement, then such license shall be deemed to include such additional rights of Use without additional charge; and

if Health Net and Supplier have an existing license agreement applicable to such Software, the terms of such license agreement shall apply.

The foregoing licenses shall be provided at the fees that are ordinarily charged by Supplier to licensees of such Software, for the period after the applicable Disengagement Assistance Periods; provided, however, that if the fees that are ordinarily charged are for a perpetual license and Health Net desires to use such Software for only a limited time period after the applicable Disengagement Assistance Periods, Health Net shall not be required to purchase a perpetual license for such Software (or pay the equivalent of a perpetual license fee).


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(2)

Supplier will offer to provide to Health Net, generally available Software Updates, maintenance, support and other services for such Supplier Software on Supplier’s then-current standard terms and conditions for such services, including pricing not in excess of that customarily charged to Supplier’s other commercial customers comparable to Health Net in terms of use of the Software. If Health Net elects to receive such services, (a) Health Net shall only be obligated to pay for such services to the extent applicable to the period after the applicable Disengagement Assistance Periods; and (b) the charges for such services will reflect that maintenance and support on such Software is current (i.e., no “catch-up” or similar payments shall be required to be made by Health Net because maintenance and support may have lapsed – if maintenance and support has lapsed, Supplier shall pay charges necessary to bring maintenance and support current).

(B)

Non-Commercially Available Supplier Software

(1)

Supplier (on behalf of itself and those Supplier Affiliates that own any Supplier Provided Software that is Non-Commercially Available Supplier Software) grants to Health Net and its Affiliates (and for the sole purpose of providing services to Health Net, its Affiliates, Former Health Net Affiliates and Service Recipients, to Health Net’s and its Affiliates’ respective service providers), a worldwide, irrevocable, fully paid-up, royalty-free, non-exclusive, non-transferable (except pursuant to a permitted assignment of the Agreement pursuant to Section 27.1) license to Use (solely to the extent such Use is reasonably necessary for use and receipt of the applicable Services being disengaged or for Health Net, its Affiliates and their respective service providers to provide and deliver to Health Net, Health Net Affiliates, Former Health Net Affiliates and Service Recipients services that are substantially similar to the Services being disengaged) Supplier Provided Software that is Non-Commercially Available Supplier Software (including technical interfaces, Documentation, artifacts, manuals and other materials useful in connection with the authorized Use of such Software), during all Disengagement Assistance Periods for any Service for which such Software is used, and continuing through the date that is two (2) years after the last day of the Disengagement Assistance Period pertaining to the applicable Services being disengaged.


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(2)

If Health Net requests, the Parties will mutually agree on applicable terms for Supplier’s maintenance and support of such Non-Commercially Available Supplier Software, and performance of software development requested by Health Net relating to such Software, after such termination or expiration of the Agreement (in whole or in part) or termination of Services for which such Supplier Software was used; provided that:

Health Net shall only be obligated to pay for such maintenance and support and development services for the period after the applicable Disengagement Assistance Periods; and

If Health Net elects, such Software maintenance and support and development services shall be performed (i) under the AO Agreement, in which event the Parties shall negotiate in good faith an appropriate amendment or work order to the AO Agreement, or (ii) on a time and materials basis, including using the professional service rates for applicable skill sets set forth in Schedule C (Charges).

If Supplier fails to provide commercially reasonable maintenance and support and development services for such Non-Commercially Available Supplier Software at the charges described in this Section 12.3(b)(i)(B)(2) , then within ten (10) days of Health Net’s request, Supplier shall provide Health Net and its designees access to the reasonably necessary Source Code for such Software in a Supplier-provided development environment during the period of Health Net’s license to such Software described above, in order to enable Health Net and its designees to perform such maintenance and support and development work on such Software, subject to the license limitations set forth in Section 12.3(b)(ii)(B)(1). Supplier shall reasonably cooperate with Health Net and its designees in connection therewith to enable Health Net to realize the benefits of the license granted under Section 12.3(b)(i)(B)(1).

If Supplier fails to provide the access and cooperation described in the preceding Section 12.3(b)(i)(B)(2)(c), then within ten (10) days of Health Net’s request Supplier shall provide the Source Code to such Non Commercially Available Supplier Software for Use in accordance with the license granted in Section 12.3(b)(i)(B)(1).

(ii)	Third Party Software

(A)

Commercially Available Third Party Software. Supplier shall provide written notice to Health Net identifying any Supplier Provided Software that is Third Party Commercially Available Software as set forth in Section 12.2(a) above.

(B)

Non-Commercially Available Third Party Software.


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(1)

Supplier shall not utilize any Non-Commercially Available Third Party Software that would constitute Supplier Provided Software without Health Net’s prior written consent, which consent Health Net may withhold in its discretion.

(2)

Without limiting Health Net’s rights under this Section, no consent of Health Net shall be valid unless such consent outlines Health Net’s material rights to such Software during the Term and during any Disengagement Assistance Periods and for the two years after the applicable Disengagement Assistance Period. Unless Health Net expressly (i) consents to other specifically outlined license rights in writing in which this Section 12.3(b)(ii)(B)(2) is cross referenced as being superseded, (ii) enters into a license agreement with the applicable third party under different terms or (iii) otherwise waives in such written consent the following requirements, such Health Net material rights shall include the following:

a world-wide, irrevocable, fully-paid up, royalty-free, non-exclusive license for Health Net and its Affiliates (and for the sole purpose of providing services to Health Net, its Affiliates, Former Health Net Affiliates and Service Recipients, to Health Net’s and its Affiliates’ respective service providers) to Use such Non-Commercially Available Third Party Software (including Source Code, programmer interfaces, Documentation, artifacts, manuals and other materials useful in connection with the Use of such Software), at no additional charge, during any Disengagement Assistance Periods for any Services for which such Software is used, and continuing through the date that is two (2) years after the last day of the Disengagement Assistance Period with the latest end date, or such other license terms as Health Net may agree in writing to accept, and

a commercially reasonable maintenance and support agreement for such Software from the licensor of such Third Party Software, provided that:

if Health Net elects to receive such maintenance and support, Health Net will be responsible for charges under such maintenance and support agreement only with respect to the period after the end of the Disengagement Assistance Period with the latest end date, and

ii.

the charges under such maintenance agreement shall reflect the fact that maintenance and support on such Software is current (i.e., no “catch-up” or similar payments shall be required to be made by Health Net because maintenance and support may have lapsed during the Term or Disengagement Assistance Period).


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(C)

If Supplier fails to comply with its obligations under Section 12.3(b)(ii)(B)(1) or (2), such failure shall constitute a breach of this Agreement. In such event, by way of endeavoring to mitigate Health Net’s damages resulting from the failure, Supplier shall use all Commercially Reasonable Efforts, at Supplier’s cost and expense to (i) promptly secure for Health Net a license comparable to a Deliverables License for the Non-Commercially Available Third Party Software, or (ii) if this cannot be accomplished with Commercially Reasonable Efforts, replace the Non-Commercially Available Third Party Software without degrading the functionality or performance of the Services and bear any costs of implementing the replacement Software, and secure for Health Net a license for such replacement Software as follows: (i) if such replacement Software is Non Commercially Available Third Party Software, then a license comparable to a Deliverables License, and (ii) if such replacement Software is Commercially Available, then a license on the standard terms on which such Software is licensed to customers comparable to Health Net.

(c)

Relationship to License in Section 15 (IP Rights). Nothing set forth in this Section 12.3 shall limit Health Net’s rights under Section 15 (Intellectual Property Rights).

12.4

Colocation Facilities.

(a)

Prior to the Effective Date, Supplier entered into agreements (each a “Colocation Agreement”) to procure certain colocation space in a data center in Centennial, Colorado and a data center in Chandler, Arizona. Supplier intends to exercise an option to procure additional colocation space under each of the Agreements for use in providing the Services to Health Net (“Health Net Colocation Space”).

(b)

Health Net shall have the option, at any time after it has requested Disengagement Assistance from Supplier and continuing through the date that is two (2) years after the last day of the Disengagement Assistance Period pertaining to the applicable Services, to assume Supplier’s rights and obligations under the Colocation Agreements with respect to such Health Net Colocation Space only. Supplier represents and warrants that each of the providers of such Health Net Colocation Space (“Colocation Providers”) has consented to such arrangement.

(c)

If Health Net elects to exercise such option, Health Net shall give written notice to Supplier. Supplier will assign the Colocation Agreement to Health Net or, if Health Net so elects, provide Health Net with reasonable cooperation and support in Health Net’s efforts to procure a replacement agreement with the Colocation Provider for use of such Health Net Colocation Space.


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13.

TRANSITION

13.1

Overview

(a)

This Article 13 (Transition) addresses at a high level the transition of the Functions comprising the Services from Health Net to Supplier. Schedule Z (High-Level Transition Information) provides a consolidated view of Transition across all of the Initial SOWs and, in addition, each of the Initial SOWs contains an exhibit describing the Transition approach and plans for the relevant Service Tower.

(b)

The Transition approaches, plans and schedules set forth in Schedule Z (High-Level Transition Information) and the Initial SOWs reflect the Parties’ preliminary understanding as to how the Transition will be conducted, but they do not contain the necessary level of detail to serve as executable Transition plans. Promptly following the execution of this Agreement, Supplier will work diligently with Health Net’s team leads for each Service Tower to develop and submit executable Transition plans containing the necessary level of operational detail, as set forth in Section 13.4(b).

(c)

The Transition will be carried out in sequential phases and discrete ‘waves’ encompassing different Functions and work streams. Some waves are independent from other waves, and some are dependent on the progress and results of other waves. To help ensure that the Transition proceeds smoothly and with minimal disruption to Health Net’s business operations, the Parties will establish and include in the executable Transition plans appropriate ‘check-point gates’ intended to assess and validate the progress of Transition waves at logical points along the way, both to ensure that problems encountered during a Transition wave are resolved before dependent work proceeds and that lessons learned from performance of Transition waves are documented and communicated to the Transition teams working on other waves in order to minimize the recurrence of problems during Transition.

13.2

“Transition” Defined

(a)

“Transition” means the process (and associated time period) of migrating performance of the Services from Health Net or from Health Net’s then-current service provider to Supplier, completing any contemplated movement of services from onshore locations to alternate onshore locations, near shore locations and offshore locations (each as contemplated by the applicable Transition Documents), making any planned improvements to the process and methods and infrastructure used to perform and deliver the Services that are intended to be made during the period of Transition, and causing any required knowledge transfer from Health Net personnel to Supplier Personnel.

(b)

The Transitions for each of the Initial SOWs (each, an “Initial SOW Transition”) shall commence on the BPaaS Services Commencement Date, and continue through the date that Supplier has assumed all responsibility with respect to the SOW Services covered by the Initial SOWs and completed the transition to the contemplated off-shore service delivery model. The Parties expectation is that Transition will occur over an approximately two (2) year period after the BPaaS Services Commencement Date.

(c)

The Transition for each Future SOW (each, a “Future SOW Transition”) shall commence on the applicable SOW Effective Date, and continue through the date that Supplier has assumed all responsibility with respect to the SOW Services covered by such Future SOW and completed the transition to the contemplated off-shore service delivery model (if any).

(d)

The Transition for the Initial SOWs includes the closing of the transaction contemplated by the APA. Health Net and Supplier shall close on such transaction in accordance with the terms of the APA.


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13.3

Transition Changes

(a)

Given the breadth, complexity and criticality of the Functions being outsourced by Health Net to Supplier under the Initial SOWs, a well-planned, orderly, well-executed Transition is critical to preventing damage to Health Net, its Members, Providers, and employer Groups and to the continued, undisrupted operation of Health Net’s and its Affiliates businesses during the Term. Accordingly, it is agreed and understood that If Health Net determines in good faith that the Transition, or any part of the Transition, poses a meaningful risk or hazard to Health Net’s business interests (a “Transition Risk”), Health Net may request a suspension of or alteration to the Transition (each a “Transition Change”).

(b)

Upon Supplier receiving a Transition Change request from Health Net:

(i)

Notwithstanding anything else to the contrary in this Section 13.3, Supplier shall immediately suspend the Transition or those aspects of the Transition that Health Net requests be suspended; and

(ii)

the Parties’ respective Transition Management Offices shall immediately begin conferring to determine how to implement the Transition Change going forward (i.e., after any suspension) so as to eliminate the Transition Risk in the least disruptive and least costly way, taking into account the risk to Health Net’s business and the financial impact on Supplier, but giving priority to minimizing the risk to Health Net’s business.

(c)

If the Parties have not reached agreement as to the nature of the Transition Change to be made going forward or the manner in which it is to be made within a reasonable amount of time after Health Net’s sending the notice of Transition Change to Supplier, the dispute shall immediately be escalated to the Executive Council.

(d)

If the Executive Council has not resolved the disagreement within a reasonable amount of time after referral of the disagreement to the Executive Council, Health Net’s Chief Executive Officer shall have the final say on the nature and manner of the Transition Change, taking into account the risk to Health Net’s business and the financial impact on both Parties, but giving priority to minimizing the risk to Health Net’s business. In all events, Health Net’s Chief Executive Officer must act reasonably and in good faith and shall choose a manner of Transition Change that, all else being equal, seeks to address the Transition Risk in a satisfactory way to Health Net while minimizing the incremental financial burden on Supplier.

(e)

Supplier will bear financial responsibility for its cost impacts from the Transition Change if the Transition Risk giving rise to the Transition Change met the threshold of posing a meaningful risk or hazard to Health Net’s routine business operations (an “Operational Transition Risk”), except to the extent that such Operational Transition Risk has resulted from the failure by Health Net (including failure by a Health Net contractor, agent or other party for which Health Net is responsible, but excluding Supplier) to perform an express obligation of Health Net under this Agreement. The foregoing allocation of cost, if any, will be subject to Supplier following the procedures outlined in Section 8.3 (Savings Clause). If not, Health Net will bear financial responsibility for Supplier’s cost impacts from the Transition Change.


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(f)

If the Executive Council cannot agree on whether (i) the risk threshold stated in Section 13.3(a) has been met, or (ii) Health Net was partially at fault in creating the Transition Risk and, if so, what portion of Supplier’s cost impact is therefore equitably allocable to Health Net, then either Party may refer the disagreement for resolution to a third party subject matter expert (“Mediator”) for non-binding resolution. In order to avoid conflicts of interests, the fees for such Mediator shall be paid for by both Parties equally. The selection of the Mediator shall be approved by at least three (3) members of the Executive Council. Both Parties shall cooperate fully with the Mediator and provide any reasonably requested information as promptly as practicable. The Mediations shall be completed in not more than thirty (30) days. If either Party disagrees with the non-binding resolution(s) proposed by the Mediator, , then such Party may refer the disagreement for resolution via litigation in accordance with Section 26.2 (Litigation); provided, however, that the existence of such disagreement (at any stage) and the mediation process shall not constitute grounds for delaying or altering the Transition Change while the dispute is being resolved if so directed by Health Net.

(g)

Where possible, all Transition Changes shall be processed via the Change Control Process on an expedited basis, including as an Emergency Change when necessary under the circumstances.

13.4

Transition Documents

(a)

Each Transition shall be conducted in accordance with a written plan and documents (the “Transition Documents”) which shall include: (i) a description of the operations being transitioned; (ii) a general description of the methods and procedures, personnel and organization Supplier will use to perform the Transition; (iii) a schedule of the Transition activities; (iv) a detailed description of the respective roles and responsibilities of Health Net and Supplier; (v) such other information and planning as are necessary to conduct the Transition in accordance with the other terms in this Agreement.

(i)

A draft of the Transition Documents for the Initial SOWs Transition is attached to the Transition Manual for each SOW as Exhibit A-2 (Transition Description), Exhibit A-2-1 (Transition Project Plan) and Exhibit A-2-2 (Transition Staffing Plan) and Schedule Z (High-Level Transition Information); and

(ii)

A draft of the Transition Documents for any Future SOW Transition shall be included as part of the applicable Future SOWs as contemplated by Schedule R (SOW Template).

(b)

Following the Effective Date with respect to the Initial SOW Transitions or the applicable SOW Effective Date for any Future SOW Transition, Supplier shall be responsible for revising and finalizing the applicable Transition Documents, provided that: (i) Supplier shall cooperate and work closely with Health Net in finalizing such Transition Documents (including incorporating Health Net’s reasonable comments); and (B) all changes to such Transition Documents shall be subject to the prior written approval by Health Net.


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13.5

Conduct of the Transition

Supplier will carry out and complete the Initial SOW Transitions and any Future SOW Transition in accordance with the applicable Transition Documents, including its time schedule. Except as otherwise expressly provided in the applicable Transition Documents, Supplier’s responsibilities with respect to each Transition include:

(a)

performing and managing the Transition and In-Flight Projects and activities;

(b)

establishing communications lines and network connections, and providing Equipment, Software, tapes, records and supplies, as made necessary by the Transition;

(c)

performing the Transition without interruption, and without disrupting Health Net’s business operations;

(d)

paying Supplier’s costs associated with the Transition, including communications circuit costs (both installation/de-installation and ongoing) except as otherwise expressly provided in this Agreement; and

(e)

otherwise performing such migration tasks as are necessary to enable Supplier to complete the Transition and provide the Services.

13.6

Health Net Cooperation and Support

Health Net will cooperate with Supplier in the conduct of each Transition and provide support as described in the applicable Transition Documents.

13.7

In Flight Projects

As part of the Transition, Supplier will also assume responsibility for completing the projects listed or described in Schedule X (In-Flight and Accelerated Projects), which are in progress as of the SOW Effective Date or expected to commence promptly following the Effective Date (the “In-Flight and Accelerated Projects”).

13.8

Completion of Transition Projects

(a)

Health Net reserves the right to monitor, test and otherwise observe and participate in each Transition. Supplier will notify Health Net without delay if any Health Net monitoring, testing or participation has caused (or Supplier expects it to cause) a problem or delay in a particular Transition and work with Health Net to prevent or circumvent the problem or delay.

(b)

Health Net’s as-is operations will not be disabled until Supplier demonstrates to Health Net’s reasonable satisfaction that the affected processes and operations have been successfully migrated to Supplier and are functioning properly.


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(c)

If any of the Transition activities are not completed on schedule and the delay is not due to the fault of Health Net (or its Affiliates, customers or other suppliers), Force Majeure, or a failure to secure required Regulatory Consents, then for the period of delay:

(i)

if Supplier’s charges to Health Net are greater than they would have been if the delayed Transition activity had been completed on schedule, Health Net will receive a credit against Supplier’s monthly charges in an amount equal to the difference between Supplier’s actual charges and what Supplier’s charges would have been if the delayed Transition activity had been completed on schedule; and

(ii)

Supplier will give Health Net an additional credit against Supplier’s monthly charges in an amount sufficient to reimburse Health Net for any excess or continuing costs incurred for personnel, third-party equipment, Software and/or services that would not have been incurred if the delayed Transition activity had been completed on schedule.

(d)

Provided that a Transition is on schedule and that there are no problems with such Transition, Supplier may request the approval of Health Net to accelerate a wave of such Transition, provided that granting of such approval shall be in Health Net’s reasonable discretion.

14.

DATA SECURITY AND PROTECTION

14.1

[Reserved.]

14.2

Health Net Data, Generally

(a)

As between the Parties, Health Net Data will be and remain the property of Health Net. Supplier may not use Health Net Data for any purpose other than to render the Services. No Health Net Data will be sold, assigned, leased or otherwise disposed of to third parties or commercially exploited by or on behalf of Supplier (or any of its Subcontractors). Neither Supplier nor any of its Subcontractors may possess or assert any lien or other right against or to Health Net Data. Without limiting the generality of the foregoing, (a) Supplier may only use Health Net Data as strictly necessary to render the Services and must restrict access to such information to Supplier Personnel on a strict need-to-know basis, and (b) Supplier shall not download, copy, transmit or make available any Health Net Data to any third party (other than an Approved Subcontractor) except as expressly permitted by this Agreement.

(b)

At Health Net’s request at any time during the Term, Suppler shall provide Health Net with access to and/or copies of (in format reasonably requested by Health Net) any Health Net Data stored on Supplier systems or otherwise under the control of Supplier.

14.3

Data Security

(a)

When present at Health Net Facilities or accessing Health Net systems or Health Net Data (whether such data is in Health Net’s systems of Supplier’s systems), Supplier will observe and comply with Health Net’s Policies regarding data security procedures that have been communicated to Supplier. Prior to performing Services from any new service location (i.e., any service location other than those set forth in Schedule F (Supplier Facilities)), Supplier shall complete a security questionnaire, which Health Net requires before Services are permitted to be provided from a new service location. If Health Net requests, Supplier shall provide Health Net with access to any new service location for due diligence purposes.


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(b)

Supplier will establish and maintain reasonable safeguards designed to protect against the occurrence of any Security Breach, including by establishing and maintaining appropriate network and internet security procedures, protocols, security gateways and firewalls with respect to Health Net Data.

(c)

Supplier shall comply with the security requirements and standards set forth in Schedule Q (Security Addendum), which represent the minimum security requirements and standards with which Supplier must comply. Supplier shall also comply with:

(i)

All applicable Laws relating to privacy and information security, as they may evolve during the Term, including those establishing federal services requirements (such as the Federal Information Processing Requirements and FIPS 140-2), the National Institute of Standards and Technology (NIST) and as may be required for Health Net to qualify for the safe harbor exemption for de-identified health information under the HIPAA Privacy Rule (45 CFR 164.502 (d));

(i)

the Payment Card Industry Data Security Standards (promulgated by the PCI Data Security Standards Council) (“PCI DSS”);

(ii)

the applicable legal or regulatory requirements of the Exchange Agreement, to the extent provided to Supplier reasonably in advance of the need to implement any such requirements; and

(iii)

the legal or regulatory requirements, obligations or other terms with which Health Net must comply under any Regulatory Contract that are provided to Supplier reasonably in advance of the need to implement any such requirements.

(d)

Supplier shall be responsible for implementing additional security measures as may be necessary to protect Health Net Data from any unauthorized access or use and to prevent any Security Breach in accordance with this Agreement.

(e)

Supplier shall meet with Health Net not less frequently than once every six (6) months to review the continually evolving security threat environment and potential changes to the applicable security standards to address the same.

(f)

No Health Net Data may be stored outside of the United States. No Health Net Data may be accessed from outside of the United States without Health Net’s prior written consent, which may be granted or withheld in Health Net’s discretion. Supplier may access Health Net Data from those Supplier Facilities shown on Schedule F (Supplier Facilities), and Supplier may store Health Net Data at those on-shore Supplier Facilities shown on Schedule F (Supplier Facilities), that are denoted as facilities from which Supplier may access and store (as applicable) Health Net Data.

(g)

Health Net will be provided with backup copies of Health Net Data from the Supplier upon written request. Supplier must store and transmit backup Health Net Data in accordance with Schedule Q (Security Addendum). Supplier will document such safeguards in the Procedures Manual.


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(h)

Without limiting the generality of the foregoing:

(i)

Supplier’s information security policies shall provide for (A) regular assessment and re-assessment of the risks and vulnerabilities to the confidentiality, integrity, and availability of Health Net Data, including electronic data, and systems acquired or maintained by Supplier and its agents and contractors, including (1) identification of internal and external threats that could result in a Security Breach, (2) assessment of the likelihood and potential damage of such threats, taking into account the sensitivity of such data and systems, and (3) assessment of the sufficiency of policies, procedures, and information systems of Supplier and its agents and subcontractors, and other arrangements in place, to control risks; (B) protection against such risks; and (C) establishment and monitoring of key risk indicators (▇▇▇▇). Supplier shall provide such policies, and conduct and report on the results of such assessments to Health Net.

(ii)

Supplier shall (A) require all users to enter a user identification and password prior to gaining access to the information systems; (B) control and track the addition and deletion of users; (C) control and track user access to areas and features of Supplier’s information systems, and (D) encrypt Health Net Data in accordance with Schedule Q (Security Addendum).

(iii)

Supplier Personnel will not attempt to access, or allow access to, any Health Net Data that they are not permitted to access under this Agreement. Without limiting any of Supplier’s other obligations in respect of a Security Breach, including those set forth in Section 14.7, as soon as Supplier first becomes aware that unauthorized access to Health Net Data has been attained, (i) Supplier will report such unauthorized access to Health Net, describing to the best of Supplier’s knowledge the Health Net Data that was accessed, and (ii) Supplier shall take all necessary measures to stop the access, prevent recurrences, and return to Health Net any copied or removed Health Net Data.

(iv)

Except as provided in Section 21 (Confidentiality), Supplier shall (A) remove all Health Net Data from any media within the scope of the Services that is taken out of service; (B) destroy or securely erase such media in accordance with Health Net Policies and otherwise in a manner designed to protect against Security Breaches; and (C) provide to Health Net, within five (5) business days after a receipt of a request from Health Net, a notification of destruction, which may be provided via an automated solution that creates an auditable record.

14.4

Intrusion Detection/Interception

Supplier will provide Health Net and its representatives with:

(a)

reasonable access to the alerts, logs and data feeds from Supplier’s and its Subcontractors’ network intrusion detection systems, host intrusion detection systems and anti-virus tools on assets at Health Net Facilities or in data center(s) being used for the Services each to the extent used exclusively to provide Services to Health Net in order to enable Health Net to have adequate and timely access to system data regarding security incidents that have a nexus to Health Net, including Security Breaches;

(b)

access to Supplier’s information security policies and Supplier’s procedures relating to intrusion detection and interception with respect to the Supplier systems used to provide the Services for the purpose of examining and assessing those policies and procedures in accordance with Section 18 (Audits and Records); and


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(c)

(d)

the other requirements set forth in Schedule A (Services) or an SOW.

14.5

Litigation and Investigation Requests

(a)

Supplier recognizes that (i) Health Net may, from time to time, ▇▇▇ third parties, be sued by third parties, or have grounds to believe that one or more lawsuits will be filed for or against Health Net, (ii) Health Net may be the subject of governmental, regulatory or similar investigations and requests or demands for information from third parties, and (iii) Health Net may conduct internal investigations at its own prerogative (including investigations conducted by or on behalf of its Organization Effectiveness, Legal and/or Special Investigations business units). Upon any of the foregoing events occurring (for avoidance of doubt, these events do not include any legal proceeding directly between Health Net and Supplier, or their respective Affiliates), Supplier hereby agrees to fully cooperate with Health Net and its legal counsel, and to create and implement a process sufficient to comply, in a timely manner, with any requests from Health Net or its legal counsel to categorize, identify, view, preserve, extract, produce, filter, convert and and/or provide to Health Net or its designee (in the format reasonably requested by Health Net), any hard copy documents or electronically stored information or data of any type that is associated with the Services, that results from or reflects the Services, or that evidences or memorializes Supplier’s efforts on behalf of Health Net pursuant to this Agreement (hereinafter, the “Requested Information”). Requested Information may include: claims data, email data, home drive data, server data, common drive data, data stored in cloud repositories, data on smartphones or peripheral devices, and data stored with any third-parties on Supplier’s behalf. Requested Information may include any type of reports or other information received, created or collected as part of the Services, all information created by or for Health Net or Health Net’s employees, or at their request, and any information or “metadata,” associated with other types of Requested Information. Requested Information may include any type of information relating to the foregoing within Supplier’s possession, custody or control, including information entrusted to its employees or third parties, or housed in any type of repository or media whatsoever, such as servers, systems, applications, discs, equipment, tapes, or other locations. Supplier shall use best efforts to provide requested information in a timely manner to enable Health Net to meet regulatory and internal deadlines.

(b)

Supplier acknowledges and agrees that Supplier may, in some instances, be required to utilize or required to involve outside professionals to utilize forensic extraction methods and techniques to obtain Requested Information without alteration, to set-up a new or use an existing non-production environment to retrieve and provide Requested Information, and if requested by Health Net, Supplier shall provide access to such environment or Requested Information so that Health Net and/or its designee may access, view, download and extract the Requested Information, including reasonable access to third-party litigation support providers selected by Health Net to facilitate requests for Requested Information. Supplier shall maintain and support an access method for allowing such access and extractions, as determined by Health Net (e.g., SFTP connections, remote access, on-site access). Supplier will use its best efforts to provide all Requested Information within the time period specified by Health Net or its legal counsel, and, if such deadlines cannot be met, Supplier shall promptly notify Health Net of the reason and extent of any delay.


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(c)

Health Net shall direct any request under this Section 14.5 (Litigation and Investigation Requests) to the Supplier Account Executive. Upon Health Net’s request, Supplier shall promptly designate a Supplier attorney to work with Health Net and who can facilitate any Health Net request under this Section. In the event that Health Net is the target of a governmental inquiry or investigation, Health Net shall retain all responsibility for directly interacting with such governmental entity regarding such inquiry or investigation. Supplier shall comply with and follow all restrictions and requirements reasonably imposed by Health Net or its legal counsel to maintain the protections of the attorney-client privilege and attorney work-product doctrine for all efforts and communications connected with requests and efforts made under this section 14.5.

If requests for Requested Information do not comprise Services under this Agreement, and require additional time or resources to meet the specifications of Health Net or its legal counsel, then such requests shall be responded to through the Change Control Process, but Health Net shall have the right to direct that any such request constitutes an Emergency Change under such process requiring expedited handling and fulfillment.

14.6

Compliance with Data Privacy and Data Protection Laws, Regulations and Policies

(a)

In carrying out its activities under this Agreement, and without limiting Section 27.7 (Compliance with Laws), each Party will observe and comply with all applicable data privacy and data protection Laws. In addition, when accessing or handling any Health Net Data that contains personal identifying information, Supplier will comply with Health Net Policies that have been disclosed to Supplier relating to the use and disclosure of such information.

(b)

The Parties hereby reaffirm their agreement to the terms of the Business Associate Agreement between the Parties which is being executed on or about the Effective Date (“Business Associate Agreement”). The Business Associate Agreement is hereby incorporated into this Agreement by reference and made a part of this Agreement. In the event of any conflict between the terms of this Section 14 (Data Security and Protection), Section 21 (Confidentiality) and the terms and conditions of the Business Associate Agreement, the terms and conditions that are more protective of the Protected Health Information (as such term is defined in HIPAA) shall govern to the extent of that conflict.

14.7

Security Breach.

(a)

If Supplier becomes aware of (or if Health Net notifies Supplier of) any Security Breach (even if such Security Breach arises out of events or items that are not in the possession of or operated by (or for) or under the control of Supplier or a third party which receives Health Net Data (directly or indirectly) through Supplier, notwithstanding the limitations in the definition of Security Breach), Supplier shall:

(i)

notify Health Net’s Chief Information Security Officer (or his or her identified delegate) of such Security Breach in accordance with Section 14.3(f)(iii) and, thereafter, perform a root cause analysis thereon, the results of which shall be provided to Health Net;


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(ii)

investigate such Security Breach and report its findings to Health Net, including providing updates of such investigation as they occur and promptly responding to requests for information from Health Net;

(iii)

unless such investigation shows that a suspected or threatened Security Breach was unsuccessful, provide Health Net with a remediation plan, acceptable to Health Net in Health Net’s reasonable discretion, to address the Security Breach and which is designed to prevent any further similar incidents;

(iv)

remediate such Security Breach in accordance with such approved plan;

(v)

after consulting with Health Net’s Chief Privacy Officer, conduct a forensic investigation to determine what systems, data and information have been affected by such event, and provide Health Net with daily updates of the results of such investigation;

(vi)

cooperate with Health Net’s investigation of the Security Breach, including promptly providing any information that Supplier (or a Subcontractor) has with respect to the Security Breach; and

(vii)

at Health Net’s request, cooperate with any law enforcement or regulatory officials, credit reporting companies, and credit card associations investigating such Security Breach.

(b)

Where permitted by Law, Health Net shall, acting reasonably, make the final decision on notifying Health Net’s members, employees, suppliers and/or the general public of such Security Breach, and the implementation of the remediation plan.

(c)

With respect to such Security Breach:

(i)

Except to the extent that Supplier is able to demonstrate that the Security Breach was caused by Health Net’s negligence, willful misconduct or breach of this Agreement, Supplier shall be responsible at its own expense for performing the activities described in Section 14.7(a) and for all other costs and expenses incurred by Supplier (and its Subcontractors) in relation to the Security Breach;

(ii)

Supplier shall have Financial Responsibility for all costs and expenses incurred by Health Net (and Health Net’s Affiliates) in relation to the Security Breach, including Identity-Related Costs, except as provided in Section 14.7(c)(iii) ; and

(iii)

To the extent the Security Breach arises out of Health Net Data that was compromised (“Compromised Data”) due to any Health Net-provided technologies, Software, or other assets prior to the time that such Compromised Data was scheduled to be relocated to a Supplier-furnished data center as set forth in the Transition Documents for SOW#4 attached to the Transition Manual as Exhibit A-2 (Transition Description), Exhibit A-2-1( Transition Project Plan), and Exhibit A-2-3 (Transition ITO Plan (Phase 2 Implementation)) (as such documents are updated by the Parties pursuant to Section 13.3 (Transition Documents) and Section 1 of Schedule Z (Transition)), and provided the Security Breach was not attributable to (A) Supplier’s failure to adhere to the information, data and physical security practices and standards observed by Health Net and at


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the affected data center as of the BPaaS Services Commencement Date, or (B) Supplier’s acts, omissions, negligence, willful misconduct, breach of this Agreement or failure to take reasonable actions or employ industry best practices to protect the Health Net Data, Health Net Software or systems in question, then (x) Supplier shall not have Financial Responsibility for such Security Breach other than as provided in Section 14.7(c)(i), and (y) Supplier shall not have Financial Responsibility for remediating the Security Breach under Section 14.7(a)(iv).

(d)

Supplier shall reimburse Health Net on demand for all costs and expenses described in Sections 24.2(f)(x) and 24.2(f)(xi) relating to any Security Breach.

14.8

Import/Export Controls

(a)

The Parties acknowledge that certain software and technical data exchanged pursuant to this Agreement may be subject to import/export controls under the Laws of the United States and other countries. Neither Party will import, export or re-export any such items, any direct product of those items, or any technical data in violation of applicable import/export control Laws.

(b)

Each Party will be responsible for compliance with import/export control Laws with respect to any items it is deemed under such Laws to have imported or exported, including responsibility for preparing and filing all required documentation and obtaining all licenses, permits and authorizations required for compliance. Each Party will cooperate with the other Party in that Party’s efforts to comply with applicable import/export control Laws.

(c)

Supplier will include with copies of all Software provided to Supplier by Health Net’s U.S.-based personnel that Supplier will use outside of the United States documentation stating that “These commodities, technology or software were exported from the United States in accordance with Export Administration Regulations. Diversion or re-export contrary to U.S. law is prohibited.”

14.9

Compliance with ▇▇▇▇▇-▇▇▇▇▇-▇▇▇▇▇▇

(a)

“GLB Act” means the ▇▇▇▇▇-▇▇▇▇▇-▇▇▇▇▇▇ Act, 15 USC §6801 et. seq., and the implementing regulations and regulatory interpretations thereto, as amended from time to time. Supplier acknowledges that Health Net is subject to Title V of the GLB Act, pursuant to which Health Net is required to obtain certain undertakings from Supplier with regard to the privacy, use and protection of nonpublic personal financial information of Health Net’s (or of any Health Net Affiliate’s or Service Recipient’s) customers or prospective customers (“Health Net Non-public Data”). Therefore, notwithstanding anything to the contrary contained in this Agreement and in addition to (and not in substitution for) Supplier’s other obligations hereunder, Supplier agrees that:

(b)

it will not disclose or use any Health Net Non-public Data except to the extent necessary to carry out its obligations under this Agreement and for no other purpose;

(i)

it will not disclose Health Net Non-public Data to any third party, including, without limitation, its third party service providers without the prior consent of Health Net and an agreement in writing from the third party to use or disclose such Health Net Non-public Data only to the extent necessary to carry out Supplier obligations under this Agreement and for no other purposes; and


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(ii)

it will maintain, and will require all third parties approved under Section 7.7 (Subcontracting) to maintain, effective information security measures to protect Health Net Non-public Data from unauthorized disclosure or use; and it will provide Health Net with information regarding such security measures upon the reasonable request of Health Net and promptly provide Health Net with information regarding any failure of such security measures or any security breach related to Health Net Non-public Data.

(c)

The obligations set forth in this Section 14.9 (Compliance with ▇▇▇▇▇-▇▇▇▇▇-▇▇▇▇▇▇) will survive termination or expiration of this Agreement. For purposes of this Agreement, Health Net Non-public Data includes the nonpublic personal information (as defined in 15 USC §6809(4)) received by Supplier in connection with the performance of its obligations hereunder, including (i) an individual’s name, address, e-mail address, IP address, telephone number and/or social security number; (ii) the fact that an individual has a relationship with Health Net; and (iii) an individual’s account information. For the avoidance of doubt, Health Net Non-public Data does not include (A) information collected from Health Net employees (in their capacity as employees, and not as Health Net’s customers) by Supplier for the purpose of administering and providing the Services, and (B) nonpublic information collected from a source other than Health Net that has been obtained on a non-confidential basis and which is not subject to the GLB Act.

15.

INTELLECTUAL PROPERTY RIGHTS

This Article 15 sets forth the Parties’ respective rights in Work Product and other materials provided or created pursuant to this Agreement. As between the Parties, the rights apply as set forth in this Article 15 whether the work in question is performed solely by Supplier Personnel or by Supplier Personnel working jointly with others.

15.1

Certain IP-related Definitions

(a)

“Derivative Work” means a work of authorship or expressive creation (i) that includes more than a de-minimis amount of copyright-protected elements of a pre-existing work, or (ii) such work is incapable of being used without the pre-existing work or in conjunction with the pre-existing work, including a work in which a pre-existing work has been modified, enhanced, recast, transformed, or adapted.

(b)

“Independent IP” of a party (including a third party) means any materials, methods, processes, and other forms of intellectual property that either (i) were created or acquired by or for the party on or prior to the Effective Date, or (ii) are subsequently created or acquired by or for the party outside the scope of and independent from this Agreement, and (iii) any Derivative Works of either of the foregoing. Supplier Independent IP includes the Acquired Seller Intellectual Property Rights as defined in the APA.

(c)

“New Work” means any Material produced by Supplier Personnel specifically for Health Net in the course of performing the Services that is not a Derivative Work.


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15.2

Independent IP, Generally

(a)

The Parties agree that:

(i)

As between the Parties, each Party will have and retain all ownership of all right, title and interest, including Intellectual Property Rights, in and to its Independent IP, and will be entitled to seek Intellectual Property Rights protection for its Independent IP as it deems appropriate;

(ii)

a Party will not submit patent applications or otherwise seek to file for or obtain Intellectual Property Rights protection with respect to or based upon the other Party’s Independent IP without the other Party’s prior written consent, which may be withheld at the other Party’s sole discretion;

(iii)

a Party will not be permitted to use the other Party’s Independent IP except as otherwise expressly provided in this Agreement or in any other written agreement between the Parties;

(iv)

EXCEPT AS OTHERWISE EXPRESSLY PROVIDED IN THIS AGREEMENT OR IN ANY OTHER WRITTEN AGREEMENT BETWEEN THE PARTIES, ANY RIGHTS OF USE OF A PARTY’S INDEPENDENT IP GRANTED IN THIS AGREEMENT ARE GRANTED ON AN ‘AS-IS, WHERE-IS’ BASIS WITHOUT EXPRESS OR IMPLIED WARRANTIES OF ANY KIND; and

(v)

If Health Net provides any of its Independent IP to Supplier for use in rendering the Services, Health Net hereby grants to Supplier a nonexclusive, non-transferable, worldwide, fully paid-up right and license during the Term and any Disengagement Period to Use such Independent IP solely to perform the Services, with the right to sublicense Approved Subcontractors to do the same on Supplier’s behalf, subject to any limitations or restrictions set forth in agreements between Health Net (or its Affiliate) and third party licensors of the Health Independent IP that are disclosed in writing, in advance by Health Net to Supplier. Supplier may not Use Health Net’s Independent IP for the benefit of any entities other than Health Net and Health Net’s Affiliates (and their respective Service Recipients under this Agreement) without the prior written consent of Health Net, which may be granted or withheld in Health Net’s discretion.

15.3

Rights in Deliverables

(a)

“Deliverable” means any material that is produced by Supplier Personnel specifically for Health Net (or another Service Recipient) in the course of performing Services and is either (i) listed or described in an SOW (or Work Order, Project plan or any other document signed or agreed to in writing by the Parties) as a Deliverable, or (ii) actually delivered or otherwise required to be delivered to Health Net (or another Service Recipient) as an intended output of the Services. A Deliverable may be a one-off material resulting from performance of Project Services (e.g., a Software application) or, alternatively, a recurring form of material resulting from performance of BPaaS Services (e.g., a document containing processed Health Net Data or a periodic operational or management report).

(b)

“Software Deliverable” means any Deliverable that is (or contains) Software.


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(c)

Except as otherwise expressly provided in a subsequent written agreement between the Parties, the Parties’ respective Intellectual Property Rights in Deliverables shall be as follows:

(i)

If the Deliverable is developed as part of an Accelerated Project, a BPaaS Roadmap Project a BPaaS Non-Discretionary Project, or any other type of Project under this Agreement that is not a BPaaS Discretionary Project, Supplier will be the owner of the Deliverable, and Supplier hereby grants to Health Net, during the Term and any Disengagement Period, a nonexclusive, world-wide, fully paid-up, non-transferable (except as part of a permitted assignment pursuant to Section 27.1 (Binding Nature and Assignment)) right and license for Health Net (or its Affiliate or another Service Recipient) to Use (or have Used on its behalf) the Deliverable solely in connection with Health Net’s (or its Affiliate’s or such other Service Recipient’s) receipt and use of the BPaaS Services, subject to any additional limitations that may be set forth in a written agreement between the Parties. Health Net license rights with respect to Software Deliverables owned by Supplier (including those developed as part of an Accelerated Project, a BPaaS Roadmap Project or a BPaaS Non-Discretionary Project) following the Term and any Disengagement Period shall be pursuant to the terms of Section 12.3 (Health Net Rights to Use Certain Software) of this Agreement and Section 4 of the BPaaS Supplemental Terms and Conditions for BPaaS Services.

(ii)

If the Deliverable is developed as part of a BPaaS Discretionary Project and consists solely of New Work (or does not contain any Independent IP of Supplier or a third party who has licensed Independent IP to Supplier), the Deliverable and all Intellectual Property Rights in and to the Deliverable will be owned by Health Net from the moment it is created, and the Deliverable will be deemed to be a ‘work made for hire’ for Health Net under applicable copyright Laws. To the extent that title and ownership rights in the Deliverable may not originally vest in Health Net as contemplated herein, Supplier hereby irrevocably assigns, transfers and conveys to Health Net all such right, title and interest without further consideration. Supplier agrees to execute such other documents or take such other actions as Health Net may reasonably request to file, record, perfect, and enforce Health Net’s Intellectual Property Rights in and to the Deliverable, as set forth herein, including obtaining any necessary assignments, consents, or waivers from individual authors, creators, or inventors.

(iii)

If the Deliverable is developed as part of a BPaaS Discretionary Project and does contain some Independent IP of Supplier, Supplier will be the owner of the Deliverable (including any New Work incorporated into the Deliverable), and Supplier hereby grants to Health Net a nonexclusive, perpetual, irrevocable, fully paid-up, world-wide, transferable and sub-licensable (through multiple levels of sub-licensees) right and license to Use (or have Used on its behalf) such Deliverable, including the Supplier Independent IP incorporated in such Deliverable, including for the creation and use of Derivative Works, without any further consideration or duty of accounting to Supplier or any third party (a “Deliverables License”) provided, however, that if such Supplier Independent IP comprises Software, in no event shall such Supplier Independent IP be unbundled or separated from the applicable Deliverable or used as a stand-alone product or development tool. In addition, unless and except as expressly provided in the proviso contained in the following sentence or as Health Net otherwise expressly


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agrees in a written agreement with Supplier, Supplier shall be restricted to using such Deliverable solely to provide the Services under this Agreement (each such Deliverable, a “Restricted Use Deliverable”). Health Net shall be obligated to compensate Supplier separately for providing ongoing maintenance and support services for any Restricted Use Deliverable, in a per annum amount equal to fifteen percent (15%) of Supplier’s charges to Health Net for developing the Restricted Use Deliverable, or such other amount as may be agreed in writing between the Parties; provided, however, that Health Net shall have the right to provide written notice to Supplier at any time that Health Net no longer requires that such Deliverable be a Restricted Use Deliverable, in which event Supplier shall thereafter provide maintenance and support for such Restricted Use Deliverable at no additional charge to Health Net for the remainder of the Term and any Disengagement Period.

(d)

Any representations and warranties of Supplier that are applicable to a Deliverable shall apply equally to any Independent IP of Supplier or a third party incorporated into such Deliverable.

(e)

If the Deliverable is owned by Health Net or is a Restricted Use Deliverable, Supplier will ▇▇▇▇ the Deliverable with such proprietary rights and confidentiality legend(s) as Supplier may be reasonably instructed by Health Net to use.

(f)

If Supplier desires to use any Deliverable that is owned by Health Net or is a Restricted Use Deliverable, or a Derivative Work of thereof, in connection with providing services to another customer, Supplier shall notify Health Net of its proposal. If Health Net consents to Supplier’s proposed use of such Deliverable, Supplier may use such Deliverable to perform services for other customers in the manner and on the terms and conditions set forth in Health Net’s written consent.

15.4

Incorporation of Third-Party Independent IP in a Deliverable

(a)

Supplier Personnel shall not incorporate any Independent IP of a third party into a Deliverable without first notifying Health Net of its nature and obtaining Health Net’s written consent to do so unless Supplier has all necessary rights to grant Health Net a Deliverables License in and to such third party Independent IP as set forth herein. If Supplier does not have all such rights (or if Supplier is unwilling to grant Health Net a Deliverables License in and to such Supplier Independent IP), then prior to incorporating the third party Independent IP into the Deliverable, Supplier shall enter into with Health Net, or procure for Health Net or assist Health Net in procuring, a license to Use the incorporated third party Independent IP on terms that are acceptable to Health Net.

(b)

If Supplier incorporates any Independent IP of a third party into a Deliverable without first notifying Health Net of its nature and obtaining for Health Net, or confirming that Health Net has obtained, the necessary rights of use as provided in Section 15.4(a), such failure shall constitute a breach of this Agreement. In such event, by way of endeavoring to mitigate Health Net’s damages resulting from the failure, Supplier shall, at Supplier’s cost and expense: (i) use all Commercially Reasonable Efforts to promptly secure for Health Net a license comparable to a Deliverables License for the incorporated third party Independent IP, or (ii) if this cannot be accomplished on commercially reasonable terms with Commercially Reasonable Efforts, replace or modify the Deliverable to remove the incorporated third party Independent IP without degrading the functionality or performance of the Deliverable and without adversely affecting Supplier’s performance of the Services, and Supplier shall bear any costs of implementing the replaced or modified Deliverable.


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15.5

Work Products

(a)

“Work Product” means any material produced by Supplier Personnel in the course of performing the Services that is not a Deliverable.

(b)

Supplier will own all Intellectual Property Rights in and to all Work Products; provided, however, that if a Work Product contains any Health Net Data or other Health Net material, Health Net will retain all of its Intellectual Property Rights in and to such Health Net material (and Derivative Works thereof) contained in the Work Product. Health Net hereby grants to Supplier a nonexclusive, non-transferable, worldwide, fully paid-up right and license during the Term and any Disengagement Period to Use the subject Health Net materials solely to perform the Services, with the right to sublicense Approved Subcontractors to do the same on Supplier’s behalf.

(c)

If a Work Product is (or incorporates) Software, Health Net’s rights with respect to such Software shall be as set forth in Section 12.3 (Health Net Rights to Certain Software).

(d)

If a non-Software Work Product is necessary or useful for Health Net’s (or another Service Recipient’s) use of a Deliverable for its intended purpose or receipt and use of the Services, then, unless Health Net agrees to enter and does enter into another form of license with Supplier with respect to the Work Product, Supplier hereby grants to Health Net, during the Term and any Disengagement Period, a nonexclusive, world-wide, fully paid-up, non-transferable (except as part of a permitted assignment pursuant to Section 27.1 (Binding Nature and Assignment)) right and license for Health Net or another Service Recipient to Use (or have Used on its behalf) the Work Product as necessary or useful for Health Net’s (or such other Service Recipient’s) use of the Deliverable or receipt and use of the Services.

15.6

Delivery of Deliverables and Other Materials

Upon expiration or termination of this Agreement or any SOW or Services, to the extent Supplier has not already done so, Supplier will turn over to Health Net all Deliverables and other materials owned by Health Net or to which Health Net has been granted (or is to be granted) license rights pursuant to this Agreement.

15.7

Use of Material Subject to Open Source Licenses

Without Health Net’s prior written approval, which Health Net may grant or withhold in its sole discretion, no Deliverable will incorporate, link to or call upon any components subject to an Open Source License (including the GNU General Public License). The provisions of this Section 15.7 (Use of Material Subject to Open Source Licenses) shall not apply to any Deliverable that forms part of the ABS Platform.

15.8

Intellectual Property Rights Agreements with Supplier Personnel

Supplier is responsible for having in place with all Supplier Personnel (either directly or indirectly through their respective employers) such agreements respecting Intellectual Property Rights as are necessary for Supplier to fulfill its obligations under this Section 15 (Intellectual Property Rights).


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15.9

Bankruptcy

All licenses and rights of Use granted under or pursuant to this Agreement shall be deemed to be, for the purposes of Section 365(n) of the United States Bankruptcy Code (the “Bankruptcy Code”), licenses to rights in “intellectual property” as defined under the Bankruptcy Code. Accordingly, the licensee of such rights shall retain and may fully exercise all of its rights and elections under the Bankruptcy Code. Upon the commencement of bankruptcy proceedings by or against either Party under the Bankruptcy Code, the other Party shall be entitled to retain all of its license rights and Use rights granted under this Agreement.

15.10 Mental Impressions

(a)

“Mental Impressions” means general ideas, concepts, know-how and techniques relating to data processing and computer programming that are learned and retained in the unaided memory of a Party’s and or any of its Affiliates’ personnel involved in performance of this Agreement who have had access to Confidential Information or materials of the other Party and its Affiliates without deliberately memorizing them for purposes of reuse.

(b)

Each Party and its Affiliates may use the Mental Impressions of their personnel in their business activities provided that in doing so they do not disclose Confidential Information of the other Party in violation of Section 21 (Confidentiality) or misappropriate or infringe the Intellectual Property Rights of the other Party, its Affiliates, or third parties who have licensed or provided materials to the other Party or its Affiliates.

16.

TERMINATION

16.1

Termination By Health Net

(a)

Termination for Cause. If Supplier (i) commits a material breach of this Agreement or any SOW and fails to cure such breach within thirty (30) days after receiving notice of the breach from Health Net, or (ii) commits multiple breaches of this Agreement or any SOW, whether material or non-material, that collectively constitute a material breach of a material provision of this Agreement or any Related SOW(s), (iii) fails to close on the transaction contemplated by the APA in breach thereof, or (iv) commits a material breach of its obligations under Section 3.6 of Schedule E (Transitioned Employees), then Health Net may, by giving written notice to Supplier, terminate this Agreement (in whole or in part) or any Related SOW(s) (in whole or in part) for cause as of a date specified in the notice of termination. Any termination by Health Net shall not constitute an election of remedies and shall be without prejudice as to Health Net’s other rights and remedies under this Agreement or at law or in equity.

(b)

Termination for Convenience. Health Net may terminate this Agreement (in whole or in part) or any SOW (in whole or in part) at any time for convenience (i.e., for any reason or no reason) by giving Supplier at least three (3) months’ prior written notice specifying the terminated Services and designating the termination date.

(c)

Termination for Certain Service Level Failures. If (i) the amount of Service Level Credits (excluding those associated with Non-BPaaS IT Services) that Supplier is obligated to credit to Health Net equals the entire BPaaS Amount at Risk for *** or more months in any rolling *** continuous month period, or (ii) the amount of Service Level Credits relating to the Non-BPaaS IT Services that Supplier is obligated to credit to Health Net equals the


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entire Non-BPaaS Amount at Risk for *** or more months in any rolling *** continuous month period, then Health Net may, by giving notice to Supplier, terminate this Agreement (in whole or in part) or any Related SOW(s) (in whole or in part), as of a date specified in the notice of termination. The foregoing rights to terminate shall not be construed as precluding Health Net from claiming that any other Service Level Failure (or combination thereof) is a material breach of this Agreement and to exercise any available remedies in connection with such material breach.

(d)

Termination Following a Change of Control of Health Net. “Change of Control of Health Net” means an announcement by Health Net (i) that any other entity, person or “group” (as such term is used in Section 13(d) of the Securities Exchange Act of 1934, as amended) will acquire Control, of all or substantially all of the assets or customers, of Health Net (or any parent company of Health Net), whether directly or indirectly, in a single transaction or series of related transactions, or (ii) that Health Net (or any parent company of Health Net) will consolidate with, or be merged with or into, another entity, or will sell, assign, convey, transfer, lease or otherwise dispose of all or substantially all of its assets or customers to another person(s) or entity(ies). At any time within one year after the effective date of the consummation of the transaction described in (i) or (ii) above, Health Net may terminate this Agreement (in whole or in part) or any Related SOW(s) (in whole or in part) by giving Supplier at least ninety (90) days prior written notice specifying the terminated Services and designating the termination date.

(e)

Termination Following a Change of Control of Supplier. A “Change of Control of Supplier” means an announcement by Supplier (A) that any other entity, person or “group” (as such term is used in Section 13(d) of the Securities Exchange Act of 1934, as amended) that is a health plan, or offers a health plan to its customers, will acquire Control, of all or substantially all of the assets, of Supplier (or any parent company of Supplier), whether directly or indirectly, in a single transaction or series of related transactions, or (B) that Supplier (or any parent company of Supplier) will consolidate with, or be merged with or into, another such entity, or will sell, assign, convey, transfer, lease or otherwise dispose of all or substantially all of its assets to another such person(s) or entity(ies). At any time within *** after the effective date of the consummation of the transaction described in subsections (i) or (ii) above, Health Net may terminate this Agreement (in whole) or in part (provided that such in part termination is limited to termination of all BPaaS Services or all Non-BPaaS IT Services) by giving Supplier at least ninety (90) days’ prior written notice specifying the terminated Services and designating the termination date.

(f)

Termination in the Event of a Force Majeure. Health Net may terminate this Agreement (in whole or in part) or any Related SOW(s) (in whole or in part) as provided in Section 24.3 (Force Majeure).

(g)

Termination Due to Change in Law. Health Net may terminate this Agreement (in whole or in part) or any Related SOW(s) (in whole or in part) by giving Supplier at least ninety (90) days’ prior written notice specifying the terminated Services and designating the termination date if a Law enacted after the Effective Date (i) precludes or substantially restricts Health Net from using or receiving Services or (ii) substantially increases Health Net’s cost of using or receiving Services.

(h)

[Reserved.]


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(i)

Termination Due To Adverse Changes in Supplier’s Financial Circumstances. If an Adverse Change in Supplier’s Financial Circumstances occurs then Health Net may terminate this Agreement by giving written notice to Supplier designating the termination date. Supplier shall notify Health Net as soon as possible after becoming aware of an actual or likely Adverse Change in Supplier’s Financial Circumstances. Supplier shall (i) endeavor to certify to Health Net at least annually, and (ii) otherwise certify within ten (10) days of a request by Health Net, that an Adverse Change in Supplier’s Financial Circumstances has not occurred as of the date of certification or, to the best of Supplier’s knowledge, is not likely to occur within twenty (24) months after the date of certification.

(j)

Termination Relating to Customer Consents or Regulatory Approval. Health Net may terminate this Agreement (in whole or in part) or any SOW (in whole or in part), as provided in Section 4.3 (Regulatory and Customer Approvals).

(k)

Termination if Supplier Becomes a Competitor of Health Net. If Supplier develops or acquires a business line or service offering that is a health plan or offers health plans to its customers and is competitive with Health Net’s business, Health Net may terminate this Agreement (in whole or in part) or any SOW(s) (in whole or in part) by giving Supplier at least ninety (90) days’ prior written notice specifying the terminated Services and designating the termination date; provided however, that this Section 16.1(k) shall not be considered to apply to Supplier’s provision of Services to a third party that competes with Health Net’s business.

(l)

Termination Relating to Supplier’s Liability Cap. If Supplier owes or has paid to Health Net damages in an amount greater than *** of the Liability Cap evidenced by one or more of the following:

(i)

an agreement by Supplier that it owes Health Net such damages,

(ii)

a settlement agreed to by the Parties, or

(iii)

an order from a court of competent jurisdiction or an arbitration award, and Supplier does not agree to refresh the Liability Cap to its original amount (i.e., meaning that none of such damages incurred prior to the date of Health Net’s request for Supplier to refresh the Liability Cap shall, after such refresh, be considered to apply against the refreshed Liability Cap) within thirty (30) days after a Health Net written request to Supplier to refresh the Liability Cap, then Health Net may terminate this Agreement (in whole or in part) or any Related SOW(s) (in whole or in part) upon not less than thirty (30) days’ prior written notice to Supplier.

(m)

Termination Relating to Business Associate Agreement. Health Net may terminate this Agreement as provided in the Business Associate Agreement.

(n)

Pre-BPaaS Services Commencement Date Termination. Health Net shall have the right to terminate this Agreement prior to the BPaaS Services Commencement Date by sending written notice to Supplier and paying to Supplier the Breakup Fee.


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16.2

Termination Related Payments.

(a)

Health Net and/or Supplier, as applicable, may exercise its rights to terminate under this Article 16 or Section 4.3(d)(iii) without charge, except that, subject to Section 16.2(a)(iii), on the effective date of any termination under this Article 16 or Section 4.3, Health Net shall pay to Supplier:

(i)

the Break-Up Fee (and no other amounts) if the termination of the entire Agreement is prior to the BPaaS Services Commencement Date; or

(ii)

the following if the termination is on or after the BPaaS Services Commencement Date:

(A)

outstanding charges (if any) for all terminated Services completed in accordance with the Agreement through to the effective date of termination (including for work in progress);

(B)

the applicable termination fee calculated pursuant to Section 18 of Schedule C (Charges); and

(C)

any due and unpaid payments relating to the applicable Minimum Revenue Commitment fee through to the effective date of termination, calculated pursuant to Section 17 of Schedule C (Charges);

provided that nothing set forth herein shall limit Health Net’s right to dispute Charges under Section 10.7.

(iii)

For any termination under Sections 16.1(a), 16.1(c), 16.1(l) or 16.1(m),

(A)

Health Net shall have the right to offset against the amounts owed under Section 16.2(a)(ii)(A), any damages that can be reasonably quantified as having been incurred by Health Net and arising directly out of the event(s) giving rise to the termination; and

(B)

Health Net shall pay any remaining amounts owed to Supplier (if any) under Section 16.2(a) concurrently with the final resolution of Health Net’s underlying damage(s) claims, rather than on the effective date of termination.

(b)

Nothing set forth in this Section 16.2 shall limit Health Net’s right to make a claim for damages or to exercise any other remedies available under this Agreement, at law or at in equity.

(c)

Termination Not Supported By Competent Authority. If a purported termination by Health Net under any of Sections 16.1(a) or 16.1(c) – 16.1(n) is found by a competent authority not to be a proper termination under such section, then such termination will be deemed to be a termination for convenience by Health Net under Section 16.1(b).


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16.3

Termination By Supplier

If Health Net fails to pay Supplier when due material undisputed charges totaling at least *** *** Charges under this Agreement, and fails to make such payment within sixty (60) days after the date Health Net receives notice of non-payment from Supplier, then Supplier may terminate this Agreement by sending written notice to Health Net, in which event this Agreement shall terminate as of the date specified in the notice of termination. Following Supplier’s termination pursuant to this Section 16.3 (Termination By Supplier), Health Net shall pay to Supplier all fees and charges set forth in Section 16.2(a)(ii).

16.4

Extension of Termination/Expiration Date

Health Net may extend the effective date of any termination/expiration of this Agreement or a SOW one or more times as it elects in its discretion. However, the total of all such extensions for any single termination/expiration may not exceed one hundred eighty (180) days following the effective date of termination/expiration in place immediately prior to the initial extension under this Section 16.4. If any extension notice provided to Supplier within thirty (30) days of the then-scheduled date of termination/expiration would cause Supplier to incur Out-of-Pocket Expenses, Supplier may so notify Health Net. In that case, the extension will be subject to Health Net agreeing to reimburse Supplier for its Out-of-Pocket Expenses incurred as a result of the extension notice being provided within thirty (30) days of the then-scheduled date of termination/expiration. If Supplier terminated pursuant to Section 16.3 (Termination By Supplier), then Health Net will pay for any such extension Services thirty (30) days in advance based on projected usage, with the following month’s invoice showing a true up or true down to account for actuals.

16.5

Partial Termination

(a)

Partial Terminations by Health Net. With respect to any partial terminations described herein, included those set forth in this Article 16 or Section 4.3, Health Net may only terminate by Line of Business or by Service Tower. All other purported partial terminations hereunder will be considered a reduction in Services unless otherwise agreed to by the Parties.

(b)

If this Agreement or any SOW is terminated in part:

(i)

the portions of this Agreement (or the applicable SOW) not terminated will continue in force according to the terms of this Agreement and the applicable SOW;

(ii)

if this Agreement (or the applicable SOW) does not otherwise specify the basis for determining Supplier’s charges for the continuing Services that are not terminated, the charges payable under this Agreement (or the applicable SOW) will be equitably adjusted to reflect the Services that have been terminated, taking into account any increased per-unit charges for remaining Services;

(iii)

the amounts (if any) payable by Health Net pursuant to Section 16.2 in respect of such termination will be, where applicable, equitably adjusted to reflect the portion of the Services being terminated and any changes in Supplier’s costs; and


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(iv)

the Agreement documents specifying the termination-related payments for which Health Net is responsible will be revised to reflect the amounts paid by Health Net pursuant to Section 16.2.

(c)

For clarity, Health Net’s reduction in volume of a particular Service (e.g., a reduction in the number of Claims or Members) shall not constitute a termination in part pursuant to Section 16.1 unless Health Net provides written notice to Supplier terminating this Agreement in part or an SOW in part pursuant to Section 16.1.

16.6

Disengagement Assistance

(a)

General.

(i)

During each Disengagement Assistance Period, Supplier shall provide Disengagement Assistance to Health Net, or at Health Net’s request to Health Net’s designee. For the avoidance of doubt, there may be more than one Disengagement Assistance Period for any Affected Services.

(ii)

The Parties further agree that:

(A)

Health Net’s request for (and Supplier’s provision of) Disengagement Assistance may be in the context of any reduction or removal of a portion of the Services (or volumes of Services) or Functions that is in accordance with this Agreement or any SOW, although this Agreement or the applicable SOW is not itself expiring or being terminated; and

(B)

Disengagement Services provided by Supplier shall be subject to the other applicable provisions of this Agreement.

(b)

Except as may be permitted by Section 16.6(c), the quality of Services (including the Affected Services) provided by Supplier, and Supplier’s performance of the Services, will not be materially degraded during the period Supplier is providing Disengagement Assistance. Supplier shall not (i) make any changes to the number of the Supplier Personnel providing the Services during the applicable Disengagement Assistance Period, or (ii) reassign any Supplier Personnel away from performing Services under this Agreement during the applicable Disengagement Assistance Period, in each case except as otherwise permitted by this Agreement or set forth in any disengagement plan mutually agreed to by the Parties.

(c)

Except to the extent permitted by this Section 16.6(c), Supplier shall provide Disengagement Assistance utilizing Supplier Personnel then being regularly utilized to provide the Services (“Existing Supplier Personnel”).

(i)

If Supplier believes in good faith that providing Disengagement Assistance utilizing Existing Supplier Personnel will prevent Supplier from meeting the Service Levels or otherwise complying with other obligations under this Agreement, Supplier shall provide written notice to such effect to Health Net, describing the circumstances in which the provision of such Disengagement Assistance by some or all Existing Supplier Personnel would prevent Supplier from meeting Service Levels or comply with its obligations under this Agreement.


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(ii)

Upon receipt of such notice, Health Net may (in its sole discretion), elect to either:

(A)

Permit Supplier to utilize personnel in addition to the Existing Supplier Personnel to provide the Disengagement Assistance, or

(B)

Waive the Service Level Credits and any other remedy for failure to meet the applicable Service Levels and other affected obligations of Supplier, in which case Supplier shall only utilize the Existing Supplier Personnel to provide the Disengagement Assistance, and shall nonetheless use good faith efforts to continue to meet the Service Levels and perform in accordance with its obligations under this Agreement.

(d)

Charges for Disengagement Assistance. Charges for Disengagement Services shall be as follows:

(i)

For Disengagement Assistance for which there is a predetermined charge in Schedule C (Charges) (e.g., a charge to maintain and support a server), such pre-determined charge in the applicable SOW shall apply.

(ii)

For Disengagement Assistance for which (1) there are no predetermined charges in Schedule C (Charges) (i.e., for assistance that is not part of the routine Services) and (2) Supplier is permitted under Section 16.6(c) to utilize (and does in fact utilize) personnel in addition to the Existing Supplier Personnel to provide such Disengagement Assistance, then the Services performed by such additional Supplier Personnel will be chargeable on a time and material basis pursuant to Section 16.1(b) of Schedule C (Charges).

(iii)

If Supplier terminates for non-payment by Health Net under Section 16.3, Supplier shall have the right to request payment of the charges for the Disengagement Assistance monthly, in advance.

16.7

Survival

Any provision of this Agreement that contemplates or governs performance or observance subsequent to termination or expiration of this Agreement will survive the expiration or termination of this Agreement for any reason, including the following Sections:

(a)

Article 2 (Definitions);

(b)

Article 10 (Invoicing and Payment);

(c)

Section 12.3 (Health Net Rights to Certain Software);

(d)

Article 15 (Intellectual Property Rights);

(e)

Section 16.6 (Disengagement Assistance);

(f)

Section 18.6 (Records Retention);

(g)

Section 19.4 (Deliverable);

(h)

Section 19.7 (Non-Infringement);


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(i)

Section 19.9 (Disabling Code);

(j)

Article 21 (Confidentiality);

(k)

Article 23 (Indemnification);

(l)

Article 24 (Liability);

(m)

Article 25 (Rules of Construction);

(n)

Section Sections 4 and 5 of Annex 1 (Supplemental Terms and Conditions for BPaaS Services); and

(o)

Software Escrow Agreement.

16.8

Bid Assistance

(a)

In the process of deciding whether to undertake or allow any cessation of Services, or any termination, expiration or renewal of this Agreement (or a SOW), in whole or in part, Health Net may consider or seek offers for performance of services similar to the Services. As and when reasonably requested by Health Net for use in any such process, Supplier will provide to Health Net such information and other cooperation regarding performance of the Services as would be reasonably necessary to enable Health Net to prepare a request for proposal relating to some or all of such services, and for a third party to conduct due diligence and prepare an informed, non-qualified offer for such services.

(b)

Without limiting the generality of Section 16.8(a), the types of information and level of cooperation to be provided by Supplier pursuant to this Section 16.8 will be no less than those initially provided by Health Net to Supplier prior to the Effective Date, and shall include the following information which Health Net may distribute to third-party bidders in a request for proposal(s), request for information, specification, or any other solicitation relating to the Services and as necessary to support any related due diligence activities:

(i)

General organization charts showing the overall structure of Supplier’s organization supporting Health Net, and a description of the roles and responsibilities of the various functions described in such organization charts;

(ii)

General organization charts showing the overall structure of the organization supporting the Services and a description of the roles and responsibilities of the various Functions described in such organization charts;

(iii)

The number of personnel at each location used to provide Services classified by job title, skill level, and experience;

(iv)

Generic descriptions of the functions and classifications of the personnel used to provide the Services;

(v)

New training materials, policies and procedures, work instructions, and other written Deliverables created as a result of the Services;


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(vi)

First order descriptions of Health Net’s IT infrastructure environment, including a listing of major infrastructure components and locations;

(vii)

Up-to-date Service Level performance histories, asset inventories (including Equipment and Software) with current book values, third party contracts, and (where possible) then-current work volumes and general information relating to projects underway; and

(viii)

Detailed network topographies.

17.

GOVERNANCE AND MANAGEMENT

17.1

Contract Governance Structure and Processes

(a)

Supplier acknowledges that it is a key business requirement of Health Net that Supplier provide the Services in a consistent, integrated manner. Schedule G (Governance) describes the Contract Governance (as defined therein) and the related framework and processes to manage the relationship between the Parties and Supplier’s performance under this Agreement.

(b)

Notwithstanding anything set forth in this Agreement to the contrary, any term in this Agreement that states that a matter shall be referred to or resolved in accordance with Schedule G (Governance) shall not affect either Party’s right to escalate such matter to the dispute resolution provisions in Article 26.

17.2

Procedures Manual

(a)

The “Procedures Manual” is a document (or set of documents) to be prepared by Supplier describing how Supplier will perform and deliver the Services under this Agreement, the Equipment and Software used, and the documentation (e.g., operations manuals, user guides, specifications) that provide further details of the activities. The Procedures Manual will:

(i)

describe the activities Supplier shall undertake in order to provide the Services, including those direction, supervision, monitoring, staffing, reporting, planning and oversight activities normally undertaken to provide services of the type Supplier is to provide under this Agreement;

(ii)

include Supplier’s escalation procedures and the other standards and procedures of Supplier pertinent to Health Net’s interactions with Supplier in obtaining the Services; and

(iii)

include such other information as would be reasonably necessary to an Auditor when performing audits as permitted by this Agreement.

The Procedures Manual shall describe the aforementioned information in sufficient detail so as to permit a reader to understand how the Services are being provided. The table of contents for the Procedures Manual is set forth in Schedule S (Procedures Manual TOC) .


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(b)

Working in consultation with Health Net, Supplier will deliver to Health Net a detailed outline of the Procedures Manual describing the Services to be transitioned from Health Net to Supplier within ninety (90) days after the Effective Date. Health Net may review the draft Procedures Manual to confirm that it is sufficiently comprehensive to enable Health Net to understand how the Services are being provided. In the event Health Net identifies any deficiencies, Supplier will address such deficiencies and will finalize the Procedures Manual with respect to each wave, within one hundred eighty (180) days after the occurrence of such wave. The final Procedures Manual will be subject to the approval of Health Net for the limited purposes described above.

(c)

The Procedures Manual will be considered an operational document, which Supplier shall revise and periodically update to reflect changes in the operations or procedures described in it. Updates of the Procedures Manual will be provided to Health Net for review, comment and approval, which approval shall be for the limited purposes described in Section 17.2(b).

(d)

Supplier will perform the Services in accordance with the most recent Procedures Manual. In the event of a conflict between the provisions of this Agreement and the Procedures Manual, the provisions of this Agreement will control.

(e)

Notwithstanding anything to the contrary in Article 15 (Intellectual Property Rights), Health Net and its Affiliates may retain and Use the Procedures Manual in their businesses and for their benefit both during the Term and following the expiration or termination of this Agreement for any reason. Subject to appropriate non-disclosure agreements for the limited purpose of protecting any Independent IP of Supplier incorporated into the Procedures Manual, Health Net and its Affiliates may permit any of their other service providers to use the Procedures Manual during and after the Term, but solely in connection with their provision of services for Health Net and its Affiliates.

17.3

Technology Plans

Supplier will update Health Net’s annual technology plan in accordance with the provisions of this Section 17.3 (Technology Plan) (the “Technology Plan”). Each Technology Plan updated by Supplier will include a review and assessment of the immediately preceding Technology Plan. The Technology Plan will consist of a three-year plan and an annual implementation plan as described below.

(a)

Contents of the Technology Plan.

(i)

The Technology Plan will include a comprehensive assessment and strategic analysis of Health Net’s then-current technology environments that are in-scope hereunder for the next three (3) years, including an assessment of the appropriate direction for Health Net’s systems and services in light of Health Net’s business priorities and strategies and competitive market forces (to the extent such business information is available or provided to Supplier). The Technology Plan will include a specific identification of proposed Software and Equipment strategies and direction, a cost projection, a costs-vs.-benefits analysis of any proposed Changes, a description of the types of personnel skills and abilities needed to respond to any recommended Changes or upgrades in technology, a general plan and a projected time schedule for developing and achieving the recommendations made, and references to appropriate operating platforms that support Service Level requirements, exploit industry trends in production capabilities and provide potential price-performance improvement opportunities.


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(ii)

As necessary to support the overall objectives and directions of the three (3)-year plan, the annual implementation plan will provide specific guidance as to the information services requirements, projects and plans for the upcoming year, including details on operations, maintenance backlog and development activities. The annual implementation plan will include a summary review of Supplier’s performance of the Services in the year then concluding, and will provide updates and revisions of the long-term plan as appropriate. Supplier will prepare an annual implementation plan for each year of the Term.

(b)

Process for Developing the Technology Plan.

(i)

As part of the process of preparing the annual implementation plan, (A) Health Net will inform Supplier of its strategic direction, (B) the Parties will mutually agree on the content of the Technology Plan, and (C) the Parties will review the overall operation of this Agreement to ensure that the Services continue to be aligned with Health Net’s strategic business and IT requirements.

(ii)

Supplier will submit for Health Net’s review and approval a draft Technology Plan that reflects the content agreed to pursuant to Section 17.3(b)(i). Supplier will submit the final Technology Plan to Health Net within fifteen (15) days after receiving Health Net’s comments on the draft. Supplier will submit the draft of the Technology Plan within nine (9) months after the Effective Date.

The schedule for developing and delivering each Technology Plan will be coordinated to support Health Net’s annual business planning cycle. Supplier will update the Technology Plan during the year as necessary to reflect changes to Health Net’s and its Affiliates’ businesses that materially affect the validity of the then-current Technology Plan. Supplier will recommend modifications to the Technology Plan as it deems appropriate, and will revise the Technology Plan as requested or approved by Health Net.

17.4

Action Plans and Step In Rights

(a)

Triggers for an Action Plan. If Supplier fails to perform any material or critically important Function or material portion thereof for which it is responsible in accordance with the requirements of this Agreement or the applicable SOW, Supplier shall perform a root cause analysis to determine the underlying cause of such failure to perform, and Health Net may request an action plan from Supplier (the “Action Plan”). If Health Net requests an Action Plan, Supplier will prepare and deliver, at Supplier’s expense an Action Plan for Health Net’s review and approval within five (5) business days after receiving the request, unless a communication from a Regulator requires an earlier date, in which case Supplier will use its best efforts to accelerate the production of the plan.

(b)

Contents of Action Plan. Each Action Plan must be submitted using a Health Net-provided corrective action plan template (or other Health Net-approved format). Each Action Plan must specify in detail reasonably satisfactory to Health Net:

(i)

a description of the problem or problems (each, an “Underlying Problem”) or the process for identifying the Underlying Problem(s) that caused the failure that lead to Health Net’s request for an Action Plan;


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(ii)

where remedy of the Underlying Problem is possible, the actions that will be implemented by Supplier to effect that remedy;

(iii)

the actions that will be implemented by Supplier to prevent the same or a substantially similar Underlying Problem from occurring in the future;

(iv)

a timeline for the implementation of the Action Plan; and

(v)

any other content that may reasonably be requested by Health Net.

(c)

Health Net’s Response to Draft Action Plan.

(i)

After receiving the draft Action Plan, Health Net may give Supplier notice that it approves the draft Action Plan or comment on the draft Action Plan, in which case Supplier must (i) at the reasonable request of Health Net, meet at Supplier’s sole expense to discuss Health Net’s comments; and (ii) within two (2) Business Days (or such longer period as Health Net may set in writing) after the meeting, or receipt of Health Net’s comments where no meeting is required by Health Net (unless as otherwise agreed by the Parties), prepare at Supplier’s sole expense a revised Action Plan addressing Health Net’s comments and submit it to Health Net for its approval.

(ii)

This Section 17.4(c) applies to any proposed Action Plan until it has been approved by Health Net.

(d)

Implementation of Action Plan. Supplier will only implement an Action Plan if Health Net has approved it and in the form approved by Health Net.

(e)

Exercise of Step In Rights.

(i)

In the event:

(A)

Supplier fails to comply in a timely manner with Supplier’s obligations regarding the creation or implementation of an Action Plan, or

(B)

the implementation of the Action Plan does not and will not (within a reasonable period of time) result in the resolution of the Underlying Problem and the prevention of the same or a substantially similar Underlying Problem from occurring in the future; or

(C)

an event (or multiple events) has occurred that Health Net reasonably believes could lead to the right for Health Net to terminate the Agreement (in whole or in part) or any SOW (in whole or in part), then

Health Net may by giving written notice to Supplier have Health Net personnel and/or contractors retained by Health Network along-side Supplier personnel to assist Supplier in resolving the Underlying Problem and preventing its recurrence (a “Step In”). Health Net’s Step In rights shall include the right to access the Health Net Colocation Space and Supplier shall facilitate such access with the Colocation Providers.


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(ii)

If Health Net Steps In, Supplier must cooperate fully with Health Net and its personnel and will provide, at no additional charge to Health Net, all assistance reasonably required by Health Net as soon as possible, including providing all reasonable access to Supplier Personnel and all relevant Equipment, premises and Software under Supplier’s control to facilitate the purpose of the Step In.

(iii)

Health Net’s right to Step In will end when Supplier demonstrates to Health Net’s reasonable satisfaction that Supplier has resolved the Underlying Problem and Supplier is capable of providing the affected Service in accordance with the requirements of this Agreement and the affected SOW.

(iv)

Supplier must reimburse Health Net for its out-of-pocket expenses incurred by Health Net in the event Health Net exercises its right to Step In for up to *** months.

(v)

For the avoidance of doubt, Health Net’s election to Step In:

(A)

does not act to relieve Supplier of its obligations under this Agreement; and

(B)

shall not be construed as limiting any rights and remedies Health Net may have under this Agreement, or at law or equity, in connection with any Underlying Problem, the resulting failure(s) by Supplier to perform in accordance with the Agreement.

17.5

Change Control

(a)

“Change” means any addition to, modification or removal of any aspect of the Services “Change Control Process” means the written procedure set forth in Schedule H (Change Control Process) for considering, analyzing, approving and carrying out Changes, which is designed to ensure that only desirable Changes are made and that Changes made by or on behalf of Supplier are carried out in a controlled manner with minimal disruption to the Services and Service Recipients’ business operations.

(b)

Except as otherwise expressly provided in Schedule A (Services) or in an SOW, Health Net has retained responsibility for establishing the standards (including security standards) and strategic direction of Health Net (and its Affiliates) with respect to outsourcing.

(c)

The Parties agree that a Change might not require changes to the Charges. Supplier shall not be entitled to request an additional charge for a Change unless, and then only to the extent that, (i) such Change (A) is either (1) not within the scope of the Services and is not otherwise Supplier’s financial responsibility under this Agreement or (2) even if it is within such scope or financial responsibility and except as otherwise provided in Section 17.5(e), is a non-de minimus change requested by Health Net in the required manner or location of performance of the Services, and (B) would demonstrably increase Supplier’s costs to implement the Change or to deliver the Services in accordance with such Change; and (ii) the additional charge requested by Supplier for such Change must be directly and reasonably related to the net additional costs incurred by Supplier arising out of the Change (after taking into account any reductions to Supplier’s costs arising out of the Change). Supplier shall include in the applicable Change Order a proposal on how Charges for the affected Services will change.


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(d)

Supplier will not make any Changes, except in accordance with the Change Control Process and with Health Net’s prior written approval; provided, however, that Supplier operational changes that do not fall within clauses (i), (ii) or (iii) and are not subject to other agreed restrictions shall not be subject to such approval. Health Net’s approval of any Change may be withheld in its discretion for any Change that may reasonably be expected to do or result in any of the following in any non- de minimis way: (i) adversely affect the specifications, functionality, performance or resource efficiency of any Services; (ii) increase Health Net’s internal costs, Supplier’s charges to Health Net under this Agreement or charges by other Health Net suppliers to Health Net; (iii) disrupt or adversely affect any of Health Net’s or its Affiliates’ business or operations; or (iv) discontinuing the use of the ABS platform or claim edit system (ihealth) to provide the Services. If Supplier implements any Change without securing Health Net’s prior written approval via the Change Control Process, the Change will be deemed to be provided as part of the Services at no additional charge.

(e)

With respect to any change in a Law or Health Net Policy (or any new Law or Health Net Policy) that either Party determines may require a potential Change to the Services:

(i)

The Parties will mutually discuss the potential Change to the Services, and based on such discussions, Supplier shall provide a proposed Change Order addressing such Change, to reflect how the Services would be modified to be in compliance with such changed or new Law or Health Net Policy (as applicable).

(ii)

With respect to any Change resulting from (x) a change in or a new Law, or (y) a change in or a new Health Net Policy (but only to the extent such change in or new Health Net Policy was required in order to comply with an existing Law or caused by a change in or a new Law):

(A)

Supplier shall use Commercially Reasonable Efforts to implement the Change sufficiently in advance of the effective date of compliance with such changed or new Law such that Health Net has a reasonable amount of time to perform testing of any of Health Net’s equipment, systems, processes or other items that may be impacted by such Change; and

(B)

Supplier shall have financial responsibility for any such Change, except to the extent that Health Net is financially responsible as expressly set forth in Section 13 of Schedule C (Charges).

(f)

If an approved Change would result in:

(i)

New Services or a change to an existing SOW, then (unless otherwise agreed by Health Net to be documented in a Change Notice) the Change must be authorized via, as applicable, a Future SOW pursuant to Section 3.7 or an amendment or modification to an existing SOW made pursuant to Section 25.3 (Contract Amendments and Modifications) or documentation resulting from agreeing to such Change pursuant to the Change Control Procedure; or

(ii)

A change to any other terms of this Agreement, the Change must be authorized via a contract amendment or modification made pursuant to Section 25.3 (Contract Amendments and Modifications).


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18.

AUDITS AND RECORDS

18.1

Audit Rights

(a)

Health Net and its agents, auditors (internal and external), Regulators, Health Net customers, provider groups and hospitals (and their respective auditors), and other representatives as Health Net may designate (collectively, “Auditors”) will have the right to reasonably inspect, examine and audit those portions of the systems, records (including financial records), facilities, data, practices and procedures of Supplier and its Subcontractors that are used in rendering the Services or pertain to the Services (collectively, “Audits”) for any of the following purposes:

(i)

to verify the accuracy of Supplier’s invoices;

(ii)

to verify the integrity of those elements of Health Net’s corporate control processes that are performed by Supplier, in order to permit Health Net’s management and independent auditors to make certifications required by the securities or other Laws of any country;

(iii)

to verify the integrity of Health Net Data and Supplier’s compliance with the data privacy, data protection, confidentiality and security requirements of this Agreement;

(iv)

to examine Supplier’s performance of the Services and to verify Supplier’s compliance with this Agreement, including (to the extent applicable to the Services and to the charges therefore), performing audits of:

(A)

practices and procedures;

(B)

systems, equipment, and Software;

(C)

general controls and security practices and procedures;

(D)

disaster recovery and back-up procedures;

(E)

the validity of Supplier’s charges, but Auditors shall not be given access to information concerning Supplier’s costs except in relation to the following: (1) charges billed on a time and materials basis or using another form of ‘price x quantity’ charging model, (2) Supplier’s proposed charges for Changes, and (3) invoiced charges for reimbursement of Out-of-Pocket Expenses;

(F)

as necessary to enable Health Net to meet, or to confirm that Supplier is meeting, applicable regulatory and other legal requirements; and

(G)

Supplier’s methodology and approach for estimating the charges for Projects;

(v)

to satisfy the requirements of the Health Net audit committee and the requirements of Regulators (including with respect to the requirements of any corrective action plan);


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(vi)

to verify Health Net’s compliance with applicable Laws and Health Net’s agreements with customers and employer groups;

(vii)

to verify Supplier’s compliance with Section 9.5 (Most Favored Customer); and

(viii)

to perform mock Audits.

(b)

Health Net shall also have the right to retain a third party to perform Audits of Supplier’s Service Level measurements, calculations and reporting, and to confirm statistically valid random sampling.

(c)

All Audits shall be subject to the following limitations:

(i)

Audits will be conducted during Business Hours and upon reasonable advance notice to Supplier except in the case of Audits by Regulators, emergency or security Audits and Audits investigating claims of illegal behavior;

(ii)

Health Net and its Auditors will comply with Supplier’s reasonable security and confidentiality requirements, guidelines and other policies of Supplier when accessing facilities or other resources owned or controlled by Supplier with respect to the Audit;

(iii)

Use of any third party auditor that is a Supplier Competitor, shall be subject to Supplier’s prior written approval, such approval not to be unreasonably withheld or delayed;

(iv)

Heath Net and its Auditor(s) must obtain Supplier’s written approval prior to utilizing tools or utilities within Supplier’s computer systems and network, and Supplier shall have the opportunity to thoroughly test such tools prior to granting such approval, such approval not to be unreasonably withheld or delayed.

(d)

Supplier will cooperate with Health Net, its Regulators and its and their Auditors conducting Audits and provide such assistance as they reasonably require to carry out the Audits, including providing audit support as contemplated in any SOWs and providing knowledgeable staff to assist them in conducting Audits. Furthermore, Supplier will comply with Health Net’s internal audit methodology, as it is provided to Supplier by Health Net. Subject to the foregoing, Auditors will be provided reasonable access to systems or Supplier facilities used in the performance of the Services, provided that the Auditors will not have access to any data of any customer of Supplier other than Health Net.

18.2

Supplier Audits

(a)

Supplier will conduct its own audits pertaining to the Services consistent with the audit practices of well-managed companies that perform services similar to the Services. Without limiting the generality of the foregoing, Supplier will conduct the following audits upon Health Net’s request (provided that Health Net shall not request any audit more frequently than annually) at each Supplier Facility and obtain the appropriate compliance certification:

(i)

a security (including physical security) audit;


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(ii)

an audit of privacy practices as related to the Services;

(iii)

a Statement on Standards for Attestation Engagements No. 16, Service Organization Control 2, Type 2 (“SSAE 16”) audit as defined by the American Institute of Certified Public Accountants (or an equivalent ISAE 3402 Type 2 audit or an audit made pursuant to any other guidance that supersedes or replaces SSAE 16 SOC 1 and 2, Type 2). Supplier will provide copies of SSAE 16 or International Standard on Assurance Engagements 3402 (“ISAE 3402”) audit reports for the Services. Supplier will provide such audit reports for the Term of this Agreement. The Audits will be conducted in accordance with third party auditor’s control requirements and industry standards or guidelines. Such audits will be performed on a service or facility basis and not on a customer specific basis;

(iv)

ISO 20000-1 audits (or similar audits based upon industry-recognized successor standards) to be performed by a reputable, independent third party auditor;

(v)

a corporate-wide ISO 9001:2008 audit (or similar audit based upon an industry-recognized successor standard); and

(vi)

an ISO 27001 audit; and

(vii)

such other audits in order to verify compliance with the provisions of the ▇▇▇▇▇▇▇▇-▇▇▇▇▇ Act of 2002, as such Act may be amended from time to time.

(such audits referenced in this Section 18.2 collectively the “Required Supplier Audits”). Supplier’s SSAE 16/ISAE 3402 audits will cover the time period on an overlapping six (6) month basis of each calendar year. Each calendar year, one of Supplier’s SSAE 16/ISAE 3402 audits will cover a six (6) month period ending no later than two (2) months prior to the end of such calendar year, and no earlier than three (3) months prior to the end of such calendar year, with the related SSAE 16/ISAE 3402 report provided to Health Net within three (3) months after the end date of the period under audit.

(b)

If Supplier receives a qualified opinion resulting from a Supplier Audit, Supplier will promptly remediate the audited services and provide Health Net with a supplemental audit report removing the qualification.

(c)

As requested by Health Net for a Required Supplier Audit as of a date that is specified by Health Net in such request and that is within the period in which such Required Supplier Audit remains valid, Supplier shall provide Health Net with a “bring down” certification letter, signed by an appropriate Supplier employee, which certifies that such Required Supplier Audit remain materially accurate.

(d)

Supplier shall make available promptly to Health Net (i) the results of any review or audit conducted by or for Supplier or its Affiliates relating to Supplier’s operating practices or procedures, to the extent relevant to the Services or Health Net, and (ii) summaries of business continuity test results to the extent relevant to the Services or Health Net, which shall include frequency of the testing, that which was tested, and a summary of the outcome of those tests; and which shall be no less detailed than similar information that which Supplier provides to government or other customers similar to Health Net. In addition, Supplier will cause its account management team to maintain an awareness of any material issues that relate to Health Net and that are discovered by Supplier or its auditors (including


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as part of any internal review or audit). If any such resulting review or audit report is relevant to Health Net, its Affiliates or other Service Recipients, Supplier will provide a copy of the audit report to Health Net and its independent auditors for review and comment as soon as reasonably possible, and in any event within thirty (30) days after completion of the audit report. Supplier will also provide information regarding its plans to correct, and will correct, any material errors or problems identified in the audit report.

18.3

Supplier’s Internal Controls

(a)

Supplier will develop and maintain internal control processes and controls that are designed to prevent and detect a material misstatement in financial information processed or generated by Supplier, as required to achieve and maintain compliance with the provisions of the ▇▇▇▇▇▇▇▇-▇▇▇▇▇ Act of 2002, as such Act may be amended from time to time.

(b)

Supplier will permit Health Net access to Supplier’s processes and controls relevant to the Services and provide such documentation as reasonably requested by Health Net to the extent reasonably necessary for Health Net to complete its internal control testing to satisfy the ▇▇▇▇▇▇▇▇-▇▇▇▇▇ Act of 2002.

18.4

Audit Follow-up

(a)

Following an Audit or examination, Health Net may conduct, or request its external Auditors or examiners to conduct, an exit conference with Supplier to obtain factual concurrence with issues identified in the review. Supplier will make available promptly to Health Net the results of any review or audit conducted by Supplier and Supplier’s Affiliates (including by internal audit staff or external auditors), or by inspectors, Regulators or other representatives, relating to Supplier’s operating practices and procedures to the extent relevant to the Services or Health Net. Supplier shall comply with Health Net’s internal audit methodology as Health Net makes it known to Supplier in order resolve any issues that arise from the audit.

(b)

At Health Net’s request, Supplier will meet with Health Net to review each audit report promptly after the issuance thereof and to mutually agree upon the appropriate manner, if any, in which to respond to the changes suggested by the audit report. Supplier and Health Net agree to develop operating procedures for the sharing of audit and regulatory findings and reports related to Supplier’s operating practices and procedures produced by auditors or regulators of either Party. Supplier shall comply with Health Net’s internal audit methodology as Health Net makes it known to Supplier.

18.5

Confidentiality of Audits

All Audit results and disclosed records of Supplier’s performance of the Services will be treated as Supplier Confidential Information (except to the extent they contain Health Net Confidential Information or fall within an exception in Section 21.1(b)) and shall not be used for any purpose except to verify Supplier’s compliance with its obligations under this Agreement and except that such results and records may be disclosed to Regulators in accordance with Section 21.2(d).

18.6

Records Retention

(a)

In support of Health Net’s Audit rights, Supplier will keep and maintain (i) financial records relating to this Agreement in accordance with generally accepted accounting principles applied on a consistent basis, (ii) records substantiating Supplier’s invoices, (iii) records pertaining to Supplier’s compliance with the Service Levels, including root cause analyses, and (iv) such other operational records pertaining to performance of the Services as Supplier keeps in the ordinary course of its business.


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(b)

Supplier will retain such records and provide access to them upon request for Audits until the last to occur of the following: (i) ten (10) years after expiration or termination of this Agreement; (ii) all pending matters relating to this Agreement (including disputes) are closed; and (iii) the information is no longer required to meet the Health Net Policy on records retention. Before destroying or otherwise disposing of such records, Supplier will provide Health Net with sixty (60) days prior notice and offer Health Net the opportunity to recover the records or to request Supplier to deliver the records to Health Net, with Health Net paying Supplier’s Out-of-Pocket Expenses.

(c)

Supplier will cause any Subcontractor of Supplier under this Agreement to make such Subcontractor’s books and records with respect to the Services available for inspection, examination and copying by the applicable Regulator and to retain such books and records in accordance with applicable Laws (e.g., the California ▇▇▇▇-▇▇▇▇▇ Act requirements), which requirements shall be provided by Health Net to Supplier. In the event that Health Net or its Affiliates receives any notice that a Regulator requires such access to a Subcontractor’s books and records, it will notify Supplier promptly to allow Supplier to notify the applicable Subcontractor, if not prohibited by Law. If Supplier or Subcontractor requests that any information disclosed to Regulators be given confidential treatment by the Regulator, Health Net or the applicable Affiliate will make such request, will cooperate reasonably with Supplier in communicating with the Regulator and will take all reasonable actions to obtain confidential treatment.

18.7

Financial Reports

At Health Net’s request, Supplier will provide to Health Net copies of all publicly-available audited and unaudited financial statements of Supplier and its Controlling Affiliates.

18.8

Overcharges

(a)

If as a result of an audit or otherwise it is determined that Supplier has overcharged Health Net, Supplier shall credit Health Net’s account (or, at Health Net’s option, pay Health Net directly) an amount equal to the overcharge plus interest at *** above the prime rate (as shown in The Wall Street Journal) calculated from the date the overcharge was paid by Health Net.

(b)

If an audit of the charges discloses that Supplier’s overcharges exceeded *** percent of the audited charges during the period audited, Supplier shall also reimburse Health Net for the reasonable cost of such audit.

19.

REPRESENTATIONS, WARRANTIES AND COVENANTS OF SUPPLIER

19.1

Work Standards

Supplier covenants that the Services will be rendered with promptness and diligence and be executed in a professional and workmanlike manner in accordance with the practices and standards observed by the leading companies in Supplier’s industry when performing similar services. Supplier covenants that it will use adequate numbers of qualified Supplier Personnel with suitable training, education, experience and skill to perform the Services in accordance with timing and other requirements of this Agreement.


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19.2

Maintenance

Supplier represents, warrants and covenants that it will maintain the Equipment and Software for which it has operational responsibility or Financial Responsibility so they operate in accordance with their specifications, including (i) maintaining Equipment in good operating condition, subject to normal wear and tear; (ii) undertaking repairs and preventive maintenance on Equipment in accordance with the applicable Equipment manufacturer’s recommendations; and (iii) performing Software maintenance in accordance with the applicable Software vendor’s documentation and recommendations.

19.3

Efficiency and Cost-Effectiveness

Supplier covenants that it will use Commercially Reasonable Efforts to use efficiently the resources or services necessary to provide the Services. Supplier covenants that it will use Commercially Reasonable Efforts to perform the Services in a cost-effective manner consistent with the required level of quality and performance.

19.4

Deliverable

Supplier represents, warrants and covenants that each Deliverable produced by Supplier under this Agreement will not, during the Warranty Period, deviate in any material respect from the specifications and requirements for such Deliverable set forth or referred to in this Agreement (or a SOW, work order, service request, project plan or similar document developed pursuant to this Agreement). If Health Net notifies Supplier of a breach of the foregoing warranty within the Warranty Period, Supplier will promptly correct and redeliver the affected Deliverable at no additional charge to Health Net without delay. “Warranty Period” shall mean the period of time commencing on the date of delivery of the Deliverable to Health Net and continuing for ninety (90) days ; provided that with respect to Deliverables that are modifications or enhancements or additions to the Technology Platform, the Warranty Period shall be the period of time commencing on the earlier to occur of (i) the date of delivery of such Deliverable to Health Net, and (ii) use of such Deliverable to provide the Services, and continuing for the duration of the Term and all Disengagement Assistance Periods.

19.5

Documentation

Supplier represents, warrants and covenants that any Documentation developed for Health Net by or on behalf of Supplier under this Agreement, except portions of the Documentation provided by Health Net, will (a) accurately and with reasonable comprehensiveness describe the operation, functionality and use of the item described in such Documentation, and (b) for Application Software, accurately describe in terms understandable to a typical End User the functions and features of such item and the procedures for exercising such functions and features.

19.6

Compatibility

Supplier represents, warrants and covenants that, during the Warranty Period, Deliverables that are developed and that are intended to interact or otherwise work together as part of a functioning system, including with other technology components that exist at the time such Deliverables are created, will be compatible and will properly inter-operate and work together as components of an integrated system.


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19.7

Non-Infringement

(a)

Subject to Section19.7(b), Supplier represents, warrants and covenants that:

(i)

Supplier will perform their responsibilities under this Agreement in a manner that does not infringe or constitute an infringement or misappropriation of any Intellectual Property Rights of any third party;

(ii)

Supplier has all rights and licenses necessary to convey to Health Net (and to its Affiliates, where applicable) the ownership of or license rights to, as applicable, all Software, Work Product, Independent IP, and other items provided to Health Net by or on behalf of Supplier; and

(iii)

no Software, Work Product, Independent IP, or other item used to provide the Services or otherwise provided to Health Net by or on behalf of Supplier, nor their use by Health Net or other Service Recipients in accordance with the applicable Documentation (if any), will infringe or constitute an infringement or misappropriation of any Intellectual Property Right of any third party.

(b)

Supplier will not be considered in breach of the representations, warranties and covenants set forth in Section 19.7(a) to the extent (but only to the extent) that any claimed breach, infringement or misappropriation (if true) would be attributable to any of the following:

(i)

Health Net’s modification of an item provided by or on behalf of Supplier unless the modification was expressly authorized, approved or made by Supplier; or

(ii)

Health Net’s combination, operation or use of an item provided by or on behalf of Supplier with other specific items not furnished by, through or at the specification of Supplier or its Subcontractors; provided, however, that this exception will not be deemed to apply to the combination, operation or use of an item with other commercially available products that could reasonably have been anticipated by Supplier that Health Net would likely use in combination with the item provided by or on behalf of Supplier (e.g., the combination, operation or use of application Software provided by Supplier with a commercially available computer and operating systems Software not provided by Supplier); or

(iii)

Any aspect of Health Net’s Software, Documentation or data which existed prior to Supplier’s performance of Services provided the claimed breach, infringement or misappropriation (if true) would not be attributable to any work performed by (or on behalf of) Supplier for Health Net or a Health Net Affiliate; or

(iv)

Claims relating to the ABS Platform in respect of which Health Net is obligated to indemnify Supplier under the APA; or

(v)

Any instruction, information, design or other materials furnished to Supplier hereunder by or on behalf of Health Net; or

(vi)

Health Net’s continuing the allegedly infringing activity after (A) being notified thereof, and (B) being provided with modifications that would have avoided the alleged infringement without adversely affecting Health Net’s use of or the functionality of the applicable item or Health Net’s receipt of the Services.


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19.8

Viruses

“Virus” means (i) program code or programming instruction(s) or set(s) of instructions intentionally designed to disrupt, disable, harm, interfere with or otherwise adversely affect computer programs, data files or operations; or (ii) other code typically described as a virus, Trojan horse, worm, back door or other type of harmful code. Supplier covenants that Supplier Personnel will not knowingly introduce a Virus or allow a Virus to be introduced into Health Net’s or any other Service Recipient’s system or any system used to provide the Services. In addition, Supplier will use Commercially Reasonable Efforts to prevent Supplier Personnel from unknowingly introducing a Virus or allowing a Virus to be introduced into Health Net’s or any other Service Recipient’s system or any system used to provide the Services. If a Virus is found to have been introduced into Health Net’s or other Service Recipients’ systems or the systems used to provide the Services as a result of a breach of the foregoing representation, warranty and covenant, Supplier will use Commercially Reasonable Efforts at no additional charge to assist Health Net in eradicating the Virus and reversing its effects and, if the Virus causes a loss of data or operational efficiency, to assist Health Net in mitigating and reversing such losses.

19.9

Disabling Code

Supplier covenants that in the course of providing the Services it will not intentionally insert into Software or any systems used to provide the Services any code that would have the effect of disabling or otherwise shutting down all or any portion of the Services. With respect to any disabling code that was already part of Software or systems used to provide the Services, Supplier covenants that it will not intentionally invoke such disabling code or knowingly permit it to be invoked at any time without Health Net’s prior written consent. For purposes of this covenant, programming errors will not be deemed disabling code to the extent Supplier can demonstrate that such errors were not made with the intention of disabling or otherwise shutting down all or any portion of Health Net’s or any other Service Recipient’s systems or any system used to provide the Services.

19.10

Date and Currency Compliance

Supplier represents, warrants and covenants to Health Net that the Services and any Deliverable provided by Supplier do and will, operate in a manner which prevents ambiguous or erroneous output with respect to all (a) date-related data and functions and (b) currency-related data and functions.

19.11

Corporate Social Responsibility

Supplier represents, warrants and covenants to Health Net that Supplier and Supplier Facilities comply, and during the Term will comply, with the following:

(a)

Supplier will not use forced or compulsory labor in any form, including prison, indentured, political, bonded or otherwise.

(b)

Supplier will not follow policies promoting or resulting in unacceptable worker treatment such as the exploitation of children, physical punishment, female abuse, involuntary servitude, or other forms of abuse.

(c)

Supplier will not discriminate based on race, creed, gender, marital or maternity status, class or caste status, religious or political beliefs, age or sexual orientation. Supplier’s decisions related to hiring, salary, benefits, advancement, termination or retirement will be based solely on the ability of an individual to do the job, Supplier’s business and technical requirements, and those of Supplier’s customers.


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(d)

Supplier’s management practices will recognize the dignity of the individual employee and the right to a work place free of harassment, abuse or corporal punishment, and will respect Supplier’s employees’ voluntary freedom of association.

(e)

Supplier will comply with all applicable Laws concerning the conditions of employment of its employees, including those relating to pay, benefits, and working conditions.

(f)

Supplier will maintain on file all documentation needed to demonstrate compliance with these standards and shall make these documents available for Health Net and its auditors with or without prior notice. Supplier will publicize to its employees and enforce a non-retaliation policy that permits Supplier’s employees to speak with Health Net and Health Net’s auditors without fear of retaliation by Supplier or Supplier’s management.

19.12

Subcontractor Confidentiality and Data Protection

Supplier will ensure that each of Supplier’s Subcontractors performing the Services will, prior to performing any Services, have executed an agreement satisfying the confidentiality and data protection obligations provided in this Agreement.

19.13

No Improper Inducements

Supplier represents, warrants and covenants to Health Net that it has not violated any applicable Laws or any Health Net Policy regarding the offering of unlawful or improper inducements in connection with this Agreement. If at any time during the Term, Health Net determines that the foregoing representation, warranty and covenant is inaccurate, then, in addition to any other rights Health Net may have at law or in equity, Health Net may terminate this Agreement for cause without affording Supplier an opportunity to cure.

19.14

Foreign Corrupt Practices Act

(a)

Supplier represents, warrants and covenants that it has not and will not offer, pay, promise to pay, or authorize the payment of any money, or offer, give, promise to give, or authorize the giving of anything of value to a foreign official (as defined in the Foreign Corrupt Practices Act (P.L. 95-213), as amended), to any foreign political party or official thereof or any candidate for foreign political office, or to any person, while knowing or being aware of a high probability that all or a portion of such money or thing of value will be offered, given or promised, directly or indirectly, to any foreign official, to any foreign political party or official thereof, or to any candidate for foreign political office, for the purposes of:

(i)

influencing any act or decision of such foreign official, political party, party official, or candidate in his or its official capacity, including a decision to fail to perform his or its official functions; or

(ii)

inducing such foreign official, political party, party official, or candidate to use his or its influence with the foreign government or instrumentality thereof to affect or influence any act or decision of such government or instrumentality, in order to assist Health Net or Supplier in obtaining or retaining business for or with, or directing business to Health Net or Supplier.


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(b)

Supplier further represents, warrants and covenants that it will not violate the Foreign Corrupt Practices Act or any other applicable anti-corruption laws or regulations. Supplier agrees that if subsequent developments after the Effective Date cause the representations, warranties, covenants and information reported herein to be no longer accurate or complete, Supplier will promptly furnish Health Net with a supplementary report detailing such change in circumstances.

19.15

Claims Procedures, Appeals and External Review

Supplier shall ensure that its decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to Supplier Personnel (such as a claims adjudicator, appeals processor, or medical expert) shall not be made based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits for Health Net members and/or customers.

19.16

ABS Platform

The representations, warranties, covenants and other provisions contained in Sections 19.1-19.12 shall not apply to any part of the ABS Platform developed by or for Health Net (other than by Supplier) prior to the BPaaS Services Commencement Date.

20.

MUTUAL REPRESENTATIONS AND WARRANTIES; DISCLAIMER

20.1

Mutual Representations and Warranties

Each Party represents, warrants and covenants to the other that:

(a)

It has the requisite corporate power and authority to enter into this Agreement and to carry out the transactions and activities contemplated by this Agreement;

(b)

The execution, delivery and performance of this Agreement and the consummation of the transactions contemplated by this Agreement have been duly authorized by the requisite corporate action on the part of such Party, are a valid and binding obligation of such Party, and do not constitute a violation of any existing judgment, order or decree;

(c)

The execution, delivery and performance of this Agreement and the consummation of the transactions contemplated by this Agreement do not constitute a material default under any existing material contract by which it or any of its material assets is bound, or an event that would, with notice or lapse of time or both, constitute such a default; and

(d)

There is no proceeding pending or, to the knowledge of the Party, threatened that challenges or could reasonably be expected to have a material adverse effect on this Agreement or the ability of the Party to perform and fulfill its obligations under this Agreement.


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20.2

Disclaimer

OTHER THAN AS PROVIDED IN THIS AGREEMENT, THERE ARE NO EXPRESS WARRANTIES AND THERE ARE NO IMPLIED WARRANTIES, INCLUDING THE IMPLIED WARRANTIES OF MERCHANTABILITY AND FITNESS FOR A PARTICULAR PURPOSE, ALL OF WHICH ARE EXPRESSLY DISCLAIMED EXCEPT WHERE REQUIRED BY LAW.

21.

CONFIDENTIALITY

21.1

“Confidential Information” Defined

(a)

“Confidential Information” of a Party means any non-public, commercially sensitive information (or materials) belonging to, concerning or in the possession or control of the Party or any of its Affiliates (and, in the case of Health Net, any of the Service Recipients) (the “Furnishing Party”) that is furnished, disclosed or otherwise made available (directly or indirectly) to the other Party (the “Receiving Party”) (or entities or persons acting on the other Party’s behalf) in connection with this Agreement and which is either marked or identified in writing as confidential, proprietary, secret or with another designation sufficient to give notice of its sensitive nature, or is of a type that a reasonable person would recognize it to be confidential. In the case of Health Net, “Confidential Information” includes any (i) information to which Supplier has access in Health Net Facilities or Health Net systems (or those of any Health Net Affiliates or Service Recipients) (ii) information belonging to or concerning Health Net, any Health Net Affiliates or any of the Service Recipients in Supplier Facilities or systems used to provide the Services; (iii) Deliverables and information pertaining to them, (iv) Health Net Data, Health Net Owned Software, Health Net Licensed Software, and systems access codes, (v) information concerning Health Net’s and/or its Affiliates’ and/or Service Recipients’ products, marketing strategies, financial affairs, employees, customers or suppliers, (vi) personal information and Personally Identifiable Information of Health Net’s employees and members and any information protected under the Business Associate Agreement (including Protected Health Information), (vii) Proprietary Business Rules and (viii) all data and information in any form derived from any of the foregoing, in each case regardless of whether or how any of the foregoing is marked. In the case of Supplier, “Confidential Information” includes any (a) information regarding Supplier’s systems, marketing plans, Software, processes and controls, products and services, (b) Work Product (other than Deliverables) and Supplier’s Independent IP, and (c) any part of the Required Information that is not Health Net Data, in each case regardless of whether or how any of the foregoing is marked. Any notes, memoranda, compilations, derivative works, data files or other materials prepared by or on behalf of the Receiving Party that contain or otherwise reflect or refer to Confidential Information of the Furnishing Party will also be considered Confidential Information of the Furnishing Party.

(b)

“Confidential Information” does not include any particular information (other than personal information, -Personally Identifiable Information and Protected Health Information) that the Receiving Party can demonstrate: (i) was rightfully in the possession of, or was rightfully known by, the Receiving Party without an obligation to maintain its confidentiality prior to receipt from the Furnishing Party; (ii) was or has become generally known to the public other than as a result of breach of this Agreement or a wrongful disclosure by the Receiving Party or any of its agents; (iii) after disclosure to the Receiving Party, was received from a third party who, to the Receiving Party’s knowledge, had a


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lawful right to disclose such information to the Receiving Party without any obligation to restrict its further use or disclosure; or (iv) was independently developed by the Receiving Party without use of or reference to any Confidential Information of the Furnishing Party.

21.2

Obligations of Confidentiality

(a)

Each Party acknowledges that it may be furnished, receive or otherwise have access to Confidential Information of the other Party in connection with this Agreement.

(b)

The Receiving Party will not use, disclose or reproduce Confidential Information of the Furnishing Party except as reasonably required to accomplish the purposes and objectives of this Agreement. The Receiving Party will not disclose the Confidential Information of the Furnishing Party to any person or appropriate it for the Receiving Party’s own use, or for any other person’s use or benefit, except as specifically permitted by this Agreement or approved in writing by the Furnishing Party.

(c)

The Receiving Party will keep the Confidential Information of the Furnishing Party confidential and secure and will protect it from unauthorized use or disclosure by using at least the same degree of care as the Receiving Party employs to avoid unauthorized use or disclosure of its own Confidential Information, but in no event less than reasonable care.

(d)

As necessary to accomplish the purposes and objectives of this Agreement, the Receiving Party may disclose Confidential Information of the Furnishing Party to any employee, officer, director, contractor, Service Recipient, agent or representative of the Receiving Party who is bound to the Receiving Party to protect the confidentiality of the information in a manner substantially equivalent to that required of the Receiving Party under this Agreement. As necessary to accomplish the purposes and objectives of this Agreement, Health Net may also provide Confidential Information of Supplier to contractors (including outsourcing suppliers that may replace Supplier under this Agreement) who provide services to Health Net, provided any such contractor and outsourcing supplier (but not their employees) (i) is bound to Health Net to use such Confidential Information for the sole purpose of providing services to Health Net, and (ii) shall, prior to receipt of any Confidential Information, execute a non-disclosure agreement for Supplier substantially in the form set forth in Schedule N (the “Non-Disclosure Agreement”), provided further that (A) Supplier has the right to make reasonable modifications to the form of Non-Disclosure Agreement, and (B) Supplier shall consider in good faith any changes to the form Non-Disclosure Agreement reasonably requested by a contractor or outsourcing supplier and shall not unreasonably withhold agreement to any such changes. The Receiving Party may also disclose Confidential Information of the Furnishing Party to the Receiving Party’s Auditors provided they are made aware of the Receiving Party’s obligations of confidentiality with respect to the Furnishing Party’s Confidential Information and such Auditors are obligated to maintain the confidentiality of such Confidential Information on terms that are substantially equivalent to the terms of this Section 21 (Confidentiality). Health Net and its Affiliates may also disclose Supplier Confidential Information, including this Agreement and the transactions contemplated by this Agreement, in any reports furnished, filed or required to be filed with the Securities and Exchange Commission (“SEC”) pursuant to the rules and regulations promulgated by the SEC, as well as to the New York Stock Exchange and any other Regulator charged with the administration, oversight or enforcement of regulations applicable to any business conducted by Health Net or any of its Affiliates (collectively, the “SEC and Regulatory Filing Requirements”). In the event that Health Net or its Affiliates intend to disclose


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Supplier Confidential Information as permitted by the immediately preceding sentence it will, to the extent commercially practicable, notify Supplier prior to disclosing the information and provide copies of the intended disclosure to allow Supplier to comment on such disclosures. If Supplier requests that Health Net or its Affiliates request confidential treatment of the Confidential Information by the SEC or other Regulator, Health Net or the applicable Affiliate will make such request and will take all commercially reasonable actions to obtain confidential treatment. Notwithstanding the foregoing, Health Net shall maintain sole discretion regarding compliance with SEC and Regulatory Filing Requirements.

(e)

If any unauthorized use, disclosure, loss of, or inability to account for any Confidential Information of the Furnishing Party occurs, the Receiving Party will promptly so notify the Furnishing Party and will cooperate with the Furnishing Party and take such actions as may be necessary or reasonably requested by the Furnishing Party to minimize the violation and any damage resulting from it.

21.3

No Implied Rights

Each Party’s Confidential Information will remain the property of that Party. Nothing contained in this Section 21 (Confidentiality) will be construed as obligating a Party to disclose its Confidential Information to the other Party, or as granting to or conferring on a Party, expressly or by implication, any rights or license to the Confidential Information of the other Party. Any such obligation or grant will only be as provided by other provisions of this Agreement.

21.4

Compelled Disclosure

If the Receiving Party becomes legally compelled to disclose any Confidential Information of the Furnishing Party in a manner not otherwise permitted by this Agreement, the Receiving Party will provide the Furnishing Party with prompt notice of the request so that the Furnishing Party may seek a protective order or other appropriate remedy. If a protective order or similar order is not obtained by the date by which the Receiving Party must comply with the request, the Receiving Party may furnish that portion of the Confidential Information that, after consulting with legal counsel, it determines it is legally required to furnish. The Receiving Party will exercise reasonable efforts to obtain assurances that confidential treatment will be accorded to the Confidential Information so disclosed.

21.5

Confidential Treatment of this Agreement

Each Party may disclose the existence and general nature of this Agreement as permitted by Section 27.9 (Public Disclosures), but otherwise the terms and conditions of this Agreement will be considered the Confidential Information of each Party; provided however, that this Agreement may be disclosed by either Party in connection with an actual or good-faith proposed merger, acquisition, divestiture or similar transaction, so long as such receiving entity first agrees in writing to obligations substantially similar to those described in this Section 21 (Confidentiality).

21.6

Disclosure of Information Concerning Tax Treatment

Notwithstanding anything to the contrary in this Section 21 (Confidentiality), each Party (and its Affiliates), and any person acting on their behalf, may disclose to any person or entity the “tax structure” and “tax treatment” (as such terms are defined in the U.S. Internal Revenue Code and regulations under it) of the transactions effected by this Agreement and any materials provided to


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that Party (or its Affiliates) describing or relating to such tax structure and tax treatment; provided, however, that this disclosure authorization will not be interpreted to permit disclosure of (i) any materials or portions of materials that are not related to the transaction’s tax structure or tax treatment, or (ii) any materials or information that the Party (or its Affiliate(s)) must refrain from disclosing to comply with applicable securities Laws.

21.7

Return or Destruction

(a)

As requested by the Furnishing Party during the Term, the Receiving Party will return or provide the Furnishing Party a copy of any designated Confidential Information of the Furnishing Party. When Confidential Information of the Furnishing Party is no longer required for the Receiving Party’s performance under this Agreement, or in any event upon expiration or termination of this Agreement, the Receiving Party will return all materials that contain, refer to, or relate to Confidential Information of the Furnishing Party or, at the Furnishing Party’s election, destroy them. In addition, Supplier shall, within sixty (60) days of the expiration or termination of this Agreement, delete all of Health Net’s Confidential Information from its databases, servers, personal computers, web site and other electronic media that exist now or in the future.

(b)

The Receiving Party may, however, keep (i) any Confidential Information of the Furnishing Party that the Receiving Party has a license to continue using, (ii) in the files of its legal department or outside counsel, for record purposes only, one copy of any material requested to be returned or destroyed, (iii) archival copies as may be necessary to comply with document retention laws and regulations applicable to such Party’s business operations, and (iv) data that is necessary to be retained by Supplier in order to comply with Supplier’s back-up policies and procedures; provided that any electronic Confidential Information that is stored on routine back-up media for the purpose of disaster recovery will be subject to destruction in due course. Additionally, the Receiving Party shall have no obligation to destroy any Confidential Information that is subject to a claim, dispute, lawsuit, or subpoena or in any other circumstances in which such Party reasonably believes that destruction of such Confidential Information would be unethical or unlawful. Any Confidential Information of the Furnishing Party that is retained by the Receiving Party pursuant to the foregoing shall continue to be subject to the confidentiality obligations of this Agreement.

(c)

At the Furnishing Party’s request, the Receiving Party will certify in writing to the Furnishing Party that it has returned or destroyed all copies of the Furnishing Party’s Confidential Information in the possession or control of the Receiving Party’s or any of its Affiliates or contractors that are required to be returned or destroyed pursuant to this Section 21.7 (Return or Destruction).

21.8

Duration of Confidentiality Obligations

The Receiving Party’s obligations under this Section 21 (Confidentiality) apply to Confidential Information of the Furnishing Party disclosed to the Receiving Party before or after the Effective Date and will continue during the Term and survive the expiration or termination of this Agreement as follows:

(a)

The Receiving Party’s obligations under Section 21.7 (Return or Destruction) will continue in effect until fully performed;


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(b)

As to any portion of the Furnishing Party’s Confidential Information that constitutes a trade secret under applicable Law, the obligations will continue for as long as the information continues to constitute a trade secret;

(c)

As to all other Confidential Information of the Furnishing Party, the obligations will survive for four (4) years after the Receiving Party’s fulfillment of its obligations under Section 21.7 (Return or Destruction) with respect to the Confidential Information in question; and

(d)

With respect to personal information, Personally Identifiable Information and Protected Health Information, the obligations shall survive indefinitely.

22.

INSURANCE

Supplier represents that it has, as of the Effective Date, and agrees to maintain in force throughout the Term at least the types and amounts of insurance coverage specified in Schedule I (Supplier Insurance).

23.

INDEMNIFICATION

23.1

Indemnification By Supplier

Supplier will at its expense indemnify, defend and hold harmless Health Net and its Affiliates, and their respective officers, directors, customers, employees, agents, representatives, successors and assigns (collectively, “Health Net Indemnitees”) from and against any and all Losses suffered or incurred by any of them arising from, in connection with, or based on any of the following, whenever made, except to the extent caused by Health Net or an Health Net Affiliate:

(a)

Any Indemnity Claim by, on behalf of or relating to any of the Affected Employees relating to Supplier’s employee selection, communications, recruitment or hiring process or a breach by Supplier of Schedule E (Employee Transfer);

(b)

Any Indemnity Claim by, on behalf of or relating to any of the Transitioned Employees with respect to matters arising out of acts or omissions of Supplier occurring on or after the Transfer Date, excluding Indemnity Claims for which Health Net is required to indemnify under Section 23.3(b);

(c)

Any Indemnity Claim (i) by a Subcontractor or by other Supplier Personnel, including claims by such personnel that Health Net is liable to such personnel for employee benefits or as the employer or joint employer of such personnel, except to the extent, if any, that Health Net is required by this Agreement to indemnify Supplier in respect of the Indemnity Claim, or (ii) based upon the acts or omissions of any Subcontractor in performance of or relating to the Services to the same extent as if Supplier had committed the act or omission;

(d)

Any Indemnity Claim arising out of Supplier’s breach of its obligations under Section 14 (Data Security and Protection) or Section 21 (Confidentiality) or the Business Associate Agreement;

(e)

Any Indemnity Claim arising out of a Security Breach, except to the extent that such Security Breach was caused by Health Net’s negligence, willful misconduct or breach of this Agreement;


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(f)

Any Indemnity Claim arising out of Supplier’s breach of Section 19.7(a) (Non-Infringement);

(g)

Any Indemnity Claim arising out of Supplier’s breach of its obligations under Section 27.7 (Compliance with Laws)

(h)

Any Indemnity Claim for death or bodily injury, or the damage, loss or destruction of real or tangible personal property of any third party (including employees of Health Net or Supplier or their respective subcontractors) brought against a Health Net Indemnitee alleged to have been caused by the tortious acts or omissions of Supplier, Supplier Personnel or anyone else for whose acts Supplier is responsible. However, Supplier will have a right of contribution from Health Net with respect to the Indemnity Claim to the extent Health Net’s comparative negligence is responsible for causing the alleged injury or damage, loss or destruction;

(i)

Any Indemnity Claim with respect to Supplier’s use of any Health Net Provided Resources made available by Health Net to Supplier or Subcontractors pursuant to Section 11 to the extent the loss results from a breach by Supplier or any Subcontractor of, or an act or omission of Supplier which creates liability for Health Net pursuant to (A) a Health Net Provided Resource or an agreement between Health Net and a third party relating to such Health Net Provided Resources, or certain provisions thereof, which have been provided to Supplier in writing, including obligations to comply with requirements regarding numbers and types of licenses under any such agreements; (B) the terms of this Agreement, including Supplier’s obligations with respect to Managed Third Party Contracts set forth in this Agreement, or (C) any other reasonable restrictions required by Health Net relating to the Health Net Provided Resources, which restrictions are provided to Supplier in writing;

(j)

Any amounts, including taxes, interest, and penalties, assessed against Health Net which arise as a result of Supplier’s failure to comply with and perform its obligations under Section 9.3 (Taxes);

(k)

Supplier’s (i) improper or wrongful termination of this Agreement or part thereof, or (ii) except to the extent any cessation of Services is expressly permitted under this Agreement, abandonment of any work under this Agreement;

(l)

Any breach of any of Supplier’s representations or warranties set forth in Section 20 (Mutual Representations and Warranties), Section 19.8 (Disabling Code), or the second sentence of Section 19.7 (Viruses);

(m)

Any intentional misconduct or criminal misconduct by Supplier; and

(n)

Any Indemnity Claim arising out of occurrences Supplier is required to insure against under this Agreement, but only to the extent Supplier has failed to procure the insurance that Supplier is obligated to procure under this Agreement.

Any act or omission of a Subcontractor shall be deemed to be an act or omission of Supplier for purposes of determining Supplier’s indemnification obligations pursuant to this Section 23.1.


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23.2

Infringement Indemnity Claims

If any item used by Supplier to provide the Services or provided by Supplier to Health Net or any Deliverable becomes, or in Supplier’s reasonable opinion is likely to become, the subject of an infringement or misappropriation Indemnity Claim, Supplier will, in addition to indemnifying Health Net Indemnitees as provided in this Section 23 (Indemnification) and to the other rights Health Net may have under this Agreement, and at law or equity, at its expense: (i) promptly at Supplier’s expense secure the right to continue using the item or Deliverable, or (ii) if this cannot be accomplished with Commercially Reasonable Efforts, then at Supplier’s expense, replace or modify the item or Deliverable to make it non-infringing or without misappropriation, while not degrading performance, functionality, or quality, increasing Health Net costs, or disrupting Health Net’s business operations, or (iii) if neither of the foregoing can be accomplished by Supplier with Commercially Reasonable Efforts, and only in such event, then upon at least one hundred eighty (180) days’ prior written notice to Health Net, (A) with respect to non-Deliverable items, Supplier may remove the item from use in performing the Services, in which case Supplier’s Charges will be equitably adjusted to reflect such removal, and (B) in the case of Deliverable, Supplier may recall the Deliverables and shall refund to Health Net all Charges and fees paid by Health Net relating to such Deliverable. If removal of the item from use in performing Services or recall of a Deliverable causes the loss or degradation of the Services or any portion of the Services that is material to Health Net or has a material impact on Health Net, such loss, degradation or material impact will constitute a material breach of this Agreement by Supplier in respect of which Health Net may exercise its termination and other rights and remedies under this Agreement. This Section 23.2 (Infringement Indemnity Claims) will not apply to any Indemnity Claim relating to the ABS Platform in respect of which Health Net is obligated to indemnify Supplier under the APA.

23.3

Indemnification By Health Net

Health Net will at its expense indemnify, defend and hold harmless Supplier and its Affiliates and their respective officers, directors, employees, agents, representatives, successors and assigns (collectively, “Supplier Indemnitees”) from and against any and all Losses suffered or incurred by any of them arising from, in connection with or based on any of the following, whenever made, except to the extent caused by Supplier or a Supplier Affiliate: Any Indemnity Claim by, on behalf of or relating to any of the Transitioned Employees with respect to matters arising out of the acts or omissions of Health Net occurring prior to the Transfer Date, excluding Indemnity Claims for which Supplier is required to indemnify under Section 23.1(a);

Any Indemnity Claim by, on behalf of or relating to any Supplier Personnel who is a Transitioned Employee and which arises out of Health Net’s employee selection, communications, recruitment or hiring process relating to Health Net’s rehiring of such Transitioned Employees pursuant to the terms of this Agreement;

Any Indemnity Claim arising out of Health Net’s breach of its obligations under Schedule E (Employee Transfer);

Any Indemnity Claim arising out of (i) Health Net’s failure to observe or perform any duties or obligations to be observed or performed prior to the Effective Date by Health Net under any of the Health Net Third Party Service Contracts or licenses for Health Net Licensed Software that are being made available for use by Supplier pursuant to Section 11.2(a);

Any Indemnity Claim arising out of Health Net’s breach of its obligations under Section 21 (Confidentiality) or the Business Associate Agreement;


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Any Indemnity Claim arising out of Health Net’s breach of its obligations under Section 27.7 (Compliance with Laws), including a failure to comply with Law by (1) any of the Transitioned Employees prior to their respective Transfer Date, or (2) any third party under any of the Health Net Third Party Service Contracts that are being made available for use by Supplier pursuant to Section 11.2(a) (provided the Indemnity Claim did not arise due to the failure of Supplier to perform its management obligations under this Agreement with respect to such contracts);

Any Indemnity Claim to the extent such claim alleges that (1) any Health Net Owned Software or Health Net Licensed Software that is being made available for use by Supplier pursuant to Section 11.2(c), or (2) systems or other items made available to Supplier by Health Net under this Agreement, infringes or misappropriates any Intellectual Property Right of any third party, provided however that this Section 23.3(g) does not apply to any such Indemnity Claim (x) that relates to any part of the ABS Platform or Configurations developed by or for Supplier, or (y) in which the alleged infringement or misappropriation is attributable to the following:

Supplier’s modification of such Health Net Owned Software, Health Net Licensed Software, or any such system or other item, unless the Indemnity Claim (if true) would be attributable to Health Net’s instructions, specifications or requirements; or

Supplier’s combination, operation or use of such Health Net Owned Software, Health Net Licensed Software, or any such system or other item with other Software, systems or items not provided by Health Net for use with such Health Net Developed Software, Health Net Provided Resource, or system or other item; or

Supplier’s continuing the allegedly infringing activity after (A) being notified thereof, and (B) being provided with modifications that would have avoided the alleged infringement without adversely affecting Supplier’s ability to provide the Services and a reasonable time to implement them for use.

Any Indemnity Claim for death or bodily injury, or the damage, loss or destruction of real or tangible personal property of any third party (including employees of Health Net or Supplier or their respective subcontractors) brought against a Supplier Indemnitee alleged to have been caused by the tortious acts or omissions of Health Net, Health Net personnel or anyone else for whose acts Health Net is responsible. However, Health Net will have a right of contribution from Supplier with respect to the Indemnity Claim to the extent Supplier’s comparative negligence is responsible for causing the alleged injury or damage, loss or destruction;

Any Indemnity Claim caused by Supplier’s proper compliance with any Health Net Policy or other requirement mandated by Health Net; an Any Indemnity Claim based upon the gross negligence or willful misconduct of Health Net or any Health Net third party contractor (excluding Supplier, Supplier’s Affiliates and its subcontractors).


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23.4

Indemnification Procedures

The following procedures will apply to Indemnity Claims for which a Party seeks to be indemnified pursuant to this Agreement:

(a)

Notice.

(i)

Promptly after an indemnitee receives notice of any Indemnity Claim for which it will seek indemnification pursuant to this Agreement, the indemnitee will notify the indemnitor of the Indemnity Claim in writing (an “Indemnity Notice”). No failure to so notify the indemnitor will abrogate or diminish the indemnitor’s obligations under this Section 23 (Indemnification) if the indemnitor has or receives knowledge of the Indemnity Claim by other means, or if the failure to notify does not materially prejudice its ability to defend the Indemnity Claim, or if the indemnitor does not have the right to defend the Indemnity Claim pursuant to Section 23.4(b)(ii). Within fifteen (15) days after receiving an indemnitee’s Indemnity Notice of an Indemnity Claim, or otherwise obtaining knowledge of the Indemnity Claim, but no later than ten (10) days before the date on which any formal response to the Indemnity Claim is due, the indemnitor will notify the indemnitee in writing (a “Notice of Election”) as to whether:

(A)

the indemnitor acknowledges its obligation to indemnify and hold the indemnitee harmless with respect to such Indemnity Claim, and

(B)

with respect to any such Indemnity Claim that is not an Identified Health Net Indemnity Claim (as defined below), the indemnitor elects to assume control of the defense and settlement of the Indemnity Claim.

(ii)

Each Notice of Election shall be delivered to the indemnitee at the address set forth in Section 27.5 (Notices), as such address may be modified pursuant to such Section.

(b)

Procedure Following Indemnity Notice.

(i)

Procedure for Indemnity Claims that are not Identified Health Net Indemnity Claims.

With respect to any Indemnity Claim that is not an Identified Health Net Indemnity Claim, if the indemnitor timely (i.e., in accordance with Section 23.4(a)) delivers a Notice of Election that both (1) acknowledges indemnitor’s obligation to indemnify and hold the indemnitee harmless with respect to such Indemnity Claim, and (2) includes an express election to assume control of the defense and settlement of such Indemnity Claim, then:

(A)

the indemnitor will be entitled to have sole control over the defense and settlement of such Indemnity Claim; provided that the indemnitee shall have the right to approve:

(1)

the legal counsel selected by the indemnitor, and

(2)

in the indemnitee’s sole discretion, any settlement (or portion thereof) that is not a monetary settlement, including settlements involving injunctive relief; and

(B)

the indemnitor will not be required to reimburse the indemnitee for (1) any legal expenses incurred by the indemnitee in defending or settling such Indemnity Claim after the indemnitee’s receipt of such Notice of Election unless reasonable and necessary (e.g., costs incurred prior to receipt of the Indemnitor’s Notice of Election), or (2) any amounts paid or payable by the indemnitee in settlement of such Indemnity Claim after the indemnitee’s receipt of such Notice of Election if the settlement was agreed to without the written consent of the indemnitor.


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(ii)

Procedure for Identified Health Net Indemnity Claims.

(A)

An “Identified Health Net Indemnity Claim” means any of the following Indemnity Claims brought against Health Net with respect to which Health Net expressly elects to retain control of the defense and settlement in its written Indemnity Notice to Supplier pursuant to Section 23.4(a) (or as soon as reasonably practicable thereafter so long as such notice is given by Health Net prior to receipt of Supplier’s Notice of Election pursuant to Section 23.4(a)), and for which Health Net indicates in such Indemnity Notice that Health Net will seek indemnification from Supplier pursuant to this Agreement:

(1)

any Indemnity Claim brought by a governmental or regulatory entity (a “Public Indemnity Claim”); and

(2)

any Indemnity Claim brought by a private party that is based on the same events that also resulted in a Public Indemnity Claim being brought against Health Net, and where adjudication of the private party Indemnity Claim or some part of it may result in collateral estoppel with respect to a material issue of the Public Indemnity Claim.

(B)

With respect to any Identified Health Net Indemnity Claim, if Supplier timely (i.e., in accordance with Section 23.4(a)) delivers a Notice of Election acknowledging its obligation to indemnify and hold Health Net harmless with respect to such Identified Health Net Indemnity Claim, then:

(1)

Health Net will be entitled to have sole control over the defense and settlement of such Identified Health Net Indemnity Claim at the cost and expense of Supplier, including payment of any settlement, judgment or award and the reasonable costs of defending or settling such Identified Health Net Indemnity Claim; provided that in the event of a settlement by Health Net, Supplier shall only be obligated to reimburse Health Net for reasonable amounts paid or payable by Health Net in settlement of such Identified Health Net Indemnity Claim (the reasonableness of such amount determined by taking into consideration all of the facts and circumstances relating to such Identified Health Net Indemnity Claim, including reputational risks to Health Net, the potential for the Identified Health Net Indemnity Claim to cause adverse impacts to Health Net’s business or operations, and costs incurred by Health Net as a result of or in connection with such Identified Health Net Indemnity Claim); and


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(2)

Health Net shall keep Supplier informed regarding the status of and developments in any such Identified Health Net Indemnity Claim (subject to execution where appropriate of a mutually acceptable joint defense or common interest agreement), shall invite and allow Supplier to be present at relevant discussions, negotiations and proceedings to the greatest extent practicable, and shall, in advance of settling any such Identified Health Net Indemnity Claim, meet and confer with Supplier regarding the terms and conditions of such settlement with respect to which it intends to seek indemnification so as to give Supplier an opportunity to provide its input regarding such terms and conditions; and

(3)

in the event that Health Net rejects any settlement offer with respect to an Identified Health Net Indemnity Claim (over Supplier’s written objection, assuming Health Net has complied with its obligations under Section 23.4(b)(ii)(B)(2) above) and later settles such Identified Health Net Indemnity Claim for an amount exceeding any rejected settlement offer, or has a judgment entered against it with respect to such Identified Health Net Indemnity Claim for an amount exceeding any rejected settlement offer, then Supplier will be responsible only for reimbursing Health Net for the lesser of (a) the lowest rejected settlement offer with respect to such Identified Health Net Indemnity Claim; or (b) the reasonable amounts paid or payable by Health Net in settlement of such Identified Health Net Indemnity Claim, considering the factors described in Section 23.4(b)(ii)(B)(1) above; and

(4)

subject to the limitations described in Sections 23.4(b)(ii)(B)(1) and 23.4(b)(ii)(B)(3) above, Supplier will promptly reimburse Health Net upon demand for all Losses suffered or incurred by Health Net as a result of or in connection with such Identified Health Net Indemnity Claim; and

(5)

in the event of a dispute between the Parties as to the reasonableness of the amount of a settlement that Health Net approves or the reasonableness of costs, including but not limited to attorneys’ fees, of defending the Identified Health Net Indemnity Claim, (i) Supplier shall reimburse Health Net for that portion of the settlement or defense costs that it believes in good faith to be a reasonable amount, and (ii) the Parties agree to use the arbitration process described in Section 23.4(e) below to resolve any dispute relating to the reasonableness of the difference between the actual amount of the settlement that Health Net approves or the defense costs that Health Net incurs and the amount that Supplier reimbursed Health Net pursuant to item (i).

(c)

Procedure Where No Proper Notice of Election Is Delivered (Applicable to all Indemnity Claims including, for clarity, Identified Health Net Indemnity Claims).

If the indemnitor does not deliver a timely (i.e., in accordance with Section 23.4(a)) Notice of Election that both (i) acknowledges its obligation to indemnify and hold the indemnitee harmless with respect to the Indemnity Claim, and (ii) in the case of any Indemnity Claim


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that is not an Identified Health Net Indemnity Claim, includes an express election by the indemnitor to assume control of the defense and settlement of the Indemnity Claim, then the indemnitee may defend and/or settle the Indemnity Claim in such manner as it may deem appropriate at the cost and expense of the indemnitor, including payment of any settlement, judgment or award and the costs of defending or settling the Indemnity Claim. The indemnitor will promptly reimburse the indemnitee upon demand for all Losses suffered or incurred by the indemnitee as a result of or in connection with the Indemnity Claim.

(d)

Cooperation regarding Indemnity Claims. The indemnitor and the indemnitee shall provide reasonable cooperation with one another in connection with the defense and resolution of any Indemnity Claim, provided that any costs incurred by the indemnitee in connection with such cooperation shall be borne by the indemnitor, and shall be promptly reimbursed by the indemnitor upon demand from the indemnitee.

(e)

Arbitration of Disputed Settlement Amounts.

(i)

A dispute between the Parties as described in Section 23.4(b)(ii)(B)(5) above shall be finally settled by mandatory and binding arbitration administered by the American Arbitration Association (“AAA”) in accordance with its then-effective Commercial Arbitration Rules (the “Rules”). One (1) arbitrator shall be appointed in accordance with the Rules. Either Party may initiate arbitration by submitting a written request for arbitration to the AAA and the other Party, setting forth in reasonable detail the subject of the dispute and the relief requested.

(ii)

The arbitration shall be conducted in accordance with the Rules, provided that to the extent this Section 23.4(e) modifies, supplements or is inconsistent with the Rules, this Section 23.4(e) will govern. The arbitrator shall have no power or authority to amend or disregard any provision of this Section 23.4(e) or any other provision of this Agreement. The arbitration hearing shall be commenced promptly and conducted expeditiously, with each Party being allocated one-half of the time for the presentation of its case.

(iii)

Unless otherwise agreed by the Parties, arbitration hearings hereunder shall be held in Los Angeles, California. The language of the arbitration shall be English. Unless otherwise agreed by the Parties, an arbitration hearing shall be conducted on consecutive days. The Parties will participate in the arbitration in good faith, and will share equally in the administrative costs of the arbitration; provided however, that each Party will pay its own attorneys’ fees (subject to the next sentence). The arbitrator may, in his or her discretion, award the prevailing Party its attorneys’ fees and out-of-pocket expenses, including its share of the arbitration fees.

(iv)

Recognizing the express desire of the Parties for an expeditious means of dispute resolution, (A) each Party will, upon the written request of the other Party, promptly provide the other with copies of documents relevant to the issues raised by the dispute, and (B) there will be no depositions.

(v)

The award shall be made within thirty (30) days of the filing of the notice of intention to arbitrate (demand), and the arbitrator shall agree to comply with this schedule before accepting appointment. However, this time limit may be extended by agreement of the Parties or by the arbitrator if necessary.


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(vi)

The arbitration shall be conducted as follows:

(A)

Each Party shall submit to the arbitrator and exchange with each other not less than seven (7) days prior to the scheduled hearing date their last, best offers, along with a brief and documentation in support of their offer. The arbitrator shall have the authority to limit the length of such submissions.

(B)

The arbitration hearing shall not exceed eight (8) hours and may be less if the arbitrator decides that less time is required.

(C)

The arbitrator shall be limited to awarding only one or the other of the two figures submitted. The arbitrator shall not have the option of deciding upon a resolution that reflects a compromise between (or is outside of) the Parties’ respective proposed resolutions. For example, if the amount that Health Net demands from Supplier (above any amounts already reimbursed by Supplier pursuant to Section 23.4(b)(ii)(B)(5)(i) above) as its last, best offer is $250,000, and Supplier has proposed to reimburse Health Net an additional $150,000 as its last, best offer, the arbitrator shall determine which of the two proposals (i.e., $250,000 or $150,000) is more appropriate and may not select an amount somewhere between (or outside of) the two proposals.

(vii)

The arbitrator’s decision shall be final and binding on the Parties, and judgment on the award rendered by the arbitrator may be entered in any court having jurisdiction thereof.

(viii)

The arbitrator is instructed that time is of the essence in the arbitration proceeding.

24.

LIABILITY

24.1

General Intent

Subject to the specific provisions of this Section 23.1 (Liability), it is the intent of the Parties that if a Party fails to perform its obligations in the manner required by this Agreement, that Party will be liable to the other Party for any damages suffered or incurred by the other Party as a result.

24.2

Limitations of Liability

(a)

Consequential Damage Exclusion. Except as otherwise expressly provided below in this Section 24, in no event, whether in contract or in tort (including breach of warranty, negligence and strict liability in tort or otherwise), will a Party be liable to the other Party under this Agreement for (1) indirect, incidental, consequential, exemplary, punitive or special damages of any kind or nature whatsoever, or (2) lost revenues, profits, savings or business, even if such Party has been advised in advance of the possibility of such damages or such damages could have been reasonably foreseen by such Party.


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(b)

General Liability Cap. Except as otherwise expressly provided below in this Section 24, each Party’s total liability to the other under this Agreement, whether in contract or in tort (including breach of warranty, negligence and strict liability in tort) will be limited, in the aggregate, to an amount equal to the greater of:

(i)

***; and

(ii)

the total charges paid or payable by Health Net to Supplier pursuant to this Agreement for proper performance of the Services for the twelve (12) months prior to the month in which the most recent event giving rise to liability occurred, provided that if the event giving rise to liability occurs during the first twelve (12) months after the BPaaS Services Commencement Date, the liability cap under this clause (ii) will be an amount equal to twelve (12) times the result obtained by dividing the total charges paid or payable under this Agreement from the BPaaS Services Commencement Date through the date on which such event occurred, by the number of months from the BPaaS Services Commencement Date through such date***.

Service Level Credits and Deliverable Credits do not count against and do not reduce the amounts available under the foregoing limitations. The limitations specified in this Section will survive and apply even if any limited remedy specified in this Agreement is found to have failed of its essential purpose. For purposes of this Section, fees shall be deemed payable when accrued to the benefit of and legally collectable by Supplier.

(c)

Items to which the Liability Caps and Consequential Damages Exclusion do not apply. Sections 24.2(a) and 24.2(b) will not apply to any of the following:

(i)

damages arising out of the intentional or reckless misconduct or gross negligence of a Party;

(ii)

damages arising out of (A) the improper or wrongful termination of this Agreement by Supplier, or (B) abandonment of the Services by Supplier (except to the extent any such cessation of Services is expressly permitted under this Agreement), or (C) Supplier’s refusal or failure to provide Disengagement Assistance as required by this Agreement;

(iii)

damages arising out of a Party’s breach of its obligations in Article 21 (Confidentiality), except with respect to Protected Health Information and Personally Identifiable Information (which are governed by Section 24.2(d)(iii) below);

(iv)

damages arising out of a Party’s breach of its obligations to comply with applicable Laws as set forth in Section 27.7;

(v)

Claims and Losses that are the subject of indemnification pursuant to Sections 23.1 (Indemnification by Supplier) and 23.3 (Indemnification by Health Net), but not those indemnities described in Section 24.2(d)(iv).

(d)

Liability Cap relating to PHI, PII and certain other items. Notwithstanding Sections 24.2(a), 24.2(b), and 24.2(e), each Party’s total liability to the other, including under this Agreement, whether in contract or in tort (including breach of warranty, negligence and strict liability in tort) for all claims, liabilities and damages relating to or arising from the following, will be limited in the aggregate, to ***:

(i)

A Party’s breach of the Business Associate Agreement, including breaches related to Protected Health Information;


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(ii)

A Party’s breach of its obligations in Article 14 (Data Security And Protection) or damages attributable to Supplier’s breach of its obligations with respect to Health Net Data;

(iii)

a Party’s breach of its obligations in Article 21 (Confidentiality) relating to Protected Health Information or Personally Identifiable Information;

(iv)

Claims and Losses that are the subject of indemnification pursuant to Section 23.1(d) and 23.1(e) (Indemnification by Supplier) and 23.3(e) (Indemnification by Health Net);

(v)

a Party’s misappropriation or infringement of the other Party’s Intellectual Property Rights; and

(vi)

any other damages relating to Health Net Data or Personally Identifiable Information, or a Security Breach.

For clarity, the exclusions of liability set forth in Section 24.2(a) will not apply to any of the damages described in this Section 24.2(d).

(e)

Damages Subcap relating to TPUSA. Notwithstanding Section 24.2(b), Supplier’s total liability to Health Net arising out of the acts or omissions of TPUSA in its role as an Approved Subcontractor providing Contact Center Services under this Agreement, whether in contract or in tort (including breach of warranty, negligence and strict liability in tort) will be limited, in the aggregate, to the greater of:

(i)

*** of the total charges paid or payable by Health Net to Supplier pursuant to this Agreement for proper performance of the Services for the twelve (12) months prior to the month in which the most recent event based on TPUSA’s acts or omissions giving rise to liability occurred, provided that if the event giving rise to liability occurs during the first twelve (12) months after the BPaaS Services Commencement Date, the liability cap amount for this clause (i) will be an amount equal to (A) *** of (B) twelve (12) times the result obtained by dividing (1) the total charges paid or payable under this Agreement from the BPaaS Services Commencement Date through the date on which such event occurred, by (2) the number of months from the BPaaS Services Commencement Date through such date; and

(ii)

*** with respect to the following items: (a) damages arising out of the intentional or reckless misconduct or gross negligence of TPUSA, (b) damages arising out of TPUSA’s improper or wrongful termination of Supplier’s subcontract agreement with TPUSA for the Contact Center Services, wrongful abandonment of the Services by TPUSA or TPUSA’s refusal or failure to provide disengagement assistance as required by Supplier’s subcontract agreement with TPUSA, (c) TPUSA’s obligations under Sections 6.5 (Compliance with Law), Section 7 (Intellectual Property and Confidentiality) or Section 9 (Indemnity) of Supplier’s subcontract agreement with TPUSA for the Contact Center Services.


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Notwithstanding the foregoing, the cap set forth in this Section 24.2(e) shall not apply to the extent that the TPUSA-caused event giving rise to liability is the result of Supplier’s failure to properly manage (i) TPUSA or (ii) the Services performed by TPUSA. For clarity, the exclusions set forth in Section 24.2(a) will not apply to any of the damages governed by this Section 24.2(e) to the extent that they are also covered under Sections 24.2(c), 24.2(d) or 24.2(f).

(f)

Stipulated Direct Damages. Without limiting (1) each Party’s responsibility for direct damages under this Agreement, and (2) each Party’s right to claim other direct damages, the following items shall be considered direct damages under this Agreement and are not prohibited by Section 24.2(a), to the extent they are reasonable:

(i)

Costs incurred by Health Net to correct or have corrected any errors or other deficiencies in the Services rendered by Supplier;

(ii)

Any portion of overpayments paid by Health Net to members due to errors of Supplier that remain unrecovered by Health Net ***;

(iii)

Amounts paid by Health Net for interest arising out of Supplier’s performance of the Services relating to examiner error ***;

(iv)

Amounts paid by Health Net for fines arising out of Supplier’s performance of the Services during each calendar year ***

(v)

Performance Guarantee Group Payment Amounts owed by Supplier to Health Net pursuant to Schedule B (Service Levels);

(vi)

Costs of recreating, restoring or reloading any of Health Net’s information lost or damaged as a result of a failure by Supplier to perform the Services at all or in accordance with this Agreement. Such recreation, restoration and reloading costs shall include all activities and efforts that an IT group of a health insurance company may reasonably undertake to recreate, restore or reload such lost or damaged information, using efforts that are proportionate to the importance to Health Net of the information to be recreated, restored or reloaded and the volume of such lost or damaged information;

(vii)

Costs of implementing a workaround in respect to a failure to perform the Services at all or in accordance with this Agreement;

(viii)

Costs and expenses incurred by Health Net to acquire and have performed substitute services conforming to this Agreement in place of any Services Supplier fails to provide at all or in accordance with this Agreement;

(ix)

Straight time, overtime, or related expenses incurred by Health Net or its Affiliates, including wages and salaries of additional personnel, travel, expenses, telecommunication and similar charges, arising out of the failure of Supplier to perform at all or in compliance with this Agreement;

(x)

Amounts required to be paid by Health Net under any Law or by any court or governmental or regulatory authority, or incurred by Health Net to create and implement any corrective actions plan, and to satisfy an order or directive of a court or governmental or regulatory authority arising out of Supplier’s acts or omissions, and costs arising from settlements with such authorities, provided that interest and fines shall be governed by Sections 24.2(f)(iii) and (iv) above;


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(xi)

Identity-Related Costs incurred by Health Net, except to the extent that Supplier is able to demonstrate that a Security Breach was caused by Health Net’s negligence, willful misconduct or breach of this Agreement, and

(xii)

Damages arising out of a breach by Supplier of its obligations under Section 3.6 Schedule E (Transitioned Employees) with respect to the retention of Personnel Groups of Transitioned Personnel,

provided, however, that nothing in this Section 24.2(f) shall limit Supplier’s obligations or liability under Section 23.1 (Indemnification by Supplier) above.

Each Party shall pay to the other Party upon request of such other Party any amount for which it is responsible under Sections 24.2(f)(ii). 24.2(f)(iii), 24.2(f)(iv), 24.2(f)(v) and 24.2(f)(xi) .

(g)

For clarity, the amounts spent by an indemnitor in defense of a Claim for which it is responsible under this Agreement shall not be counted for purposes of computing the amount of total damages that have been incurred relative to the liability cap set forth in Section 24.2.

(h)

Each Party has a duty to mitigate the damages suffered by it for which the other Party is or may be liable.

24.3

Force Majeure

(a)

No Party will be liable for any default or delay in the performance of its obligations under this Agreement (i) if and to the extent such default or delay is caused, directly or indirectly, by fire, flood, pestilence, earthquake, elements of nature or acts of God, riots, or civil disorders, (ii) provided the non-performing Party is without fault in causing such default or delay, and such default or delay could not have been prevented by reasonable precautions and could not reasonably be circumvented by the non-performing Party through the use of alternate sources, workaround plans or other means (including with respect to Supplier by Supplier meeting its obligations for performing disaster recovery and business continuity services as described in this Agreement) (each such event a “Force Majeure Event”).

(b)

In such event the non-performing Party will be excused from further performance or observance of the obligations so affected for as long as such circumstances prevail and such Party continues to use Commercially Reasonable Efforts to recommence performance or observance without delay. Any Party so delayed in its performance will immediately notify the Party to whom performance is due by telephone (to be confirmed in writing within twenty-four (24) hours of the inception of such delay) and describe at a reasonable level of detail the circumstances causing such delay. To the extent the provision of the Services or any part thereof is prevented or materially affected by a Force Majeure Event, Health Net’s obligation to pay Charges hereunder shall accordingly be reduced by an equitable amount (which in the case of total suspension of the Services would be an amount equal to the total charges hereunder for the period of suspension).


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(c)

If any event under Section 24.3(a) substantially prevents, hinders or delays performance of the Services, then Supplier shall use Commercially Reasonable Efforts to identify another Supplier location from which it might provide the Services without interference from such event, and if Health Net requests, Supplier shall assist Health Net in identifying an alternate source that may be able to provide the Services to Health Net during the time of such Force Majeure Event. If any event under Section 24.3(a) substantially prevents, hinders or delays performance of the Services necessary for the performance of functions reasonably identified by Health Net as critical for more than five (5) consecutive business days, then at Health Net’s option: (i) Health Net may procure such Services from an alternate source, and in such event Supplier will reimburse Health Net for one-half of the difference between (A) the amount Health Net is obligated to pay the alternate source for such services, and (B) the amount that Health Net would have paid Supplier for such Services under this Agreement, for a period not to exceed one hundred eighty (180) days; (ii) Health Net may terminate any portion of this Agreement (including a SOW or a portion of a SOW) so affected without charge to Health Net or liability to Supplier and the Charges payable under this Agreement will be equitably adjusted to reflect those terminated Services; or (iii) Health Net may terminate this Agreement, without charge to Health Net or liability to Supplier, as of a date specified by Health Net in a written notice of termination to Supplier. Supplier will not have the right to any additional payments from Health Net for costs or expenses incurred by Supplier as a result of any Force Majeure Event.

(d)

A Force Majeure Event will not relieve Supplier of its obligations to implement successfully all of the Services relating to disaster recovery services that are included in this Agreement within the time period described in this Agreement.

25.

RULES OF CONSTRUCTION

25.1

Entire Agreement

This Agreement – consisting of the signature page, these Terms and Conditions and the attached Schedules and all SOWs and their attached Exhibits – constitutes the entire agreement between the Parties with respect to its subject matter and merges, integrates and supersedes all prior and contemporaneous agreements and understandings between the Parties (including as described in Section 3.1(c), the Original BPO Agreement), whether written or oral, concerning its subject matter. For clarity, at such time as the Original BPO Agreement is terminated as provided in Section 3.1(c), Health Net will not owe any penalties, termination fees, wind-down charges, or similar fees or charges in connection with such termination.

25.2

Contracting Parties; No Third Party Beneficiaries

This Agreement is entered into solely between, and may be enforced only by, Health Net and Supplier. This Agreement does not create any legally enforceable rights in third parties, including suppliers, subcontractors and customers of a Party, except as provided in this paragraph and Section 23 (Indemnification).

25.3

Contract Amendments and Modifications

Any terms and conditions varying from this Agreement on any order or written notification from either Party will not be effective or binding on the other Party. This Agreement may be amended or modified solely in a writing signed by an authorized representative of each Party.


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25.4

Governing Law

This Agreement and performance under it shall be governed by and construed in accordance with the laws of the state of California without regard to its choice of law principles.

25.5

Relationship of the Parties

Supplier, in furnishing the Services, is acting as an independent contractor. Supplier has the sole right and obligation to supervise, manage, contract, direct, procure, perform or cause to be performed, all work to be performed by Supplier under this Agreement. Supplier is not an agent or partner of Health Net and has no authority to represent or bind Health Net as to any matters, except as expressly authorized in this Agreement. This Agreement establishes a nonexclusive relationship between the Parties.

25.6

Consents and Approvals

Where approval, acceptance, consent or similar action by either Party is required under this Agreement, such action will not be unreasonably delayed, conditioned or withheld unless this Agreement expressly provides that it is in the discretion of the Party. No approval or consent given by a Party under this Agreement will relieve the other Party from responsibility for complying with the requirements of this Agreement, nor will it be construed as a waiver of any rights under this Agreement (except to the extent, if any, expressly provided in such approval or consent). Each Party will, at the request of the other Party, perform those actions, including executing additional documents and instruments, reasonably necessary to give full effect to this Agreement.

25.7

Waiver

No failure or delay by a Party in exercising any right, power or remedy will operate as a waiver of that right, power or remedy, and no waiver will be effective unless it is in writing and signed by an authorized representative of the waiving Party. If a Party waives any right, power or remedy, the waiver will not waive any successive or other right, power or remedy that Party may have.

25.8

Remedies Cumulative

Except as otherwise expressly provided in this Agreement, all remedies provided in this Agreement are cumulative and in addition to and not in lieu of any other remedies available to a Party under this Agreement, at law, or in equity.

25.9

References

(a)

The section headings and the table of contents used in this Agreement are for convenience of reference only and will not enter into the interpretation of this Agreement.

(b)

Unless otherwise indicated, section references are to sections of the document in which the reference is contained. For example, section references in these Terms and Conditions are to sections of the Terms and Conditions and, likewise, section references in a Schedule to this Agreement are to sections of that Schedule.

(c)

References to numbered (or lettered) sections of this Agreement also refer to and include all subsections of the referenced section.


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(d)

Unless otherwise indicated, references to Schedules to this Agreement also refer to and include all sub-Schedules to the referenced Schedule.

25.10

Rules of Interpretation

(a)

Unless the context requires otherwise, (i) “including” (and any of its derivative forms) means including but not limited to, (ii) “may” means has the right, but not the obligation to do something and “may not” means does not have the right to do something, (iii) “will” and “shall” are expressions of command, not merely expressions of future intent or expectation, (iv) “written” or “in writing” is used for emphasis in certain circumstances, but that will not derogate from the general application of the notice requirements set forth in Section 27.5 (Notices) in those and other circumstances, (v) use of the singular imports the plural and vice versa, and (vi) use of a specific gender imports the other gender(s).

(b)

References in this Agreement to “hours”, “days”, or “years” that do not specifically refer to Business Hours, Business Days or Contract Years are references to clock hours, calendar days, or calendar years, respectively, unless otherwise provided.

25.11

Order of Precedence

(a)

If there is any conflict between this Agreement and any document incorporated by reference into this Agreement, the Parties shall attempt to read any such conflicting provisions consistently, however, in the event such a consistent reading cannot be accomplished, the order of precedence will be as follows: (i) the Terms and Conditions and any amendments thereto, (ii) the Schedules, (iii) the Initial SOWs and the Transition Manual (it being the intent of the Parties that such documents shall be give equal priority), (iv) other attachments to this Agreement, and (v) other documents incorporated by reference.

(b)

If there is any conflict between any Future SOW and the other terms of this Agreement, the Parties shall attempt to read any such conflicting provisions consistently, however, in the event such a consistent reading cannot be accomplished, such Future SOW will take precedence over such other terms of this Agreement with respect to such Future SOW only if and to the extent the requirements of Section 3.7(a)(ii)(A) are satisfied. If such requirements are not satisfied, then the other terms of this Agreement shall govern.

25.12

Severability

If any provision of this Agreement conflicts with the Law under which this Agreement is to be construed or if any provision of this Agreement is held invalid, illegal, or otherwise unenforceable by a competent authority, such provision will, if possible, be deemed to be restated to reflect as nearly as possible the original intentions of the Parties in accordance with applicable Law. In any event, the remainder of this Agreement will remain in full force and effect.

25.13

Counterparts

This Agreement may be executed in several counterparts and by facsimile or PDF signature, all of which taken together constitute a single agreement between the Parties. Each signed counter-part, including a signed counterpart reproduced by reliable means (including facsimile and PDF), will be considered as legally effective as an original signature.


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25.14

Reading Down

If a provision of this Agreement is reasonably capable of an interpretation which would make that provision valid, lawful and enforceable and an alternative interpretation that would make it unenforceable, illegal, invalid or void then, so far as is possible, that provision will be interpreted or construed to be limited and read down to the extent necessary to make it valid and enforceable.

26.

DISPUTE RESOLUTION

Any dispute between the Parties arising out of or relating to this Agreement, including with respect to the interpretation of any provision of this Agreement or with respect to performance by Supplier or Health Net, will be resolved as provided in this Section 26 (Dispute Resolution).

26.1

Informal Dispute Resolution

(a)

Subject to Section 26.1(b), the Parties initially will attempt to resolve any dispute arising out of or relating to this Agreement informally in accordance with the following:

(i)

Within ten (10) days after a Party receives notice of a dispute from the other Party (“Dispute Date”), it will designate a senior representative (i.e., a person whose rank within the company is superior to, in the case of Supplier, the Client Partner, and in the case of Health Net, the Health Net Program Manager) who does not devote substantially all of his time to performance under this Agreement, who will offer to meet with the designated senior representative of the other Party for the purpose of attempting to resolve the dispute amicably.

(ii)

The appointed representatives will meet promptly to discuss the dispute and attempt to resolve it without the necessity of any formal proceeding. They will meet as often as the Parties deem necessary in order that each Party may be fully advised of the other’s position. During the course of discussion, all reasonable requests made by one Party to the other for non-privileged information reasonably related to the matters in dispute will be honored promptly.

(iii)

The specific format for the discussions will be left to the discretion of the appointed representatives.

(b)

Formal dispute resolution may be commenced by a Party upon the first to occur of any of the following:

(i)

the appointed representatives conclude in good faith that amicable resolution of the dispute through continued negotiation does not appear likely;

(ii)

thirty-five (35) days have passed from the Dispute Date (this period will be deemed to run notwithstanding any claim that the process described in this Section 26.1 (Informal Dispute Resolution) was not followed or completed); or

(iii)

commencement of formal dispute resolution is deemed appropriate by a Party to avoid the expiration of an applicable limitations period or to preserve a superior position with respect to other creditors, or a Party makes a good faith determination, including as provided in Section 26.4 (Equitable Remedies), that a breach of this Agreement by the other Party is such that a temporary restraining order or other injunctive or conservatory relief is necessary.


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(c)

All timeframes specified in this Section 26.1 are not-to-exceed durations. In the event of disputes related to compliance with Laws, Health Net may request (and Supplier shall use all best efforts to comply with) shorter timeframes as needed in order for Health Net to respond to any Regulator or regulatory deadlines.

26.2

Litigation

For all litigation which may arise with respect this Agreement, the Parties irrevocably and unconditionally submit (a) to the exclusive jurisdiction and venue (and waive any claim of forum non conveniens and any objections as to laying of venue) of the United States District Court for the Central District of California, or (b) if such court does not have subject matter jurisdiction, to the Superior Court of the State of California, Los Angeles County in connection with any action, suit or proceeding arising out of or relating to this Agreement. The Parties further consent to the jurisdiction of any state court located within a district that encompasses assets of a Party against which a judgment has been rendered for the enforcement of such judgment or award against the assets of such Party.

26.3

Continued Performance

Each Party agrees (a) to continue performing its obligations under this Agreement while a dispute is being resolved except (and then only) to the extent performance is prevented by the other Party or the issue in dispute precludes performance, and (b) not to take any action that intentionally obstructs, delays, or reduces in any way the performance of such obligations. For the avoidance of doubt, a good faith dispute regarding invoiced charges and Health Net’s withholding payment of disputed charges as permitted under this Agreement will not be considered to prevent Supplier from performing the Services or preclude performance by Supplier, nor will this Section 26.3 be interpreted to limit either Party’s right to terminate this Agreement (in whole or in part) or any SOW (in whole or in part) as provided in Section 16 (Termination).

26.4

Equitable Remedies

Each Party acknowledges that a breach of any of its obligations under the Sections of this Agreement listed below, or its infringement or misappropriation of any Intellectual Property Rights of the other Party, may irreparably harm the other Party in a way that could not be adequately compensated by money damages. In such a circumstance, the aggrieved Party may (in addition to all other remedies and rights) proceed directly to court notwithstanding the other provisions of this Section 26 (Dispute Resolution). If a court of competent jurisdiction should find that a Party has breached (or attempted or threatened to breach) any such obligations, such Party agrees that without posting bond or proving damages and without any additional findings of irreparable injury or other conditions to injunctive relief, it will not oppose the entry of an appropriate order compelling its performance of such obligations and restraining it from any further breaches (or attempted or threatened breaches) of such obligations. The following Sections are subject to this paragraph:

(a)

Section 14 (Data Security and Protection);

(b)

Section 15 (Intellectual Property Rights);


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(c)

Section 16 (Termination);

(d)

Section 21 (Confidentiality);

(e)

Section 23 (Indemnification);

(f)

Section 27.7; and

(g)

Schedule E (Transitioned Employees).

26.5

Waiver of Jury Trial

THE PARTIES HEREBY UNCONDITIONALLY WAIVE THEIR RESPECTIVE RIGHTS TO A JURY TRIAL OF ANY CLAIM OR CAUSE OF ACTION ARISING DIRECTLY OR INDIRECTLY OUT OF, RELATED TO, OR IN ANY WAY CONNECTED WITH, THE PERFORMANCE OR BREACH OF THIS AGREEMENT, OR THE RELATIONSHIP THAT IS BEING ESTABLISHED BETWEEN THEM. THE SCOPE OF THIS WAIVER IS INTENDED TO BE ALL ENCOMPASSING OF ANY AND ALL DISPUTES THAT MAY BE FILED IN ANY COURT OR OTHER TRIBUNAL (INCLUDING, WITHOUT LIMITATION, CONTRACT CLAIMS, TORT CLAIMS, BREACH OF DUTY CLAIMS, AND ALL OTHER COMMON LAW AND STATUTORY CLAIMS). THIS WAIVER IS IRREVOCABLE, MEANING THAT IT MAY NOT BE MODIFIED EITHER ORALLY OR IN WRITING, AND THE WAIVER SHALL APPLY TO ANY SUBSEQUENT AMENDMENTS, RENEWALS, SUPPLEMENTS OR MODIFICATIONS TO THIS AGREEMENT, AND RELATED DOCUMENTS, OR TO ANY OTHER DOCUMENTS OR AGREEMENTS RELATING TO THIS TRANSACTION OR ANY RELATED TRANSACTION. IN THE EVENT OF LITIGATION, THIS AGREEMENT MAY BE FILED AS A CONSENT TO A TRIAL BY THE COURT.

26.6

Disclaimer of Uniform Computer Information Transactions Act

TO THE MAXIMUM EXTENT PERMITTED UNDER APPLICABLE LAW, THE PARTIES DISCLAIM AND NONE OF THIS AGREEMENT SHALL BE SUBJECT TO THE UNIFORM COMPUTER INFORMATION TRANSACTIONS ACT (“UCITA”) (PREPARED BY THE NATIONAL CONFERENCE OF COMMISSIONERS ON UNIFORM STATE LAWS) AS CURRENTLY ENACTED OR AS MAY BE ENACTED, CODIFIED OR AMENDED FROM TIME TO TIME BY ANY JURISDICTION. TO THE EXTANT THAT ANY ASPECT OF THIS AGREEMENT OR ANY LICENSE GRANTED UNDER THIS AGREEMENT IS UNCLEAR OR DISPUTED BY THE PARTIES AND UCITA, IF APPLIED, WOULD CLARIFY SUCH LICENSE OR RESOLVE SUCH DISPUTE, THE PARTIES AGREE TO CLARIFY SUCH LICENSE OR RESOLVE SUCH DISPUTE INDEPENDENTLY OF UCITA BY APPLYING THE INTENT OF THE PARTIES AT THE TIME THAT THEY ENTERED THIS AGREEMENT.

27.

GENERAL

27.1

Binding Nature and Assignment

This Agreement is binding on the Parties and their respective successors and permitted assigns. Supplier acknowledges that the Services are personal in nature and that, as a result, Supplier may not assign this Agreement or delegate (except to Subcontractors as permitted in Section 7.7 its rights or obligations under this Agreement, whether by operation of law or otherwise, without the


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prior written consent of Health Net (which may be conditioned upon Health Net (or the applicable Health Net Affiliate or Health Net lines of business) providing prior notification to, and receiving approval from, applicable Regulator(s) and customers). Health Net may not assign this Agreement or delegate its rights or obligations under this Agreement without the prior written consent of Supplier except to a Health Net Affiliate or to the successor in a merger or reorganization of Health Net or an entity that acquires Control of Health Net or acquires all or substantially all of Health Net’s business or assets. Any attempted assignment in violation of this Section 27.1 will be void and will constitute a material breach of this Agreement by the Party attempting the assignment. A Party assigning this Agreement or delegating its rights or obligations under this Agreement must provide prompt notice of the assignment or delegation to the other Party after its effective date, subject to the prior regulatory approval set out above.

27.2

Ethics Hotline

Supplier agrees to report any violation of Law (including HIPAA and the FCPA) committed by Supplier, its employees or subcontractors in the performance of the Services to Health Net’s Ethics Hotline at (▇▇▇) ▇▇▇-▇▇▇▇ or Health Net’s Ethics Officer at Health Net’s address for Notices.

27.3

Nondiscrimination

(a)

Neither Party shall discriminate against any Beneficiary in the provision of Services hereunder, whether on the basis of the Beneficiary’s coverage under a Benefit Program, age, sex, marital status, sexual orientation, race, color, religion, ancestry, national origin, disability, handicap, health status, source of payment, utilization of medical or mental health services or supplies, or other unlawful basis including, without limitation, the filing by such Beneficiary of any complaint, grievance or legal action against Supplier, Health Net, or a Health Net Affiliate. Supplier agrees to make reasonable accommodations for Beneficiaries with disabilities or handicaps, including but not limited to, providing auxiliary aids and services to Beneficiaries at Supplier’s expense, as required by law.

(b)

This Agreement is subject to the affirmative action and nondiscrimination requirements of Executive Order 11246 as amended, Section 503 of the Rehabilitation Act of 1973, and Section 402 of the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, and with all rules, regulations, pertaining thereto, which are incorporated herein by specific reference.

(c)

Supplier and its subcontractors shall abide by the requirements of 41 CFR 60-300.5(a) and 60-741.5(a). These regulations prohibit discrimination against qualified individuals on the basis of protected veteran status or disability, and require affirmative action by covered prime contractors and subcontractors to employ and advance in employment qualified protected veterans and individuals with disabilities.

27.4

Beneficiary Hold Harmless

Supplier will (a) not hold any Beneficiary liable for fees that are the responsibility of Health Net or a Health Net Affiliate; and (b) ensure that Supplier’s subcontractors will not hold any Beneficiary liable for fees that are the responsibility of Health Net or a Health Net Affiliate.


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27.5

Notices

(a)

All notices, requests, demands and determinations under this Agreement (other than routine operational communications), shall be in writing and shall be deemed duly given (i) when delivered by hand, (ii) on the designated day of delivery after being timely given to an express overnight courier with a reliable system for tracking delivery, (iii) six (6) days after the day of mailing, when mailed by United States mail, registered or certified mail, return receipt requested and postage prepaid, and addressed as follows:

(i)

In the case of Health Net:

Health Net, Inc.

▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇

Attn: Vendor Management Officer

With a copy to:

Health Net, Inc.

▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇

Attn: General Counsel

(ii)

In the case of Supplier:

Cognizant Technology Solutions US Corporation

▇▇▇ ▇▇▇▇▇ ▇. ▇▇▇▇ ▇▇▇▇.

▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇

Attn: General Counsel

(b)

A Party may from time to time change its address or designee for notification purposes by giving the other prior written notice of the new address or designee and the date upon which it will become effective.

27.6

Non-solicitation of Employees

(a)

Except as provided in Schedule E (Employee Transfer), Supplier will not solicit or seek to procure the employment of any Health Net personnel, either directly or indirectly (other than by general advertising not specifically targeted at Health Net’s employees) until after the date on which any such Health Net personnel is terminated by Health Net, or three (3) months after any such Health Net Personnel voluntarily ceases to be employed by Health Net, without the prior written consent of Health Net (which consent is deemed given as of the Effective Date for the Affected Employees).

(b)

Except as provided in Schedule L (Disengagement Assistance), Health Net will not solicit or seek to procure the employment of any Supplier Personnel, either directly or indirectly (other than by general advertising not specifically targeted at Supplier’s employees) until after the date on which any such Supplier Personnel is terminated by Supplier, or three (3) months after any such Supplier personnel voluntarily ceases to be employed by Supplier, without the prior written consent of Supplier.


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27.7

Compliance with Laws

(a)

Supplier’s Obligations.

(i)

Supplier agrees at its cost and expense (x) to comply with its obligations under the Regulatory Compliance Addendum attached hereto as Schedule K (Regulatory Compliance Addendum), and (y) obtain all necessary approvals, licenses, and permits required by Law, and to comply with all Laws, in each case as applicable to:

(A)

its business (or that of any of its Affiliates);

(B)

the performance of any of its obligations under this Agreement;

(C)

the Services that Supplier is obligated to provide under this Agreement, including as such obligations may evolve pursuant to this Agreement, including Services provided with respect to any jurisdiction in which Health Net does business; or

(D)

its obligations under Sections 14.3, 14.6, 14.8, and 14.9.

(ii)

If Supplier is charged with failing to comply with any such Laws, it shall promptly notify Health Net of the charges in writing.

(iii)

Supplier shall identify, track and report any failure by Supplier to comply with Laws or failure (or suspected failure) to comply with the Compliance Services set forth in Section 3.5 of Schedule A (Cross Functional Services). Such report shall be made to Health Net with five (5) days of Supplier’s learning of same.

(iv)

Health Net, not Supplier, shall be responsible (as provided in Section 27.7(b)(iii)(ii) below) for discovering, identifying, and notifying Supplier of new Laws and changes in Laws applicable to Health Net’s own business and operations that are applicable to the Services but would not otherwise be applicable to Supplier. Upon receiving notification of a new Law or change in Law applicable to the Services, Supplier shall prepare for Health Net’s approval draft policies concerning compliance with the new Law or change in Law. Health Net shall review and the following portions of policies submitted by Supplier: policy statement, policy purpose, scope/limitations, references and definitions (“Reviewed Policy Provisions”), but Supplier shall be responsible for any other portions of such policies. Supplier shall comply with all such Reviewed Policy Provisions approved by Health Net. Supplier shall alone be responsible for the development and implementation of operational procedures to facilitate Supplier’s compliance with such policies.

(b)

Health Net’s Obligations.

(i)

Health Net agrees at its cost and expense (x) to comply with its obligations under the Regulatory Compliance Addendum attached hereto as Schedule K (Regulatory Compliance Addendum), and (y) obtain all necessary approvals, licenses and permits required by Law, and to comply with all Laws, in each case as applicable to:

(A)

its business (or that of any of its Affiliates);


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(B)

the performance of any of its obligations under this Agreement; or

(C)

its obligations under Sections 14.6 and 14.8.

(ii)

If Health Net is charged with failing to comply with any such Laws it shall promptly notify Supplier of the charges in writing.

(iii)

As between Health Net and Supplier, Health Net shall be responsible for discovering, identifying, and notifying Supplier of new Laws and changes in Laws applicable to Health Net’s own business and operations that are applicable to the Services but would not otherwise be applicable to Supplier.

(c)

If there is a Law with which Supplier is obligated to comply pursuant to Section 27.7(a) and Health Net is obligated to comply pursuant to Section 27.7(b), each Party shall have the financial responsibility for its own compliance with such Law.

(d)

When either Party receives notice of a change in Law applicable to the Services or the other Party’s activities pursuant to this Agreement, such Party will promptly provide notice to the other Party.

(e)

For the avoidance of doubt, nothing contained in this Agreement shall require either Party to act in any illegal manner.

27.8

Covenant of Good Faith

Each Party, in its respective dealings with the other Party under or in connection with this Agreement, will act reasonably and in good faith.

27.9

Public Disclosures

Neither Party shall make any media releases, public announcements or public disclosures relating to this Agreement or the subject matter of this Agreement, including promotional or marketing material, but not including disclosures to the extent required to meet legal or regulatory requirements beyond the reasonable control of the disclosing Party without the prior written consent of the other Party.

27.10

Service Marks

Supplier will not, without Health Net’s consent, use the name, service marks or trademarks of Health Net in any advertising or promotional materials prepared by or on behalf of Supplier.

27.11

Guaranty

Supplier shall cause the Guaranty Agreement, attached as Schedule V (Guaranty), to be executed by Cognizant Technology Solutions Corporation and delivered to Health Net concurrently with the execution of this Agreement. Failure to do so will constitute a material breach of this Agreement by Supplier.


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27.12

Mutually Negotiated

No rule of construction will apply in the interpretation of this Agreement to the disadvantage of one Party on the basis that such Party put forward or drafted this Agreement or any provision of this Agreement.


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IN WITNESS WHEREOF, Health Net and Supplier have each caused this Agreement to be signed and delivered by its duly authorized officer, all as of the date first set forth above.


Health Net, Inc.		Cognizant Healthcare Services, LLC

By:	/s/ ▇▇▇▇▇ ▇. ▇▇▇▇	By:	/s/ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇
Print Name:	▇▇▇▇▇ ▇. ▇▇▇▇	Print Name:	▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇
Title:	EVP, COO & CFO	Title:	Executive Vice President Chief Legal and
Date:			Corporate Affairs Officer
		Date:


Terms and Conditions				Health Net / Cognizant Confidential

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SCHEDULE A

CROSS FUNCTIONAL SERVICES


Schedule A				Health Net / Supplier Confidential

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SCHEDULE A

CROSS FUNCIONAL SERVICES

Table of Contents


1	INTRODUCTION		1
	1.1	General	1
	1.2	Solution	1
	1.3	Hours of Coverage	i
	1.4	Definitions	2
	1.5	Changes	3

2	RESPONSIBLE PARTY		4

3	CROSS-FUNCTIONAL SERVICES		4
	3.1	Business Continuity & Disaster Recovery Services	5
	3.2	Training Services	8
	3.3	Documentation	9
	3.4	ERM Services	10
	3.5	Regulatory Compliance Adherence Services	10
	3.6	Innovation Services	11
	3.7	Root Cause Analysis Services	13
	3.8	Managed Third Party Contract Services	13
	3.9	Reporting and Analytics Services	16
	3.10	User Acceptance Testing Services	17
	3.11	Return Mail Processing Services	18
	3.12	Inventory Management Services	18
	3.13	Collection of Funds Services	19
	3.14	Issue and Error Resolution Services	19
	3.15	Integration Services	19
	3.16	Translation Services	20

4	EMBEDDED PROCESSES		20
	4.1	General	20
	4.2	Embedded Processes	20


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SCHEDULE A

CROSS FUNCTIONAL SERVICES

1	INTRODUCTION

1.1

General

(a)

This Schedule A (Cross Functional Services) describes, among other things, those Cross Functional Services and Embedded Processes to be performed and delivered by Supplier, which are applicable to all of the Services performed by Supplier under this Agreement.

(b)

The Services are required for Health Net’s business operations in the United States, including its territories.

(c)

References to specific resources (e.g., tools, systems) in this Schedule A (Cross Functional Services), any SOW, or elsewhere in the Agreement that are used by Supplier in performing the Services shall be deemed to include successor or replacement resources.

(d)

Supplier shall manage and perform the Services in a tightly integrated manner (with appropriate consideration given at all times to the impact of change to all Services).

(e)

Supplier shall provide such information as may be reasonably requested by Health Net from time to time to support Health Net’s investigation into potential violations of Health Net’s policies and procedures.

(f)

All communications and documentation will be in English unless otherwise specified in the Agreement.

(g)

Supplier shall generate and provide to Health Net (i) each operational report generated prior to the BPaaS Services Commencement Date, unless and until Health Net confirms in writing that such operational report is no longer required, (ii) such other operational reports as Health Net may reasonably request from time to time, and (iii) such modifications to or replacements for the foregoing reports as may be necessary to reflect changes to and evolutions of the Cross Functional Services during the term of the Agreement.

1.2

Solution

Schedule A-1 (Cross Functional Solution) describes how Supplier will perform and deliver the Services in a manner that meets the requirements of the Agreement (the “Cross Functional Solution”). Except where explicitly noted otherwise, Schedule A-1 (Cross Functional Solution) is intended to describe the future “To-Be” service delivery environment and processes and tools to be implemented and used by Supplier in performing the Services. Supplier’s performance of the Services will be in accordance with the Solution. The Solution may not modify or change the scope of Services to be provided under, or any other terms or conditions of, this Agreement.

1.3

Hours of Coverage

The hours of coverage for each of the Services are set forth in Schedule A-1 (Cross Functional Solution). Supplier will at minimum mirror the regular operating hours adhered to by the Health


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Net personnel performing the Cross Functional Services as of the Effective Date. Supplier acknowledges and agrees that performance of the Cross Functional Services will regularly require Supplier Personnel to perform additional/overtime work outside regular operating hours, and that such additional/overtime work is within the scope of the Cross Functional Services.

Supplier will extend its hours of operations (for example, through overtime, weekend and holiday work) from time to time as needed to meet regulatory requirements, Compliance and Service Level metrics and other requirements of the Agreement. Supplier’s work during such extended hours of operations is within the scope of the Cross Functional Services.

Within the regular hours of operations set forth in Schedule A-1 (Cross Functional Solution), Supplier will have staff work according to defined shift schedules. However, Supplier will make reasonable efforts to permit Supplier staff to work flexible shift times when that can be done without jeopardizing Supplier’s ability to meet regulatory requirements, Compliance and Service Level metrics and other requirements of the Agreement.

1.4

Definitions

Capitalized terms not defined in this Schedule A (Cross Functional Services) shall have the meanings given them in Schedule W (Glossary) or elsewhere in this Agreement.

(a)

“Channels” means various forms of communication including phone, chat, email, text, and SMS.

(b)

“Health Net Departments” means Claims, Membership, Configuration, Correspondence, Customer Contact Center, and Appeals & Grievances.

(c)

“Health Net Investigations” means any effort that Health Net (including the Health Net Compliance Department, Vendor Oversight, or any other department) undertakes to obtain information necessary to perform an internal audit or monitoring process, obtain information necessary to respond to regulators or other external entities, or otherwise ensure compliance with business and regulatory requirements.

(d)

“Member” means a person who is properly enrolled in and eligible to receive covered services under a Health Net benefit program at the time covered services are rendered.

(e)

“Plan” means a health insurance plan offered by Health Net.

(f)

“Provider” means a facility, physician, physician organization, independent practice association, health care provider, supplier, or other organization that may provide covered services.

(g)

“Ramp Up” means the period of time from when an associate completes process training to the time when the agent starts meeting the required quality SLAs and 100% productivity standards.

(h)

“Regions” means (i) Arizona, (ii) California, and (iii) Oregon/Washington.

(i)

“RTO” means recovery time objective.

(j)

“Supplier Facilities” means those locations set forth in Schedule F (Supplier Facilities).


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(k)

“Tower(s)” means the set of Services described in each Statement of Work.

(l)

“Transition Management Office” or “TMO” means the Supplier resources dedicated to managing the Transition as further described in the Transition Manual.

1.5

Changes

Material additions to, deletions from, or other changes in the Services described in this Schedule A (Cross Functional Services) are subject to the Change Control Process.


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2	RESPONSIBLE PARTY


Process / Function ID	Process/Function Name / Description	Line of Business	Region	Resp. Party
Process / Function ID	Process/Function Name / Description	Line of Business	Region	Supplier	HN
CF1	Business Continuity & Disaster Recovery Services	All	All	X
CF2	Training Services	All	All	X
CF3	Documentation	All	All	X
CF4	ERM Services	All	All	X
CF5	Regulatory Compliance Adherence	All	All	X
CF6	Innovation	All	All	X
CF7	Root Cause Analysis	All	All	X
CF8	Managed Third Party Contract Service	All	All	X
CF9	Reporting and Analytics	All	All	X
CF10	User Acceptance Testing	All	All	X
CF11	Return Mail Processing	All	All	X
CF12	Inventory Management	All	All	X
CF13	Collection of Funds	All	All	X
CF14	Issue/Error Resolution	All	All	X
CF15	Integration Services	All	All	X
CF16	Translation Services	All	All	X

3	CROSS-FUNCTIONAL SERVICES

Supplier shall provide the following cross-functional services (the “Cross Functional Services”) as part of the Services and any other Services the Parties may agree to add to the scope of this Agreement. In the event that Health Net terminates the provision of any part of the Services pursuant to this Agreement, Supplier shall continue to provide the Cross Functional Services set forth in this Section 3 as such Cross Functional Services relate to the remaining Services.


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3.1

Business Continuity & Disaster Recovery Services

(a)

“Business Continuity and Disaster Recovery Services” are (i) the Functions associated with planning, documenting, implementing, maintaining and periodically testing a mutually agreed-upon business continuity plan that ensures that the Services are sustained at a suitable and appropriate level during any business disruption, disaster or Force Majeure event (the “Business Continuity Plan”), and (ii) the IT Continuity and Business Recovery Services set forth in Schedule A-3 (IT Continuity and Business Recovery Services).

(b)

Supplier will assume responsibility for performing Business Continuity and Disaster Recovery Services for each Service as of the BPaaS Services Commencement Date. Supplier will adopt Health Net’s then existing business continuity plan for all operations that remain at Health Net Facilities following the BPaaS Services Commencement Date. Supplier will develop a Business Continuity Plan and Disaster Recovery Plan for all Services to be performed at Supplier Facilities (i) prior to the BPaaS Service Commencement Date or (ii) for Services transitioned after the BPaaS Services Commencement Date, prior to the date that such Service is transitioned from a Health Net Facility to a Supplier Facility. No later than eighteen (18) months following the BPaaS Services Commencement Date, Supplier will fully implement a tested Business Continuity Plan for the Services in compliance with all enhanced requirements set forth in this Agreement.

(c)

Supplier will ensure during the Transition and during steady state that at all times the Services comply with Health Net’s disaster recovery policies and business requirements (and changes thereto), including any applicable regulatory requirements, to the extent such plans, policies, requirements and regulations apply to the Services. Supplier will store the Business Continuity Plans in readily accessible locations for access in the event of a disaster.

(d)

Among other things, the Business Continuity Plan shall:

(i)

Contain a brief description of processes and procedures used to recover the Services, and associated time frames for the recovery of such Services, including a prioritized listing of Services, subject to Health Net’s input, review and approval;

(ii)

Contain notification procedures to alert Health Net of Service disruptions including off-hour and weekend coverage; and

(iii)

Describe Supplier’s and Health Net respective recovery responsibilities.

(e)

The Parties will alert each other of any deficiencies discovered in the Business Continuity Plan that would adversely affect Health Net or the provision of Services.

(f)

With cooperation and approval from Health Net, Supplier shall review and update, the Business Continuity Plan at a minimum on an annual basis or as otherwise warranted by (i) business or technical changes (or both), (ii) requirements of applicable Laws, and (iii) otherwise as necessary to maintain compatibility with Health Net’s overall business continuity plan. Supplier will receive business direction and requirements from Health Net and must receive authorization from Health Net to make significant changes to the strategic and/or tactical direction of Health Net’s overall business continuity plan.


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(g)

As part of the Business Continuity and Disaster Recovery Services, Supplier will:

(i)

assess and define functional, performance, availability, maintainability and disaster recovery needs and the security requirements to meet user, regulatory, client and company policy requirements; and

(ii)

propose functional, performance, availability, maintainability and disaster recovery requirements and establish standards (e.g., support processes and procedures).

(h)

As part of the Business Continuity and Disaster Recovery Services, Supplier will:

(i)

provide training and support to Health Net technical and business unit employees for the necessary technical and non-technical (process oriented) changes that would become necessary and executed during emergencies and business disruption events affecting the Services; and

(ii)

perform education and awareness training related to the Business Continuity Plan for all Supplier Personnel.

(i)

As part of the Business Continuity and Disaster Recovery Services Supplier will, at a minimum:

(i)

Perform the Business Continuity and Disaster Recovery Services in accordance with ISO 22301 (or any replacement standard during the Term that is mutually agreed upon by Supplier and Health Net) and any additional standards and procedures mutually agreed upon by Supplier and Health Net;

(ii)

Include the capabilities to transition back from the disaster recovery site to Supplier Facilities of the affected services and restoration of Services at the affected site upon cessation of the disaster;

(iii)

Include the capabilities to allow the same Supplier Personnel assigned to perform the Services to continue providing the Services in the event of a disaster;

(iv)

Upon cessation of the disaster, implement the activities necessary to restore the affected Services at the affected locations with the capabilities to meet the RTO and other turnaround times set forth in the Business Continuity Plan;

(j)

Test Supplier’s disaster recovery and business continuity plans (including the Business Continuity Plan), as warranted by (i) business or technical changes (or both), (ii) Health Net requirements as defined in this Schedule A (Cross Functional Services) or requirements of applicable Laws, and (iii) otherwise as necessary to maintain compatibility with Health Net’s overall business continuity plan. Supplier will receive business direction and requirements from Health Net and must receive authorization from Health Net to make significant changes to the strategic and/or tactical direction of Health Net’s overall business continuity plan, procedures and capabilities with respect to each Supplier Facility and those related to or affecting the Services.


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(k)

Interface Supplier’s disaster recovery and business continuity plans, procedures and capabilities with, and provide support and assistance to Health Net in connection with Health Net’s annual testing of, Health Net’s disaster recovery and business continuity plans, processes and procedures. Supplier will permit Health Net and its auditors to audit the Business Continuity Plans on an annual basis.

(l)

In the event of a disaster, Supplier shall provide the Services and other business continuity Functions in accordance with the Business Continuity Plan. Supplier’s Functions shall include the following:

(i)

Providing a single 24 hour per day, 365 day per year (24/365) point-of-contact with at least two (2) alternative back-up points-of-contact with 24/365 availability for business continuity related communications and activities;

(ii)

Paying all travel and living expenses incurred by Supplier Personnel in the performance of Supplier’s responsibilities described in this Section 3.1 for Supplier’s facilities offshore; and

(iii)

Meet service levels established in the approved BCP/DR Plan related to mission critical processes required during the disaster event, with relief during the phase of Transition from any penalties (financial or otherwise) that occur as a result of documented deficiencies in the existing Health Net business continuity and disaster recovery testing reports related to services and supporting technology that are adopted by Supplier prior to development, approval, and testing of the Supplier’s Business Continuity Plan, and with relief from consequences (financial impact or otherwise) outside of Supplier control and within scope of services provided by third parties contracted directly to Health Net.

(m)

In the event of a disaster, Supplier shall not give priority to the recovery of other Supplier clients’ processes with recovery time objectives that exceed Health Net’s recovery time objectives for recovery of affected Equipment, Software, Services and data related to the Services deemed mission critical in the Business Continuity and Disaster Recovery Plan.

(n)

In addition to the Functions described in Section 3.1(b) through 3.1(m) above, the Business Continuity & Disaster Recovery Services include the following activities:

(i)

Develop, subject to Health Net’s approval, the Business Continuity Plan in accordance with the requirements of this Section 3.1;

(ii)

Conduct gap analyses of potential faults in meeting the RTO, in applications or processes used to perform the Services;

(iii)

Propose to Health Net updates to Health Net’s overall disaster recovery and business continuity plans and to the Business Continuity Plan, as needed to reflect changes in the Services, the technical environment, or requirements of applicable Laws;

(iv)

Conduct tests of the Business Continuity Plan related to the Services;


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(v)

Participate, as requested by Health Net, in Health Net’s disaster recovery and business continuity tests that will enable Health Net to test compatibility of their applications and processes with the recovery center environment;

(vi)

Participate, as requested by Health Net, in Health Net’s disaster recovery and business continuity testing (or, in the event of a disaster, disaster recovery and business continuity execution) for Health Net customers and business partners, including by coordinating with third parties as such third parties relate to the Services;

(vii)

Integrate Supplier’s disaster recovery and business continuity plans, procedures and capabilities with Health Net’s disaster recovery and business continuity plans, processes and procedures;

(viii)

Review and approval by Health Net of Supplier’s disaster recovery and business continuity plans, test plans and testing results;

(ix)

Participate with Health Net in the Joint Steering Committee and test team meetings for disaster recovery and business continuity;

(x)

Communicate to Health Net proposed disaster recovery and business continuity plan changes, including changes in the Business Continuity Plan, due to any technical or business changes;

(xi)

Identify and inform Health Net of opportunities (if any) for improvement of effectiveness and efficiencies in disaster recovery and business continuity functions;

(xii)

Review and recommend opportunities for improvement of effectiveness and efficiencies in disaster recovery and business continuity functions;

(xiii)

Communicate to Health Net disaster recovery and business continuity goals and initiatives, related to Supplier Services for the following year; and

(xiv)

Report to Health Net, quarterly, all business continuity and disaster recovery activities as outlined in ISO 22301.

3.2

Training Services

“Training Services” are those Functions associated with the curriculum development, planning, scheduling and delivery of trainings in compliance with Laws for all Supplier Personnel performing the Services in the Claims, Membership, Appeals & Grievances, and Contact Center, including the following activities:

(a)

Develop training curriculum needed to deliver the Services including training scenarios and knowledge checks;

(b)

Develop training, including computer based training that comply with regulatory requirements;

(c)

Provide training and oversight for External Employer Group Auditors;


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(d)

Maintain training calendar and inventory;

(e)

Provide training reports to various parties including but not limited to Health Net Management, Health Net areas, Compliance, and Regulators;

(f)

Document training attendance, course completion and other training related details;

(g)

Manage and maintain intake process and system for new and adjusted training requests;

(h)

Regular review of training technology, methodologies, courses, and approach;

(i)

Perform needs assessment and training validation for any new training requests;

(j)

Review audit findings and make recommendations to business areas for policy and procedure creation/updates, additional training, process automation tools, and/or process change/improvement;

(k)

Provide regulatory training support including but not limited to ad hoc training requests and reporting; and

(l)

Certify training staff.

Any Training Associates who perform any Training Services associated with the Offshore Restricted Entities listed in Section 3.1 of Schedule Y (Offshore Prohibitions and Restrictions) shall remain on-shore.

3.3

Documentation

“Documentation Services” means those Functions associated with maintaining, archiving, offsite storage, retrieval, and destruction of documentation as related to the Services in hard copy and/or electronic form, including the following activities:

(a)

Recommending documentation requirements, location, and formats;

(b)

Reviewing and approving documentation requirements, location and formats as appropriate;

(c)

Maintaining, retrieving and archiving documentation in agreed format in support of the Services;

(d)

Identifying documentation for archival per Health Net retention policies and coordinating with Health Net to prepare documents for delivery to offsite storage;

(e)

Providing to Health Net any documentation as required in response to regulatory requirements, Health Net Investigations, and/or inquiries;

(f)

Providing additional information as requested to support Health Net documentation requirements and Health Net proposal efforts;

(g)

Enabling Health Net direct electronic access to documentation retained in accordance with the documentation requirements;


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(h)

Following Health Net’s policies and processes for destruction of records, including acquiring Health Net approval prior to any document destruction;

(i)

Storing business continuity documentation separate from standard retention documents;

(j)

Complying with Health Net’s Records Information Management (RIM policies, processes and procedures related to the retention, archive and destruction of documents (including any documents containing Confidential Information), and the ability to retain information in compliance with laws, legal and regulatory obligations and disaster recovery requirements;

(k)

Maintaining documentation per legal hold requirements per regulatory and Health Net policies; and

(l)

Marking and handling documentation in accordance with Health Net’s Data Classification Policies and Procedures.

3.4

ERM Services

“Enterprise Risk Management Services” or “ERM Services” are those Functions associated with a formalized process to identify, assess, mitigate, monitor and report on risks, consistent with the Health Net ERM Guide and related processes/policies (“ERM Framework”), to the proper performance and fulfillment of the Solution and all Services performed by Supplier. Any such risks, assessment, mitigation and monitoring activity are reported to Health Net for its evaluation, monitoring and reporting requirements. In addition, ERM Services require Supplier to develop, implement, and manage solutions to mitigate the impact of existing and emerging risks.

ERM Services shall be overseen by a single accountable individual within Supplier’s organization. Supplier shall conduct a risk assessment no less than twice a year that is consistent with and which supports the ERM Framework and report on the results of such risk assessments to Health Net along with Supplier’s plans to monitor and mitigate any identified risks. Health Net will retain the final decision making authority of whether any suggested risks actually make the formal list and what risks can be closed and removed.

3.5

Regulatory Compliance Adherence Services

As a basic principle, Health Net must retain ownership of the compliance functions associated with the Services. For avoidance of doubt, Health Net will own and fully retain responsibility for (i) maintaining relationships with Regulators and policy makers as it relates to Health Net’s business, (ii) interpreting new or modified Laws with which Health Net is responsible for complying pursuant to Section 27.7 (Compliance with Laws) of the Terms and Conditions; and (iii) drafting and submitting responses to regulator Communications.

“Regulatory Compliance Adherence Services” are the Functions necessary to manage compliance of the Services, including managing the compliance of all related downstream entities and entities with delegated Functions, in accordance with Law. The Regulatory Compliance Adherence Services include the following activities:

(a)

As requested by Health Net to comply with Law, provide information related to the Services to enable Health Net to respond to directives, complaints, requests for information or other communications from Regulators (e.g., CMS Memo, Annual call letters) (collectively, “Regulator Communications”);


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(b)

Provide data to Health Net related to any in-scope Functions including audit activities and participate in data validation activities;

(c)

Develop and distribute content for, and monitor evidence of completion of, compliance training for Supplier Personnel;

(d)

Monitor Cognizant’s compliance with Laws with which Cognizant is responsible for complying pursuant to Section 27.7 (Compliance with Laws) of the Terms and Conditions;

(e)

Identify, track, report, and escalate issues of non-compliance (or suspected non-compliance) to Health Net within required timeframes;

(f)

Implement, monitor and report on normal course of business controls;

(g)

Notify downstream entities of compliance requirements, monitor downstream entity compliance, and report to Health Net on the compliance of downstream entities;

(h)

Respond to data requests to support active Health Net Investigations; and

(i)

Comply with due dates and turnaround times as specified by Health Net Legal and Regulatory Affairs.

3.6

Innovation Services

(a)

“Innovation” means the development, discovery and/or application of new ideas, techniques, methods, processes or technology related to the Services that improve outcomes – be they financial or experiential – for Health Net’s Members, Providers, Shareholders or other Stakeholders. “Innovation Services” are the Functions the Supplier will provide to ensure Innovation of the Services (including as required for Supplier to continuously evolve and improve the Services as required by Section 3.3 (Evolution of the Services) of the Terms and Conditions and Section 5.4 (Continuous Improvement) of Schedule B (Service Levels) and that Health Net receives the benefits from Supplier’s continuous Innovation.

(b)

As part of the Innovation Services and subject to 3.7(h), Supplier shall develop, implement, manage and maintain a set of processes, procedures and tools through which Supplier will continually monitor and improve its service delivery methods using industry recognized best practices. Supplier will identify weaknesses and opportunities for Innovation and improvement in its service delivery methods and systematically implement those Innovations and improvements.

(c)

By the end of Transition and annually thereafter Supplier will provide to Health Net an Innovation Plan. Health Net will provide input to the Innovation Plan as it is developed and updated. Each Innovation Plan will include:

(i)

An identification of general and industry specific business, medical (e.g., related to medical trends regarding claims and authorizations), and technical trends and forecasts that inform both the Supplier and Health Net of new opportunities that could be used to improve financial or experiential outcomes;


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(ii)

An annual benchmark conducted by Supplier comparing itself against the Supplier Competitors listed in Schedule M (Supplier Competitors). The underlying purpose of the benchmark will be for Health Net to understand market capabilities and to stay current with market advancements;

(iii)

The business challenges facing the Health Care Industry and Heath Net relative to Health Net’s stated business goals and objectives;

(iv)

Specific new, disruptive technological or scientific advances and their expected timeframes for practical (e.g., economically feasible) application of future advances within the context of Health Net’s business and the Services;

(v)

Reporting on the current STARs, HEDIS and NCQA rating for the Services over the previous year and a plan for improving each rating during the upcoming year;

(vi)

For STARS, identifying goals for the upcoming year for each measure, initiatives to achieve the goals, and correlating metrics to track progress and inform that goals are on track; and

(vii)

A rolling two year forecast identifying specific improvements in techniques, methods, processes or technologies that Supplier will implement to deliver ongoing Innovation within the scope of the Services and a list of prioritized recommendations as to how Health Net could take advantage of opportunities to innovate in areas related to the Services.

(d)

Health Net and Supplier will utilize the Governance structure to ensure the Innovation Plan is completed timely, with Health Net participation as part of the Technology/Services Meetings, and that Supplier is executing upon the Innovation Plan. Supplier will provide quarterly reports to Health Net on Supplier’s Innovation activities in support of the Innovation Plan.

(e)

In addition to the annual Innovation Plan, Supplier shall:

(i)

Continuously monitor industry trends, including through independent research, and document and report on products and services with potential use for Health Net on a quarterly basis.

(ii)

Participate, as requested by Health Net, in technical and business planning sessions.

(f)

Without limiting Supplier’s obligation under Section 3.7(c), annually Health Net may conduct an assessment of (i) Supplier’s Solution, (ii) Supplier’s Service delivery environment, and (iii) the processes, procedures, software, systems and tools Supplier uses to perform the Services, that compares Supplier against Supplier’s competitors and other entities (including other health insurance companies) performing similar services. The results of the assessment will be used to determine whether Supplier’s Service offering and performance remain on pace with industry best practices and developments. At Health Net’s discretion, an assessment under this Section 3.7(f) may be conducted by


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Health Net or an independent industry-recognized service provider designated by Health Net (“Assessor”). Supplier agrees to cooperate with the Assessor, including, as appropriate, promptly making available knowledgeable personnel and pertinent documents and records, and providing the Assessor with access to relevant facilities, software, systems and tools used to perform the Services. At the conclusion of the assessment process the Assessor will issue a report of its findings and conclusions to Health Net. The Assessor’s findings will be used to inform the annual Innovation Plan (described in Section 3.7(c) above).

(g)

The assessment performed in accordance with Section 3.7(f) and Health Net’s assessment of Supplier’s execution of Innovation Services and the value of the Innovation Services will be included in the Stakeholder Satisfaction Survey.

(h)

Health Net is not obligated to implement any recommendations by Supplier. Supplier does not need to seek Health Net approval for implementation of Innovation activities except as expressly required by this Agreement, including those subject to Change Control.

3.7

Root Cause Analysis Services

Supplier will develop, implement, and maintain a process to coordinate root cause analysis activities required to diagnose, analyze, recommend, take corrective measures across the Services, and provide reports on root cause analyses (“Root Cause Analysis Services”). Supplier will staff the Root Cause Analysis Services with appropriate roles in order to see Root Causes Analysis activities to conclusion. In addition to root cause analyses related to the operations, Supplier will perform all root cause analyses required by Health Net regulators (and within the timeframes specified by Health Net regulators) that relate to the Services. These Root Cause Analysis Services shall also include the Functions associated with Problem Identification and Resolution performed as part of the IT Services set forth in SOW #4 (IT Services).

3.8

Managed Third Party Contract Services

“Managed Third Party Contract” means a contract in the name of Health Net or a Health Net Affiliate used in support of the Services or complimentary to the Services (including those Managed Third Party Contracts set forth in Schedule O (Health Net Provided Resources) and those third party contracts identified through Exhibit A of SOW #4 (IT Services).

“Managed Third Party Contract Services” means the Functions associated with managing the Managed Third Party Contracts in place as of the Effective Date and entered into by Health Net after the Effective Date . Health Net shall have the right to add additional Managed Third Party Contracts by sending written notice to Supplier.

Supplier shall provide the Managed Third Party Contract Services with respect to the Managed Third Party Contracts, including the following activities:

(a)

Performing commercial Functions including:

(i)

Understanding contractual commitments in the Managed Third Party Contracts.

(ii)

Serving as primary point of contact with Health Net for interpretation and modification of contracts with third party suppliers.


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(iii)

Authorizing scope changes, project work and obtaining and documenting all requisite approvals to establish an appropriate audit trail, within Health Net guidelines for Managed Third Party Contracts. Any such scope changes as well as exceptions to Health Net guidelines will require Health Net’s prior written approval before any work is performed. If no guidelines are established for a specific Managed Third Party Contract, Supplier will consult with Health Net regarding any such scope change.

(iv)

Revising Managed Third Party Contracts to reflect changes in scope, new services, service levels and other conditions upon prior approval by Health Net, including those related to formal change requests.

(v)

Performing general administrative tasks associated with Managed Third Contracts, including maintaining records and documentation related to Managed Third Contracts, recording decisions in contract files.

(vi)

Maintaining Health Net-provided copies of all Managed Third Party Contracts (or a Health Net-provided summary of the pertinent information contained in each Managed Third Party Contract), including such contracts that expire during the Term, in a secure, online location accessible to designated individuals at both Health Net and Supplier.

(vii)

Monitoring license usage and maintaining compliance with the terms of third party licenses (ie., the number of licenses and scope of licenses) and including performing the Functions set forth in subtask 2.7.4 (Configuration and Asset Management) of SOW #4 (IT Services) Exhibit A-1-1 (Process Definitions).

(viii)

Escalating and resolving issues and disputes related to the Managed Third Party Contracts, and referring matters to Health Net legal where appropriate.

(ix)

Overseeing the performance of Managed Third Party Contracts, striving to (i) maximize the operational and financial performance of such contracts (from Health Net’s perspective) and (ii) minimize risk to Health Net from the performance of such contracts. Supplier’s responsibilities include:

(A)

Monitoring Managed Third Party Contract performance with respect to all material contractual requirements directly related to the provision of products or services and tracking and reporting on service levels or similar performance metrics included in the applicable contract;

(B)

Coordinating work performed under the Managed Third Party Contracts between Supplier and Supplier’s Subcontractor(s);

(C)

Validating assessments, calculations, and if Health Net elects to receive credits related to service level failures, the timely payment of such credits and other similar types of credits and rebates under Managed Third Party Contracts; provided, however, that execution and escalation on service level failures, or application of credits and rebates, will be in cooperation with Health Net;


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(D)

Monitoring the compliance with any service levels contained in the applicable Managed Third Party Contract; Notifying Health Net of material failure to perform in accordance with the provisions of its Managed Third Party Contract;

(E)

Notifying Health Net promptly if (i) there are performance failures or other issues regarding contractual responsibilities related to any Managed Third Party Contract, or (ii) there are issues with a Managed Third Party Contract adversely affecting the Services or Health Net (or its Affiliates),

(F)

Evaluating and recommending retention, modification, or termination of a Managed Third Party Contract based on the performance or cost benefits to Health Net as tracked by Supplier; and

(G)

Monitoring Managed Third Party Contract adherence to compliance activities, including auditing and training.

(x)

Providing assistance with Managed Third Party Contract negotiations as required.

(b)

Performing financial contract management Functions including:

(i)

Managing contract and order pricing;

(ii)

Reviewing third party supplier invoices to confirm validity and accuracy;

(iii)

Assigning applicable financial coding or other coding;

(iv)

Managing invoice discrepancies and disputes; and

(v)

Submitting processed invoices for payment.

(c)

Performing contract order management Functions including:

(i)

Maintaining third party supplier catalogs;

(ii)

Obtaining/placing orders for goods and services;

(iii)

Tracking and managing orders;

(iv)

Advising applicable process owners of problems with orders;

(v)

Managing receipt and acceptance/rejection (and return) of delivered goods and services; and

(vi)

Notifying the applicable financial management function of accepted and rejected deliveries.


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3.9

Reporting and Analytics Services

“Reporting and Analytics Services” means those Functions associated with producing management reports, operational and performance indicators, and information in a form that will allow Health Net to focus on business outcomes leveraging market capabilities. The Reporting and Analytics Services include all forms of reporting and analytics including web analytics. The objective of this service is to provide the Parties with real time access to information that will enable optimal performance of the Services and continuous improvement. The Reporting and Analytics Services employ advanced techniques to derive risks, opportunities and insights from the information to support Health Net’s business and strategic decision making. The Reporting and Analytics Services include:

(a)

Continuing to provide the same reporting and analytics capabilities that exist as of the BPaaS Services Commencement Date;

(b)

Identifying applicable sources of data or information and enabling Health Net real time access to all such sources;

(c)

Providing Health Net with real time performance monitoring (in read only access) that is no less robust than that which Health Net provides as of the Effective Date;

(d)

Extracting and collating data;

(e)

Reporting on outcome based metrics related to the Services;

(f)

Reporting on end to end function level metrics;

(g)

Analyzing data and summarizing findings related to a specific business issue or problem;

(h)

Developing applicable modeling methodologies to assess specific business issues or problems;

(i)

Performing trend analysis and modeling;

(j)

Using results of analyses to assist Health Net to develop business strategies and solutions; and

(k)

Responding to and fulfilling regulatory, ongoing, and ad hoc requests for reports from regulators or other business areas.


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In addition to the Monthly Performance Report defined in Schedule G-3 (Management Reporting) the Reporting and Analytics Services include creating and providing Health Net with access to a dashboard that reflects on Supplier’s performance with respect to each of the Service Levels (including Compliance Measures) (“Dashboard”). Supplier shall provide the initial version of the Dashboard as defined in Schedule R (Critical Deliverables). Information on the Dashboard shall be updated on a daily basis. The Dashboard (including the type of information provided, format, and layout of the Dashboard) shall be subject to the prior written approval of Health Net. Supplier shall make such changes to the Dashboard as Health Net requests, including requests made during the Term after the initial approval of the Dashboard. The Dashboard shall include the following:

(i)

Interactive capability that will permit Health Net to drill down on metrics;

(ii)

Ability to create custom views;

(iii)

Ability to extract reports;

(iv)

Messaging capability to question results;

(v)

Corrective Action Plan (CAP) for any Service Level that has been missed.

The Reporting and Analytics Services detailed in this Section 3.10 do not limit Supplier’s reporting obligations specified elsewhere in this Agreement including in Schedule G.

3.10

User Acceptance Testing Services

“Testing Services” mean the Functions associated with coordinating testing activities related to the Services, including user acceptance testing (e.g., support for Health Net’s testing in connection with a system release), with Health Net users including the following activities:

(a)

Coordinating User Acceptance Testing with Health Net users;

(b)

Developing valid business requirements for test script development by retained departments;

(c)

Coordinating access to test environments for Health Net testers;

(d)

Supporting data preparation needs within the test environments, i.e. system support for entry of BPaaS area of data needed for test script execution;

(e)

Preparing required documentation artifacts related to user acceptance testing, including appropriate redactions;

(f)

Reporting of test results and tracking and resolution of issues and defects;

(g)

Coordinating with third parties on file exchanges or other inputs/outputs;

(h)

Overseeing user acceptance testing;


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(i)

Coordinating with system releases, including on-site presence during release ‘go-live’ dates when necessary; and

(j)

Support of system rollouts.

3.11

Return Mail Processing Services

“Return Mail Processing” are the Functions associated with processing and correcting correspondence (including notification letters, checks, EOBs) that were returned to Health Net by the post office and routed to Cognizant from Health Net’s mail intake Function, including the following activities:

(a)

Receiving and processing all mail onshore after physical receipt of returned mail from Health Net’s mail intake Function;

(b)

Handling and processing return mail and corrections to names and addresses consistent with Health Net department’s policies and procedures;

(c)

Researching and correcting the address and name that was utilized for the original mailing;

(d)

Where possible/permitted, updating the applicable System(s) with the correct mailing information;

(e)

For all returned mail related to contracted Providers, forwarding all findings to the Provider Network Department (PNM) for review;

(f)

For Medicare, researching the change of address, updating the Beneficiary record, and perform all other Functions required by Health Net and Laws for the following categories of returned mail:

(i)

All returned Beneficiary materials that were originally generated and sent by Supplier in accordance with this Agreement;

(ii)

Returned Beneficiary materials not originally generated and mailed by Supplier by accepting and processing address update files from Caremark ` and sending the CMS required Beneficiary letter reminding Caremark to contact SSA to update their address; and

3.12

Inventory Management Services

“Inventory Management” are the Functions associated with creating and maintaining a daily accurate accounting of all inventories and transactions, reporting to Health Net production and inventory numbers (including aged claim statistics), and attending meetings to discuss volumes, issues, and other operational topics, including the following activities:

(a)

Performing inventory control and management;

(b)

Creating and maintaining a daily accurate accounting of transactional inventories, including enrollments and other eligibility related transactions received, “in process” (i.e. transactions received, but not considered “complete” in the core system.) and transactions completed and inventory aging statistics;


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(c)

Utilizing daily inventory management reports to control and maintain inventory within compliance and business service levels;

(d)

Making all daily and cumulative monthly inventory management reports available to Health Net; and

(e)

Providing access to daily inventory reports / systems and cumulative monthly inventory management reports to Health Net.

3.13

Collection of Funds Services

“Collection of Funds Services” means the Functions associated with collecting, depositing, and processing of all monies collected by Supplier personnel for or on behalf of Health Net on a daily basis into the applicable Health Net bank account. Such amounts shall not at any time be deposited in or held in any other account of Supplier or any of its other customers. All funds shall at all times be the sole property of Health Net or the applicable Health Net Affiliate. All monies in the Health Net bank account(s) shall not be subject to any lien, charge, security interest, right of offset or setoff or any other rights or encumbrances due to any act or omission of Supplier. As standard practice, all funds should be directed to be deposited to an approved Health Net bank account, however, if such funds are misdirected or received by Supplier then Supplier shall follow the Collection of Funds Services outlined in this Section 3.14.

3.14

Issue and Error Resolution Services

“Issue and Error Resolution” means the Functions associated with resolving all issues related to the Services that are identified by Supplier’s Quality Assurance Services set forth in Statement of Work #5 (Quality Assurance Services), Health Net’s internal audit, customer complaints, any errors identified by regulators, or in Section 3.8 above, or any other Health Net or Supplier quality assurance activities, including the following:

(a)

Reviewing requests to correct errors;

(b)

Correcting all errors in the applicable Systems; and

(c)

Timely reporting to Health Net on the Issue and Error Resolution.

These Issue and Error Resolution Services shall also include the Functions associated with Problem Identification and Resolution performed as part of the IT Services set forth in SOW #4 (IT Services).

3.15

Integration Services

“Integration Services” mean the Functions associated with integrating third party services into the Health Net Technology Platform including creating new EDI interfaces and third party pricer feeds, subject to Schedule H (Change Control). Changes to existing third party interfaces or the addition of new interfaces will not result in additional Charges to Health Net unless a particular change or addition to the third party interfaces meets the Material Change threshold set forth in Section 8 (Material Changes) of Schedule C (Charges).


Schedule A		A-i		Health Net / Supplier Confidential

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3.16

Translation Services

“Translation Services” mean the Functions associated with coordinating for the translation of written and verbal communications in accordance with Health Net Policies, including the following activities:

(a)

Overseeing all translation needs across towers and in accordance with any Service specific translation requirements set forth in each Statement of Work;

(b)

Receiving requests from Members, Providers or Lines of Business for translation of a written or verbal communication;

(c)

Prior to using a Health Net approved third party translator, determining if translated materials already exist;

(d)

Determining if a translation request is in compliance with Health Net Policy and regulatory requirements;

(e)

Escalating any requests that fall outside of Health Net Policy or regulatory requirements;

(f)

Contacting one of Health Net’s approved third party translators to have the translation request fulfilled; and

(g)

Managing the budget, billing and allocation cost of third party translation services allocation across each tower.

4	EMBEDDED PROCESSES

4.1

General

To the extent Supplier is responsible for performing a particular Function (either as identified in Section 3 of this Schedule A (Cross Functional Services) or in any SOW, then Supplier is responsible not only for performing the indicated Function, but also for providing the resources necessary to perform such Function and any other Functions and responsibilities described in this Section 4.1 as they may relate to such Function (the “Embedded Processes”).

4.2

Embedded Processes

The Embedded Processes include:

(a)

Developing the procedures underlying the Function, subject to and in compliance with Health Net regulatory requirements and in alignment with Health Net Policies as defined in Schedule P (Policies) and the requirements of this Agreement so as to enable the Services to function cohesively and in a coordinated manner;

(b)

Performing the activities comprising the Function in accordance with Health Net Policies as defined in Schedule P (Policies) and the requirements of this Agreement;

(c)

Except as provided in Schedule O (Health Net Provided Resources), providing and maintaining the necessary non-human resources (e.g., hardware, property, plant, supplies, software, tools, infrastructure) and human resources (including to provide training) to perform the Function;


Schedule A		A-i		Health Net / Supplier Confidential

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(d)

Retaining all financial, operational and administrative responsibility for the Function, including the resources necessary for its performance;

(e)

Performing the required activities necessary to manage the Function, including (i) supervising and reporting, including reporting to other personnel within the Function, (ii) measuring and reporting on the performance of the Function (or parts thereof) to other Health Net, its Affiliates, other Service Recipients or anyone else requested by Health Net, and (iii) developing and distributing operational reporting related to the Function, including any reporting related to the Service Levels;

(f)

Managing documents and data (including data acquisition, data entry, data recording and data distribution) related to the Function;

(g)

Coordinating with Health Net business units as necessary to perform the Services;

(h)

Performing “self audits” of the Function, including testing the (i) accuracy, reliability and quality of work, (ii) compliance with approved policies and procedures, and (iii) performance and correction of any issues identified during such audits and reporting of self audit results;

(i)

Participating in internal and external audits;

(j)

Engineering the Function, including performing those actions necessary to maintain or improve the underlying activities based on (i) then-current best practices, and (ii) how it is intended to interact with other activities performed by Supplier or by Health Net; Notifying Health Net as required of output or other findings or information developed or learned through the Function, including notifying Health Net of the readiness for activities to be performed by Health Net that are necessary to either complete or progress a Function being performed by Supplier;

(k)

Responding to queries and requests concerning activities associated with the performance of the Function, including making the applicable subject matter experts, documentation and other relevant content available as necessary to be responsive;

(l)

Handling all aspects of incidents and problems relevant to the Functions, including (i) receiving notification of and resolving incidents and problems, (ii) providing Health Net with updated information regarding the status of such incidents and problems and the associated resolution efforts, (iii) escalating incidents and problems that cannot be resolved, and (iv) responding to requests from Health Net;

(m)

Interacting and coordinating as needed with Health Net, including (i) integrating the Function with the activities of Health Net such that the overall delivery of services is optimized (i.e., not sub-optimized within the confines of the Function), and (ii) monitoring the activities performed by Health Net to mitigate negative impact on the Function;

(n)

Researching and planning for new products, open enrollment (Commercial), AEP (Medicare), and Duals including by (i) participating in Health Net information gathering initiatives (i.e., by providing access to former Health Net Personnel rebadged as part of this Agreement), (ii) assisting with the development of requirements definitions, and (iii) supporting the analysis and testing of new products;


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(o)

Supporting Health Net’s sales and marketing processes including responding to prospective or existing Customer requests for proposals (RFPs), providing access to Supplier Facilities and Supplier Personnel as part of any prospective or existing Customer requests, and providing Health Net with all information concerning the Services or delivery of the Services as (i) reasonably requested by the prospective or existing Customer, (ii) required by Health Net for the purpose of responding to an RFP, or (iii) necessary to support the Health Net sales and marketing process (e.g., sales pitches)

(p)

Providing advice and guidance on the Function to Health Net (e.g., best practices, operational issues, impact from other activities) so as to enable Health Net to optimize the linkages of its activities with the Function being performed by Supplier; Adhering to the applicable documentation standards; and

(q)

Providing information to support any Health Net Investigations (including Health Net’s special investigation unit) or threatened, pending or commenced litigation against Health Net related to the Services.


Schedule A		A-i		Health Net / Supplier Confidential

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SCHEDULE A-1

CROSS-FUNCTIONAL SERVICES SOLUTION DOCUMENT


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SCHEDULE A-1

CROSS-FUNCTIONAL SERVICES SOLUTION DOCUMENT

TABLE OF CONTENTS


1.	INTRODUCTION	1
2.	BUSINESS CONTINUITY & DISASTER RECOVERY SERVICES	2
3.	TRAINING SERVICES	3
4.	DOCUMENTATION SERVICES	6
5.	ENTERPRISE RISK MANAGEMENT SERVICES	9
6.	REGULATORY COMPLIANCE ADHERENCE SERVICES	13
7.	INNOVATION SERVICES	20
8.	ROOT CAUSE ANALYSIS SERVICES	22
9.	MANAGED THIRD PARTY CONTRACT SERVICES	25
10.	REPORTING AND ANALYTICS SERVICES	30
11.	USER ACCEPTANCE TESTING	32
12.	RETURN MAIL PROCESSING SERVICES	34
13.	INVENTORY MANAGEMENT SERVICES	36
14.	COLLECTION OF FUNDS SERVICES	37
15.	ISSUE AND ERROR RESOLUTION AND REPORTING SERVICES	38
16.	INTEGRATION SERVICES	40
17.	TRANSLATION SERVICES	42


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SCHEDULE A-1

CROSS-FUNCTIONAL SERVICES

SOLUTION DOCUMENT

1.	INTRODUCTION

Health Net has engaged Supplier to deliver End-to-End Services in an outcome based service, delivery model for multiple Health Net lines of business. The initial LOBs to be supported are Individual, Commercial, Medicaid, Medicare and Duals with the potential for additional LOBs during the Term. Each LOB will be supported by the Services (as set forth in Exhibit A of each SOW) combined and enabled through a transforming market relevant Application Platform and Infrastructure. Supplier will deliver these services under this Agreement.

The Cross-Functional Services are as specified in Schedule A (Cross Functional Services). This Schedule A-1 (Cross Functional Services Solution Description) describes Supplier’s solution and approach for delivery of the Cross Functional Services.

The Cross-Functional Solution includes capabilities for the following Services:

•

Business Continuity and Disaster Recovery Services,

•

Training Services,

•

Documentation Services,

•

Enterprise Risk Management Services,

•

Regulatory Compliance Adherence Services,

•

Innovation Services,

•

Root Cause Analysis Services,

•

Managed Third Party Management Services,

•

Reporting and Analytics Services,

•

User Acceptance Testing Services,

•

Return Mail Processing Services,

•

Inventory Management Services,

•

Collection of Funds Services,

•

Issue and Error Resolution Services,

•

Integration Services,

•

Translation Services.


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Cross Functional Services performed by Health Net as of the Effective Date provide a level of capability referred to as the “As-Is” capability. The Cross Functional Services will be evolved from the As-Is capability to an improved way of delivering the Services referred to as the “To-Be” as a result of certain Transition and Transformation activities set forth in the Transition Manual. This Schedule A-1 (Cross Functional Services Solution Description) describes Supplier’s To-Be approach for performing the Cross Functional Services. Specific processes and procedures for executing the Cross Functional Services will be documented and maintained as part of the Procedures Manual.

2.	BUSINESS CONTINUITY & DISASTER RECOVERY SERVICES

Business Continuity Planning (BCP) and Disaster Recovery (DR) Services are a Cross Functional Service as the function involves a solution that spans all towers and impacts Services defined across all SOWs. The following Schedules contain information related to the requirements, solution and approach, and transition for the BCP and DR Services:

•

Schedule A (Cross Functional Services): Contains requirements for BCP/DR Services

•

Schedule A-1-1 (Business Continuity and Disaster Recovery Solution)

•

Schedule A-4 (Supplemental Business Continuity and Disaster Recovery Requirements)

•

Schedule Q (Security Requirements)

Refer to Schedule A-1-1 (Business Continuity and Disaster Recovery Solution) for the solution and approach to meet the requirements outlined in Schedule A (Cross Functional Services), Schedule Q (Security Requirements) and A-4 (Supplemental Business Continuity and Disaster Recovery Requirements).


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3.	TRAINING SERVICES

The Training Services includes functions associated with curriculum development, planning, scheduling and delivery of training to staff performing delivery of the Services. Training is linked to improving performance, developing new skills, adherence to regulatory/compliance regulation.

3.1

Overall Approach

Supplier will follow industry standard human resource practices to manage service related Training Services as performed for the Services.

The Training Model will be set up as shown in the diagram below:

(a)

Skill Gap Assessment:

•

All resources will be mapped to the skills for their level and the next level for their role,

•

Supplier will perform personnel competencies verification,

•

The results will reflect, by resource, the gap in skill for the resource’s current job level and the next level,

•

Supplier will review the audit findings for gaps in training material or policy and procedure and update accordingly,

•

Supplier will also assess the gaps in the Supplier training staff capabilities.

(b)

Develop training material:

•

Training requirements will be divided into process and soft skills,

•

For domain training, Healthcare Boot Camp Training will be used to induct new team members for Healthcare specific processes,


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•

For process training, the desktop procedures created by operation teams will be reviewed to ensure they are as per defined procedures & formats and all new changes & updates are being documented,

•

Training curriculum and material to bridge the gap for the current level and ‘up-skilling’ will be identified for every resource including on Regulatory, Compliance, HIPAA Privacy and Security related aspects,

•

Training curriculum and material will be created for gaps identified in audits,

•

Other than process training, gaps in soft skills, e.g., communication, leadership, etc. will be addressed by customizing the standard Supplier training programs.

(c)

Training delivery:

•

Training sessions will be organized for resources that have on boarded or per their individual training plan,

•

The Policies and Procedures will be used in the initial and refresher training sessions and will also be used to serve as reference material for resources on the job,

•

Training calendar will be created and updated related to process training and soft skills development,

•

Training staff will be trained using internal and external resources,

•

Training reports will be published to include attendance, course completion, etc.,

•

Training will be provided on researching, responding to, tracking and reporting privacy related incidents.

(d)

Training Effectiveness:

•

New Supplier Personnel supporting the Services will undergo and successfully complete the boot camp training,

•

Training technology, methodologies, courses, content and approach will be reviewed and updated on a regular basis,

•

Testing of associates that have undergone training will be conducted to ensure that associates have learned and can apply what they have learned,

•

Supplier will measure the impact of training on service level performance, productivity improvements, etc.

3.2

Delivery Location

During Phase 2, Supplier will deliver the Cross Functional Training Services primarily from Woodland Hills, Rancho ▇▇▇▇▇▇▇ and San ▇▇▇▇▇▇. During Transition, Supplier will gradually build training teams in India and Manila to coincide with the movement of staff to offshore locations. It is the intent to have trainers co-located with the staff for ongoing training to deliver the Services as well as onboarding of new staff. Prior to Phase 3 the Supplier will move any remaining Training Services from Health Net facilities to Supplier service delivery location.


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3.3

Staffing Considerations

Supplier will staff Training Services with a dedicated team while leveraging SME’s from each Tower as needed.

3.4

Hours of Coverage


Training Services		08:00 am to 5:00 pm		*Ad-hoc / after hour support will be provided necessary to meet Schedule A (Cross-* Functional Services) requirements.**

3.5

Tools

The Learning Management System (LMS), or equivalent, as provided by Health Net.

3.6

Reliance and/or Constraints Associated with Third Parties

None.


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4.	DOCUMENTATION SERVICES

Documentation Services includes functions associated with the life cycle management of documents, specifically the cataloguing, archiving, retrieval, and destruction of paper and electronic documents, in adherence with Health Net’s Record Information Management (RIM) procedures.

4.1

Overall Approach

During execution of the Services, Supplier will classify documents according to the procedures outlined in Health Net’s RIM process as outlined as follows:

•

Supplier will also identify documents that are to be archived and retained,

•

For paper documents, Supplier will coordinate with Health Net staff to catalog and package documents for offsite storage using Health Net’s Managed Third Party Contract with Iron Mountain or other vendor designated by Health Net,

•

Retrieval will be accomplished via the Iron Mountain Connect service/tool, or equivalent provided by Health Net,

•

For electronic documentation. Supplier will retain document files per RIM procedures. Archival and destruction will be accomplished via coordination and approval steps with and by Health Net,

•

The Supplier will archive Documentation consistent with RIM Procedures as well as submit request for authorization to destroy documents to the Heath Net Document Manager and execute accordingly.

4.2

Delivery Process and Methods

The Cross Functional Document Services will provide coordination across Towers and consistency of delivery as relating to the Services.

Supplier’s Solution will include:

•

Classifying documents adhering to Health Net RIM policy,

•

Identifying retention period for specific hard copy and electronic documents,

•

Identifying documents to be archived periodically to offsite storage location,

•

Coordinating with Health Net staff to catalog and package documents for shipment to offsite storage location,

•

Utilizing automated tools to retrieve documents, as needed to support the Services, from offsite storage,

•

Identifying documents or electronic information to be destroyed per retention policies and coordinating with Health Net to obtain proper approvals prior to destruction,

•

Adhering to Health Net policies related to legal hold and records management,


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•

Notifying of any process changes to Documentation coordinators across the Towers,

•

Destroying documents and / or electronic information as authorized by Health Net,

•

Escalating issues or inconsistencies identified by Health Net and / or the Supplier for correction,

•

Developing detailed procedures for producing, catalogue management, storing, retention, retrieval and deletion of the documents as part of the Procedures Manual,

•

Ensuring the document management process is consistently deployed across all towers,

•

Ensuring that user rights are defined in the desktop procedure and will conduct audits to ensure compliance,

•

Conducting training on regular intervals for all resources working on document management tool and processes to ensure that the staff is adequately trained on procedures and policies,

•

Updating procedures regularly (at least annually) or as needed to incorporate any changes,

•

Auditing the document management process to ensure adherence to applicable policies.

Health Net Responsibilities will include:

•

Reviewing and approving the detailed procedure created by Supplier for document management in the Procedures Manual as defined in Schedule R (Critical Deliverables),

•

Providing the third party service for physical shipment and retrieval of documents to and from offsite storage location,

•

Providing the automated document management tool to be utilized by Supplier and Health Net for retrieval of archived documents,

•

Providing the retention policy to the Supplier.

4.3

Delivery Location

Supplier will deliver the Cross Functional Document Services from all locations where hard copy and electronic documents are created and maintained, including the Woodland Hills, Rancho ▇▇▇▇▇▇▇, and other facilities put into operation during the Term. Supplier will leverage Health Net’s offsite storage locations. Prior to Phase 3, the Supplier will move personnel performing Cross Functional Documentation Services from Health Net facilities to a Supplier Service Delivery Center near the Health Net Woodland Hills location.

4.4

Staffing Considerations

•

Supplier will identify a Document Manager to be the centralized contact to coordinate document management services across towers. Supplier anticipates this to be a part time role in addition to other responsibilities within the centralized team.

•

In addition, Supplier will identify an individual within each tower who will be responsible to coordinate document archival for their service area and to function as a single point of contact for the centralized Document Manager as well as for Health Net for their service area. This document management responsibility within the tower will be a part time role in addition to their other responsibilities to deliver Services within the tower.


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4.5

Hours of Coverage


Documentation Services		08:00 am to 5:00 pm		*Ad-hoc after hour support will be provided necessary to meet Schedule A (Cross-* Functional Services) requirements.**

4.6

Tools

Iron Mountain Connect, or equivalent tool as provided by Health Net for catalog and retrieval of documents in offsite storage.

4.7

Reliance and/or Constraints Associated with Third Parties

•

Iron Mountain Connect, or equivalent tool as provided by Health Net for catalog and retrieval of documents in offsite storage,

•

Managed Third Party Contract with Iron Mountain, or equivalent as provided by Health Net,

•

Reliance on Health Net-provided vendor who handles intake of paper claims with responsibility for Documentation Services as it relates to the paper documents.


Schedule A-1		A-1-8		Health Net / Cognizant Confidential

▇▇▇▇▇

▇.	ENTERPRISE RISK MANAGEMENT SERVICES

In support of Health Net’s Enterprise Risk Management team (ERM), Supplier will work with Health Net’s Enterprise Risk Officer to identify existing and emerging risks to the fulfillment of the Services. Supplier will support the process to address risks that have been raised via a variety of channels, including identification of risks by Health Net’s team, Supplier Risk Officer, and Supplier teams within the towers who are responsible for delivery of the Services. Supplier will support risk assessments, and take necessary steps to monitor, report, re-assess, and mitigate identified risks.

5.1

Overall Approach

Supplier will support Health Net’s Enterprise Risk Management program, including applicable policies and procedures. Health Net’s risk framework will be used to define how Supplier will conduct and document risk assessments and mitigation strategies in coordination with Health Net. The framework will also be utilized to mitigate and monitor existing and emerging risks and to report such exposures, as well as mitigation plans, for visibility to appropriate stakeholders, owners, and executive leadership.


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5.2

Delivery Process and Methods

Risk assessment processes will be established and adhered consistently across the towers and coordinated through a centralized Supplier function. The Supplier Risk Officer will:

•

Be the single point of contact for the Health Net Risk Officer as well as a leader providing oversight and direction for internal Supplier teams who are integral to the process.

•

Work with Supplier teams to identify current and emerging risks identified during performance of the Services.

•

Collect and collate risks as identified by Supplier and provides material risk to the Health Net Enterprise Risk Officer as input to the Enterprise Risk Management process.

•

Supports the entire life cycle of each material risk, including identification of emerging drivers of risks, maintenance of the risks inventory, assignment of owners responsible for creating and executing mitigation plans, monitoring and status reporting on mitigation activities, and ensuring proper focus to ensure risks are actively mitigated to the fullest extent possible.

Supplier will leverage the inherent relationship that exists between the Issues and Error Resolution Services, Root Cause Analysis (“RCA”) and Enterprise Risk Management to provide a robust solution to risk management:

•

Where a tower level issue is determined to be material enough to cause an Enterprise risk, an RCA and corrective action plan will become part of the risk description and the mitigation strategy,

•

Where Issues and Errors are identified by either the Quality Assurance Process or the Audit Process and are material enough to cause an Enterprise risk an RCA performed will be performed and a corrective action plan will be developed.

Supplier will work with Health Net to both manage the mitigation of the risks identified by Health Net as well as the agreed material risks raised by the Supplier.

Supplier will include the following in its Solution:

•

Adopting Health Net’s Enterprise Risk Management framework to ensure that risks are being properly identified, assessed, monitored and reported at an enterprise level,

•

Mitigating and managing the risk exposures as part of the day to day operational processes at the tower level,

•

Identifying events (an important realistic threat that exploits a significant applicable vulnerability) with a potential negative impact on the goals or operations of the enterprise, including events that are market driven, regulatory, financial, legal, technological, involving third parties and operational aspects,

•

Assessing on a recurring basis the likelihood and impact of identified risks, using qualitative and quantitative methods. The likelihood and impact associated with inherent and residual risk should be determined individually, by risk category including by not limited to operational, technology applications, infrastructure, third party contracts associated with the delivery of all Services,


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•

Developing and maintaining a risk mitigation process designed to ensure that cost-effective controls mitigate exposure to risks on a continuing basis. The risk mitigation process should identify risk strategies such as avoidance, reduction, determine associated responsibilities; and consider Health Net’s tolerance levels for material risks,

•

Prioritizing and planning the control activities at all levels to implement the risk mitigation strategies, including mitigation goals and responsibility for execution,

•

Evaluating Third Party Managed Services deemed material in nature for enterprise risks, financial viability, technical currency, and marketplace reputation and reliance for Health Net’s consideration in the overall Risk Inventory,

•

Establishing operational risk management committees with representation from delivery head, tower leads and resources across all delivery locations,

•

Defining a governance model to ensure the committees meet on periodic intervals to serve as a forum to track, report and rectify potential risk concerns and manage any risk,

•

Monitoring execution of the plans, and report on any deviations to senior management; and

•

Participating in Health Net’s Risk Management Committee and/or Task/Force if requested by Health Net.

Health Net will engage the Supplier in the Enterprise Risk Management program to both manage the mitigation of the risks identified by Health Net as well as the agreed material risks raised by the Supplier.

Heath Net will have the following responsibilities:

•

Providing an opportunity to the Supplier leadership team to have an representation in the risk committee and operation risk review forum,

•

Providing support and resolution as needed to execute mitigation plans where there are dependencies with Health Net retained responsibilities under the Agreement.

5.3

Delivery Location

Enterprise Risk Management services will be supported by individuals across all facilities in all delivery locations. The Enterprise Risk Officer will be onshore, with an offshore counterpart located in India. Prior to Phase 3, the Supplier will move personnel performing Cross Functional ERM Services from Health Net facilities to a Supplier Service Delivery Center.

5.4

Staffing Considerations

Supplier will staff a Supplier Risk Officer who will be dedicated in a full time capacity to perform the duties outlined in this section. In addition, there will be a Risk Lead identified in each tower who will function in a part time capacity as the single point of contact for the Supplier Risk Officer for their respective tower.


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•

The Risk Leads support all aspects of ERM services at the tower level including aggregation, identification, assessment, impact determination, mitigation strategies and plans, monitoring of status, and reporting risk information as appropriate.

•

The Risk Leads have responsibility to manage risks specific to their tower – as well as the responsibility for enterprise level risks impacting their tower. Supplier SMEs and other resources also support the entire risk lifecycle as it relates to their assigned responsibility to execute the Services.

5.5

Hours of Coverage

Enterprise Risk

Management Services

08:00 am to 5:00 pm

Ad-hoc /after hour support will be provided necessary to meet Schedule A (Cross- Functional Services) requirements.

5.6

Tools

•

Enterprise Risk Inventory as owned and maintained by Health Net

•

Tower level Risk Inventory as owned and maintained by Supplier

5.7

Reliance and/or Constraints Associated with Third Parties

•

None.


Schedule A-1		A-1-12		Health Net / Cognizant Confidential

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6.	REGULATORY COMPLIANCE ADHERENCE SERVICES

Supplier will build a quality and effective Compliance Program to support the Services which is based upon industry best practices, benchmarks, and Supplier’s extensive background and familiarity with health care regulations and the foundational work and example set by Health Net. The Compliance Program is an essential tool for promoting regulatory compliance for operations and ethical conduct, and which enforces the detection, prevention, and resolution of non-compliant and illegal conduct, including fraud, waste or abuse. The core elements of the Regulatory Compliance Adherence Services will include the following seven essential elements:

•

Conducting Internal Auditing and Monitoring,

•

Implementing written policies, procedures and standards of conduct,

•

Responding promptly to detected offenses and developing Corrective Action Plans,

•

Developing effective lines of communication,

•

Conducting effective training and education,

•

Enforcing Standards through well-publicized disciplinary guidelines,

•

Designating Compliance Officer and Compliance Committee.

6.1

Overall Approach

Supplier will assign a Compliance Officer to oversee and manage the Supplier Compliance Program for Services provided under this Agreement. The Supplier Compliance Officer will manage and oversee all aspects of Compliance for delivery of the Services. The Supplier Compliance Officer will report, in a timely fashion and in conformance with timeframes established by Health Net, incidents of suspected or identified noncompliance to Health Net’s Compliance Officer.

Supplier’s Compliance Officer will provide information as required by Health Net’s Compliance Officer to ensure that Health Net’s Boards of Directors are appropriately apprised of compliance issues and risks. Supplier will develop a comprehensive Compliance Plan that will be a written document describing the specific manner in which the Compliance Program elements will meet the standards for all lines of business. Specific procedures to execute the functions required of the Compliance Plan

will be documented as part of the Procedures Manual.

Supplier’s Compliance Plan will be reviewed and revised at least annually and align with Health Net’s compliance plans for each line of business. If there are changes in regulatory requirements or changes to Health Net and Supplier business processes, the Compliance Plan will be modified throughout the year to reflect current Laws and business practices serving as the means of documentation of record and approach to be in compliance. The Compliance Plan will also include ongoing risk assessment and issue event response procedures so the program will respond in near real time to regulatory issues that arise, and have the capability to deploy appropriate resources where and when needed. The Compliance Plan will include processes for assessing the effectiveness of the Compliance Program, through the use of effective, two-way communications self-audit, feedback mechanisms, and reporting metrics.


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Supplier will be accountable and have responsibility for ensuring compliance of all Services as of the BPaaS Services Commencement Date. Health Net will be the responsible party for performing the final interpretation of Compliance rules as they impact BPaaS operations and will provide specific requirements to Supplier’s services teams to implement within the BPaaS scope. ▇▇▇▇▇▇ ▇▇▇▇▇ ▇, ▇▇▇▇▇▇▇▇ will support Health Net’s compliance activities and become familiar with Health Net’s compliance processes. Supplier will build controls or leverage existing controls in all operational areas to maintain compliance with all applicable Laws as well as compliance expectations and requirements as determined by the Health Net Compliance Officer.

Supplier will provide operational dashboards and alerts to Health Net management. The Supplier’s Compliance Officer will work to align development plans necessary to address the Changes Laws and directives as interpreted by Health Net.

Supplier will actively engage and maintain effective lines of communications with Health Net’s Compliance Office and ensure information needed by Health Net compliance, legal and regulatory staff to provide information and support responding to any regulator requests is provided within the requested time periods to Health Net. Supplier will support all audits from state and federal agencies or their designees, as well as internal and external audits.

The Supplier acknowledges and recognizes that Health Net is responsible for ensuring Health Net compliance with applicable Law and Regulations. As such, Health Net will be responsible for interpreting new and modified Laws regarding the impact on performance of the Services. Health Net will also provide specific requirements regarding these Laws and the Supplier will implement within the scope of Services consistent with Health Net’s interpretation and requirements. Health Net will continue to have direct responsibility for interacting with State and Federal Regulators. Supplier will participate in such meetings at the request of Health Net.

Supplier will incorporate and adopt, whenever possible, Health Net’s Compliance Framework including Health Net’s Code of Business Conduct and Ethics and all other applicable policies and procedures. Supplier will support the basic ▇▇▇▇▇ of that framework such that leadership of each tower understands and takes accountability for the implementation and adherence to these standards, procedures and Laws in addition to working collaboratively with the Suppliers Compliance Officer to meet the requirements outlined through the Agreement.

The Supplier Compliance Officer will coordinate activities at an enterprise level, engaging responsible parties within the towers to achieve, monitor, and maintain compliance. In addition, the Supplier intends to adopt Health Net’s Medicare Compliance Plan and various associated compliance policies and procedures.

6.2

Delivery Process and Methods

Supplier will create a Compliance Office within the organizational structure that will be responsible for the following essential services:

•

Developing Compliance policies and procedures,

•

Monitoring to ensure guidelines and standards are being followed,

•

Initiating and manage compliance projects,

•

Reporting on status of compliance activities,


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Final

•

Self-identification (self-reporting and self-audits) and the subsequent implementation of corrective actions,

•

Participation on compliance committee.

The Compliance Office will take direction from Health Net’s Compliance Office on the interpretation and impact on the Services or Health Net’s departments of new Laws or changes to existing, state, and federal regulations. In addition, under Health Net’s direction the Compliance Office will participate in external audits and interact with regulators from the DMHC, CMS, DMHCS, HHS, etc., or their designee.

The Compliance Office, led by the Supplier Compliance Officer, will manage compliance related aspects for the ongoing performance of the Services. The Compliance Office will develop or adopt policies and procedures and audits to ensure that all Supplier areas are following the guidelines and standards documented and established by Health Net. This will include the following activities:

•

Implementing written policies, procedures and standards of conduct related to Health Net’s interpretation of Laws into Policy supported by Procedures,

•

Conducting Compliance education and training to the in-scope resources thereby enabling them to understand and conduct their duties consistent with Laws and Regulations,

•

Providing for effective communication with Supplier Personnel related to Health Net’s interpretations and policy decisions,

•

Enforcing Standards through well-publicized disciplinary guidelines linked to education and training, monitoring and audit functions.

The Supplier will monitor Services to oversee and measure that Compliance guidelines and standards are being followed. From time to time, Regulatory Agencies or other interested parties may request reports or responses to their inquiries from Supplier. Such requests will need to be managed by the Suppliers Compliance Office under the direction of Health Net’s Compliance Office.

Health Net’s Compliance Office will be the overall responsible party in responding to Regulatory requests with direct support from the Supplier Compliance Officer and Tower Leads ensuring that the associated supporting documentation are accurate and available on a timely basis. As directed by Health Net, the Suppliers Compliance Office will respond to requests and create reports for regulators or other third parties such as but not limited to the following:

•

Notice of Non-Compliance, Corrective Action Plans, or mitigation requests from any Regulatory agency (CMS, DMHC, DCHS, DOI),

•

Complaints filed with any of the Regulatory agencies,

•

Complaints related to sales and marketing issues,

•

Secret Shopper issues and findings identified by CMS,

•

Clarification of risks as identified in the OIG work plan,

•

Audit findings from any Regulatory agency (CMS, DMHC, DHCS, DOI),


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Final

•

Member “touch points” such as Appeals & Grievances, Claims, Member Services,

•

Corrective Action Plan follow-up.

The Compliance Office will participate in responding to Regulatory requests and ensuring that the associated supporting documentation are accurate and available on a timely basis. The Compliance Office may also be periodically required to respond to requests and create reports for Employer Groups or other third parties.

Because it is essential that the Compliance Office is continuously updated about pending changes in Compliance standards or metrics, the office will participate in CMS’s annual Call Letter, receive CMS bulletins directly, compliance (HHS + CMS) webinars, conferences, and in-person hearings. For avoidance of doubt, the Compliance Office will not (i) represent Health Net in any way in any of these activities (e.g., indicating that Supplier is participating in a meeting or conference call on behalf of Supplier, and, (ii) act on any changes in Compliance standards or metrics without direction from Health Net. Health Net’s Compliance Office has the sole responsibility for final determination of the interpretation of any regulatory requirement.

The initiation and management of compliance projects is necessary to meet Health Net’s interpretation of Law and Regulations. The Supplier’s Compliance Officer will provide Health Net with project plans and status reports about the progress of all regulatory projects. The actual management of those projects will be performed by Supplier teams under the responsibility of the Supplier’s Compliance Officer. Supplier’s Compliance Officer will keep Health Net abreast of the currents progress of these projects.

The Supplier will monitor and audit critical elements of a Compliance Program while each year Health Net’s Compliance Officer determines which Compliance-related elements will be used to develop the metrics for evaluating performance against regulatory standards. Supplier operational teams on behalf of Health Net will perform these monitoring and auditing activities including the necessary reporting.

The Supplier will provide reports and information that allows Health Net to identify areas that may require corrective action in order for the Health Net to achieve compliance with specific regulatory requirements.

The Supplier operational teams will perform audits and reporting with subsequent implementation of corrective actions to enable Health Net’s overall Compliance. The Supplier’s Compliance Office will lead the overall program and follow up to ensure that corrective actions plans to address identified risks are effectively implemented (including enforcing disciplinary actions where necessary).

The Supplier will provide education and training for its personnel necessary related to Compliance

Laws and Health Net Policies.

The Supplier Compliance Officer will attend the appropriate Health Net compliance committees to respond to questions or provide details on audits or corrective action plans.

6.3

Supplier Compliance Standards

Supplier associates will be trained upon on-boarding and annual re-certifying on Code of Conduct and Ethics. Specific Supplier employee related job training & certifications will include the following:

•

OIG and GSA Background checks prior to employment and monthly thereafter for all Medicare and Medicaid associates,


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Final

•

Health Net required compliance training (as revised and updated during the Term) including:

•

Mandatory for all Supplier Personnel and must be completed within 30 days of the date the Supplier Personnel is assigned to the Health net account and annually thereafter:

•

Health Net General Compliance Program (within 30 days of the date the Supplier Personnel is assigned)

•

HIPAA Basic Privacy and Security

•

The following training programs are mandatory for all Supplier Personnel and must be completed within 60 days of the Effective Date or the date the Supplier Personnel is assigned to the Health Net account and annually thereafter:

•

The Painful price of Health Care and Pharmaceutical Fraud (within 60 days of hire),

•

Health Net Code of Business Conduct and Ethics,

•

Record Information Management Training (previously Getting the Records Straight),

•

Access provided to all Supplier Personnel to a Supplier 24X7 Hotline to report Compliance / Ethics issues.

6.4

HIPAA Compliance

Supplier associates will also be trained on HIPAA regulations, including enterprise responsibilities related to HIPAA and individual responsibilities. Compliance training will include the following:

•

HIPAA Privacy and Security

•

Supplier security policies map to PHI mandates,

•

Administrative: Policy and Procedures necessary to detect, contain and correct security violations, Privacy Officer for Compliance, training modules & Contingency plans,

•

Physical: Workstation rules and standard configuration settings, Control on usage of portable devices,

•

Technical: Data encryption, Access Controls and Internal Audits.

6.5

Supplier’s Corporate Compliance Audits

Supplier is familiar with Regulatory mandates, compliance and auditing. The following are examples of Supplier’s current standards as of the Effective Date:

•

SAS 70 / SSAE 16 Audit,

•

SOX & Security Audit,

•

ISO Surveillance.


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Final

Supplier resources will conduct training courses as required at a corporate level by the Supplier organization, including, but not limited to, HIPAA Training, Acceptable Use Policy, and Code of Conduct, in addition to the required Health Net required training courses.

6.6

Self-Reporting

Supplier will utilize the Cognizant Corporate Compliance Hot Line and associated policies and procedures, which articulates its commitment to comply with all applicable laws and regulations. Any material items will be reported to Health Net immediately.

As a policy, Supplier culture and workplace environment is based on individual integrity, ethical behavior and non-retaliation of reported incidents or breaches by employees.

6.7

Delivery Location

•

During Phase 2, the Supplier Compliance Officer will be located in Rancho ▇▇▇▇▇▇▇ and Woodland Hills to facilitate establishment of the Supplier Compliance Program. During Phase 3, specific members of the Compliance Office may be co-located with service delivery teams where it is determined to be preferable.

•

Close proximity is needed between the Health Net Compliance Office, the Supplier Compliance Office, and the Supplier delivery staff located both onshore and offshore who have compliance responsibilities. Members of the Compliance Office will be strategically placed to ensure optimum coordination by embedding Compliance team members offshore when appropriate.

6.8

Staffing Considerations

•

The design of the Supplier Compliance organization is intended to mirror the Health Net Compliance Office in terms of alignment of responsibility to specific roles and individuals.

•

Counterparts within the respective organizations will facilitate the coordination between the two Compliance organizations and help them to work in tandem.

•

Supplier will hire a full time Compliance Officer as the counterpart to Health Net’s Compliance Officer. The Supplier Compliance Office will include the following full time positions:

•

Compliance Officer,

•

Compliance Lead – Medicare,

•

Compliance Specialist – Medicare (2),

•

Compliance Lead – Medicaid,

•

Compliance Specialist – Medicaid (1),

•

Compliance Lead – Commercial,

•

Compliance Specialist – Commercial (2).


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Final

•

In addition to the full time Compliance Office, Supplier will identify a Business Compliance Consultant (BCC) within each tower who will be the primary point of contact for the Compliance Leads for coordination and execution of compliance functions performed at the tower level.

•

Additional members will be added to the compliance office during Transition and over the Term as needed to successfully execute the Compliance Program.

6.9

Hours of Coverage


Regulatory Compliance Adherence Services		08:00 am to 5:00 pm		*Ad-hoc / after hour support will be provided necessary to meet Schedule A (Cross- Functional Services) requirements.*

•

Supplier Compliance Ethics and Fraud and Abuse Hot-Lines will be available 24 by 7.

6.10

Tools

Tools currently used by the functional teams in support of Compliance will continue to be utilized.

6.11

Reliance and/or Constraints Associated with Third Parties

While there are third parties engaged in keeping the Services compliant (Optum, for example), there are no specific third party reliance or constraints as it pertains to the management of Regulatory Compliance Adherence Services.


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Final

7.	INNOVATION SERVICES

The intent of the Innovation Services is to provide guidance for the Road Map and operational transformation of Services compared to the marketplace resulting in market relevant and commercially viable products / services.

7.1

Overall Approach

In addition to continuous improvement to the Services the Supplier will develop and annually update an Innovation Plan that will be the basis for material improvements to the Services over the Term.

Development of the Innovation Plan will involve an assessment of market trends, challenges, and capabilities in the market space, including market advancements, changing and evolving legislative drivers, competitive capabilities, as well as existing and emerging opportunities. The Innovation Plan will include benchmarks within the industry that can be used to measure efficiency and maturity of the Services.

The Innovation Plan will include targeted improvements, priorities, and recommendations that can be evaluated for inclusion in:

•

The Road Map and/or,

•

Discretionary projects,

•

Non-Discretionary projects

with the goal of capitalizing on opportunities to continually mature and innovate the Services.

7.2

Delivery Process and Methods

Supplier will assess the marketplace using a scoring system to rate the capability and maturity of the Services as compared to existing capabilities of competitors within the marketplace as well as emerging capabilities and needs within the industry.

The market place assessment will be evaluated against current capabilities as well as with the Road Map, Discretionary and Non-Discretionary project to determine material gaps that exist and the extent to which they are bridged by adopting the recommendations documented in the Innovation Plan. Supplier will engage Health Net in the development and evaluation of the Innovation Plan in order to align priorities and particular areas of interest as input to the plan.

Innovation Services will include the following activities:

•

Monitoring and improving service delivery methods and identify weaknesses and opportunities for evolution and improvement to the service delivery methods while systematically implement those innovations,

•

Monitoring industry trends, including through independent research, and document and report on products and services with potential application for Health Net on a quarterly basis,

•

Developing an innovation plan that will be reviewed annually to include:


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Final

•

Identifying general and industry specific business, technical and medical trends and forecasts that inform both the Supplier and Health Net of new opportunities that could be used to improve medical, financial or experiential outcomes;

•

Identifying business challenges facing the Health Care Industry and Heath Net relative to Health Net’s stated business goals and objectives;

•

Categorizing disruptive technological or scientific advances and their expected timeframes for practical (e.g., economically feasible) application of future advances within the context of Health Net’s business and the Services;

•

Reporting on the current STARs, HEDIS and NCQA rating for the Services over the previous year and a plan for improving each rating during the upcoming year;

•

Identifying STARS goals for the upcoming year for each measure, initiatives to achieve the goals, and correlating metrics to track progress and inform that goals are on track; and

•

Maintaining a rolling two year forecast outlining specific improvements in techniques, methods, processes or technologies that Supplier will implement to deliver ongoing Innovation within the scope of the Services and a list of prioritized recommendations as to how Health Net could take advantage of opportunities to innovate in areas related to the Services.

7.3

Delivery Location

Innovation Services will be supported by individuals across all facilities in all delivery locations. ▇▇▇▇▇▇ ▇▇▇▇▇ ▇, the Innovation Lead will be onshore, with a counterparts in each tower in corresponding location of service delivery for each tower. Prior to Phase 3, the Supplier will move any remaining Innovation Services personnel from Health Net facilities to Supplier service delivery location near Health Net’s headquarters.

7.4

Staffing Considerations

The Innovation Lead will be a part time role with support from SMEs at the tower level.

7.5

Hours of Coverage


Innovation Services		08:00 am to 5:00 pm		*Ad-hoc / after hour support will be provided necessary to meet Schedule A (Cross- Functional Services) requirements.*

7.6

Tools

None.

7.7

Reliance and/or Constraints Associated with Third Parties

None.


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Final

8.	ROOT CAUSE ANALYSIS SERVICES

Supplier’s solution will use a Root Cause Analysis (RCA) process that will ensure the resolution of issues designated for inclusion in the RCA including the identification and correction of root cause associated with any systemic issues until they are fully resolved while preventing reoccurrence.

8.1

Overall Approach

The intent of the Root Cause Analysis Services is to thoroughly resolve issues through identification and resolution of root causes and to proactively identify systemic issues before they adversely impact delivery or outcomes of the Services. Issues that are candidates for Root Cause Analysis may come from many different sources, including issues identified during the course of delivery of the Services, issues logged in the Issue/Error Resolution process, issues identified through regulatory and audit processes, and many other sources.

Supplier will perform Root Cause Analysis (RCA) using a process that includes diagnosing, analyzing, recommending, and taking corrective measures across the Services. It is essential that RCA be performed across towers (i.e., not in a silo approach) to be effective. Supplier will maintain a centralized team that will monitor the Root Causes Analysis activities to conclusion.

The Root Cause Analysis solution will ensure improvement in efficiency and effectiveness by proactively identifying potential problems before these become trends and analyzing root causes of incidents once sources of the problem is uncovered. Supplier will perform an in-depth and formal RCA for critical issues and escalated issues or incidents.

8.2

Process and Delivery Methods

Root Cause Analysis will be performed using industry standard practices. Supplier will conduct weekly Cross Functional meetings with representatives across the towers to review identified issues, identify and analyze root cause, and discuss progress towards resolution of root cause. Supplier will participate in meetings related to RCA with Health Net as needed to address RCA across the enterprise as needed.

Meetings will increase in frequency as needed, including daily and multiple times each day during peak periods. During these meetings, call drivers will be analyzed, identifying systemic issues in upstream processes.

Supplier will establish a centralized RCA function to manage and oversee activities across the towers.

The Supplier Solution includes the following:

•

Collecting issues from multiple sources, including proactive search for issues that are candidates for Root Cause Analysis,

•

Maintaining catalog of issues requiring Root Cause Analysis,

•

Identifying owners responsible for RCA for each issue,

•

Developing solution / corrective action,

•

Monitoring status from identification to resolution,

•

Documenting and reporting issues and root cause for compliance related issues within required timeframes.


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Final

Supplier will periodically meet with Health Net to refine the process and monitor progress. As required by Health Net, Supplier will include representatives from other areas of Health Net (e.g., Provider Network Management Department).

Specific procedures to perform the Root Cause Analysis function will be documented in the Procedures Manual. Identifying and categorizing all issues that need RCA including the following activities:

•

Assessing the impact of the incident,

•

Gathering data and other information required for the RCA,

•

Performing RCA for all identified issues,

•

Creating a corrective action plan to address and resolve the root cause while working to prevent recurrence of the incident,

•

Providing RCA status reporting including action items,

•

Performing root cause analysis as required by Health Net regulators in the required time frames,

•

Monitoring and report on success of RCA solutions implemented,

•

Analyzing incidents and RCA to identify trends,

•

Analyzing trending to proactively identify, diagnose and correct recurring problems, and performance degradation and identify associated consequences,

•

Tracking, diagnose and report recurring incidents, problems and failures, and performance degradation,

•

Leveraging trending analysis methods and techniques to eliminate issues before they become problems.

8.3

Delivery Location

The centralized function of Root Cause Analysis Services will be performed primarily from Woodland Hills and Rancho ▇▇▇▇▇▇▇. Additional support will be provided from all delivery teams across all towers that reside in all delivery locations both onshore and offshore. Prior to Phase 3, the Supplier will move any remaining Innovation Services personnel from Health Net facilities to Supplier service delivery location near Health Net’s headquarters.

8.4

Staffing Considerations

The Supplier will establish a dedicated Project Management Office (PMO) that will include staff responsible to manage the Root Cause Analysis Services across the towers. The PMO will include full time dedicated resources that will include Root Cause Analysis as one of their responsibilities.


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Final

Resources within each tower will be engaged as it relates to Root Cause Analysis impacting their specific tower.

8.5

Hours of Coverage

Root Cause Analysis

Services

08:00 am to 5:00 pm

Ad-hoc /after hour support will be provided necessary to meet Schedule A (Cross-

Functional Services) requirements.

8.6

Tools

Existing Dashboards (i.e., Excel Spreadsheets) will continue to be used with plans to improve and mature the capability with a more robust tool during Transition. Focus of improvement in the area will include more direct point of capture of issues such that there is more data captured that can be used for identification of commonalities and root cause.

8.7

Reliance and/or Constraints Associated with Third Parties

None.


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Final

9.	MANAGED THIRD PARTY CONTRACT SERVICES

As of the BPaaS Services Commencement Date, Supplier will manage Managed Third Party Contracts on behalf of Health Net as set forth in Section 3.8 (Managed Third Party Management Services) of Schedule A (Cross Functional Services).

9.1

Overall Approach

The portfolio of Managed Third Party Contracts is as set forth in Schedule A and will be segmented into either BPaaS scope with the intent to re-contract before Phase 3 (where applicable) or Non-BPaaS. Whether Supplier will subsequently re-contract directly with vendor will be guided by the terms as outlined in Schedule O (Health Net Provided Resources). Some contracts that are extremely large such as IBM and AT&T will be managed by a dedicated team and have specific financial objectives associated with oversight and optimization as called out in Schedule C (Charges). Managed Third Party Contracts is subject to the terms relating to the Use of Health Net Resources as outlined in Section 11.2(d) of the Terms and Conditions.

Managed Third Party Contracts will be managed by Supplier beginning on the Services Commencement Date. Any third party contracts that are procured by the Supplier prior to the Service Commencement Date will be managed from the effective date of that agreement. Contracts that are shared across BPaaS and non-BPaaS will either be split or agreed with Health Net to remain in the appropriate category for management as a combined entity with the intent of greater cost savings and management efficiency. The remaining Non-BPaaS managed contracts will be under the governance and control of Health Net. Supplier will help Health Net look for opportunities to optimize and reduce costs.

Supplier will manage third party services to help ensure BPaaS SLAs will be met. Supplier will focus on establishing a relationship with Health Net and bilateral responsibilities with qualified third-party service providers and monitoring the service delivery to verify and ensure adherence to SLAs, and underpinning contracts. This will be achieved by identifying and categorizing services, identifying and mitigating risk and monitoring and measuring performance

9.2

Process and Delivery Methods

The Managed Third Party Contract management team will liaise and communicate directly with technical and subject matter expertise in the Health Net retained organization and also report to the commercial and service integration team from a portfolio management and cost standpoint.

For the BPaaS portfolio, each contract will be evaluated and recommendations will be made to Health Net based upon review of the results. When applicable as outlined in Schedule O (Health Net Provided Resources), Supplier will determine if a contract already exists with Supplier that could be leveraged and, if not, look to negotiate appropriate terms and conditions for the Supplier to contract for the services directly.

Supplier may choose to use the same or similar solution as Health Net is currently using or in some cases may consider replace the technology or service component with something different but comparable allowing Health Net to terminate current services.

Depending on the category of third party services, different expertise and tools will be leveraged. There will be a central contract repository which will be the database for each contract to be managed by Supplier. While Supplier continues to manage the Managed Third Party Contracts, the original


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Final

Health Net contracts will be maintained by Health Net. Linked to this database will be other Supplier interactions which may be pertinent to the review process. Copies of all contracts and notes on key terms, conditions and licensing will be linked to the database.

Reporting will be created that forecasts, at the individual or portfolio level depending on agreed, “Hard Cap” or gain sharing agreements actual costs vs. baseline costs and performance. Compliance reports will be created to document license usage and to ensure no third party contracts are in violation of stated licensing requirements or guidelines.

Managed Third Party Management Services activities for both BPaaS and Non-BPaaS Health Net Contracts include:

•

Identification of all suppliers services, and categorizes them according to supplier type, significance and criticality. Maintain formal documentation of technical and organizational relationships covering the roles and responsibilities, goals, expected deliverables, performance track record of past and current issues, escalations, and resolutions,

•

Performance monitoring to ensure compliance with contract terms and conditions, SLAs,

•

Recommendations and resolution of issues related to non-compliance,

•

Monitoring license usage and maintaining compliance with the terms of third party licenses as defined in subtask 2.7.4 (Configuration and Asset Management) of SOW#4 Exhibit A-1-1 (Process Definitions),

•

Tracking and managing orders, third-party catalog management throughout Phase 2 and Phase 3 for any remaining contracts that remain with Health Net,

•

Monitoring performance to ensure compliance with contract terms and conditions as well as SLAs,

•

Managing financial obligations such as reviewing invoices for discrepancies, submitting processed invoices for payment, resolution of billing and invoices disputes, etc.,

•

Identifying and managing fee reductions and incentives, based on performance information and Agreement terms,

•

Managing risks through mitigation to ensure services are delivered securely, efficiently and effectively meeting Health Net SLAs. Identify and mitigate risks relating to suppliers’ ability to continue effective service delivery in a secure and efficient manner on a continual basis,

•

Escalating to Health Net known risks and areas of non-compliance,

•

Ensuring that contracts conform to universal business standards in accordance with legal and regulatory requirements,

•

Monitoring service delivery to ensure that the supplier is meeting current business requirements and continuing to adhere to the contract agreements and SLAs, and that performance is competitive with alternative suppliers and market conditions.


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Health Net retains final decision making authority for any contracts that are managed on their behalf until such time they are procured by the supplier and the corresponding service is terminated by Health Net and the provider.

9.3

Delivery Location

The centralized function of Managed Third Party Management Services will be performed primarily from Woodland Hills and Rancho ▇▇▇▇▇▇▇. Additional delivery and execution support will be provided from all delivery teams across all towers that reside in all delivery locations both onshore and offshore. Prior to Phase 3, the Supplier will move any remaining Third Managed Party Management Services personnel from Health Net facilities to Supplier service delivery location near Health Net’s headquarters.

9.4

Staffing Considerations

For contracts managed by Supplier, Supplier will designate a Contract Manager as a single point of contact for Managed Third Party Contract Management Services. Contract Manager would be responsible for leading and owning the day-to-day decisions related to contract administration and negotiations pertaining to the services as identified and set forth in the Agreement. He/she will coordinate the contract negotiations/renegotiations to accommodate scope Changes, Changes to business requirements as identified by Health Net, and the management of Contract Change requests.

For contracts managed by Supplier, Individual portfolio leads will handle the specific negotiations and optimization of services based on the segmentation of the overall inventory of suppliers. These portfolio teams will report directly to the Contract Manager and PMO. During Phase 1, the team will be established and the dedicated portfolio leads will have team members who will each manage a section of the in scope contracts with objectives to review, optimize and close terms and conditions as defined. Each portfolio lead will leverage the virtual support of the following resources:

•

Legal support for review and compliance,

•

Alliance support services for major partners where applicable,

•

Sourcing specialists to optimize buying power and cross client leverage,

•

Technical Subject Matter Experts to review accuracy,

•

Technical program management to measure and forecast pricing and outcomes,

•

Product management across scope of services.

Supplier and Health Net Contract Management and Contract portfolio teams will work closely with procurement and legal counsel from both sides and follow Change Control procedures as outlined in Schedule H (Change Control Process) to:

•

Create, negotiate and incorporate amendments into the Agreement,

•

Coordinate the Agreement negotiations/renegotiations to accommodate scope changes or changes to business requirements per the contract change management process. Any such scope changes as well as exceptions to Health Net guidelines will require Health Net’s prior written approval before any work is performed,

•

Obtaining and documenting all requisite approvals to establish an appropriate audit trail, within Health Net guidelines for Managed Third Party Agreements.


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Final

Managed Third Party Contract activities include:

•

Leading and facilitating contract agreement activities from agreement signing through transition and ongoing operations (e.g., Interface for contractual change implementation),

•

Performance monitoring to ensure compliance with contract terms and conditions, SLAs,

•

Recommendations and resolution of issues related to non-compliance,

•

Monitoring license usage and maintaining compliance with the terms of third party licenses as defined in subtask 2.7.4 (Configuration and Asset Management) of SOW#4 Exhibit A-1-1 (Process Definitions),

•

Tracking and managing orders, third-party catalog management throughout Phase 2 and Phase 3,

•

Monitoring performance to ensure compliance with contract terms and conditions as well as SLAs,

•

Managing financial obligations such as reviewing invoices for discrepancies, submitting processed invoices for payment, resolution of billing and invoices disputes, etc.,

•

Identifying and managing fee reductions and incentives, based on performance information and Agreement terms,

•

Escalating to Health Net known risks and areas of non-compliance,

•

Ensuring that contracts conform to universal business standards in accordance with legal and regulatory requirements,

•

9.5

Hours of Coverage

Managed Third Party

Management Services

08:00 am to 5:00 pm

Ad-hoc /after hour support will be provided

necessary to meet Schedule A (Cross-

Functional Services) requirements.


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9.6

Tools

To be developed

9.7

Reliance and/or Constraints Associated with Third Parties

As defined by each Third Party Agreement.


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Final

10.

REPORTING AND ANALYTICS SERVICES

Supplier will provide Health Net with data, tools and reports; operational and performance indicators; and other information deemed necessary by Health Net in order for Health Net to assess its business and Supplier service performance.

10.1

Overall Approach

Supplier will approach Reporting and Analytics in three stages. Stage 1 will continue the current capabilities and tools that Health Net leverages today with the intent of producing the same information as of the Service Commencement Date. Stage 2 will focus on the requirements gathering and design of a Service Performance Reporting capability. Stage 3 will commence 6 months post the implementation of the Stage 2 and will focus on the requirements gathering and design of performance analytics for the Services and SLA associated with the Agreement. The market analysis research, solution/capability analysis, and resulting recommendations specific to Health Net will be documented for inclusion in the Innovation Plan. Stage 2 and Stage 3 are key input to the Innovation Plan and will feed directly into the improvement plans and Innovation Services process outlined in Schedule A-1 (Cross Functional Services Solution Description).

10.2

Process and Delivery Methods

Supplier will use tools and methods available as of the BPaaS Service Commencement Date to:

•

Continuing with same reporting format as at the time of execution of the Agreement. Any changes to the content and format must be pre-approved by Health Net,

•

Providing reports based on ad-hoc and on-going requests,

•

Analyzing the data to identify trends and potential risks. The output of this exercise will be added to the monthly and quarterly management reports,

•

Leveraging the performance reports and the results of the trend analysis to assist Health Net develop business strategies and solutions.

As part of Stage 2, the Supplier will implement a Service Reporting tool that enables the Supplier to create reporting and dashboards for performance, joint situational awareness and governance meetings and end to end service delivery management.

Supplier will also provide other inputs to Stage 2 (reporting) and Stage 3 (analytics) as input to the Innovation Plan providing comparison with market peers and industry trends as input to market and Industry capabilities related to performance reporting for like services in the marketplace.

10.3

Delivery Location

Supplier will deliver the Cross Functional Reporting and Analytics Services initially from Woodland Hills and/or Rancho ▇▇▇▇▇▇▇ facilities as determined by the Supplier. Phase 3 the Supplier will move any remaining Innovation Services personnel from Health Net facilities to Supplier service delivery location near Health Net’s headquarters.

10.4

Staffing Considerations

The Supplier will establish a Reporting and Analytics team that will work across all towers to perform Reporting and Analytic Services. SMEs from individual towers will support these efforts as needed.


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Final

10.5

Hours of Coverage

Reporting and Analytics

Services

08:00 am to 5:00 pm

Ad-hoc / after hour support will be provided

necessary to meet Schedule A (Cross-

Functional Services) requirements.

10.6

Tools

To be determined during performance of the Services.

10.7

Reliance and/or Constraints Associated with Third Parties

To be determined during performance of the Services.


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Final

11.

USER ACCEPTANCE TESTING

11.1

Overall Approach

Cross Functional User Acceptance Testing includes those functions associated with planning, coordinating, and executing testing activities related to the Services with appropriate members of the Health Net retained organization. User Acceptance Testing methods and procedures are outlined in Schedule J (Project Framework).

11.2

Processes and Delivery Methods

Supplier will coordinate and manage Cross Functional UAT Services for new and modified functionality as part of the system life cycle prior to the release into the production environment.

During the requirements gathering phase, UAT Coordinators and Business Analysts within the Supplier organization will perform the following functions:

•

Determining the scope of testing that will be required,

•

Identifying who within the retained organization will be involved in the testing phase for the set of requirements,

•

Coordinating with the testers in the retained organization as they develop their own test cases to be executed during the testing phase of the project,

•

Determining what needs to be in the UAT environment for the specific testing effort, including surround and core systems.

During the build phase, UAT Coordinators and Business Analysts within the Supplier organization will perform the following functions:

•

Coordinating and managing the that test scripts are written,

•

Identifying synergies that can be achieved across a particular release,

•

Coordinating access administration to the testing systems,

•

Providing training for the testers in the business area,

•

Overseeing the preparation and loading of test data into the environments in the proper sequence so it is available when ready to test,

•

Establishing a sequenced plan for data loads and batch cycles to support testing efforts,

•

Overseeing and managing testing completion per plan,

•

Prioritizing defect resolution to enable testing progress,

•

Updating dashboards for reporting progress of UAT,

•

Managing and coordinate “go-live” phase activities including:


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Final

•

Performing testing immediately prior to the release to confirm there are no defects being staged into production,

•

Monitoring system functionality and performance onsite during cutover to the new release (typically during off hours),

•

Ensuring successful cutover into production,

•

Environment planning, including when the test environments can be decommissioned.

11.3

Delivery Location

Supplier staff performing the coordination directly with testers in the retained organization will be co-located with the Health Net staff in on shore locations during Phase 2. Specific functions related to UAT planning, data loads, and the like may be performed in India and Manila. Prior to Phase 3, the Supplier will move any remaining Innovation Services personnel from Health Net facilities to Supplier service delivery location near Health Net’s headquarters.

11.4

Staffing Considerations

Supplier will have a dedicated team for Cross Functional User Acceptance Testing Services coordinating all User Acceptance Testing.

11.5

Hours of Coverage

User Acceptance Testing

Services

08:00 am to 5:00 pm

Ad-hoc / after hour support will be provided

necessary to meet Schedule A (Cross-

Functional Services) requirements.

11.6

Tools

Testing Dashboard currently being used by Health Net.

11.7

Reliance and/or Constraints Associated with Third Parties

None.


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Final

12.

RETURN MAIL PROCESSING SERVICES

12.1

Overall Approach

As of the BPaaS Services Commencement Date, Health Net will deliver the return mail to centralized locations within Supplier departments and Supplier Personnel will receive the return mail from Health Net and perform the Return Mail Processing Services. Detailed Process and Procedures to execute Return Mail Processing Services will be included in the Procedures Manual.

12.2

Delivery Process and Methods

Supplier will process the Return Mail Services based upon the type of return mail and the action required that would enable the mail to be re-delivered to the recipient. Steps will also be taken to ensure records are updated properly for any future mailings and correspondence. Where possible the new address information, if known (and permitted by regulators), will be updated in the system of record for the Member, thus raising the potential for successful delivery.

During the Term, Supplier may introduce improvements to the Return Mail Processing Services to enable portions of this Service to be performed offshore (subject to all Health Net offshoring restrictions). As part of Supplier’s Solution for the Return Mail Processing Services, the physical handling of return mail will remain onshore.

12.3

Delivery Location

Supplier will deliver the Cross Functional Return Mail Services from the Woodland Hills and/or the Rancho ▇▇▇▇▇▇▇ facilities in accordance with the location of return mail receipt by Health Net. If deemed to generate savings and/or efficiencies into the process, capabilities may be added offshore. In all cases, applicable data privacy and protection steps will be added to the process prior to an offshore movement. Prior to Phase 3, the Supplier will move any remaining Innovation Services personnel from Health Net facilities to Supplier service delivery location near Health Net’s headquarters.

12.4

Staffing Considerations

Supplier will identify a specific point of contact for Return Mail Processing and distribution. The staffing of the Cross Functional Return Mail Processing and Document Services will be a combined part time role and flex with the amount of volume of return mail received for processing.

12.5

Hours of Coverage


Return Mail Processing Services	08:00 am to 5:00 pm	Ad-hoc / after hour support will be provided
		*necessary to meet Schedule A (Cross-***
		*Functional Services)* requirements.

12.6

Tools

Member Name and Address Information via Systems Support.


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12.7

Reliance and/or Constraints Associated with Third Parties

Reliance on Health Net-provided vendor who receives mail from the post office and delivers to Supplier staff within the Departments.


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13.

INVENTORY MANAGEMENT SERVICES

Supplier’s approach to Inventory Management will include reporting to Health Net production and inventory numbers and attending meetings to discuss volumes, issues, and other operational topics to maintain work inventories within target levels.

13.1

Overall Approach

Inventory Management levels will be monitored and managed within the threshold tolerance levels to meet Service Levels.

•

During Phase 2, Supplier will upgrade the current reporting system and integrate it into the management reporting approach outlined in Schedule G-3 (Management Reports).

•

As an example of the approach, Supplier will create and maintain a daily accurate accounting for all inventories including transactions received, “in process” (i.e., transactions received, but not considered “complete” in the core system) and transactions completed to arrive at the production and inventories number. Based on the established process the Supplier will create an action plan when the inventory is outside of the established thresholds to get back to established target inventory levels.

Supplier will use the daily inventory management reports to control and maintain inventory within compliance and business service levels. Supplier will report the daily and cumulative monthly inventory management reports to Health Net.

13.2

Delivery Location

Supplier will deliver the Inventory Management Services across delivery location in US, India and Manila. Prior to Phase 3, the Supplier will move any remaining Innovation Services personnel from Health Net facilities to Supplier service delivery location near Health Net’s headquarters.

13.3

Staffing Considerations

Existing operational team across delivery locations in US, India and Manila will be leveraged for staffing with the Cross Functional Reporting and Analytics Services. The centralized PMO will establish process and procedure to ensure consistency across towers.

13.4

Hours of Coverage


Inventory Management Services	08:00 am to 5:00 pm	Ad-hoc / after hour support will be provided
		*necessary to meet Schedule A (Cross-***
		*Functional Services)* requirements.

13.5

Tools

Current Reporting Tools used by Health Net (EIS, Omni/Prime, Macess, Excel Workbooks).

13.6

Reliance and/or Constraints Associated with Third Parties

None.


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14.

COLLECTION OF FUNDS SERVICES

Supplier will perform “Collection of funds” associated with collecting and depositing all monies for or on behalf of Health Net as envisioned in Schedule A (Cross Functional Services).

14.1

Overall Approach

Supplier will manage the Collection of Funds consistent with each of the Services in all the in-scope Towers. Supplier will redirect such funds to the appropriate lock box in a timely manner when funds are received outside of the standard process.

14.2

Delivery Process and Methods

Supplier will collect the checks/funds that are received at any facility at any time. Supplier will log the funds, package them for mailing and deposit and will direct them to the appropriate lock box via the United States Postal Service.

As part of the monthly operating meetings, the log and total funds received will be reviewed with Health Net. For monthly funds received that are in excess of thresholds set and adjusted for seasonality, a Root Cause Analysis will be executed and the results including recommendations and implementation plans for corrections, where appropriate, provided in the following month’s report.

14.3

Delivery Location

Supplier will deliver the Cross Functional Collection of Funds Services from any location where such funds are received. Prior to Phase 3, the Supplier will move any remaining Innovation Services personnel from Health Net facilities to Supplier service delivery location near Health Net’s headquarters.

14.4

Staffing Considerations

Supplier will staff the Cross Functional Collection of Funds Services on a part time basis as part of the Services being performed by the Supplier.

14.5

Hours of Coverage


Collection of Funds Services	08:00 am to 5:00 pm	Ad-hoc / after hour support will be provided
		necessary to meet Schedule A *(Cross-*
		*Functional Services)* requirements.

14.6

Tools

Collection of Funds log.

14.7

Reliance and/or Constraints Associated with Third Parties

None.


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15.

ISSUE AND ERROR RESOLUTION AND REPORTING SERVICES

15.1

Overall Approach

Cross Functional Issue and Error Resolution and Reporting Services is the specific function that logs, tracks and manages issues and errors identified as part of the internal audit, Compliance and QA functions. This Cross Functional Service is the management of the inventory of Issues and Errors that are identified to be resolved and managed to closure with the Towers as part of closing out the QA action items and Compliance and internal audit report findings. The intent of the Issue and Error Reporting Services is to provide an enterprise view of the material issues and errors that exist in the towers and timely manage them to closure while protecting against recurrence.

15.2

Processes and Delivery Methods

Supplier will receive the Issues and Errors from Health Net in its scheduled weekly meetings or as a result of audit findings. Supplier will work with the internal audit, Compliance and QA processes to manage the inventory of Issues and Errors to closure and assess the month inventory to determine if there are any repeating patterns and material items that are candidates for inclusion in the Enterprise Risk Management Inventory or warrant the conducting of a Root Cause Analysis and corrective action plan. Supplier will ensure that Health Net’s business and supplier delivery teams are meeting periodically to define and discuss Issues and Errors, identify owners, develop solutions/corrective action, including an assessment of the adequacy of current system and process controls, track and resolve issues. As required, Supplier will also include representatives from provider networks, pharmacy networks and other towers in the meetings.

In addition to this, Supplier will also manage all SOX/IPC requirements relative to its solution and Issues and Errors impacting these requirements.

Root Cause Analysis will be performed if the Issues or Errors are systemic and can be prevented in the future. Supplier will use the lessons learned to create a risk and mitigation plan to contain such Issues and Errors in the future if these are deemed material in nature. Data will be mined to help uncover Issues and Errors that will ultimately lead to process improvements and cost savings. Supplier will identify systemic issues along the process flow, especially upstream. All compliance related issues

will be escalated following Health Net guidelines. Higher priority will be assigned to recurring Issues and Errors.

Supplier will automate the data collection and synthesis process. Efforts will also be made to collect observations from resources on the ground to better understand the Issues or Errors.

15.3

Delivery Location

The centralized function of Issue and Error Resolution and Reporting Services will be performed primarily from Woodland Hills and Rancho ▇▇▇▇▇▇▇. Additional support will be provided from all delivery teams across all towers that reside in all delivery locations both onshore and offshore. Prior to Phase 3, the Supplier will move any remaining Innovation Services personnel from Health Net facilities to Supplier service delivery location near Health Net’s headquarters.

15.4

Staffing Considerations

Supplier will establish a dedicated Project Management Office (PMO) that will include staff responsible to manage the Issue and Error Resolution and Reporting Services across the towers. The PMO will include full time dedicated resources whose responsibilities will include Issue and Error Resolution and Reporting. Resources within each tower will be engaged as it relates to Issue and Error Resolution and Reporting impacting their specific tower.


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Final

15.5

Hours of Coverage

Issues and Error

Resolution Services

08:00 am to 5:00 pm

Ad-hoc / after hour support will be provided

necessary to meet Schedule A (Cross-

Functional Services) requirements.

15.6

Tools

Issue and Error Log.

15.7

Reliance and/or Constraints Associated with Third Parties

None.


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16.

INTEGRATION SERVICES

16.1

Overall Approach

Supplier will support interfaces that integrate third party products and services as of the Effective Date. Subject to Change Control, Supplier will additionally support modifications to existing interfaces as well as support for new interfaces as needed to support the Services and as requested by Health Net. Supplier will coordinate directly with third parties as necessary to support the Integration Services.

Integration Services categories are anticipated to be:

•

Electronic Data interface (EDI) scheduled at regular intervals, it will be used to send and receive data from third party vendors and will be scheduled at regular intervals. Such interfaces will use proprietary framework,

•

Third-party integration in real time (▇▇▇▇▇▇▇, for example) typically used for claims processing or pricing,

•

Integration aligned to processing, (iHealth, for example).

16.2

Processes and Delivery Methods

Integration Services will be evaluated on a case-by-case basis and managed as part of the Third Party Management Services to evaluate the overall effort of integration as well as the long term maintenance and support of the integration. In conjunction with the towers, the Cross Functional Integration Services will manage the overall inventory of external interfaces as well as coordinating the evaluation of the services being integrated.

This process will be highly integrated with the Services in SOW 4 (IT Services) to provide oversight and coordination for an holistic view of integration across the enterprise.

16.3

Delivery Location

Supplier will deliver the Cross Functional Integration Services from the locations where Services are performed within the towers.

16.4

Staffing Considerations

Supplier will staff the Cross Functional Integration Services on a part time basis as necessary to perform the Services.

16.5

Hours of Coverage


Integration Services	08:00 am to 5:00 pm	Ad-hoc / after hour support will be provided
		necessary to meet Schedule A *(Cross-*
		*Functional Services)* requirements.

16.6

Tools

Integration Services Inventory.


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16.7

Reliance and/or Constraints Associated with Third Parties

As identified by each Integration Services as part of this process.


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17.

TRANSLATION SERVICES

“Translation Services” includes functions associated with voice translation as well as the translation of documents to multiple languages as required by policy and Health Net contracted agreements.

17.1

Overall Approach

The Supplier will perform Translation Services related to three types of communications: (i) voice translations (within the Contact Center Tower or other Towers), (ii) document/written translations (across all Towers), and (iii) translation support for a member at a Provider’s location (i.e., such member requests as handled via the Contact Center Tower).

The Supplier will coordinate this Cross Functional Service using Health Net’s current third party translation service providers using Health Net’s current process and allocation approach. Supplier will comply with Health Net’s list of approved languages by line of business for translation. The Supplier will have a centralized point of contact to facilitate/manage the coordination of translation services. Each tower will maintain policies and a budget to cover the Translation Services with the approved vendor(s).

17.2

Delivery Process and Methods

The Cross Functional Translation Services will provide coordination across Towers and consistency of delivery related to the translation required at the tower level.

Supplier responsibilities include:

•

Maintenance of the “Translation Source of Truth,” containing:

•

Health Net’s approved list of languages by line of business for translation

•

Regulation rule and section

•

Regulation verbatim

•

Compliance/SME contact

•

List of vital documents by LOB

•

Model disclaimer language

•

List of interpreter service resources to which members can be referred for translations not handled by Health Net (i.e., for non-approved translations)

•

Documentation of procedures to execute Translation Services in the Procedures Manual that are consistent with the “Translation Source of Truth” to include the following:

•

A list of required documents / languages that are proactively translated year over year and made available to business areas

•

Processes for the handling of translation requests that fall outside of departmental policy

•

Escalation process when input or decision is needed from Health Net and the Supplier’s Compliance Officer


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•

Process for notifications sent to downstream departments whose materials may be impacted

•

Process to measure operational results at established checkpoints (i.e., quarterly or annually as needed)

•

Process to review and allocate cost of third party translation services across each tower as needed by Health Net to support internal charge back needs

•

Update procedures on recurring schedule and as needed to incorporate changes in policy and/or Health Net contractual commitments,

•

Ensure continuity of service for any modification to policy and procedures, including:

•

Pilot revised policy and procedures with a selected Tower

•

Review results with Tower Leads to determine the refinements and to confirm any modifications continue to meet Regulatory and Compliance guidelines as well as Health Net’s requirements

•

Deploy updated charge back approach, providing Health Net with the appropriate charges based upon usage for Translation Services

•

Conduct training on regular intervals for all resources working on Translation Services to ensure that the staff is adequately trained on procedures and policies,

•

Manage the third party translation service providers on behalf of Health Net as part of Third Party Managed Services until such time as the Supplier can transition the contract agreement directly with Supplier.


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The graphic below illustrates the high-level process of handling requests for the translation of documents and providing approvals at the tower level.

17.3

Delivery Location

•

The centralized function of Translation Services will be performed primarily from Woodland Hills and Rancho ▇▇▇▇▇▇▇. Prior to Phase 3, the Supplier will move supplier personnel from Health Net facilities to Supplier service delivery location near Health Net headquarters.

17.4

Staffing Considerations

•

Supplier will identify a single point of contact to coordinate Translation Services across towers. Supplier anticipates this to be a part time role in addition to other responsibilities within the centralized team.

•

In addition, Supplier will identify an individual within each tower who will be responsible to coordinate Translation Services for their service area and to function as a single point of contact within the tower. This Translation services responsibility within the tower will be a part time role in addition to their other responsibilities to deliver Services within the tower.


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17.5

Hours of Coverage

Translation Services

08:00 am to 5:00 pm

Ad-hoc / after hour support will be provided

necessary to meet Schedule A (Cross-

Functional Services) requirements.

17.6

Tools

To be determined.

17.7

Reliance and/or Constraints Associated with Third Parties

Managed Third Party Services Contract with Health Net’s Translation Service Providers as provided by Health Net.


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SCHEDULE A-1-1

HEALTH NET

BUSINESS CONTINUITY PLAN/DISASTER RECOVERY


Schedule A-1-1				Health Net / Cognizant Confidential

Final

TABLE OF CONTENTS


1. EXECUTIVE SUMMARY			1

2. SCOPE			1

3. ORGANIZATION STRUCTURE OF BCP			2

3.1 Roles and Responsibilities			3

3.2 Business Process Services (BPS) Specific BCP Chart			5

4. DISASTER RECOVERY PRE-PLANNING PROCESS			6

4.1 Disaster Recovery Assessment			6

4.2 Disaster Recovery Design			7

4.3 Disaster Recovery Implementation			7

4.4 Disaster Recovery Test			8

4.5 Disaster Recovery Test Completion			8

4.6 Disaster Recovery Approach			9

5. BUSINESS CONTINUITY PLANNING PROCESS			10

5.1 Business Impact Analysis			10

5.2 Criticality of Application Description			10

5.3 Criticality of Business Process Services Description			11

5.4 BCP Triggers			11

6. BUSINESS CONTINUITY POLICIES FOR HEALTH NET			12

6.1 Intra-city/Inter-City Alternate Sites			12

6.2 Policies for Network and Systems Support			13

6.3 Policies for Business Critical Functions			13

6.4 Policies for Administration (Supplier facilities only)			13

6.5 Policies for Human Resources (Supplier resources only)			14

7. DISASTER RECOVERY STRATEGY FOR HEALTH NET			14

7.1 Infrastructure (ITO) Strategy			14


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7.2 Business Process Services (BPS) Strategy			15

8. BUSINESS RESUMPTION PROCESS			16

8.1 Infrastructure Set-Up or Recovery			16

8.2 Business Functions/Projects Recovery			16

9. BCP TESTING PROCESS			16

9.1 Purpose			16

9.2 BCP Test Plan			17

9.3 BCP Test Periodicity			17

9.4 BCP Test Reports			17

10. BCP REVIEW AND ▇▇▇▇▇▇▇▇▇▇▇			▇▇

▇▇. PROCESS FOR INCLUDING A NEW SERVICE IN BCP			18

12. ESCALATION AND COMMUNICATION PROCEDURES			18

SCHEDULE A-1-1-2			1

SCHEDULE A-1-1-2			1

SCHEDULE A-1-1-3			1


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SCHEDULE A-1-1

HEALTH NET BUSINESS CONTINUITY PLAN/DISASTER RECOVERY

1.	EXECUTIVE SUMMARY

The Business Continuity Plan (“BCP”) is designed to ensure that the business operations of Health Net are not affected by the occurrence of a disaster or in case of an emergency situation. The BCP ensures commitment of Supplier towards delivering the highest quality solutions and making sure that the services offered to Health Net are protected in the event where any of our service locations becomes inoperable, or any other issues require us to move the work elsewhere. The BCP reiterates our commitment to deliver the highest quality solution using the Global Delivery Model, and protecting Health Net from service continuity risks. Our business continuity plans are based on the need to protect professional staff, computing infrastructure, and intellectual property in order to help Health Net remain in business through any contingency; that includes provisions to ensure the mobility of professional skills along with fully redundant communications backbones and computing infrastructures.

The plan presents the actions and procedures necessary to recover from an adverse event. When totally implemented, the plan is designed to establish availability of employees to carry out the designated assignments, data center processing, network communications and all business unit functions within desired timeframes from identified recovery sites as per the plan. It is aimed at achieving the following during any disaster struck.

•

Minimizing potential economic/business loss

•

Reducing the probability of occurrence

•

Reducing disruptions to operations

•

Providing an orderly recovery

•

Ensuring the safety of personnel

•

Minimizing legal liability

•

Adhere to regulatory and legal requirements

SCOPE

This document covers the overall Supplier’s Health Net business continuity strategy that would form the base for the business continuity procedures for each of the following functions;

•

BPaaS

•

Non BPaaS

•

ITIS


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3.	ORGANIZATION STRUCTURE OF BCP


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3.1

Roles and Responsibilities


Supplier Role		Responsibilities

Steering Committee (C-Level’s, Business and IT Leaders)		• Review the detailed disaster recovery plan & Execution • Declare a disaster based on the agreed communication plan between Health Net and Supplier • Provide direction on prioritizing the list of projects applications/Systems and services to be recovered during a disaster. • Ensure effective communication across all associates/customers involved • Review the critical processes for restoration in case of a disaster • Health Net and Supplier groups will be part of this role

BCP Manager		• Coordinate the development and maintenance of the Corporate BCP manual by the BCP committee • Coordinate the development and maintenance of the center level BCP procedures manual at each center. • Coordinate the development and maintenance of the BCP plan • Manage and direct the business continuity activities across the organization • Ensure that the plan is updated on a regular basis • Drive the recovery process during disaster/emergency situations • Monitor the organization wide, center level and project specific BCP testing process • Ensure these are in compliance with the documented process • Ensure that the Corporate BCP manual is available across multiple locations • Health Net and Supplier groups will be part of this role • Ensure that all the Center Level BCP team members have the latest copy of their respective Center Level BCP Procedures manual • Ensure that such manuals are also stored in a different site. • Coordinate BCP awareness activities across the organization

BCP Committee – (Comprise of Functional Head from IT/IT IS/BPS Team)		• Develop and maintain the Corporate BCP Manual on a regular basis Develop and maintain the BCP plan on a regular basis. • Ensure that the plan is tested at least annually. • Ensure that the BCP objectives are in line with the business requirements • Identify & review the critical processes for restoration in case of a disaster • Prioritize the list of projects applications/Systems and services to be recovered during a disaster • Ensure effective communication across all associates/customers involved • Review the detailed disaster recovery report prepared by the Center Specific BCP Team members on completion of recovery process


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Supplier Role		Responsibilities
Center Specific BCP Coordinators		• Identify and nominate the Center specific BCP/DR team with representation from various functional units • Manage and direct the business continuity activities within the center • Coordinate with center specific functions for the preparation and test execution of BCP/DR • Manage the recovery process within the center during disaster/emergency situations • Initiate/approve the recovery plan for the center and inform the Center Specific BCP/DR Team to action • Ensure periodic status updates are communicated to the BCP Manager/BCP Committee • Prepare a disaster recovery report on completion of recovery process and submit the report to BCP Committee

Center Specific BCP Team		• Provide feedbacks to BCP Committee and Center Specific BCP coordinators, regarding development and maintenance of the BCP plan on a regular basis • Identify and nominate the Center specific BCP Disaster Recovery team with representation from various functional units • Identify the critical processes for restoration in case of a disaster • Ensure effective communication across all associates/customers involved • Instruct the Disaster Recovery Team to carry out the recovery process at the time of disaster • Inform concerned Functional to activate their Function Specific BCP • Review and publish a detailed disaster recovery report on completion of recovery process to Center Specific BCP Coordinator • Ensure periodic status updates are communicated to the Center specific BCP Coordinator

Disaster Recovery Team		• Assess damage • Analyze the impact on business • Clearly relate damage assessment to business continuity of organization • Identify and isolate damaged assets • Assess the reusability of damaged assets • Understand economics of repair versus replacement • Implement the recovery process as per the plan • Periodically update the Center Specific BCP Team on the status of recovery process. • Coordinate with vendors/contractors for the recovery process. • Carry out the business resumption

Functional Leads – Center Specific		• Will be part of Center Specific BCP Team • Develop current and viable plan for business continuity • Identify and nominate the BCP team for the respective functional units


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Supplier Role

Responsibilities

• Coordinate with the Corporate BCP Coordinator for maintenance of the plan

• Identify and list out all critical functions and time frame for restoration of the services in case of a disaster

• Ensure that proper Escalation and Communication process is in place and it is updated regularly

• Manage BCP activities within the function

• Monitor the implementation of the functional level plans during disaster/emergency situations

• Monitor the implementation of the tests as per the plan and schedule

• Prepare a unit specific disaster recovery report on completion of recovery process

3.2

Business Process Services (BPS) Specific BCP Chart

The chart below depicts how a BCP will be defined at each BPS Function level like Contact Center, Membership, etc. This covers all locations for a given Business Function from BCP perspective.


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4.	DISASTER RECOVERY PRE-PLANNING PROCESS

Supplier provides comprehensive DR services and would execute the DR process in accordance with ITIL V3 Service Continuity Management (SCM) and perform the activities by leveraging the existing knowledge base and frameworks of Supplier.

Supplier has built capabilities to provide end-to-end DR services which include the following:

•

Conducting Risk Assessment

•

Conducting Business Impact Analysis

•

Categorizing resources into various criticality levels

•

Designing Disaster Recovery solutions for resources under various categories of criticality

•

Implementing the DR solutions

•

Management and maintenance of the DR Program

•

DR Audit / Assessment

The below sections describes the various stages of Supplier’s DR preparedness;

4.1

Disaster Recovery Assessment

This is the most important stage of the Supplier’s DR preparedness. This stage focusses on creation of the DR plan in conjunction with all the involved stakeholders. This stage also focusses on the creation of crisis management plan and exhaustive list of activities to be executed with proper schedule.


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Activities:

•

Analyze and Propose infrastructure layer including network, storage, servers, virtualization, operating system etc. and create an as-is map of infrastructure to be later used as an input in the DR design phase

•

Analyze current platform including database servers, application servers, Email, Citrix etc. and create an as-is map of the current platform to be used later as an input to the DR design phase

•

Analyze current application integrations, dependencies and batch jobs and create a map, to create a Service Recovery Order (SRO) document

•

Analyze current support and operational processes and identify potential process gaps in both implementation and support of the DR solution.

•

Analyze end user connectivity methodology to identify dependencies and ensure transparent recovery for end users

4.2

Disaster Recovery Design

This stage focusses on the designing of an effecting DR solution for Health Net. Supplier will interview stake-holders to gain and be up to date on the DR requirements and design, update the end state DR solution for Health Net.

Activities:

•

Prepare High Level DR Solution Architecture depicting key technology components that constitute the solution. The Solution Architecture will also include the technical requirements that align to the business requirements specified in the DR Strategy as well as technology constraints, dependencies and risks.

•

Prepare detailed design for each infrastructure and platform layer including Network, Storage, Servers, virtualization, and support infrastructure stressing the role played by the respective layer in enabling the DR solution.

•

Prepare detailed application specific Disaster Recovery documents in collaboration with application subject-matter-experts with references to the infrastructure and platform recovery designs that are prerequisites for the application recovery.

•

Prepare Service Recovery Order (SRO) document derived from the BIA document and the application integration document.

4.3

Disaster Recovery Implementation

This stage focusses on the implementation of the DR design stage.


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Activities:

•

Prepare a High Level implementation plan and schedule based on inputs from the application /infrastructure Architect and detailed design. The plan should include high level resource requirements from the required cross functional teams.

•

Prepare detailed Implementation Plans and checklists for implementing the requisite Infrastructure and support platforms at the DR facility

•

Prepare a detailed vendor management plan for coordinating between various vendors that are required to implement the solution

•

Implement requisite support infrastructure (e.g. patching, monitoring) at the DR site.

•

Implement DR solution at the DR Facility and the requisite components at the Primary site in coordination with the colocation vendors and network service providers

•

Prepare updated support process documents for handover

4.4

Disaster Recovery Test

In this stage the test cases are executed to ensure full functionality of all devices and network are working as expected. This test will be done in isolated environment, production environment will not be disturbed during this testing. All the databases are tested for consistency of data. Supplier and Health Net will sign off on the post test result. In case of adverse DR test, Supplier team will ensure the normal operation of resources through primary site and shall do a root cause analysis of the causes of failure. The same will be shared with the Health Net and another DR testing for the failed test cases would be scheduled as per the plan (at least annually).

Activities:

•

Prepare DR Test Strategy aligned to the High Level DR strategy and consequentially the business requirements of disaster recovery

•

Prepare Test schedule in alignment to the Implementation schedule

•

Prepare detailed application level DR test plans derived from regression test plans of the application.

•

Prepare user acceptance plan for business sign-off for the DR test

•

Execute and Verify Test plans

4.5

Disaster Recovery Test Completion

This is the stage where the communication of successful/unsuccessful completion of the DR test is shared with various stakeholders with the key learnings. The documentations which need to be submitted in this stage are:

•

Revised DR plan

•

DR Execution run book

•

Post test results


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4.6

Disaster Recovery Approach

Supplier will follow the methodology defined—DR Assessment, Desgin, Implementation, Test , Operations. This is an iterative process to include changing business needs. Currently Supplier proposes the below DR architecture which will be validated and updated during the DR Assessment phase. The timeline of DR Design will be aligned to ▇▇▇ ▇▇▇▇▇ ▇ timelines, as there is a wave based migration approach for applications to Supplier DC and DR solution will be designed based on the application criticality, RPO & RTO.

Target DR Architecture

Below diagram illustrates the DR sites (secondary datacenter) and the involved architecture for the Supplier approach:


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Supplier approach to Health Net DR is to exceed their current DR capabilities by means of below mentioned methodologies

•

Will have dedicated Hardware for ABS HP Integrity and Alpha servers

•

Will have dedicated AIX and Solaris hardware to support applications utilizing these system types by using LPAR/LDOM

•

Will have dedicated VM for windows and LINUX needs, but will take advantage of VMware and have zero resources applied to them until need for a DR or DR test

•

Will have dedicated Storage pool for DR, that will have HUR (Hitachi Universal Replicator) replication with Centennial (Supplier primary datacenter) for production

•

Development environment may be used for Cold Stand by needs

5.	BUSINESS CONTINUITY PLANNING PROCESS

5.1

Business Impact Analysis

The Business Continuity Planning Process shall be based on the ISO 22301 standard. A Business Impact Analysis or BIA estimates the possible consequences of a sudden, unplanned, severe interruption for any reason and determines the priority of the recovery of processes and supporting technical and non-technical supporting components within the recovery time demands set forth in the BIA.

The purpose of Business Impact Analysis is to

(a)

Identify all applications and its criticality

(b)

Based on criticality, set the priority for recovery of services (tier’s in this case)

(c)

Establish an estimate of the maximum tolerable downtime for each service offering

(d)

Determine the type of fallback arrangements required in case of a disaster

(e)

Determine the priorities and processes for recovery of critical business processes

The list of all applications and its criticality has been given in Schedule A-1-1-3.

5.2

Criticality of Application Description

The applications have been classified into one of the three Tiers based on the criticality of the applications disruption

(a)

Tier 1

Any application disruption that would stop the business or function would be categorized as “Tier 1”.

(b)

Tier 2


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Any application disruption that would affect the business or function but still the bare minimum activities can be carried out would be categorized as “Tier 2”.

(c)

Tier 3

Any application disruption that would cause some inconveniences to the business or function would be categorized as “Tier 3”.

5.3

Criticality of Business Process Services Description

The services have been classified into one of the four based on the criticality of the services disruption. They are Vital, Essential, Necessary and Desirable.

(a)

Vital

Vital services are defined under Tier 1 services, any disruption in service that would stop the business or function would be categorized as “Vital”. The RTOs for Vital services are as defined in the Terms and Conditions.

(b)

Essential

Essential services are defined under Tier 2 services, the criticality would be classified as “Essential” if the service affects business but still the bare minimum activities can be carried out. The RTOs for Essential services are as defined in the Terms and Conditions.

(c)

Necessary

Necessary services are defined under Tier 3 services, “Necessary” services are the ones, which, if not available causes some inconveniences to the business or deliverable. The RTOs for Necessary services are as defined in MSA .

(d)

Desirable

Desirable services are defined under Tier 3 services, all “Desirable” services will fall into the category of cosmetic services where the downtime will not affect business in anyway. The RTOs for Desirable services are as defined in MSA .

5.4

BCP Triggers

A Disaster can happen for many reasons. Some of them are listed below;

•

Primary Data/Network Center is impacted

•

Network Connectivity Failure (LAN, WAN, Internet, MPLS, etc.)

•

Network Device Failure (Firewall, Router, Switch etc.)

•

Application Failure (Active Directory, Exchange, Project File Share etc.)

•

All Tier 1 and Tier 2 applications stop functioning

•

Multiple locations are impacted and Business cannot carry out critical functions


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•

Social unrest

•

Flood

•

Transport disruption

•

Extreme Weather

•

Fire

•

Power blackout

•

Seismic Events (Earthquake, Tsunami)

•

Pandemic Outbreak (In a situation of 25% - 50% of Absenteeism)

•

Terrorist Attack

BCP would be activated when any one of the events occur as mentioned above which would cause a serious impact to business services. The escalation process mentioned in Section 12 would be followed to control the situation, initiate recovery process and communicate as necessary.

6.	BUSINESS CONTINUITY POLICIES FOR HEALTH NET

•

The BCP Coordinator would invoke the BCP process in consultation with the BCP committee

•

It is the responsibility of the BCP Committee to ensure that adequate spare resources are made available at the backup sites as mentioned in the functional procedures

•

It is mandatory for all BCP team members to maintain two copies of business continuity procedures for their respective functions in an easily accessible and secure location

•

The BCP shall be reviewed and updated at least once a year or according to Health Net’s schedule if any major changes take place

•

The BCP shall be updated whenever major additions, upgrades, deletions take place to the underlying hardware, network environment, office infrastructure or key personnel

•

Any changes to the BCP needs to be notified to the entire BCP team and all the existing hardcopies should be withdrawn and replaced with the updated BCP

•

The BCP testing process for critical services referenced in SOW#4 (IT Services) Exhibit B (IT Service Levels) would be done once a year. All the functional tower units shall maintain BCP pertaining to their functions.

6.1

Intra-city/Inter-City Alternate Sites

Refer Schedule F (Supplier Facilities) for details around;

(a)

Infrastructure Sites


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(b)

Service Delivery Sites

(c)

Application Delivery Sites

(d)

Business Process Services Sites

6.2

Policies for Network and Systems Support

This will be updated after the due diligence phase

6.3

Policies for Business Critical Functions

•

All applications identified by their tiers will have to be up and running as per defined RTO and RPO guidelines per Schedule A-1-1-2.

•

The application teams should coordinate with the concerned functional tower unit and identify the business continuity plans for the critical services

•

Use multi-location delivery organization such that in the event of a complete facility-level outage at any of the one location, *** of the business remains unaffected on account of being in a different city

•

For all critical processes performed at the primary site, Supplier will create a minimum of *** BCP capacity by cross training resources with similar skills and expertise at alternate locations.

6.4

Policies for Administration (Supplier facilities only)

•

All the facilities shall have adequate fire detection and prevention equipment tested annually

•

All electrical fittings shall be adequately maintained for efficient functioning

•

All confidential and sensitive documents shall be stored in fire proof cabinets in secured locations

•

All facilities will be guarded round the clock by trained security personnel or by security equipment

•

There will be well defined evacuation procedures available in all the facilities

•

All facilities with multiple floors will have floor coordinators as lead personnel at times of fire, flood or similar exigencies

•

All the data centers will have adequate backups for air conditioners

•

Since power is a very vital service, we will ensure that redundant/backup UPS be available in all the facilities UPS and Generators will be tested monthly

•

It is mandatory to have a standby generator in all the facilities

•

It is mandatory to have enough fuel for generators and agreement with the vendor for fuel supply in case of extended disaster


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6.5

Policies for Human Resources (Supplier resources only)

•

In case of a disaster HR should ensure that all the associates are safe. It should also set up a helpdesk to communicate to the associates regarding the disaster.

•

It should have tie ups with travel agencies for making travel arrangements in short notice and leverage Supplier Travel Desks across delivery locations as necessary to meet the travel needs when associates need to be transported to secondary delivery centers during a business continuity scenario.

7.	DISASTER RECOVERY STRATEGY FOR HEALTH NET

Supplier has a robust and proven BCP that ensures that services offered to Health Net are protected in the event where any of our service locations becomes inoperable, or any other issues require us to move the work elsewhere. The BCP reiterates our commitment to delivering the highest quality solution using the Global Delivery Model and protecting Health Net from service continuity risks. Our business continuity plans are based on the need to protect professional staff, computing infrastructure and intellectual property in order to help Health Net remain in business through any contingency; that includes provisions to ensure the mobility of professional skills along with fully redundant communications backbones and computing infrastructures.

7.1

Infrastructure (ITO) Strategy

As part of the BCP Plan, Supplier will provide a fallback strategy to manage disruptions affecting delivery locations. The fallback strategy that we will deploy for Health Net is given below:


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Supplier has a multi-site presence in each location as well as a multi-location presence so that each site / location acts as a fall—back to the other with respect to infrastructure.

In India, the delivery centers Coimbatore and Bangalore will be fallback locations for each other. Systems for HA/DR includes Power, WAN—Connectivity Inter-City and Health Net locations, Internet Connectivity, Metro Ethernet—Connectivity to multiple facilities within the city. Supplier will strategically plan Onsite team presence to effectively respond to disruptions and meet their recovery objectives. Both the Offshore delivery centers are geographically separated by two hundred (200) miles (of reach).

Onsite support for both Federal and commercial will be delivered from Health Net office at Rancho ▇▇▇▇▇▇▇ and AeroJet, for example, will be fall back locations for each other based on Health Net’s approval and availability of office space.

Bangalore and Coimbatore are the two offshore delivery locations identified for Health Net. Both the offshore locations have Health Net skilled resources working on various technologies. In case of BCP/DR situation both locations will cover each other respectively.

At Manila, Cebu is a service desk ready location and operations can start immediately once BCP/DR is invoked and has all the required resources and skills for service desk function.

Supplier has flexi resources at their delivery centers worldwide. These can be deployed quickly during the BCP/DR situation. All these resources are technically skilled covering wide spectrum of technologies including niche skills

7.2

Business Process Services (BPS) Strategy

The BPS strategy involves the restoration of normal business operations after an unexpected event which has disrupted all or part of the business process. From a Business perspective, this is the most critical phase of the whole BCP.

The BPS strategy will either follow directly the Infrastructure recovery phase or will be directly initiated after a serious emergency incident affecting normal business operations depending upon the disaster impact.

Supplier’s BCP approach is be based on the RTO and RPO (refer Schedule A-1-1-2) and

Application Criticality (refer Schedule A-1-1-3).

When implemented, the BCP/DR plan will establish availability of employees, and workspace with the required technology and network access to carry out the designated assignments, within the proposed recovery plan and time frames

Supplier’s multi location delivery organization provides a first level of BCP/ DR of about fifty percent (50%), wherever the in-scope processes provide minimal scale and scope to have operations to be distributed equally in two different cities. For such processes, in the event of a complete facility-level outage at any of the one location, fifty percent (50%) of the business remains unaffected on account of being in a different city.

After completion of Phase 2, processes that are transactional in nature (excludes roles like Business Analysts, Business System Analyst and Project Management) and delivered from a single location, For all critical processes performed at the primary site, Supplier will create a


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minimum of twenty-five percent (25%) BCP capacity by cross training resources with similar skills and expertise at alternate locations The actual availability of the seats during an outage will also be determined by the severity of the event, and the actual BCP/ DR plan prepared during the start of the engagement will fully cover these aspects

During the transition planning phase Supplier will identify critical processes within the critical Business Functions which will be prioritized over other processes, subject to a cap of the maximum available BCP capacity in the back up location.

Please refer to Schedule F (Supplier Facilities) for identified critical Business Functions by Delivery locations.

8.	BUSINESS RESUMPTION PROCESS

Once the disaster recovery has taken place the business continues in the alternate site. However, it should be noted that the business should resume from the home site since the alternate site is for a disaster elapsed period only. The alternative site will be available / utilized until the move to the home site is completed.

For returning back to home site, the following should be planned to ensure the business operations are not disturbed:

8.1

Infrastructure Set-Up or Recovery

For Health Net ITO outage, the infrastructure recovery will be executed per the RTO, RPO guidelines defined in Schedule A-1-1-2. Regular updates will be provided to Health Net and its impacted Business Functions until the business functions are restored.

For Supplier location specific infrastructure outage, Supplier’s corporate BCP plan will be executed for restoration.

8.2

Business Functions/Projects Recovery

It will be the responsibility of functional tower units to take care of migration of their units into the home site(s) as part of the business resumption process. They will be supporting the projects move into the home site by coordinating with respective project managers.

The order of business services that need to be restored will be per the tier guidelines defined in Schedule A-1-1-3.

9.	BCP TESTING PROCESS

9.1

Purpose

It is essential that the BCP process be tested annually in order to ensure the following to

•

Ensure all critical activities outlined in the plan are functioning to combat any disaster

•

Measure the effectiveness of the Business Continuity Process

•

Verify compatibility of backup facilities


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•

Ensure the adequacy of team procedures

•

Identify deficiencies in procedures

•

Team members training and awareness

•

Provide mechanism for maintaining/updating the plan

•

Address the needs of any additional resources

•

Assess the preparedness for handling any disaster

9.2

BCP Test Plan

BCP Test Plan needs to be established for all critical Business Functions. These test plans may contain one or more of the following;

•

Structured Walkthroughs (Review of test plan)

•

Life exercises/Simulations

•

Periodic off-site recovery tests/Parallel (Done once a year currently at Health Net)

9.3

BCP Test Periodicity

The services categorized under Tier 1 category that might have an impact on the business need to be tested at least once in year. If there is a deviation from this process it should be documented and approved by Health Net.

9.4

BCP Test Reports

Upon completion of the BCP testing process a detailed test report should be presented to BCP committee and Health Net. This report should include the following

•

Type of test conducted

•

Test Scenario

•

Desired Result

•

Actual Result

•

Acceptable recovery time

•

Actual Time taken for recovery

•

Problems faced, if any

•

Corrective measures with anticipated corrective dates


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10.

BCP REVIEW AND MAINTENANCE

To ensure that the BCP is current and effective, the BCP policy and procedures should be reviewed and updated as defined in Schedule A (Cross Functional Services). The responsibility for review of Health Net BCP Manual shall lie with the BCP Coordinator and the BCP Committee.

11.

PROCESS FOR INCLUDING A NEW SERVICE IN BCP

The following process needs to be followed for including a new service as part of BCP;

•

Risk assessment should be done for the service

•

It should be categorized in Schedule A-1-1-3 based on criticality

•

An alternate plan should be developed to mitigate the risk and it should be included as part of the BCP

•

The BCP test plan should be updated to reflect this change

12.

ESCALATION AND COMMUNICATION PROCEDURES

This section would cover the communication and escalation process to be followed for any disaster. The escalation process would be based on the disaster categorization and criticality of the services affected.

If a disaster has been declared by an authorized Health Net Executive, the following shall be identified immediately

•

Details of disaster

•

Impact of the disaster

•

Identify relevant existing recovery procedure and plan

•

If it is a new disaster scenario, prepare recovery plan/procedure

•

Time estimate for recovery

The Center Specific BCP Coordinator would trigger the recovery process and also inform the BCP Manager and BCP Committee.

The Center Specific BCP Team would intimate the Disaster Recovery Team to report immediately.

The Disaster Recovery Team shall immediately initiate the recovery procedure.

If any Business/IT Functions are affected, the concerned head will be intimated by the Center Specific BCP team to take necessary action and invoke Function specific BCP.

The BCP Manager would invoke the Communication process for intimating the Steering committee.


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The Center Specific BCP Team and the BCP Committee would be updated on the status of the recovery process by the disaster recovery team every hour or on completion of each phase whichever is earlier.

The Administration and HR group would set up a temporary helpdesk for intimating the concerned people about the disaster.


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SCHEDULE A-1-1-2

DEFINITION OF BCP TERMS

1.1

Recovery Time Objective (RTO)

Elapsed Time from the time when a disaster is declared until IT infrastructure and data recovered and project can resume operations.

1.2

Recovery Point Objective (RPO)

In the event of an outage, the point in time to which systems and data must be recovered. (E.g. end of previous day’s processing) determined by the responsible business unit(s). RPOs are often used as the basis for the development of backup strategies, and as a determinant of the amount of data that may need to be recreated after the systems or functions have been recovered

1.3

Recovery Time Objective (RTO)

The targeted duration of time and a service level within which a business process must be restored after a disaster (or disruption) in order to avoid unacceptable consequences associated with a break in business continuity.


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SCHEDULE A-1-1-2

RTO, RPO BY APPLICATION CATEGORY

RTO and RPO for all Health Net applications by categories are detailed below:


Sl. No.	Application category	RPO and RTO Details
	Tier-1	As Per Schedule A- 4

	Tier-2	As Per Schedule A- 4

	Tier-3	As Per Schedule A- 4


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SCHEDULE A-1-1-3

HEALTH NET APPLICATIONS AND ITS CRITICALITY

Table below shows the list of Tier 1, 2 & 3 applications for Commercial, Federal and Corporate applications. This information is provided by Health Net and will be updated during the assessment and based on the Critical SLA commitments between Health Net and Supplier.

***


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SCHEDULE A-2

[RESERVED]


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SCHEDULE A-3

FUTURE SOW TEMPLATE

[TO BE DEVELOPED AFTER THE EFFECTIVE DATE IN ACCORDANCE WITH THE GENERAL TERMS AND CONDITIONS]


Schedule A-3				Health Net / Cognizant Confidential

MSA Schedule A-4

SCHEDULE A-4

IT CONTINUITY AND DISASTER RECOVERY SERVICES

***

[Represents 8 pages of material pursuant to a request for confidential treatment under Rule 24b-2 of the Securities Exchange Act of 1934 which has been filed separately with the Securities and Exchange Commission]

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SCHEDULE B

SERVICE LEVELS


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SCHEDULE B

SERVICE LEVELS

TABLE OF CONTENTS


1. INTRODUCTION			1

2. DEFINITIONS			1

2.1 Certain Definitions			1

2.2 Other Terms			4

3. MEASUREMENT, REPORTING AND SUPPORTING INFORMATION			4

3.1 Measurement Period and Times			4

3.2 Measurement Process and Tools			4

3.3 Reporting and Supporting Information			5

4. SERVICE LEVEL METHODOLOGY			6

4.1 General			6

4.2 Service Level Codes/Setting of Initial Operational Service Levels			7

4.3 Failure to Perform			8

4.4 Excused Critical Service Level Failures			10

4.5 Operational Service Level Credits and Compliance Service Level Credits			10

4.6 Performance Guarantee Group Payment Amounts			13

4.7 Stakeholder Satisfaction Survey Credits			13

4.8 Weighting Factors; Amounts at Risk			13

5. MODIFICATIONS AND IMPROVEMENTS TO SERVICE LEVELS			15

5.1 Deletions of Service Levels			15

5.2 New Operational Service Levels			15

5.3 New Compliance Service Levels and Compliance Measures and Changes to Existing Compliance Service Levels and Compliance Measures			16

5.4 New Performance Guarantee Group Service Levels and Changes to Existing PGG Service Levels			16

5.5 Continuous Improvement			17

5.6 Quarterly Meeting to Adjust Service Levels			18

6. STAKEHOLDER SATISFACTION SURVEY			18

7. OTHER TERMS			19

7.1 Changes to Service Levels via Change Control			19

7.2 Comparable Critical Service Levels and Performance Guarantee Group Service Levels			19

7.3 Incentive Opportunity			19


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TABLE OF SCHEDULES


Schedule B-1:		Certain Service Levels

Schedule B-2:		Compliance Service Level Metrics

Schedule B-2-1:		Compliance Measures

Schedule B-2-2:		Payment of Fines that Cover Critical Compliance Service Level Failures

Schedule B-3:		Performance Guarantee Group Service Level Metrics

Schedule B-3-1:		Standards for New or Modified Performance Guarantee Group Service Levels

Schedule B-4:		Stakeholder Satisfaction Survey


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SCHEDULE B

SERVICE LEVELS

1.	INTRODUCTION

This Schedule B (“Schedule B”) sets forth the Service Levels that Supplier is required to meet or exceed in performing certain of the Services during the Term. This Schedule also describes (a) the methodology for calculating Performance Payments that will be provided to Health Net by Supplier in the event of any Critical Service Level Failure, and (b) the process the Parties will follow to add, modify or delete Service Levels during the Term.

2.	DEFINITIONS

2.1

Certain Definitions

(a)

“BPaaS Amount at Risk” means ***percent (***%) of the aggregate monthly charges payable by Health Net under this Agreement (excluding (i) Charges applicable to Non- BPaaS IT Services which are described in Section 2.1(o)(iii), but for Phase 2 only, shall be ***percent (***%) of the monthly Phase 2 Fixed Fee, (ii) for Phase 2 only, an amount equal to $*** to reflect the adjustment made to reflect the limit of liability applicable to the AO Agreement as described in Section 24.2(b)(ii) of the Terms and Conditions, and (iii) Pass-Through Expenses).

(b)

“BPaaS Pool Percentage Available for Allocation” means *** (***) percentage points.

(c)

“Business Days” mean Monday through Friday (except holidays on which the offices of Health Net, as applicable, are not open for regular business). For purposes of measuring performance against Service Levels, each Business Day shall start at the occurrence of the event to be measured by the Service Level and end the same time of day the following Business Day (e.g., a task that requires a one (1) Business Day turnaround time and starts on 3:00 p.m. local time on Monday must be finished by 3:00 p.m. local time on Tuesday, provided that both Monday and Tuesday are Business Days).

(d)

“Compliance Measures” means the quantitative measures set forth in Schedule B-2-1 (Compliance Measures), as they may be modified or supplemented in accordance with Section 5.3. Compliance Measures are grouped together to form Compliance Service Levels, as set forth in Schedule B-2 (Compliance Service Level Metrics).

(e)

“Compliance Measure Failure” means a failure by Supplier to perform in accordance with any Compliance Measure (i.e. Yellow or Red performance) or to properly measure or report on the performance of any Compliance Measure.

(f)

“Compliance Service Level” means a Service Level set forth in Schedule B-2 (Compliance Service Level Metrics). Each Compliance Service Level consists of a grouping of Compliance Measures.

(g)

“Compliance Service Level Credit” has the meaning given in Section 4.3(b)(ii).

(h)

“Compliance Service Level Failure” means a Service Level Failure (i.e. Yellow or Red performance) with regard to any Compliance Service Level.


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(i)

“Critical Compliance Service Level Failure” means a Critical Service Level Failure with regard to a Compliance Service Level that is a Critical Service Level.

(j)

“Critical Operational Service Level Failure” means a Critical Service Level Failure with regard to an Operational Service Level that is a Critical Service Level.

(k)

“Critical Service Level” means collectively (i) an Operational Service Level, Compliance Service Level or Stakeholder Satisfaction Survey Service Level designated as a Critical Service Level in Schedule B-1 (Certain Service Levels), B-2 (Compliance Service Level Metrics) or B-3 (Performance Guarantee Group Service Level Metrics), or Exhibit B-1 to each SOW, in each case as may be modified by Health Net in accordance with Sections 4.8, 5 and 6, and (ii) any Performance Guarantee Group Service Level.

(l)

“Critical Service Level Failure” means a Service Level Failure with regard to any Critical Service Level.

(m)

“Critical Stakeholder Satisfaction Survey Service Level Failure” means a Critical Service Level Failure with regard to the Stakeholder Satisfaction Survey Service Level that is a Critical Service Level.

(n)

“Measurement Period” means, for any Service Level, the period of time during the Term, during which Supplier’s actual performance of the relevant Services is to be measured against the corresponding Service Level. The Measurement Period for each Service Level is described in Section 3.1.

(o)

“Non-BPaaS Amount at Risk” means ***percent (***%) of the aggregate monthly Charges payable by Health Net under this Agreement (excluding Pass-Through Expenses) with respect to Non-BPaaS IT Services. The following rules shall be used in computing the Non-BPaaS Amount at Risk:

(i)

▇▇▇▇▇▇ ▇▇▇▇▇ ▇, the monthly Non-BPaaS Amount at Risk shall be $ *** ($***);

(ii)

▇▇▇▇▇▇ ▇▇▇▇▇ ▇, the monthly Non-BPaaS Amount at Risk shall equal ***percent (***%) of the amount that is ***percent (***%) of the monthly Phase 2 Fixed Fee.

(iii)

▇▇▇▇▇▇ ▇▇▇▇▇ ▇, the Charges applicable to Non-BPaaS IT Services that are to be used to calculate the Non-BPaaS Amount at Risk (and excluded from the calculation of the BPaaS Amount at Risk) shall equal all amounts payable under Sections 10, 12 and 13 of Schedule C (Charges) and any other Charges payable for Services provided under SOW #4 (IT Services).

(p)

“Non-BPaaS Pool Percentage Available for Allocation” means *** (***) percentage points.

(q)

“Non-BPaaS IT Service Levels” shall mean (i) the Service Levels set forth in Exhibit B- 1 of SOW #4 (IT Services) and (ii) the Security Service Levels set forth on Schedule B-1 (Certain Service Levels), which Security Service Levels shall also be deemed to be BPaaS Service Levels, as further described herein.


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(r)

“Operational Service Level” means a Service Level set forth in Schedule B-1 (Certain Service Levels) or in Exhibit B-1 to each SOW, as they may be modified or supplemented in accordance with Section 5.2.

(s)

“Operational Service Level Credit” has the meaning given in Section 4.3(b)(i).

(t)

“Performance Payments” shall mean collectively Operational Service Level Credits, Compliance Service Level Credits, Performance Guarantee Group Payment Amounts, and Stakeholder Satisfaction Survey Credits.

(u)

“Performance Guarantee Group” means an entity with which Health Net has contracted to meet specific service levels, either as of the Effective Date or at any point during the Term.

(v)

“Performance Guarantee Group Payment Amount” has the meaning given in Section 4.3(b)(iii).

(w)

“Performance Guarantee Group Service Level” means a Service Level set forth in Schedule B-3 (Performance Guarantee Group Service Level Metrics), as they may be modified or supplemented in accordance with Section 5.4.

(x)

“Performance Guarantee Group Service Level Failure” means a Service Level Failure with regard to any Performance Guarantee Group Service Level.

(y)

“Security Service Level” means the Service Levels set forth on Schedule B-1 (Certain Service Levels), excluding the Stakeholder’s Satisfaction Survey Service Level.

(z)

“Service Levels” means a performance standard for certain Services, which are set forth in Schedules B, ▇-▇, ▇-▇, ▇-▇ and Exhibit B-1 to each SOW. Service Levels include Operational Service Levels, Compliance Service Levels, Performance Guarantee Group Service Levels, and the Stakeholder Satisfaction Survey Service Level.

(aa)

“Service Level Credit” shall mean any Performance Payment, excluding the Performance Guarantee Group Payment Amounts.

(bb)

“Service Level Failure” means, with regard to any Service Level (including Operational Service Levels, Compliance Service Levels, Performance Guarantee Group Service Levels, and the Stakeholder Satisfaction Survey Service Level), a failure by Supplier to either (i) perform at the level that meets the corresponding Service Level during any particular Measurement Period, or (ii) properly measure and report on the performance for any Service Level.

(cc)

“Stakeholder Satisfaction Survey Credit” has the meaning given in Section 4.3(b)(iv).

(dd)

“Stakeholder Satisfaction Survey Service Level” means the Service Level set forth in Section 6.

(ee)

“Weighting Factor” means the portion of the BPaaS Pool Percentage Available for Allocation or Non-BPaaS Pool Percentage Available for Allocation (as applicable) that Health Net has allocated with respect to a Critical Service Level. The initial Weighting Factor for each of the Critical Service Levels shall be established via written notice(s) provided by Health Net to Supplier not later than January 15, 2015, and in each case shall be subject to modification pursuant to Section 4.8(e).


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2.2

Other Terms

Other terms used in this Schedule B (Service Levels) (including any Schedule to this Schedule B) are either defined in the context in which they are used or are defined elsewhere in this Agreement, and in each case shall have the meanings there indicated.

3.	MEASUREMENT, REPORTING AND SUPPORTING INFORMATION

3.1

Measurement Period and Times

(a)

The Measurement Period for the Stakeholder Satisfaction Survey Service Level shall be on a quarterly basis.

(b)

For all other Service Levels, the Measurement Period shall be monthly unless otherwise set forth in Schedules ▇, ▇-▇, ▇-▇, ▇-▇ or Exhibit B-1 to each SOW.

(c)

Except as otherwise expressly indicated in this Schedule B, all references to “hour” or “hours” shall mean clock hours and all reference to “day” or “days” shall mean calendar days, unless otherwise stated as Business Days.

3.2

Measurement Process and Tools

(a)

With respect to Service Levels for which there is no measurement tool shown on Schedules ▇-▇, ▇-▇-▇ or B-3 or Exhibit B-1 to any SOW, Supplier shall develop and implement measurement and monitoring tools, processes and methodologies (collectively “Measuring Items”) required to measure such Service Levels not later than ninety 90) days prior to the BPaaS Services Commencement Date. Supplier shall also use Commercially Reasonable Efforts to develop and implement to the extent feasible Measuring Items that will measure each Service Level in an automated fashion such that Supplier’s actual performance with respect to the Service Levels shall be determined using system generated data, so that such Measuring Items are in place not later than the BPaaS Services Commencement Date. The Measuring Items described in this Section and for any modified or new Service Levels added after the Effective Date shall be subject to Health Net’s prior written approval.

(b)

Supplier shall measure Supplier’s performance with respect to each Service Level using the corresponding Measuring Items identified for such Service Level in Schedules ▇, ▇- ▇, ▇-▇, ▇-▇-▇ or B-3, or Exhibit B-1 to each SOW, as applicable, or as specified elsewhere in this Section 3.2.

(i)

Supplier shall provide and utilize (and have operational, administrative and financial responsibility for) the necessary Measuring Items required to measure and report Supplier’s performance of the Services against the applicable Service Levels set forth in this Agreement. Such Measuring Items shall (A) permit measurement and daily reporting of compliance with the Service Levels, (B) permit reporting at a level of detail sufficient to verify compliance with the Service Levels, and (C) will be subject to verification and review by Health Net. Supplier shall provide Health Net with access to such Measuring Items at all times, without the need for Health Net to specifically request such access in advance.


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(ii)

If, after the Effective Date (with respect to Service Levels for which there is a measurement tool set forth in Schedule ▇-▇, ▇-▇-▇ or B-3 or Exhibit B-1 to any SOW), or after the date that the Measuring Item has been approved by Health Net pursuant to Section 3.2(a), Supplier desires to use a different Measuring Item for any Service Level, Supplier shall provide written notice to Health Net proposing:

(A)

the alternative Measuring Item; and

(B)

any reasonable adjustments to the Service Levels that are necessary to account for any increased or decreased sensitivity that will likely result from use of the alternative Measuring Item.

Supplier may utilize such alternative Measuring Item only to the extent Supplier demonstrates to Health Net’s reasonable satisfaction (as evidenced by Health Net’s approval in writing) that such tool is capable of measuring and reporting the applicable Service Levels in the same manner or functionally equivalent manner as the Measuring Item being replaced and meets all of the requirements for Measuring Items set forth in this Schedule B (Service Levels).

(iii)

If any Service Level specifies that it will be measured based on a sampling of an overall population, the applicable Service Level shall be measured as follows:

(A)

During each Measurement Period, Supplier shall audit a statistically valid, dollar and product stratified, sampling of the applicable unit of measure in order to determine Supplier’s performance with respect to each Service Level.

(B)

Supplier shall calculate its performance against each of the Service Levels based on the results of each such audit and Supplier shall track the results of each audit in an applicable database.

(c)

Notwithstanding Sections 3.2(a), 3.2(b) or 3.3, Health Net shall have the right, by sending written notice to Supplier, to assume responsibility for the development and implementation of Measuring Items required to measure any Service Level, and/or to measure such Service Level.

3.3

Reporting and Supporting Information

(a)

Supplier shall deliver the Monthly Performance Report to Health Net in accordance with Section 4.2(b)(i) of Schedule G (Governance).

(b)

Upon Health Net’s request, Supplier shall provide to Health Net detailed supporting information (including available raw performance data) relating to Supplier’s performance relative to the Service Levels. Such information shall at a minimum include all information that is as necessary for Health Net to verify the accuracy of Supplier’s Service Level measurements and reporting, and other supporting information as reasonably requested by Health Net.


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(c)

Supplier shall make the reporting and supporting information described in this Section 3.3, available to Health Net both (i) in machine-readable form suitable for use on a personal computer; and (ii) via a secure website.

4.	SERVICE LEVEL METHODOLOGY

4.1

General

(a)

Commencing on the BPaaS Services Commencement Date, Supplier shall meet or exceed each of the Service Levels set forth in Schedules B, ▇-▇, ▇-▇, ▇-▇-▇ and B-3, and Exhibit B-1 to each of the SOWs (as the same may be amended and supplemented pursuant to this Schedule B), subject to Section 4.1(b) below. Notwithstanding the prior sentence, the Parties agree that (i) for those Service Levels that are designated as a Code “C” Service Level on an Exhibit B-1 as described in Section 4.2(c) below, Supplier shall commence meeting or exceeding each of such Service Levels promptly after the completion of the baselining process described in Section 4.2(c) below, and (ii) Supplier shall commence meeting or exceeding the Non-BPaaS IT Service Levels at such time that Supplier has assumed responsibility for performing any Non-BPaaS IT Services to which such Non-BPaaS IT Service Levels relate, which the Parties acknowledge will be on a rolling basis commencing in Phase 1 and in accordance with the applicable transition plans.

(b)

Notwithstanding Section 4.1(a) above, with respect to any Compliance Measure for which the average level of performance by Health Net during the six months prior to the BPaaS Services Commencement Date is “Red” or “Yellow”, if (1) Supplier fails to meet such Compliance Measure during any of the first six (6) months after the BPaaS Services Commencement Date (the “Grace Period”), and (2) such Compliance Measure is not within the scope of services provide by Supplier under the Original BPO Agreement, such performance of the Compliance Measure shall be excluded from the calculation of whether Supplier has met the Compliance Service Level of which such Compliance Measure is a part; provided, however, that:

(i)

if Supplier’s performance with respect to such Compliance Measure during each of the months during the Grace Period does not meet or exceed Health Net’s average performance with respect to such Compliance Measure during the six months prior to the BPaaS Services Commencement Date, then such data shall be included in the calculation of whether Supplier met the Compliance Service Level of which the Compliance Measure is included, and

(ii)

Supplier’s performance after the Grace Period with respect to such Compliance Measures shall be counted.

(c)

Service Levels constitute one means, but not the exclusive means, of measuring Supplier’s performance of its commitment under Section 5.4 of the Terms and Conditions. If a Service Level includes multiple conditions or components (e.g., components (a), (b) and(c)), then Supplier’s performance must satisfy each and every condition or component (i.e., components (a), (b) and (c)) to achieve the corresponding Service Level.


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(d)

In the event that a single incident causes more than one failure to meet a Critical Service Level (excluding the Stakeholder Satisfaction Service Level), then (i) if the incident causes more than one Critical Service Level Failure (excluding those relating to Non- BPaaS IT Service Levels), Health Net shall be entitled to each of such credits, and (ii) if the incident causes more than one Critical Service Level Failure relating to the Non- BPaaS IT Service Levels, Health Net shall have the right to select the credit or payment that it wishes to receive, but shall not be entitled to all of such credits and payments arising from the multiple Critical Service Level Failures associated with the Non-BPaaS IT Service Levels. In the event that a single incident causes a Critical Service Level Failure of BPaaS Service Levels and Non-BPaaS IT Service Levels, Health Net shall be entitled to all of such BPaaS Service Level credits and Health Net may select which of the Non-BPaaS IT Service Level credits that it elects to receive. For purposes of this Section, with respect to any Security Service Level, if Health Net has allocated Weighting Factor points from the BPaaS Pool Percentage Available for Allocation and/or the Non- BPaaS Pool Percentage Available for Allocation, the credits from the BPaaS Pool Percentage Available for Allocation shall be treated as BPaaS Service Level Credits and the credits from the Non- BPaaS Pool Percentage Available for Allocation will be treated as Non-BPaaS IT Service Level credits, in accordance with the above.

(e)

If any portion of the Services are to be provided from a business continuity recovery environment, the Service Levels shall continue to apply; except to the extent a disaster occurring at a Health Net facility prevents Supplier from meeting such Service Levels.

4.2

Service Level Codes/Setting of Initial Operational Service Levels

For each of the Operational Service Levels set forth in Schedules B-1 (Certain Service Levels) and Exhibit B-1 to each SOW, a corresponding code has been designated in the ““Code”” column of the applicable table, as follows:

(a)

Code ““A””—For each Service Level metric for which “”A”” is designated as the applicable code, then as of the BPaaS Services Commencement Date, the Service Level shall be the Service Level set forth on the applicable Schedule or Exhibit (“Code A”).

(b)

Code ““B””—For each Service Level metric for which ““B”” is designated as the applicable code, the Service Level which shall be in effect on the BPaaS Services Commencement Date shall be established based on the following process (“Code B”):

(i)

The Service Level metric will be established based on Health Net’s performance of the Services during the last six (6) months of 2014 (the ““Code B Baselining Period””).

(ii)

Immediately following the Code B Baselining Period, the Service Level for such Code B Service Level will be promptly established and shall be effective on the BPaaS Services Commencement Date. Such metric shall be the arithmetic mean of the baselined data collected during the Code B Baselining Period.

(iii)

Notwithstanding the above, if the baselined data demonstrates performance that is unsatisfactory to Health Net, then (A) Health Net may rely on the continuous improvement provision set forth in Section 5.5 to improve the Service Level, or (B) upon Health Net’s request, Supplier will promptly develop a plan to improve performance and the Parties will meet to establish a mutually agreeable Service Level. The implementation of the plan to improve the Service Level shall be done pursuant to the Change Control Process.


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(c)

Code ““C””—For each Service Level metric for which ““C”” is designated as the applicable code, the Service Level which shall be in effect on the BPaaS Services Commencement Date (or thereafter if necessary to gather additional data as described below) shall be established based on the following process (“Code C”):

(i)

The Service Level metric will be established based on Health Net’s performance of the Services commencing at such time as Health Net is able to start measurement of the Service Level, and continuing for six (6) months (the ““Code C Baselining Period””). Under this approach, the Code C Baselining Period will be six (6) months, and may be comprised of performance based on any of the possible scenarios:

(A)

Health Net’s performance only (for example if Health Net begins measuring the Service Level in September 2014 and ends in February 2015, thereby resulting in six (6) months of measurement), or

(B)

a combination of Health Net and Supplier performance (for example, if Health Net begins measuring the Service Level in October 2014, and the BPaaS Commencement Date is March 1, 2015, thereby resulting in five (5) months of measurement under Health Net’s performance of the Services and one (1) month of Supplier’s performance of the Services), or

(C)

all under Supplier (for example if Health Net is not able to start measurement prior to the BPaaS Services Commencement Date, in which event Supplier shall commence measurement upon the BPaaS Services Commencement Date, unless Health Net requests otherwise).

(ii)

Immediately following the Code C Baselining Period, the Service Level for such Code C Service Level will be promptly established and shall be effective as of the completion of the Code C Baselining Period (or as soon thereafter as Health Net requests). Such metric shall be the arithmetic mean of the baselined data collected during the Code B Baselining Period.

(iii)

(d)

Supplier shall use all Commercially Reasonable Efforts to achieve the highest possible Service Levels during any portion of the foregoing Baselining Periods which measure Supplier’s performance of the Services.

4.3

Failure to Perform

(a)

For each Service Level Failure and Compliance Measure Failure, Supplier shall (i) investigate, assemble and preserve pertinent information with respect to, and report on the causes of, the problem, including performing a root cause analysis of the problem; (ii)


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advise Health Net, as and to the extent requested by Health Net, of the status of remedial efforts being undertaken with respect to such problem; (iii) minimize the impact of and correct the problem and begin meeting the Service Level; and (iv) take appropriate preventive measures so that the problem does not recur.

(b)

Supplier recognizes that a Critical Service Level Failure may have a material adverse impact on the business and operations of Health Net and that the damages from a Critical Service Level Failure are not susceptible to precise determination. Accordingly, unless otherwise excused pursuant to Section 4.4:

(i)

In the event of a Critical Operational Service Level Failure, Supplier shall pay to Health Net a credit calculated pursuant to Section 4.5 (“Operational Service Level Credit”); and

(ii)

In the event of a Critical Compliance Service Level Failure , Supplier shall pay to Health Net a credit calculated pursuant to Section 4.5 (“Compliance Service Level Credit”); and

(iii)

In the event of a Performance Group Guarantee Service Level Failure, then Supplier shall pay to Health Net an amount calculated pursuant to Section 4.6 (“Performance Guarantee Group Payment Amount”); and

(iv)

In the event of a Critical Stakeholder Satisfaction Survey Service Level Failures, Supplier shall pay to Health Net a credit calculated pursuant to Section 4.7 (“Stakeholder Satisfaction Survey Credit”).

(c)

For the avoidance of doubt, in the event that Supplier is obligated to grant to Health Net any Operational Service Level Credit, Compliance Service Level Credit, Performance Guarantee Group Payment Amount, or Stakeholder Satisfaction Survey Credit, the obligation for Supplier to pay such credits and amounts are separate and independent obligations of Supplier.

(d)

Performance Payments will not be construed as a penalty or as liquidated damages for a Critical Service Level Failure and, accordingly, they will not be deemed to constitute Health Net’s remedy, exclusive or otherwise, for any actual damages caused by a Critical Service Level Failure. Performance Payments will be in addition to any other monetary and non-monetary remedies available to Health Net under this Agreement, at law, or in equity with respect to a Critical Service Level Failure or the events that result in a Critical Service Level Failure, including Health Net’s right to either before or after receiving any particular Performance Payment, make a claim for damages against Supplier arising out of the Critical Service Level Failure; provided, however, that if Health Net had previously received any Performance Payment as a result of such failure, then the amount of damages then recoverable by Health Net shall equal (i) the total amount of damages then recoverable under this Agreement and incurred by Health Net with respect to such failure, without consideration of whether any Performance Payment resulting from such failure had been provided to Health Net; less (ii) any Performance Payment previously provided to Health Net resulting from such failure.

(e)

This Section 4.3 shall not limit Health Net’s rights with respect to the events upon which Health Net may rely as a basis for Health Net’s termination of this Agreement.


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4.4

Excused Critical Service Level Failures

(a)

If Supplier fails to meet a Service Level and establishes within two (2) months after such failure that each of the following criteria are satisfied:

(i)

the root cause of Supplier’s failure to meet such Service Level was caused by:

(A)

the failure of Health Net, Health Net’s Affiliates or Health Net’s third party contractors or agents (other than Supplier or Supplier’s subcontractors) to perform an express obligation of Health Net under this Agreement; provided that upon becoming aware of such failure, Supplier provided Health Net with reasonable notice of such failure and used Commercially Reasonable Efforts to perform and achieve the Service Level notwithstanding the occurrence and impact of such actions, or

(B)

a Force Majeure Event under Section 24.3 of the Terms and Conditions; provided that Supplier fulfilled the obligations set forth in Section 24.3(b) of the Terms and Conditions

(each an “Excusable Critical Service Level Failure Event”);

(ii)

Supplier would have achieved such Service Level but for such Excusable Critical Service Level Failure Event; and

(iii)

Supplier is without material fault in causing such Excusable Critical Service Level Failure Event,

then Supplier shall not be obligated to pay the Service Level Credit for any resulting Critical Service Level Failure, and Supplier shall otherwise be excused from achieving such Service Level for as long as such Excusable Critical Service Level Failure Event continues and Supplier continues to use Commercially Reasonable Efforts to prevent, overcome, and mitigate the adverse effects of such Excusable Critical Service Level Failure Event to the extent required to achieve the applicable Service Level.

(b)

Supplier shall not be excused from a failure to achieve a Service Level other than under this Section 4.4, or as expressly provided elsewhere in this Agreement.

4.5

Operational Service Level Credits and Compliance Service Level Credits

(a)

Calculation. For each Critical Operational Service Level Failure and Critical Compliance Service Level Failure, the applicable Service Level Credits referenced in Sections 4.3(b)(i) and 4.3(b)(ii) above shall be calculated in accordance with the following formula:

Service Level Credit = A x B x C

Where:

A = the applicable Weighting Factor;

B = (i) the BPaaS Amount at Risk for such calendar month for all Service Levels except the Non-BPaaS IT Service Levels, or (ii) the Non-BPaaS Amount at Risk for Non-PBaaS


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IT Service Levels (as applicable), provided that if there is a Critical Operational Service Level Failure relating to a Security Service Level, the credit shall be calculated in accordance with Section 4.5(c) below; and

C =

(i)

For a Critical Operational Service Level Failure, C = 1.

(ii)

For a Critical Compliance Service Level Failure, C = the percentage determined using the table below.


	Percentage of Total Number of Compliance Measures in a Compliance Service Level for which there is a Compliance Measure Failure (Yellow or Red)
Level of Performance		*	**
Green
Yellow
Red

(A)

The levels of performance to meet the Green, Yellow and Red thresholds are set forth on Exhibit B-2-1 (Compliance Measures).

(B)

Performance at a Yellow or Red level shall constitute a Compliance Measure Failure.

(C)

There must be more than one Compliance Measure Failure in order for there to be Critical Compliance Service Level Failure which results in a Service Level Credit owed by Supplier to Health Net.

(D)

At the end of each month, the Service Level Credits shall be calculated against the actual number of Red and Yellow failures separately and then summed up to determine the total Service Level Credit from such Compliance Service Level.

(1)

For example – Assume the results of a Compliance Service Level are: *** of the measures are Yellow and *** of the measures are Red.

(2)

Then C = *** = 35%.

(E)

A Compliance Measure that is measured on a quarterly basis will be measured and counted using the above approach for the month in which such quarterly measure is measured.


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(F)

If a Regulator changes the threshold level at which it enforces its regulatory requirements or Health Net receives a different interpretation from the Regulator regarding the threshold that will be enforced, Health Net shall have the right to change the Green, Yellow and Red thresholds based on such Regulatory input. Health Net shall also have the right to add such Red/Yellow/Green thresholds for new compliance measures added per Section 5.3.

(b)

***

(c)	***Notification; Payment of Credits.

(i)

For each Critical Operational Service Level Failure and Critical Compliance Service Level Failure, Supplier shall report such failure to Health Net pursuant to Section 3. Supplier shall also report on each Compliance Measure Failure pursuant to Section 3. Such report will, at a minimum, (A) identify such Critical Service Level Failure and Compliance Measure Failure, and (B) calculate the amount of the corresponding Service Level Credit, calculated pursuant to Section 4.5(a).

(ii)

Supplier shall credit any such Service Level Credits earned in a month against the subsequent month’s Charges.

(d)

***.

(e)	***Security Service Level Service Level Credits

(i)

The Parties agree that Health Net may allocate Weighting Factor points to the Security Service Levels from the BPaaS Pool Percentage Available for Allocation and from the Non-BPaaS Pool Percentage Available for Allocation. Service Level Credits relating to the Security Service Levels referenced in Section 4.3(b)(i) shall be calculated in accordance with the following:

Service Level Credit = ((A x B) + (C x D))

Where:

A = the applicable Weighting Factor from the BPaaS Pool Percentage Available for Allocation;

B = the BPaaS Amount at Risk for such calendar month;

C = the applicable Weighting Factor from the Non-BPaaS Pool Percentage Available for Allocation; and

D = the Non-BPaaS Amount at Risk for such calendar month.


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4.6

***

4.7

Stakeholder Satisfaction Survey Credits

(a)

Calculation. For each Critical Stakeholder Satisfaction Survey Service Level Failure, the applicable Stakeholder Satisfaction Survey Credit referenced in Section 4.3(b)(iv) above shall be equal to

Stakeholder Satisfaction Survey Credit = ((A x B) + (C x D)) x E

Where:

A = the applicable Weighting Factor from the BPaaS Pool Percentage Available for Allocation;

B = the sum of the BPaaS Amounts at Risk for each calendar month during the period measured by the Stakeholder Satisfaction Survey; and

C = the applicable Weighting Factor from the Non-BPaaS Pool Percentage Available for Allocation;

D = the sum of the Non-BPaaS Amounts at Risk for each calendar month during the period measured by the Stakeholder Satisfaction Survey; and

E = ***% if Supplier’s score is ***, and ***% if Supplier’s score is less than ***.

(b)

Notification; Payment of Credits.

(i)

For each Critical Stakeholder Satisfaction Survey Service Level Failure, Health Net shall report such failure to Supplier pursuant to Section 3. Such report will, at a minimum, (A) identify such Critical Stakeholder Satisfaction Survey Service Level Failure, and (B) set forth the amount of the corresponding Stakeholder Satisfaction Survey Credit, calculated pursuant to Section 4.7(a).

(ii)

Supplier shall credit any such Stakeholder Satisfaction Survey Credit earned with respect to a calendar quarter against the first invoice in the subsequent month following such calendar quarter.

4.8

Weighting Factors; Amounts at Risk

(a)

BPaaS

(i)

BPaaS Weighting Factor limit. In no event shall any single Weighting Factor for a Critical Service Level (excluding Non-BPaaS IT Service Levels) exceed ***(***) points.

(ii)

BPaaS Weighting Factor comprehensive limit. In no event shall the sum of the Weighting Factors for all Critical Service Levels (excluding Non-BPaaS IT Service Levels) exceed the BPaaS Pool Percentage Available for Allocation.

(iii)

BPaaS Amount at Risk limit. The total amount of Performance Payments payable by Supplier (excluding Service Level Credits payable with respect to


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Non-BPaaS IT Service Levels and excluding Performance Guarantee Group Payment Amounts as described in Sections 4.6(g) and 4.8(c)(ii)) relating to a calendar month shall not exceed the BPaaS Amount at Risk for such calendar month.

(iv)

Security Service Levels.

(A)

In no event shall the Weighting Factor points (from both the BPaaS Pool Percentage Available for Allocation and the Non-BPaaS Pool Percentage Available for Allocation) allocated to any Security Service Level exceed ***.

(B)

Weighting Factor points allocated to Security Service Levels from the BPaaS Pool Percentage Available for Allocation, and Performance Payments resulting therefrom, shall be included for purposes of applying the restrictions set forth in Sections 4.8(a)(ii) and (iii), but Weighting Factor points allocated to Security Service Levels from the Non-BPaaS Pool Percentage Available for Allocation, and Performance Payments resulting therefrom, shall not be included for purposes of applying such restrictions.

(b)

Non-BPaaS

(i)

Non-BPaaS Weighting Factor limit. In no event shall any single Weighting Factor for a Non-BPaaS IT Service Level exceed ***.

(ii)

Non-BPaaS Weighting Factor comprehensive limit. In no event shall the sum of the Weighting Factors for all Non-BPaaS IT Service Levels exceed the Non- BPaaS Pool Percentage Available for Allocation.

(iii)

Non-BPaaS Amount at Risk limit. The total amount of Performance Payments payable by Supplier for Non-BPaaS IT Service Levels relating to a calendar month shall not exceed the Non-BPaaS Amount at Risk for such calendar month.

(iv)

Security Service Levels. Weighting Factor points allocated to Security Service Levels from the Non-BPaaS Pool Percentage Available for Allocation, and Performance Payments resulting therefrom, shall be included for purposes of applying the restrictions set forth in Sections 4.8(b)(ii) and (iii), but Weighting Factor points allocated to Security Service Levels from the BPaaS Pool Percentage Available for Allocation, and Performance Payments resulting therefrom, shall not be included for purposes of applying such restrictions,

(c)

***.

(d)

Rules Relating to Stakeholder Satisfaction Survey as it relates to Amounts at Risk. The Parties agree that if there is a Stakeholder Satisfaction Survey Credit with respect to any calendar quarter, that for purposes of determining whether either of the Amounts at Risk will limit payment of such credit, the amount of such credit shall be divided by the number of months in the survey period (the “Allocated Per Month Stakeholder Satisfaction Survey Credit”). ***.


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(e)

Designation of Weighting Factors. Health Net may from time to time during the Term change, in its sole discretion, the Weighting Factor for any one or more Service Levels and Critical Service Levels upon written notice to Supplier; provided, however, that

(i)

Health Net may provide only one (1) such notice during any calendar quarter (which notice may contain multiple changes), which notice shall be effective on the first day of the second month following giving such notice.

5.	MODIFICATIONS AND IMPROVEMENTS TO SERVICE LEVELS

5.1

Deletions of Service Levels

Health Net may at any time during the Term, in its sole discretion upon written notice to Supplier, delete a then-existing Service Level.

5.2

New Operational Service Levels

Health Net may, in its sole discretion upon written notice to Supplier, add a new Operational Service Level. Any additions with respect to Operational Service Levels shall be subject to the following:

(a)

If Health Net adds a new Service Level for which there is at least ***of historical data within the past ***and such data indicates performance that is acceptable to Health Net, then the Service Level metric shall be the arithmetic mean of the most recent three (3) months of historical data. For example, if the three (3) months of historical data are 99.90%, 99.92%, and 99.95%, then the Service Level would be the arithmetic mean (99.923%) (calculated as ((99.90% + 99.92% + 99.95%) / 3). Such Service Level shall become effective as of a date determined by Health Net, but no earlier than thirty (30) days after written notice from Health Net.

(b)

If Health Net adds a new Service Level for which there is at least ***of historical data within the past***, but such data does not indicate performance that is acceptable to Health Net, then, upon Health Net’s written request, Supplier will perform an assessment of the root causes of the unacceptable level of historical performance and seek to improve performance within sixty (60) days.

(i)

At the end of such sixty (60) day period, if Health Net reasonably determines that Supplier’s performance is below an acceptable level (e.g., by reference to industry standards), then Supplier *** to improve its performance of the affected Services to a level of service acceptable to Health Net.

(ii)

At the end of such***, if Health Net determines that Supplier’s performance is at an acceptable level, then the Service Level metric shall be determined in accordance with Section 5.2(a).

(c)

If Health Net adds a new Service Level for which at least ***of historical data within the past ***does not exist, then such Service Level shall be baselined in accordance with the following:

(i)

Supplier and Health Net shall promptly meet to agree upon the tools and procedures to be used to measure such new Service Level. Upon such agreement, Supplier or Health Net, as applicable, shall promptly implement such agreed upon tools and/or procedures and begin measuring the new Service Level.


Schedule B		B-15		Health Net / Cognizant Confidential

Final

(ii)

The “Baselining Period” for each such Service Level shall begin on the first day of the calendar month following the date upon which Supplier or Health Net, as applicable, is capable of beginning to measure such Service Level using the agreed upon tools and procedures, and continue for three (3) months. Health Net, acting in its sole discretion, may extend the Baselining Period by informing Supplier of such extension.

(iii)

Supplier or Health Net, as applicable, shall begin to measure its performance against each such Service Level commencing on the start date of the relevant Baselining Period, and shall report on its performance with respect to each such Service Level as provided in Section 3 or as otherwise agreed by the Parties.

(iv)

Each such Service Level shall become effective as of the expiration of such Baselining Period, and the corresponding Service Level metric shall be determined in accordance with Section 5.2(a).

5.3

New Compliance Service Levels and Compliance Measures and Changes to Existing Compliance Service Levels and Compliance Measures

Health Net may ***to Supplier:

(a)

add an additional Compliance Service Level and corresponding Compliance Measures, or

(b)

add an additional Compliance Measure to an existing Compliance Service Level, or

(c)

modify an existing Compliance Service Level or Compliance Measure;

provided that in each case such addition or modification is a result of changes to existing Laws or new Laws with which the Services are required to comply, or the result of an updated interpretation of a Law, or direction by a Regulator, or change in the threshold at which the Regulator enforces a Law, or identification of a target after the Effective Date that existed prior to the Effective Date. Any such addition or modification shall be implemented in accordance with Section 17.5 of the Terms and Conditions, Change Control, provided that Supplier shall have financial responsibility for any such additional or modified Service Level except as set forth in Section 13 of Schedule C (Charges).

5.4

New Performance Guarantee Group Service Levels and Changes to Existing PGG Service Levels

(a)

***

(i)

***

(ii)

The service levels to be included in the new or modified Performance Guarantee Group contract are within the standards set forth on Schedule B-3-1 (Standards for New or Modified Performance Guarantee Group Service Levels).


Schedule B		B-16		Health Net / Cognizant Confidential

Final

(b)

All Performance Guarantee Group Service Levels existing as of the Effective Date are grandfathered under this Agreement, even if they fall outside the standards set forth in Schedule B-3-1.

(c)

The Performance Guarantee Group Service Levels that are attached as Schedule B-3 (Performance Guarantee Group Service Level Metrics) shall be updated to reflect the actual Performance Group Guarantee Service Levels set forth in Health Net’s Performance Guarantee Group contracts in effect during 2015, provided that any such 2015 Performance Group Guarantee Service Level that is outside the standards set forth on Schedule B-3-1 (Standards for New or Modified Performance Guarantee Group Service Levels) shall be subject to Section 5.4(d) below.

(d)

If Health Net desires to (i) add a new Performance Guarantee Group Service Level (or modify an existing one) to a level that is greater or lower than the standards set forth on Schedule B-3-1 (Standards for New or Modified Performance Guarantee Group Service Levels), or (ii) modify the standards set forth in Schedule B-3-1 (Standards for New or Modified Performance Guarantee Group Service Levels), then such new or modified Performance Guarantee Service Level and such modified standards shall be changed via the Change Control Process, provided that the Parties agree that the pricing impacts associated with such changes shall be subject to the following:

(i)

***

5.5

Continuous Improvement

(a)

In addition to any improvements in Service Levels resulting from application of the review processes described in Section 5.6, then, with respect to the Service Levels described in Section 5.5(c), on the first anniversary of the Effective Date and annually thereafter on each subsequent anniversary of the Effective Date, each Service Level shall be automatically adjusted by adding to the then-current Service Level being adjusted a sum equal to five percent (5%) of the difference between the level of perfect performance (e.g., 100% Availability) and the then-current Service Level. For example, if the Service Level being adjusted were 99.0%, the increase would be 0.05% (i.e., from 99.0% to 99.05%), calculated as ((100.0%-99.0%) x 0.05 = 0.05%).

(b)

The improvements to the Service Levels made pursuant to Section 5.5(a) above shall be capped at a maximum metric of ***%.

(c)

The continuous improvement process of this Section 5.5 shall apply to all Service Levels for which continuous improvement is noted on Schedule A-1 (Initial SOWs Cross Functional Solution Description), B-1 (Certain Service Levels) or the Exhibit B-1s to each SOW.

(d)

The Parties agree that for purposes of computing continuous improvement for the Abandon Rate Service Level, “perfect performance” as used in Section 5.5(a) shall be deemed to be zero (0) percent. Continuous improvement shall apply to the Abandon Rate Service Level, provided that the maximum improvement is as set forth in the right hand column (under “New SLA”) in the table below:

***


Schedule ▇-▇		▇-▇▇		Health Net / Cognizant Confidential

Final

(e)

The descriptions of the Services Levels will be updated on an annual basis to reflect the results of the continuous improvement modifications described above; provided, however, that such modifications shall be effective automatically notwithstanding the absence of any such update to such Schedule or Exhibit.

5.6

Quarterly Meeting to Adjust Service Levels

Health Net and Supplier will meet to review the Service Levels on a quarterly basis to discuss the Service Levels and will make adjustments to the Service Levels as appropriate to reflect improved performance capabilities associated with advances in technology, processes, methods and tools. As new technologies, processes methods and tools are introduced, additional Service Levels reflecting industry best practices for those technologies and processes will be established by the Parties.

6.	STAKEHOLDER SATISFACTION SURVEY

Both as a management feedback tool and in an effort to help ensure that Supplier’s performance of the Services achieves Health Net’s objectives set forth in the Agreement, Health Net will assess key Health Net’s key stakeholders’ satisfaction of Supplier, taking into consideration the strategic direction and objectives of the relationship, using the methodology set forth below:

(a)

The Stakeholder Satisfaction Survey is attached hereto as Schedule B-4 (“Stakeholder Satisfaction Survey”). Health Net has the right, from time to time during the Term, to modify the Stakeholder Satisfaction Survey in its sole discretion, upon notice to Supplier.

(b)

No later than first quarter after the BPaaS Services Commencement Date and quarterly thereafter, Health Net shall administer the Stakeholder Satisfaction Survey (in its then-current form).

(c)

Health Net shall administer the Stakeholder Satisfaction Survey to no fewer than ten (10) and no more than twenty (20) key stakeholders within the Health Net organization (as will be identified by Health Net in advance of each Stakeholder Satisfaction Survey). Prior to each Stakeholder Satisfaction Survey, the Parties will jointly inform and educate the key stakeholders taking such survey about the questions, criteria, metrics, credit assessment, and goals of the Stakeholder Satisfaction Survey. The Stakeholder Satisfaction Survey shall be scored and the results of such scoring shall be as follows:

(i)

Each key stakeholder completing the Stakeholder Satisfaction Survey shall provide an overall score, which shall range between 1.0 (poor) and 5.0 (excellent). The score from each key stakeholder will be averaged to calculate the aggregate Stakeholder Satisfaction Survey score (the “Score”).

(ii)

If the Score for any category is less than 3.0, then the Parties shall meet to discuss the reason(s) for such Score. Within thirty (30) days of the administration of the applicable Stakeholder Satisfaction Survey, Supplier shall be required to develop a plan (“Remediation Plan”) designed to improve Supplier’s performance and Score. The Remediation Plan is subject to Health Net’s approval and Supplier shall promptly implement the Health Net-approved Remediation Plan; and


Schedule B		B-18		Health Net / Cognizant Confidential

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(iii)

If the Score for the survey is less than***, Supplier shall pay Health Net the applicable Stakeholder Satisfaction Survey Credit in accordance with Section 4.7.

(d)

Health Net may not use the results of the Stakeholder Satisfaction Survey as the sole basis for a claim that Supplier is in material breach of this Agreement for purposes of exercising Health Net’s termination rights under Section 16.1 of the Terms and Conditions.

7.	OTHER TERMS

7.1

Changes to Service Levels via Change Control

If Health Net requests, Supplier to implement a new Service Level at a particular level and the Parties agree upon the payment amount for such new Service Level, then baselining shall not be required, notwithstanding Section 5.2 or any other Section hereof.

7.2

Comparable Critical Service Levels and Performance Guarantee Group Service Levels

For the avoidance of doubt, the determination of whether Supplier has met or failed to meet any Critical Service Level shall be made without regard to whether Supplier has met or failed to meet any Performance Guarantee Group Service Level that is comparable to, but less demanding than, such Critical Service Level; similarly, the determination of whether Supplier has met or failed to meet any Performance Guarantee Group Service Level shall be made without regard to whether Supplier has met or failed to meet any Critical Service Level that is comparable to, but less demanding than, such Performance Guarantee Group Service Level.

*** ***


Schedule B		B-19		Health Net / Cognizant Confidential

Final

SCHEDULE B-1

CERTAIN SERVICE LEVELS

1.	SERVICE LEVELS GENERALLY

All Service Levels are subject to the Service Level Methodology set forth in Schedule B (Service Levels) and the applicable provisions of the Agreement.

2.	STAKEHOLDER SATISFACTION SURVEY SERVICE LEVEL

Ref

Category / Name

Description

Measurement
Period

Measurement Tool

Service
Level

BPaaS
Weighting

Factor

Non-BPaaS
Weighting
Factor

Code

Continuous
Improve

Stakeholder Satisfaction Survey

See Section 6 (Stakeholder Satisfaction Survey) of Schedule B (Service Levels)

Quarterly

Manual calculation based on Stakeholder Satisfaction Survey results

See Section 6(c)(iii) of Schedule B (Service Levels)

▇▇▇

3.	SECURITY SERVICE LEVELS

Service Area

Description

Measurement
Period

Measurement
Tools /
Process

Service Level
Metric

Formula

BPaaS
Weighting

Factor

Non-
BPaaS

Weighting
Factor

Code

Continuous
Improvement

Security & Privacy Training

Measures the level of compliance for Supplier to complete mandatory security and privacy training on time.

Monthly

Training system records or Health Net training coordinator records

100%

Number of Supplier Personnel completing training on time within the last month / Total number of Supplier Personnel assigned to perform Services x 100

▇▇▇


Schedule B-1		B-1-1		Health Net / Cognizant Confidential

Final

Service Area

Description

Measurement
Period

Measurement
Tools /
Process

Service Level
Metric

Formula

BPaaS
Weighting

Factor

Non-
BPaaS

Weighting
Factor

Code

Continuous
Improvement

IAVM Patching

Measures the number of IAVM-required security patches installed on systems and Available for Use in for hosting (a) Critical Services and on all Federal Services systems within IAVM

timelines.

Monthly

Patch Management Systems, Vulnerability Scanners, Security Assessments

³97%

(Number of IAVM-required patches installed on Critical Service and Federal Services systems that are Available for Use within IAVM timeframes / Number of IAVM-required patches applicable to Critical Services and Federal Services systems that are Available for Use) x 100 (not including exceptions agreed in advance in writing)

▇▇▇

Vulnerability Remediation for Critical Systems

Measures the number of High and Moderate Severity Vulnerabilities (including missing patches) remediated on systems that are Available for Use hosting Critical Services

within 30 days

Monthly

Patch Management Systems, Vulnerability Scanners, Security Assessments

³97%

(Number of High and Moderate-Severity Vulnerabilities remediated on systems that are Available for Use hosting Critical Services within 30 days / Number of High and Moderate-Severity Vulnerabilities identified on systems that are Available for Use hosting Critical Services) x 100 (not including exceptions agreed in advance in writing)

▇▇▇

▇

▇.

▇▇▇▇ ▇▇▇▇ Vulnerability Remediation

Measures the number of High-Severity Vulnerabilities (including missing patches) remediated on devices that are Available for Use within 30 days

Monthly

Patch Management Systems, Vulnerability Scanners, Security Assessments

³97%

(Number of High-Severity Vulnerabilities remediated on devices that are Available for Use within 30 days / Number of High-Severity Vulnerabilities identified on devices that are Available for Use) x 100 (not including exceptions agreed in advance in writing)

▇▇▇

▇


▇▇▇▇▇▇▇▇ ▇-▇		B-1-2		Health Net / Cognizant Confidential

Final

Service Area

Description

Measurement
Period

Measurement
Tools /
Process

Service Level
Metric

Formula

BPaaS
Weighting

Factor

Non-
BPaaS

Weighting
Factor

Code

Continuous
Improvement

Vulnerability Remediation for All Systems

Measures the number of Vulnerabilities (including missing patches) remediated on available devices within 90 days

Monthly

Patch Management Systems, Vulnerability Scanners,

Security

Assessments

³97%

(Number of High and Moderate-severity vulnerabilities remediated on available devices within 90 days / Number of High and Moderate-severity Vulnerabilities identified on available devices) x 100 (not including exceptions agreed in advance in writing)

▇▇▇

Security & Privacy Incident Response

Measures the time to report Information Security Incidents and Privacy incidents

Monthly

Change Management System, Incident Reporting Systems (email, phone systems, etc.)

100% of incidents reported within 1 Business Day

Number of Information Security Incidents and Privacy incidents with Response Time £ 1 Business Day / total number of Information Security Incidents and Privacy incidents

▇▇▇

Security & Privacy Incident Response - Noncompliance Reporting

Measures the time to report security and privacy non-compliance where Confidential Information has not been disclosed and is not at significant risk.

Monthly

Change Management System, Incident Reporting Systems (email, phone systems, etc.)

³ 90% of incidents reported within 1 Business Day

Number of Information Security Incidents and Privacy incidents where Confidential Information is not at significant risk with Response Time £ 1 Business Day / total number of Information Security Incidents and Privacy incidents where Confidential Information is not at significant risk

▇▇▇


Schedule B-1		B-1-3		Health Net / Cognizant Confidential

Final

Service Area

Description

Measurement
Period

Measurement
Tools /
Process

Service Level
Metric

Formula

BPaaS
Weighting

Factor

Non-
BPaaS

Weighting
Factor

Code

Continuous
Improvement

Firewall Availability

Measures continued protection of networks and systems through continuously functioning firewalls and associated access controls.

Monthly

SIEM and System Monitoring Logs, Alerts, and Reports, Firewall Logs

100%

Amount of time networks and systems are unprotected by a firewall over the measurement period.

▇▇▇

Configuration Management

Measures the configuration drift from baseline technical specifications on a quarterly basis to validate the configuration meets specifications.

Initial baseline technical specification will be the ISEC document, and will be updated and expanded from there as mutually agreed by the parties.

Monthly

Measured initially via SCCM and Altiris. Later measured through CMDB. Data validated in part by security scans.

³99%

(Number of systems with configuration differences from documented technical specifications or approved exception document / number of systems with documented configuration requirements) x 100.

▇▇▇

10.

Security & Privacy Incident Response - Confidential and Non- Confidential Information Exposure Remediation

Measures the time to implement preventive controls during Information Security Incidents and Privacy incidents when Confidential or non-Confidential Information has been inappropriately disclosed or is at significant risk or of disclosure

Monthly

Change Management System, Incident Reporting Systems (email, phone systems, etc.)

(a) Confidential Information: 98% of requested controls put into place within 15 minutes; and

(b) Non- confidential Information:

(a) Number of Information Security Incidents and Privacy incidents where Confidential Information is at risk and requested controls are put in place in £ 15 minutes / total number of Information Security Incidents and Privacy Incidents where Confidential Information is at risk; and

▇▇▇


Schedule B-1		B-1-4		Health Net / Cognizant Confidential

Final

Service Area

Description

Measurement
Period

Measurement
Tools /
Process

Service Level
Metric

Formula

BPaaS
Weighting
Factor

Non-
BPaaS
Weighting
Factor

Code

Continuous
Improvement

90% of requested controls put into place within 1 Business Day

(b) Number of Information Security Incidents and Privacy Incidents where Confidential Information is not at significant risk and requested controls are put in place in £ 1 Business Day / total number of Information Security Incidents and Privacy incidents where Confidential Information is not at significant risk

11.

Security & Privacy Incident Response - Identified Compromised System Isolation

Measures the time to isolate (e.g., remove from the network or place network restrictions around) identified compromised systems during Information Security Incidents and Privacy incidents where system isolation has been requested (measured from the time at which a request for system isolation is made by Health Net).

Monthly

Change Management System, Incident Reporting Systems (email, phone systems, etc.)

³90% of requested controls put into place within 1 hour

Number of Information Security Incidents and Privacy incidents where system isolation is requested in which requested controls are put in place within £ 1 hour / total number of Information Security Incidents and Privacy incidents where system isolation is requested

▇▇▇

12.

Security & Privacy Incident Response - Reporting

Measures the time to provide requested after action report and lessons learned during Information Security Incidents and Privacy incidents where such information has been requested

Monthly

Change Management System, Incident Reporting Systems (email, phone systems, etc.)

³ 98% of requested information provided within 5 days

Number of Information Security Incidents and Privacy incidents where an after action or lessons learned report is requested and provided in £ 5 days / total number of Security and Privacy incidents where an after action or lessons learned report is requested

▇▇▇


Schedule B-1		B-1-5		Health Net / Cognizant Confidential

Final

Service Area

Description

Measurement
Period

Measurement
Tools /
Process

Service Level
Metric

Formula

BPaaS
Weighting
Factor

Non-
BPaaS
Weighting
Factor

Code

Continuous
Improvement

13.

Information Security and Privacy Detection Response

Measures the mean time to reporting (MTTREP) of security alerts, events, event-related information, suspicious, anomalous or malicious activity in the environment and reported to the HN Security Team.

Monthly

CTS responsible for entering request for Change Management System, Incident Reporting Systems (email, phone systems, etc.)

³ 99% of incidents reported within 5 minutes

Number of Information Security Incidents and Privacy incidents and alerts, with reporting time <5 minutes / total number of Information Security Incidents and Privacy Incidents

▇▇▇

14.

Information Security and Privacy Incident Response - Information and Content Request Response Process

Measures the time to respond to requests for application, host or network information and content, related to security and privacy events, including the requested information.

Monthly

Change Management System, Incident Reporting Systems (email, phone systems, etc.)

(a) ³ 99% of security and privacy incident related information requests responded to within 5 minutes and

(b) ³ 99% of security and privacy incident related information request data provided to security team within 10 minutes

(a) Number of Information Security Incidents and Privacy incidents with Response Time <5 minutes / total number of Information Security Incidents and Privacy Incidents and

(b) Number of Information Security Incidents and Privacy Incidents with information requests fulfilled in < 10 minutes / total number of Information Security Incident and Privacy Incident information requests

▇▇▇

▇


▇▇▇▇▇▇▇▇ ▇-▇		B-1-6		Health Net / Cognizant Confidential

Final

Service Area

Description

Measurement
Period

Measurement
Tools /
Process

Service Level
Metric

Formula

BPaaS
Weighting
Factor

Non-
BPaaS

Weighting
Factor

Code

Continuous
Improvement

15.

Information Security and Privacy Incident Response - Priority 1 Response Remediation Process

Measures the time to complete remediation action required for network, host, authentication/identity, application or other change requests related to Information Security Incident and Privacy Incidents, except isolation requests covered by Service Level #64.

Monthly

Change Management System, Incident Reporting Systems (email, phone systems, etc.)

³ 95% of Information Security Incidents and Privacy Incident change requests made with confirmation provided to the security team within 10 minutes

Number of Information Security Incidents and Privacy Incident change requests fulfilled in < 10 minutes / total number of Information Security Incident and Privacy Incident change requests

▇▇▇

16.

Information Security and Privacy Incident Response - Priority 2 Response Remediation Process

Monthly

Change Management System, Incident Reporting Systems (email, phone systems, etc.)

³ 95% of Information Security Incidents and Privacy Incident change requests made with confirmation provided to the security team within 15 minutes

Number of Information Security Incidents and Privacy Incident change requests fulfilled in < 15 minutes / total number of Information Security Incident and Privacy Incident change requests

▇▇▇

17.

Information Security and Privacy Incident Response - Priority 3 Response Remediation

Measures the time to complete remediation action required for network, host, authentication/identity, application or other change requests related to Information Security

Monthly

Change Management System, Incident Reporting Systems (email, phone systems, etc.)

³ 95% of Information Security Incidents and Privacy Incident change requests made

Number of Information Security Incidents and Privacy Incident change requests fulfilled in < 30 minutes / total number of Information Security Incident and Privacy Incident change requests

▇▇▇

▇


▇▇▇▇▇▇▇▇ ▇-▇		B-1-7		Health Net / Cognizant Confidential

Final

Service Area

Description

Measurement
Period

Measurement
Tools /
Process

Service Level
Metric

Formula

BPaaS
Weighting
Factor

Non-
BPaaS

Weighting
Factor

Code

Continuous
Improvement

Process

Incident and Privacy Incidents.

with confirmation provided to the security team within 30 minutes

4.	DEFINITIONS



Vulnerability		A security vulnerability is a weakness in a product (hardware or software) that could allow an attacker to compromise the integrity, availability, or confidentiality of that product.

High-Severity Vulnerabilities		Vulnerabilities that Health Net has determined represent a major risk to security, that must be corrected as soon as possible without circumventing standard processes, and that must be prioritized for mitigation and remediation above less severe Vulnerabilities.

Moderate-Severity Vulnerabilities		Vulnerabilities that Health Net has determined represent a significant risk to security, that must be corrected without circumventing standard processes, and that must be prioritized for mitigation and remediation above less severe Vulnerabilities.

IAVM		Department of Defense Information Assurance Vulnerability Management. The IAVM program provides notifications and guidance for security patching within timelines based on threat determinations resulting from Department of Defense cyber security analysis.

Information Security Incidents		The attempted or successful unauthorized access, use, disclosure, modification, or destruction of information or interference with systems operations in an information system, or, the actual or possible loss of control, unauthorized disclosure, or unauthorized access of personal information in which persons other than authorized users gain access or potential access to such information for other than authorized purposes in which one or more individuals will be adversely affected. These Incidents are categorized utilizing the framework defined by NIST SP 800-61 rev2 and documented within the Information Security Incident Response Plan. Information Security will be the primary decision maker around the declaration that a Security Event is an Incident.


Schedule B-1		B-1-8		Health Net / Cognizant Confidential

Final



Privacy Incidents		A Privacy Incident is defined as a violation of the law or company security policies, standards or procedures, or an event which causes a loss of data confidentiality, disruption of data or system integrity, or disruption or denial of availability compromises (or has the potential to compromise) the confidentiality, integrity, security, or availability of Protected Health Information (“PHI”) or Personally Identifiable Information (“PII”). The term Privacy Incident covers all events that compromise or may compromise PHI or PII, regardless of whether characterized as involving “technical security,” “physical security,” or “privacy” issues. Health Net’s Privacy Office will determine if and declare that a Privacy Incident or Breach has occurred.

Confidential Information		Without limiting the definition in Section 21.1 of the Terms and Conditions, with respect to Health Net, Confidential Information includes without limitation personal information concerning Health Net employees or members or customers, medical information including diagnosis, treatment or benefit administration of any member, financial information relating to employees, hospitals, physicians and provider-specific information related to credentialing/recredentialing proceedings, quality review, malpractice suits and peer-review determination.


Schedule B-1		B-1-9		Health Net / Cognizant Confidential

Final



Security and Privacy Incident - Severity High or Priority 1		A Priority 1 incident is defined as an event that Health Net has determined will have a significant impact on one or more of the following: • The ability to provide products/goods/services to a significant number of Health Net’s customers. • The ability to control/measure/record/track/account for a significant amount of inventory/goods/revenue/cash • The unacceptable risk of significant punitive regulatory actions, contractual penalties, fraudulent criminal activity and or civil litigation • Significant notoriety that has the potential to affect the stock price adversely, damage the brand, and/or cause widespread concern amongst customers/shareholders. A Priority 1 should be met with the full support of the corporation and outsourced agencies. A Priority 1 incident may involve any or all of the following: • Executive involvement • Several areas of due diligence on the part of Health Net including: operational impact, criminal prosecution, contractual and statutory reporting, litigation preparation. • Unsolicited third-party involvement such as law enforcement, regulatory entities, civil subpoenas, and/or third-party contractual obligations. • Obligatory releases of internal information to the public, extensive media, and shareholder scrutiny.

Security and Privacy Incident - Severity Medium or Priority 2		A Medium or Priority 2 incident is defined as an event that Health Net has determined will meet any or all conditions as follows: • Does not fall within the description of a Priority 1 incident • Subject to mandatory reporting or notification • Requires due diligence by Health Net to assess, identify, and correct a deficiency within the organization’s data processing , data usage, and /or information security infrastructure • Presents the potential but not the likelihood of litigation and/or media attention. A Priority 2 incident response may involve any or all of the following: • Execution at a level of management appropriate to address and resolve all issues raised. • A determination as to resources and functions required for resolution as well as reports required • Documentation of all efforts • Management status reporting notifications


Schedule B-1		B-1-10		Health Net / Cognizant Confidential

Final



Security and Privacy Incident - Severity Low/None or Priority 3		Health Net routinely deals with malware, lost or stolen devices, and one off issues that affect a small group of people with limited risk to the organization. A Priority 3 incident may involve any or all of the following: • Execution at a level of management appropriate to address and resolve the incident. • A determination as to resources and functions required for resolution as well as reports required. • Documentation of efforts.

Protected Health Information “PHI”		“PHI” or “Protected Health Information” has the meaning given in Section 2.1 of the Terms and Conditions.

Personally Identifiable Information “PII”		“PII” or “Personally Identifiable Information” has the meaning given in Section 2.1(lll) of the Terms and Conditions.


Schedule B-1		B-1-11		Health Net / Cognizant Confidential

Final

SCHEDULE B-2

COMPLIANCE SERVICE LEVEL METRICS

I.	DEFINITIONS

The following capitalized terms will have the meanings given them below:

“Medicare – Part C and Part C and D Combined Compliance Measures” mean the Compliance Measures designated as Group Code 4 in Schedule B-2-1 (Compliance Measures).

“Medicare – Part D Compliance Measures” mean the Compliance Measures designated as Group Code 8 in Schedule B-2-1 (Compliance Measures).

“Commercial – CA Compliance Measures” mean the Compliance Measures designated as Group Code 1 in Schedule B-2-1 (Compliance Measures). This includes California DMHC, CDI, DOL and HHS Compliance Measures as well as Commercial Compliance Measures combining regions.

“Commercial – AZ Compliance Measures” mean the Compliance Measures designated as Group Code 3 in Schedule B-2-1 (Compliance Measures). This includes Arizona ADOI, DOL and CMS Compliance Measures.

“Commercial – OR/WA Compliance Measures” mean the Compliance Measures designated as Group Code 2 in Schedule B-2-1 (Compliance Measures). This includes OR/ OID and WA OIC Compliance Measures.

“SHP – CA Compliance Measures” mean the Compliance Measures designated as Group Code 5 in Schedule B-2-1 (Compliance Measures). This includes SHP – CA DMHC, DHCS and HHS Compliance Measures. Includes combined Compliance Measures for CA and AZ.

“Duals Compliance Measures” mean the Compliance Measures designated as Group Code 7 in Schedule B-2-1 (Compliance Measures). This includes CA D, HCS and CMS Compliance Measures.

“SHP – AZ Compliance Measures” mean the Compliance Measures designated as Group Code 6 in Schedule B-2-1 (Compliance Measures). This includes SHP – AZ – AHCCCS Compliance Measures.


Schedule B-2		B-2-1		Health Net / Cognizant Confidential

Final

II.

COMPLIANCE SERVICE LEVELS


Category	Group Code	Service Level Description	Measurement Period	Critical (Y/N)	Weighting Factor
Compliance - Medicare - Part C and Part C and D Combined Measures	4	100% compliance with all Medicare - Part C and C and D Combined Compliance Measures.	Monthly	Y	***

Compliance - Medicare - Part D	8	100% compliance with all Medicare - Part D Compliance Measures.	Monthly	Y	***

Compliance - Commercial - CA	1	100% compliance with all Commercial - CA Compliance Measures.	Monthly	Y	***

Compliance - Commercial - AZ	3	100% compliance with all Commercial - AZ Compliance Measures.	Monthly	Y	***

Compliance - Commercial - OR/WA	2	100% compliance with all Commercial OR/WA Compliance Measures.	Monthly	Y	***

Compliance - SHP - CA	5	100% compliance with all SHP - CA Compliance Measures.	Monthly	Y	***

Compliance - Duals	7	100% compliance with all SHP - Duals Compliance Measures.	Monthly	Y	***

Compliance - SHP - AZ	6	100% compliance with all SHP - AZ Compliance Measures.	Monthly	Y	***


Schedule B-2		B-2-2		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

A&G Metrics

Metric Data as of ▇▇▇-▇▇▇▇

▇▇▇-▇

A&G

HMO/POS Member Appeals Acknowledgement TAT (PG)

% of appeals acknowledged within 5 calendar days of receipt

Macess/Magic (current), Prime (future), ODW

—

DMHC

Compliance

= 100%

CPD-2

A&G

HMO/POS Member Grievances Acknowledgement TAT (PG)

% of grievances acknowledged within 5 calendar days of receipt

Macess/Magic (current), Prime (future), ODW

—

DMHC

Compliance

= 100%

CPD-3

A&G

HMO/POS Expedited Appeals Resolution TAT (PG)

% of expedited appeals resolved within 3 calendar days of receipt

Macess/Magic (current), Prime (future), ODW

—

DMHC

Compliance

= 100%

CPD-4

A&G

PPO/EPO Expedited Appeals Resolution TAT

% of expedited appeals resolved within 3 calendar days of receipt

Macess/Magic (current), Prime (future), ODW

CDI

Compliance

= 100%

CPD-5

A&G

PPO/EPO Appeals Resolution TAT

% of non-expedited appeals resolved within 30 calendar days of receipt

Macess/Magic (current), Prime (future), ODW

—

CDI

Compliance

= 100%

CPD-6

A&G

HMO/POS Appeals Resolution TAT (PG)

% of appeals resolved within 30 calendar days of receipt

Macess/Magic (current), Prime (future), ODW

—

DMHC

Compliance

= 100%

▇▇▇-▇

▇&▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Resolution TAT

% of grievances resolved within 15 calendar days of receipt

Macess/Magic (current), Prime (future), ODW

—

CDI

Compliance

= 100%

▇▇▇-▇

▇&▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Resolution TAT (PG)

% of grievances resolved within 30 calendar days of receipt

Macess/Magic (current), Prime (future), ODW

—

DMHC

Compliance

= 100%

CPD-10

A&G

HMO/PPO Member Formal Appeals ACK TAT

within 5 business days

Macess/Magic (current), Prime (future), ODW

—

ADOI

Compliance

= 100%

CPD-11

A&G

HMO/PPO Member Informal Reconsideration ACK & Appeals Packet TAT

within 5 business days

Macess/Magic (current), Prime (future), ODW

—

ADOI

Compliance

= 100%

▇▇▇-▇▇

▇&▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇ ACK TAT

within 5 business days

Macess/Magic (current), Prime (future), ODW

—

ADOI

Compliance

= 100%

CPD-13

A&G

HMO/PPO Post Svc Administrative Appeals Level 1 TAT (co-ins, copay, deduct only)

within 30 calendar days

Macess/Magic (current), Prime (future), ODW

—

DOL

Compliance

= 100%

CPD-14

A&G

HMO/PPO Post Svc Administrative Appeals Level 2 TAT (co-ins, copay, deduct only)

within 30 calendar days

Macess/Magic (current), Prime (future), ODW

—

DOL

Compliance

= 100%

CPD-15

A&G

HMO/PPO Expedited Med Review TAT

within 1 business day

Macess/Magic (current), Prime (future), ODW

ADOI

Compliance

= 100%

▇▇▇-▇▇

▇&▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇ Independent Review TAT (to ADOI)

Fwd within 5 business days

Macess/Magic (current), Prime (future), ODW

ADOI

Compliance

= 100%

CPD-17

A&G

HMO/PPO Expedited External Review TAT (to ADOI)

Fwd within 1 business days

Macess/Magic (current), Prime (future), ODW

ADOI

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
A&G Metrics
Metric Data as of ▇▇▇-▇▇▇▇
▇▇▇-▇	A&G	1	HMO/POS Member Appeals Acknowledgement TAT (PG)	% of appeals acknowledged within 5 calendar days of receipt	457	N/A	98.11%	97.89%	98.00%	99.28%	98.54%	97.95%	98.62%	99.20%	97.36%

CPD-2	A&G	1	HMO/POS Member Grievances Acknowledgement TAT (PG)	% of grievances acknowledged within 5 calendar days of receipt	388	N/A	96.43%	98.89%	98.58%	96.07%	97.31%	96.60%	97.98%	98.79%	98.52%

CPD-3	A&G	1	HMO/POS Expedited Appeals Resolution TAT (PG)	% of expedited appeals resolved within 3 calendar days of receipt	48	N/A	95.71%	100.00%	100.00%	98.28%	98.28%	100.00%	100.00%	94.55%	85.19%

CPD-4	A&G	1	PPO/EPO Expedited Appeals Resolution TAT	% of expedited appeals resolved within 3 calendar days of receipt	11	N/A	90.91%	100.00%	100.00%	100.00%	100.00%	93.75%	91.67%	90.91%	100.00%

CPD-5	A&G	1	PPO/EPO Appeals Resolution TAT	% of non-expedited appeals resolved within 30 calendar days of receipt	334	N/A	99.06%	99.32%	98.56%	97.90%	98.08%	97.72%	97.83%	99.53%	99.57%

CPD-6	A&G	1	HMO/POS Appeals Resolution TAT (PG)	% of appeals resolved within 30 calendar days of receipt	457	N/A	100.00%	99.79%	99.25%	99.76%	98.54%	99.74%	99.77%	100.00%	99.34%

▇▇▇-▇	▇&▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Resolution TAT	% of grievances resolved within 15 calendar days of receipt	132	N/A	97.59%	100.00%	100.00%	98.99%	100.00%	98.85%	100.00%	98.73%	98.46%

▇▇▇-▇	▇&▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Resolution TAT (PG)	% of grievances resolved within 30 calendar days of receipt	388	N/A	99.55%	99.63%	100.00%	98.25%	99.55%	98.72%	98.79%	100.00%	99.51%

CPD-10	A&G	3	HMO/PPO Member Formal Appeals ACK TAT	within 5 business days	26	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-11	A&G	3	HMO/PPO Member Informal Reconsideration ACK & Appeals Packet TAT	within 5 business days	41	N/A	97.06%	100.00%	100.00%	97.44%	93.33%	100.00%	100.00%	100.00%	96.97%

▇▇▇-▇▇	▇&▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇ ACK TAT	within 5 business days	119	N/A	100.00%	100.00%	100.00%	100.00%	97.44%	100.00%	100.00%	97.14%	100.00%

CPD-13	A&G	3	HMO/PPO Post Svc Administrative Appeals Level 1 TAT (co-ins, copay, deduct only)	within 30 calendar days	13	N/A	100.00%	100.00%	96.15%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-14	A&G	3	HMO/PPO Post Svc Administrative Appeals Level 2 TAT (co-ins, copay, deduct only)	within 30 calendar days	15	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	87.50%	87.50%	NULL UNIVERSE	100.00%

CPD-15	A&G	3	HMO/PPO Expedited Med Review TAT	within 1 business day	Null Universe	Null Universe	100.00%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

▇▇▇-▇▇	▇&▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇ Independent Review TAT (to ADOI)	Fwd within 5 business days	Null Universe	Null Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

CPD-17	A&G	3	HMO/PPO Expedited External Review TAT (to ADOI)	Fwd within 1 business days	Null Universe	Null Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE


Schedule B-2-1		B-2-1-2		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO		YELLOW HI		GREEN LO
A&G Metrics
Metric Data as of ▇▇▇-▇▇▇▇
▇▇▇-▇	A&G	1	HMO/POS Member Appeals Acknowledgement TAT (PG)	% of appeals acknowledged within 5 calendar days of receipt	97.54%	99.09%	97.86%	96.06%	94.99		0		0		95

CPD-2	A&G	1	HMO/POS Member Grievances Acknowledgement TAT (PG)	% of grievances acknowledged within 5 calendar days of receipt	94.37%	95.43%	96.94%	97.42%	94.99		0		0		95

CPD-3	A&G	1	HMO/POS Expedited Appeals Resolution TAT (PG)	% of expedited appeals resolved within 3 calendar days of receipt	98.33%	98.08%	100.00%	97.92%	94.99		0		0		95

CPD-4	A&G	1	PPO/EPO Expedited Appeals Resolution TAT	% of expedited appeals resolved within 3 calendar days of receipt	92.31%	86.67%	92.31%	90.91%	94.99		0		0		95

CPD-5	A&G	1	PPO/EPO Appeals Resolution TAT	% of non-expedited appeals resolved within 30 calendar days of receipt	98.09%	100.00%	100.00%	99.40%	94.99		0		0		95

CPD-6	A&G	1	HMO/POS Appeals Resolution TAT (PG)	% of appeals resolved within 30 calendar days of receipt	99.64%	100.00%	98.93%	99.78%	94.99		0		0		95

CPD-7	A&G	1	PPO/EPO Grievances Resolution TAT	% of grievances resolved within 15 calendar days of receipt	99.05%	100.00%	100.00%	100.00%	94.99		0		0		95

CPD-8	A&G	1	HMO/POS Grievances Resolution TAT (PG)	% of grievances resolved within 30 calendar days of receipt	99.57%	99.71%	99.49%	100.00%	94.99		0		0		95

CPD-10	A&G	3	HMO/PPO Member Formal Appeals ACK TAT	within 5 business days	100.00%	100.00%	88.89%	100.00%	94.99		0		0		95

CPD-11	A&G	3	HMO/PPO Member Informal Reconsideration ACK & Appeals Packet TAT	within 5 business days	95.65%	100.00%	100.00%	100.00%	94.99		0		0		95

▇▇▇-▇▇	▇&▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇ ACK TAT	within 5 business days	94.87%	99.20%	100.00%	96.64%	94.99		0		0		95

CPD-13	A&G	3	HMO/PPO Post Svc Administrative Appeals Level 1 TAT (co-ins, copay, deduct only)	within 30 calendar days	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

CPD-14	A&G	3	HMO/PPO Post Svc Administrative Appeals Level 2 TAT (co-ins, copay, deduct only)	within 30 calendar days	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

CPD-15	A&G	3	HMO/PPO Expedited Med Review TAT	within 1 business day	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99		0		0		95

CPD-16	A&G	3	HMO/PPO External Independent Review TAT (to ADOI)	Fwd within 5 business days	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99		0		0		95

CPD-17	A&G	3	HMO/PPO Expedited External Review TAT (to ADOI)	Fwd within 1 business days	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99		0		0		95


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

SHP-19

A&G

Provider Dispute Resolution Acknowledgement Letter TAT (Molina Medi-Cal)

Timeliness is measured from receipt date to letter date. 100%* within 2 working days (for Electronic) and within 15 working days (for Paper). Molina Medi-Cal is in Riverside and San Bernardino counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Macess/Magic (current), Prime (future), ODW

—

DMHC

Compliance

= 100%

CPD-20

A&G

HMO/PPO Member Appeal Post-Svc Resolution TAT

within 30 calendar days

Macess/Magic (current), Prime (future), ODW

—

ADOI

Compliance

= 100%

CPD-21

A&G

HMO/PPO Member Appeal Medical Necessity Resolution TAT

within 15 calendar days

Macess/Magic (current), Prime (future), ODW

—

ADOI

Compliance

= 100%

CPD-22

A&G

HMO/PPO Member Informal Reconsideration / Medical Necessity Resolution TAT

within 15 calendar days

Macess/Magic (current), Prime (future), ODW

ADOI

Compliance

= 100%

▇▇▇-▇▇

▇&▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇ Resolution

within 30 calendar days

Macess/Magic (current), Prime (future), ODW

—

ADOI

Compliance

= 100%

CPD-24

A&G

HMO/PPO Member Informal Reconsideration / Post-Svc Resolution TAT

within 30 calendar days

Macess/Magic (current), Prime (future), ODW

—

ADOI

Compliance

= 100%

CPD-25

A&G

Member Appeals Acknowledgement TAT

% of appeals acknowledged within 7 calendar days of receipt

Prime, ODW

—

OID

Compliance

= 100%

CPD-26

A&G

Member Grievances Acknowledgement TAT

% of grievances acknowledged within 7 calendar days of receipt

Prime, ODW

—

OID

Compliance

= 100%

CPD-27

A&G

Internal Appeals Resolution TAT

% of internal appeals resolved within 30 calendar days or within 45 calendar days, if 15-day extension requested and agreed to by enrollee

Prime, ODW

—

OID

Compliance

= 100%

CPD-28

A&G

Grievances Resolution TAT

% of grievances acknowledged within 30 calendar days or within 45 calendar days if 15-calendar-day extension requested and agreed to by enrollee

Prime, ODW

—

OID

Compliance

= 100%

CPD-29

A&G

Expedited Appeals Resolution TAT

% of expedited appeals resolved within 72 hours of receipt

Prime, ODW

—

OID

Compliance

= 100%

CPD-32

A&G

Routine Appeal for Adverse Determination Resolution TAT

% of routine adverse determination appeals resolved within 14 calendar days or within 30 calendar days with an extension of receipt

Prime, ODW

—

OIC

Compliance

= 100%

CPD-33

A&G

Enrollee Grievances Resolution TAT

% of grievances resolved within 30 calendar days of receipt

Prime, ODW

—

OIC

Compliance

= 100%

CPD-34

A&G

Expedited Appeal for Adverse Determination Resolution TAT

% of expedited adverse determination appeals resolved within 72 hours of receipt

Prime, ODW

OIC

Compliance

= 100%

CPD-36

A&G

Enrollee Appeals for Experimental/ Investigational Treatment Resolution TAT

% of appeals for experimental/investigational treatment resolved within 20 business days of receipt

Prime, ODW

OIC

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
SHP-19	A&G	5	Provider Dispute Resolution Acknowledgement Letter TAT (Molina Medi-Cal)	Timeliness is measured from receipt date to letter date. 100%* within 2 working days (for Electronic) and within 15 working days (for Paper). Molina Medi-Cal is in Riverside and San Bernardino counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	23	N/A	90.91%	100.00%	96.97%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-20	A&G	3	HMO/PPO Member Appeal Post-Svc Resolution TAT	within 30 calendar days	15	N/A	100.00%	100.00%	NULL UNIVERSE	100.00%	100.00%	NULL UNIVERSE	100.00%	100.00%	100.00%

CPD-21	A&G	3	HMO/PPO Member Appeal Medical Necessity Resolution TAT	within 15 calendar days	11	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-22	A&G	3	HMO/PPO Member Informal Reconsideration / Medical Necessity Resolution TAT	within 15 calendar days	13	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇	▇&▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇ Resolution	within 30 calendar days	119	N/A	100.00%	100.00%	100.00%	100.00%	97.44%	100.00%	100.00%	97.14%	100.00%

CPD-24	A&G	3	HMO/PPO Member Informal Reconsideration / Post-Svc Resolution TAT	within 30 calendar days	28	N/A	100.00%	100.00%	100.00%	100.00%	94.74%	100.00%	100.00%	100.00%	95.24%

CPD-25	A&G	2	Member Appeals Acknowledgement TAT	% of appeals acknowledged within 7 calendar days of receipt	49	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	95.45%	96.67%

CPD-26	A&G	2	Member Grievances Acknowledgement TAT	% of grievances acknowledged within 7 calendar days of receipt	12	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	91.67%	100.00%

CPD-27	A&G	2	Internal Appeals Resolution TAT	% of internal appeals resolved within 30 calendar days or within 45 calendar days, if 15-day extension requested and agreed to by enrollee	49	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	90.63%	95.45%	96.67%

CPD-28	A&G	2	Grievances Resolution TAT	% of grievances acknowledged within 30 calendar days or within 45 calendar days if 15-calendar-day extension requested and agreed to by enrollee	12	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	85.71%	100.00%	100.00%	100.00%

CPD-29	A&G	2	Expedited Appeals Resolution TAT	% of expedited appeals resolved within 72 hours of receipt	1	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-32	A&G	2	Routine Appeal for Adverse Determination Resolution TAT	% of routine adverse determination appeals resolved within 14 calendar days or within 30 calendar days with an extension of receipt	5	N/A	100.00%	100.00%	NULL UNIVERSE	100.00%	100.00%	100.00%	NULL UNIVERSE	NULL UNIVERSE	83.33%

CPD-33	A&G	2	Enrollee Grievances Resolution TAT	% of grievances resolved within 30 calendar days of receipt	1	N/A	100.00%	100.00%	100.00%	100.00%	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%	NULL UNIVERSE

CPD-34	A&G	2	Expedited Appeal for Adverse Determination Resolution TAT	% of expedited adverse determination appeals resolved within 72 hours of receipt	Null Universe	Null Universe	0.00%	100.00%	NULL UNIVERSE	NULL UNIVERSE	100.00%	NULL UNIVERSE	100.00%	NULL UNIVERSE	100.00%

CPD-36	A&G	2	Enrollee Appeals for Experimental/ Investigational Treatment Resolution TAT	% of appeals for experimental/investigational treatment resolved within 20 business days of receipt	Null Universe	Null Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%	NULL UNIVERSE


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO		YELLOW HI		GREEN LO
SHP-19	A&G	5	Provider Dispute Resolution Acknowledgement Letter TAT (Molina Medi-Cal)	Timeliness is measured from receipt date to letter date. 100%* within 2 working days (for Electronic) and within 15 working days (for Paper). Molina Medi-Cal is in Riverside and San Bernardino counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

CPD-20	A&G	3	HMO/PPO Member Appeal Post-Svc Resolution TAT	within 30 calendar days	100.00%	100.00%	75.00%	100.00%	94.99		0		0		95

CPD-21	A&G	3	HMO/PPO Member Appeal Medical Necessity Resolution TAT	within 15 calendar days	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

CPD-22	A&G	3	HMO/PPO Member Informal Reconsideration / Medical Necessity Resolution TAT	within 15 calendar days	100.00%	100.00%	93.75%	92.31%	94.99		0		0		95

▇▇▇-▇▇	▇&▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇ Resolution	within 30 calendar days	97.44%	99.20%	100.00%	100.00%	94.99		0		0		95

CPD-24	A&G	3	HMO/PPO Member Informal Reconsideration / Post-Svc Resolution TAT	within 30 calendar days	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

CPD-25	A&G	2	Member Appeals Acknowledgement TAT	% of appeals acknowledged within 7 calendar days of receipt	96.97%	100.00%	100.00%	95.92%	94.99		0		0		95

CPD-26	A&G	2	Member Grievances Acknowledgement TAT	% of grievances acknowledged within 7 calendar days of receipt	100.00%	88.24%	93.75%	100.00%	94.99		0		0		95

CPD-27	A&G	2	Internal Appeals Resolution TAT	% of internal appeals resolved within 30 calendar days or within 45 calendar days, if 15-day extension requested and agreed to by enrollee	100.00%	100.00%	96.55%	100.00%	94.99		0		0		95

CPD-28	A&G	2	Grievances Resolution TAT	% of grievances acknowledged within 30 calendar days or within 45 calendar days if 15-calendar-day extension requested and agreed to by enrollee	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

CPD-29	A&G	2	Expedited Appeals Resolution TAT	% of expedited appeals resolved within 72 hours of receipt	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

CPD-32	A&G	2	Routine Appeal for Adverse Determination Resolution TAT	% of routine adverse determination appeals resolved within 14 calendar days or within 30 calendar days with an extension of receipt	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

CPD-33	A&G	2	Enrollee Grievances Resolution TAT	% of grievances resolved within 30 calendar days of receipt	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

CPD-34	A&G	2	Expedited Appeal for Adverse Determination Resolution TAT	% of expedited adverse determination appeals resolved within 72 hours of receipt	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99		0		0		95

CPD-36	A&G	2	Enrollee Appeals for Experimental/ Investigational Treatment Resolution TAT	% of appeals for experimental/investigational treatment resolved within 20 business days of receipt	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99		0		0		95


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

CPD-37

A&G

TAT to Forward Medical Information for an IMR Regular Review

% of responses no later than the 3rd business day after receipt

Prime, ODW

OIC

Compliance

= 100%

CPD-39

A&G

Member Communications Response TAT (group insurance contracts) - WA

% of responses to enrollee complaints regarding claims within 15 business days of receipt

Prime, ODW

OIC

Compliance

= 100%

▇▇▇-▇▇

▇&▇

▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇
▇▇▇ - ▇▇

% of appeals acknowledged when received

Prime, ODW

—

OIC

Compliance

= 100%

MPD-102

A&G

Standard Part C - Appeals TAT (Oregon)

Written notice must be issued within 30 calendar days of the request for reconsideration for Pre-Service and 60 calendar days for Post-Service appeals - 100% of the time

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-103

A&G

Standard Part C - Appeals TAT (CA)

Written notice must be issued within 30 calendar days of the request for reconsideration for Pre-Service and 60 calendar days for Post-Service appeals - 100% of the time

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-104

A&G

Standard Part C - Appeals TAT (AZ)

Written notice must be issued within 30 calendar days of the request for reconsideration for Pre-Service and 60 calendar days for Post-Service appeals - 100% of the time

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-105

A&G

Expedited Part C - Appeals TAT (Oregon)

Oral notice must be issued within 72 hours and if successful written notice mailed within 3 calendar days. If oral notice is unsuccessful then written notice must be mailed and received by the enrollee within the 72 hour timeframe - 100% of the time

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-106

A&G

Expedited Part C - Appeals TAT (CA)

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-107

A&G

Expedited Part C - Appeals TAT (AZ)

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-108

A&G

IRE - Autoforward Part C - Appeals TAT (Oregon - MA)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time

Macess/Magic (current), Prime (future), ODW

CMS

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
CPD-37	A&G	2	TAT to Forward Medical Information for an IMR Regular Review	% of responses no later than the 3rd business day after receipt	NULL Universe	NULL Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

CPD-39	A&G	2	Member Communications Response TAT (group insurance contracts) - WA	% of responses to enrollee complaints regarding claims within 15 business days of receipt	NULL Universe	NULL Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

CPD-40	A&G	▇	▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇ - ▇▇	% of appeals acknowledged when received	5	N/A	100.00%	100.00%	100.00%	87.50%	100.00%	83.33%	100.00%	100.00%	100.00%

MPD-102	A&G	4	Standard Part C - Appeals TAT (Oregon)	Written notice must be issued within 30 calendar days of the request for reconsideration for Pre-Service and 60 calendar days for Post-Service appeals - 100% of the time	40	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	99.63%	100.00%	100.00%	100.00%

MPD-103	A&G	4	Standard Part C - Appeals TAT (CA)	Written notice must be issued within 30 calendar days of the request for reconsideration for Pre-Service and 60 calendar days for Post-Service appeals - 100% of the time	61	N/A	100.00%	97.89%	100.00%	100.00%	100.00%	100.00%	98.78%	100.00%	98.38%

MPD-104	A&G	4	Standard Part C - Appeals TAT (AZ)	Written notice must be issued within 30 calendar days of the request for reconsideration for Pre-Service and 60 calendar days for Post-Service appeals - 100% of the time	27	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	99.96%	100.00%

MPD-105	A&G	4	Expedited Part C - Appeals TAT (Oregon)	Oral notice must be issued within 72 hours and if successful written notice mailed within 3 calendar days. If oral notice is unsuccessful then written notice must be mailed and received by the enrollee within the 72 hour timeframe - 100% of the time	10	N/A	100.00%	NULL UNIVERSE	100.00%	100.00%	100.00%	100.00%	83.33%	100.00%	100.00%

MPD-106	A&G	4	Expedited Part C - Appeals TAT (CA)	Oral notice must be issued within 72 hours and if successful written notice mailed within 3 calendar days. If oral notice is unsuccessful then written notice must be mailed and received by the enrollee within the 72 hour timeframe - 100% of the time	16	N/A	100.00%	100.00%	100.00%	100.00%	96.55%	100.00%	93.54%	100.00%	92.30%

MPD-107	A&G	4	Expedited Part C - Appeals TAT (AZ)	Oral notice must be issued within 72 hours and if successful written notice mailed within 3 calendar days. If oral notice is unsuccessful then written notice must be mailed and received by the enrollee within the 72 hour timeframe - 100% of the time	2	N/A	100.00%	75.00%	100.00%	100.00%	100.00%	100.00%	83.33%	100.00%	85.71%

MPD-108	A&G	4	IRE - Autoforward Part C - Appeals TAT (Oregon - MA)	Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time	Null Universe	Null Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	100.00%	NULL UNIVERSE	100.00%	100.00%	NULL UNIVERSE	NULL UNIVERSE


Schedule B-2-1		B-2-1-8		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO		YELLOW HI		GREEN LO
CPD-37	A&G	2	TAT to Forward Medical Information for an IMR Regular Review	% of responses no later than the 3rd business day after receipt	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99		0		0		95

CPD-39	A&G	2	Member Communications Response TAT (group insurance contracts) - WA	% of responses to enrollee complaints regarding claims within 15 business days of receipt	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99		0		0		▇▇

▇▇▇-▇▇	▇&▇	▇	▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇ - ▇▇	% of appeals acknowledged when received	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

MPD-102	A&G	4	Standard Part C - Appeals TAT (Oregon)	Written notice must be issued within 30 calendar days of the request for reconsideration for Pre-Service and 60 calendar days for Post-Service appeals - 100% of the time	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

MPD-103	A&G	4	Standard Part C - Appeals TAT (CA)	Written notice must be issued within 30 calendar days of the request for reconsideration for Pre-Service and 60 calendar days for Post-Service appeals - 100% of the time	100.00%	100.00%	100.00%	98.36%	94.99		0		0		95

MPD-104	A&G	4	Standard Part C - Appeals TAT (AZ)	Written notice must be issued within 30 calendar days of the request for reconsideration for Pre-Service and 60 calendar days for Post-Service appeals - 100% of the time	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

MPD-105	A&G	4	Expedited Part C - Appeals TAT (Oregon)	Oral notice must be issued within 72 hours and if successful written notice mailed within 3 calendar days. If oral notice is unsuccessful then written notice must be mailed and received by the enrollee within the 72 hour timeframe - 100% of the time	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

MPD-106	A&G	4	Expedited Part C - Appeals TAT (CA)	Oral notice must be issued within 72 hours and if successful written notice mailed within 3 calendar days. If oral notice is unsuccessful then written notice must be mailed and received by the enrollee within the 72 hour timeframe - 100% of the time	100.00%	100.00%	100.00%	100.00%	94.99		0		0		95

MPD-107	A&G	4	Expedited Part C - Appeals TAT (AZ)	Oral notice must be issued within 72 hours and if successful written notice mailed within 3 calendar days. If oral notice is unsuccessful then written notice must be mailed and received by the enrollee within the 72 hour timeframe - 100% of the time	77.78%	100.00%	100.00%	100.00%	94.99		0		0		95

MPD-108	A&G	4	IRE - Autoforward Part C - Appeals TAT (Oregon - MA)	Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99		0		0		95


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

MPD-109

A&G

IRE - Autoforward Part C - Appeals TAT (CA - MA)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-110

A&G

IRE - Autoforward Part C - Appeals TAT (AZ - MA)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time

Macess/Magic (current), Prime (future), ODW

CMS

Compliance

= 100%

MPD-111

A&G

Standard Part D - Appeals TAT (Oregon)

Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-112

A&G

Standard Part D - Appeals TAT (CA)

Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-113

A&G

Standard Part D - Appeals TAT (AZ)

Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-115

A&G

Expedited Part D - Appeals TAT (Oregon)

Notice may be provided orally or in writing, within 72 hours, for fully favorable (overturn) decisions. For adverse (uphold), or partially adverse (partially uphold) decisions, oral notice may be issued within 72 hours, and if successful, a written notice must be mailed within 3 calendar days of that notification. If oral notification was unsuccessful then the plan must provide written notice within 72 hours of the receipt of request- 100% of the time

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%

MPD-116

A&G

Expedited Part D - Appeals TAT (CA)

Macess/Magic (current), Prime (future), ODW

—

CMS

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
MPD-109	A&G	▇	▇▇▇ - ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇ - ▇▇▇▇▇▇▇ ▇▇▇ (▇▇ - ▇▇)	Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time	1	N/A	NULL UNIVERSE	100.00%	NULL UNIVERSE	NULL UNIVERSE	100.00%	NULL UNIVERSE	100.00%	NULL UNIVERSE	NULL UNIVERSE

MPD-110	A&G	4	IRE - Autoforward Part C - Appeals TAT (AZ - MA)	Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time	Null Universe	Null Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	98.14%	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%	NULL UNIVERSE

MPD-111	A&G	8	Standard Part D - Appeals TAT (Oregon)	Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time	25	N/A	100.00%	100.00%	100.00%	87.50%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-112	A&G	8	Standard Part D - Appeals TAT (CA)	Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time	28	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-113	A&G	8	Standard Part D - Appeals TAT (AZ)	Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time	31	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-115	A&G	8	Expedited Part D - Appeals TAT (Oregon)	Notice may be provided orally or in writing, within 72 hours, for fully favorable (overturn) decisions. For adverse (uphold), or partially adverse (partially uphold) decisions, oral notice may be issued within 72 hours, and if successful, a written notice must be mailed within 3 calendar days of that notification. If oral notification was unsuccessful then the plan must provide written notice within 72 hours of the receipt of request- 100% of the time	6	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	NULL UNIVERSE

MPD-116	A&G	8	Expedited Part D - Appeals TAT (CA)	Notice may be provided orally or in writing, within 72 hours, for fully favorable (overturn) decisions. For adverse (uphold), or partially adverse (partially uphold) decisions, oral notice may be issued within 72 hours, and if successful, a written notice must be mailed within 3 calendar days of that notification. If oral notification was unsuccessful then the plan must provide written notice within 72 hours of the receipt of request- 100% of the time	9	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
MPD-109	A&G	▇	▇▇▇ - ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇ - ▇▇▇▇▇▇▇ ▇▇▇ (▇▇ - ▇▇)	Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	100.00%	94.99	0	0	95

MPD-110	A&G	4	IRE - Autoforward Part C - Appeals TAT (AZ - MA)	Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95

MPD-111	A&G	8	Standard Part D - Appeals TAT (Oregon)	Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time	100.00%	100.00%	96.29%	100.00%	94.99	0	0	95

MPD-112	A&G	8	Standard Part D - Appeals TAT (CA)	Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time	100.00%	96.87%	97.56%	100.00%	94.99	0	0	95

MPD-113	A&G	8	Standard Part D - Appeals TAT (AZ)	Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95

MPD-115	A&G	8	Expedited Part D - Appeals TAT (Oregon)	Notice may be provided orally or in writing, within 72 hours, for fully favorable (overturn) decisions. For adverse (uphold), or partially adverse (partially uphold) decisions, oral notice may be issued within 72 hours, and if successful, a written notice must be mailed within 3 calendar days of that notification. If oral notification was unsuccessful then the plan must provide written notice within 72 hours of the receipt of request - 100% of the time	100.00%	75.00%	100.00%	100.00%	94.99	0	0	95

MPD-116	A&G	8	Expedited Part D - Appeals TAT (CA)	Notice may be provided orally or in writing, within 72 hours, for fully favorable (overturn) decisions. For adverse (uphold), or partially adverse (partially uphold) decisions, oral notice may be issued within 72 hours, and if successful, a written notice must be mailed within 3 calendar days of that notification. If oral notification was unsuccessful then the plan must provide written notice within 72 hours of the receipt of request - 100% of the time	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

MPD-117

A&G

Expedited Part D - Appeals TAT (AZ)

Macess/Magic (current), Prime (future), ODW

•

CMS

Compliance

= 100%

MPD-120

A&G

IRE - Autoforward Part D - Appeals TAT (Oregon - Part D)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe - 100% of the time

Macess/Magic (current), Prime (future), ODW

CMS

Compliance

= 100%

MPD-121

A&G

IRE - Autoforward Part D - Appeals TAT (CA - Part D)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe - 100% of the time

Macess/Magic (current), Prime (future), ODW

CMS

Compliance

= 100%

MPD-122

A&G

IRE - Autoforward Part D - Appeals TAT (AZ - Part D)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe - 100% of the time

Macess/Magic (current), Prime (future), ODW

CMS

Compliance

= 100%

MPD-123

A&G

Standard Part C - Grievances TAT (Oregon)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

Macess/Magic (current), Prime (future), ODW

•

CMS

Compliance

= 100%

MPD-124

A&G

Standard Part C - Grievances TAT (CA)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

Macess/Magic (current), Prime (future), ODW

•

CMS

Compliance

= 100%

MPD-125

A&G

Standard Part C - Grievances TAT (AZ)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

Macess/Magic (current), Prime (future), ODW

•

CMS

Compliance

= 100%

MPD-126

A&G

Expedited Part C - Grievances TAT (Oregon)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Macess/Magic (current), Prime (future), ODW

CMS

Compliance

= 100%

MPD-127

A&G

Expedited Part C - Grievances TAT (CA)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Macess/Magic (current), Prime (future), ODW

CMS

Compliance

= 100%

MPD-128

A&G

Expedited Part C - Grievances TAT (AZ)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Macess/Magic (current), Prime (future), ODW

CMS

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample
Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

MPD-117

A&G

Expedited Part D - Appeals TAT (AZ)

N/A

100.00%

NULL
UNIVERSE

100.00%

100.00

MPD-120

A&G

IRE - Autoforward Part D - Appeals TAT (Oregon - Part D)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe - 100% of the time

Null
Universe

NULL
UNIVERSE

88.88%

NULL
UNIVERSE

MPD-121

A&G

IRE - Autoforward Part D - Appeals TAT (CA - Part D)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe - 100% of the time

Null
Universe

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

MPD-122

A&G

IRE - Autoforward Part D - Appeals TAT (AZ - Part D)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe - 100% of the time

Null
Universe

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

MPD-123

A&G

Standard Part C - Grievances TAT (Oregon)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

N/A

98.41%

100.00%

100.00

MPD-124

A&G

Standard Part C - Grievances TAT (CA)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

295

N/A

98.78%

100.00%

99.66%

100.00%

98.96%

100.00%

100.00

MPD-125

A&G

Standard Part C - Grievances TAT (AZ)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

N/A

95.71%

100.00%

98.28%

100.00%

98.27%

100.00%

100.00

MPD-126

A&G

Expedited Part C - Grievances TAT (Oregon)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Null
Universe

NULL
UNIVERSE

MPD-127

A&G

Expedited Part C - Grievances TAT (CA)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Null
Universe

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

MPD-128

A&G

Expedited Part C - Grievances TAT (AZ)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Null
Universe

NULL
UNIVERSE


Schedule B-2-1		B-2-1-14		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
MPD-117	A&G	8	Expedited Part D - Appeals TAT (AZ)	Notice may be provided orally or in writing, within 72 hours, for fully favorable (overturn) decisions. For adverse (uphold), or partially adverse (partially uphold) decisions, oral notice may be issued within 72 hours, and if successful, a written notice must be mailed within 3 calendar days of that notification. If oral notification was unsuccessful then the plan must provide written notice within 72 hours of the receipt of request - 100% of the time	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95
MPD-120	A&G	8	IRE - Autoforward Part D - Appeals TAT (Oregon - Part D)	Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe - 100% of the time	NULL UNIVERSE	NULL UNIVERSE	100.00%	NULL UNIVERSE	94.99	0	0	95
MPD-121	A&G	8	IRE - Autoforward Part D - Appeals TAT (CA - Part D)	Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe - 100% of the time	NULL UNIVERSE	100.00%	100.00%	NULL UNIVERSE	94.99	0	0	95
MPD-122	A&G	8	IRE - Autoforward Part D - Appeals TAT (AZ - Part D)	Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe - 100% of the time	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95
MPD-123	A&G	4	Standard Part C - Grievances TAT (Oregon)	Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time	100.00%	99.06%	100.00%	100.00%	94.99	0	0	95
MPD-124	A&G	4	Standard Part C - Grievances TAT (CA)	Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time	100.00%	99.65%	100.00%	100.00%	94.99	0	0	95
MPD-125	A&G	4	Standard Part C - Grievances TAT (AZ)	Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95
MPD-126	A&G	4	Expedited Part C - Grievances TAT (Oregon)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95
MPD-127	A&G	4	Expedited Part C - Grievances TAT (CA)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95
MPD-128	A&G	4	Expedited Part C - Grievances TAT (AZ)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement
Tools

Comment

Status

Location

Regulator

Metric
Type

Target

MPD-129

A&G

Standard Part D - Grievances TAT (Oregon)

Written notice must be provided to all concerned parties, as expeditiously as the enrollee’s health condition requires, but no later than 30 calendar days from the date the plan received the request - 100% of the time

Macess/Magic
(current),
Prime
(future),
ODW

•

CMS

Compliance

= 100%

MPD-130

A&G

Standard Part D - Grievances TAT (CA)

Macess/Magic
(current),
Prime
(future),
ODW

•

CMS

Compliance

= 100%

MPD-131

A&G

Standard Part D - Grievances TAT (AZ)

Macess/Magic
(current),
Prime
(future),
ODW

•

CMS

Compliance

= 100%

MPD-133

A&G

Expedited Part D - Grievances TAT (Oregon)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Macess/Magic
(current),
Prime
(future),
ODW

CMS

Compliance

= 100%

MPD-134

A&G

Expedited Part D - Grievances TAT (CA)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Macess/Magic
(current),
Prime
(future),
ODW

CMS

Compliance

= 100%

MPD-135

A&G

Expedited Part D - Grievances TAT (AZ)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Macess/Magic
(current),
Prime
(future),
ODW

CMS

Compliance

= 100%

SHP-136

A&G

Medi-Cal: Expedited Appeals Resolution Rate

within 3 calendar days

Prime,
ODW

DMHC

Compliance

= 100%

SHP-137

A&G

Medi-Cal: Standard Appeals Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%

SHP-138

A&G

Medi-Cal: Expedited Grievances Resolution Rate

within 3 calendar days

Prime,
ODW

•

DMHC

Compliance

= 100%

SHP-139

A&G

Medi-Cal: Standard Grievances Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%

SHP-140

A&G

Medi-Cal: Appeals Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%

SHP-141

A&G

Medi-Cal: Grievance Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
MPD-129	A&G	8	Standard Part D - Grievances TAT (Oregon)	Written notice must be provided to all concerned parties, as expeditiously as the enrollee’s health condition requires, but no later than 30 calendar days from the date the plan received the request - 100% of the time	10	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-130	A&G	8	Standard Part D - Grievances TAT (CA)	Written notice must be provided to all concerned parties, as expeditiously as the enrollee’s health condition requires, but no later than 30 calendar days from the date the plan received the request - 100% of the time	56	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-131	A&G	8	Standard Part D - Grievances TAT (AZ)	Written notice must be provided to all concerned parties, as expeditiously as the enrollee’s health condition requires, but no later than 30 calendar days from the date the plan received the request - 100% of the time	18	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-133	A&G	8	Expedited Part D - Grievances TAT (Oregon)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	Null Universe	Null Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

MPD-134	A&G	8	Expedited Part D - Grievances TAT (CA)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	Null Universe	Null Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

MPD-135	A&G	8	Expedited Part D - Grievances TAT (AZ)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	Null Universe	Null Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

SHP-136	A&G	5	Medi-Cal: Expedited Appeals Resolution Rate	within 3 calendar days	17	N/A	94.44%	90.00%	100.00%	90.00%	100.00%	100.00%	87.50%	91.67%	100.00%

SHP-137	A&G	5	Medi-Cal: Standard Appeals Resolution Rate	Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	63	N/A	100.00%	100.00%	100.00%	97.73%	100.00%	100.00%	100.00%	100.00%	97.44%

SHP-138	A&G	5	Medi-Cal: Expedited Grievances Resolution Rate	within 3 calendar days	79	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	88.89%	88.46%	100.00%

SHP-139	A&G	5	Medi-Cal: Standard Grievances Resolution Rate	Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	275	N/A	100.00%	100.00%	100.00%	100.00%	98.41%	99.51%	100.00%	99.41%	100.00%

SHP-140	A&G	5	Medi-Cal: Appeals Acknowledgement Letters Sent Timely	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	63	N/A	98.08%	100.00%	97.73%	95.45%	100.00%	100.00%	100.00%	100.00%	97.44%

SHP-141	A&G	5	Medi-Cal: Grievance Acknowledgement Letters Sent Timely	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	275	N/A	100.00%	100.00%	100.00%	99.52%	99.47%	99.51%	98.80%	99.41%	97.80%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
MPD-129	A&G	8	Standard Part D - Grievances TAT (Oregon)	Written notice must be provided to all concerned parties, as expeditiously as the enrollee’s health condition requires, but no later than 30 calendar days from the date the plan received the request - 100% of the time	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95

MPD-130	A&G	8	Standard Part D - Grievances TAT (CA)	Written notice must be provided to all concerned parties, as expeditiously as the enrollee’s health condition requires, but no later than 30 calendar days from the date the plan received the request - 100% of the time	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95

MPD-131	A&G	8	Standard Part D - Grievances TAT (AZ)	Written notice must be provided to all concerned parties, as expeditiously as the enrollee’s health condition requires, but no later than 30 calendar days from the date the plan received the request - 100% of the time	87.50%	100.00%	100.00%	100.00%	94.99	0	0	95

MPD-133	A&G	8	Expedited Part D - Grievances TAT (Oregon)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95

MPD-134	A&G	8	Expedited Part D - Grievances TAT (CA)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95

MPD-135	A&G	8	Expedited Part D - Grievances TAT (AZ)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95

SHP-136	A&G	5	Medi-Cal: Expedited Appeals Resolution Rate	within 3 calendar days	100.00%	100.00%	90.91%	88.24%	94.99	0	0	95

SHP-137	A&G	5	Medi-Cal: Standard Appeals Resolution Rate	Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95

SHP-138	A&G	5	Medi-Cal: Expedited Grievances Resolution Rate	within 3 calendar days	97.37%	97.83%	95.16%	96.20%	94.99	0	0	95

SHP-139	A&G	5	Medi-Cal: Standard Grievances Resolution Rate	Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	99.44%	100.00%	99.63%	100.00%	94.99	0	0	95

SHP-140	A&G	5	Medi-Cal: Appeals Acknowledgement Letters Sent Timely	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	100.00%	97.30%	98.57%	98.41%	94.99	0	0	95

SHP-141	A&G	5	Medi-Cal: Grievance Acknowledgement Letters Sent Timely	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	99.44%	98.07%	98.13%	99.27%	94.99	0	0	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement
Tools

Comment

Status

Location

Regulator

Metric
Type

Target

SHP-142

A&G

Cal-Viva: Expedited Appeals Resolution Rate

within 3 calendar days

Prime,
ODW

DMHC

Compliance

= 100%

SHP-143

A&G

Cal-Viva: Standard Appeals Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measure from date of receipt to letter date.

Prime,
ODW

DMHC

Compliance

= 100%

SHP-144

A&G

Cal-Viva: Expedited Grievances Resolution Rate

within 3 calendar days

Prime,
ODW

•

DMHC

Compliance

= 100%

SHP-145

A&G

Cal-Viva: Standard Grievances Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%

SHP-146

A&G

Cal-Viva: Appeals Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

DMHC

Compliance

= 100%

SHP-147

A&G

Cal-Viva: Grievance Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%

DPD-152

A&G

Standard Appeals TAT (Part D Pharmacy- LA)

Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time

Prime,
ODW

LA
COUNTY

CMS,DHCS

Compliance

= 100%

DPD-153

A&G

Standard Appeals TAT (Part D Pharmacy- SD)

Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time

Prime,
ODW

SD
COUNTY

CMS,DHCS

Compliance

= 100%

DPD-154

A&G

Expedited Cal MediConnect - Appeals TAT (CA-LA)

Prime,
ODW

LA
COUNTY

CMS

Compliance

= 100%

DPD-155

A&G

Expedited Cal MediConnect - Appeals TAT (CA-SD)

Prime,
ODW

SD
COUNTY

CMS

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample
Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

SHP-142

A&G

Cal-Viva: Expedited Appeals Resolution Rate

within 3 calendar days

Null
Universe

100.00%

NULL
UNIVERSE

SHP-143

A&G

Cal-Viva: Standard Appeals Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measure from date of receipt to letter date.

N/A

100.00%

SHP-144

A&G

Cal-Viva: Expedited Grievances Resolution Rate

within 3 calendar days

N/A

87.50%

NULL
UNIVERSE

100.00%

SHP-145

A&G

Cal-Viva: Standard Grievances Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

N/A

100.00%

SHP-146

A&G

Cal-Viva: Appeals Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

N/A

100.00%

SHP-147

A&G

Cal-Viva: Grievance Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

N/A

100.00%

93.75%

100.00%

96.67%

DPD-152

A&G

Standard Appeals TAT (Part D Pharmacy- LA)

Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time

Null
Universe

UNDER
DEV

DPD-153

A&G

Standard Appeals TAT (Part D Pharmacy- SD)

Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time

Null
Universe

UNDER
DEV

DPD-154

A&G

Expedited Cal MediConnect - Appeals TAT (CA-LA)

Null
Universe

UNDER
DEV

DPD-155

A&G

Expedited Cal MediConnect - Appeals TAT (CA-SD)

Null
Universe

UNDER
DEV


Schedule B-2-1		B-2-1-20		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
SHP-142	A&G	5	Cal-Viva: Expedited Appeals Resolution Rate	within 3 calendar days	100.00%	100.00%	100.00%	NULL UNIVERSE	94.99	0	0	95

SHP-143	A&G	5	Cal-Viva: Standard Appeals Resolution Rate	Resolution letters are sent within 30 calendar days of receipt. Timeliness is measure from date of receipt to letter date.	100.00%	100.00%	100.00%	94.12%	94.99	0	0	95

SHP-144	A&G	5	Cal-Viva: Expedited Grievances Resolution Rate	within 3 calendar days	75.00%	100.00%	90.00%	100.00%	94.99	0	0	95

SHP-145	A&G	5	Cal-Viva: Standard Grievances Resolution Rate	Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95

SHP-146	A&G	5	Cal-Viva: Appeals Acknowledgement Letters Sent Timely	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	100.00%	100.00%	91.67%	94.12%	94.99	0	0	95

SHP-147	A&G	5	Cal-Viva: Grievance Acknowledgement Letters Sent Timely	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	100.00%	100.00%	100.00%	97.30%	94.99	0	0	95

DPD-152	A&G	7	Standard Appeals TAT (Part D Pharmacy- LA)	Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-153	A&G	7	Standard Appeals TAT (Part D Pharmacy- SD)	Written notice must be provided to the enrollee no later than 7 calendar days from the date the plan received the request - 100% of the time	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-154	A&G	7	Expedited Cal MediConnect - Appeals TAT (CA-LA)	Oral notice must be issued within 72 hours and if successful written notice mailed within 3 calendar days. If oral notice is unsuccessful then written notice must be mailed and received by the enrollee within the 72 hour timeframe - 100% of the time	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-155	A&G	7	Expedited Cal MediConnect - Appeals TAT (CA-SD)	Oral notice must be issued within 72 hours and if successful written notice mailed within 3 calendar days. If oral notice is unsuccessful then written notice must be mailed and received by the enrollee within the 72 hour timeframe - 100% of the time	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

DPD-158

A&G

Expedited Appeals TAT (Part D Pharmacy) (LA)

Prime,
ODW

COUNTY

CMS,DHCS

Compliance

= 100%

DPD-159

A&G

Expedited Appeals TAT (Part D Pharmacy) (SD)

Prime,
ODW

SD
COUNTY

CMS,DHCS

Compliance

= 100%

DPD-160

A&G

IRE Appeals TAT (LA)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time

Prime,
ODW

LA
COUNTY

CMS,DHCS

Compliance

= 100%

CPD-161

A&G

Response to Regulator Inquiry about Claims TAT

% of responses to regulator inquiries about claims within 21 calendar days of receipt

Prime,
ODW

OID

Compliance

= 100%

DPD-161

A&G

IRE Appeals TAT (SD)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time

Prime,
ODW

SD
COUNTY

CMS,DHCS

Compliance

= 100%

CPD-162

A&G

Response to Inquiry from Regulator Regarding a Claim TAT

% of responses submitted to the regulator from an inquiry involving a claim within 15 business days

Prime,
ODW

OIC

Compliance

= 100%

DPD-162

A&G

Appeals Acknowledgement Letters Sent Timely (LA)

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

LA
COUNTY

CMS,DHCS

Compliance

= 100%

DPD-163

A&G

Appeals Acknowledgement Letters Sent Timely (SD)

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

SD
COUNTY

CMS,DHCS

Compliance

= 100%

DPD-166

A&G

Standard Cal MediConnect - Grievances TAT (CA-LA)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

Prime,
ODW

LA
COUNTY

CMS

Compliance

= 100%

DPD-167

A&G

Standard Cal MediConnect - Grievances TAT (CA-SD)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

Prime,
ODW

•

SD
COUNTY

CMS

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

DPD-158

A&G

Expedited Appeals TAT (Part D Pharmacy) (LA)

Null
Universe

UNDER
DEV

DPD-159

A&G

Expedited Appeals TAT (Part D Pharmacy) (SD)

Null
Universe

UNDER
DEV

DPD-160

A&G

IRE Appeals TAT (LA)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time

Null
Universe

UNDER
DEV

CPD-161

A&G

Response to Regulator Inquiry about Claims TAT

% of responses to regulator inquiries about claims within 21 calendar days of receipt

Null
Universe

UNDER
DEV

50.00%

100.00%

DPD-161

A&G

IRE Appeals TAT (SD)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time

Null
Universe

UNDER
DEV

CPD-162

A&G

Response to Inquiry from Regulator Regarding a Claim TAT

% of responses submitted to the regulator from an inquiry involving a claim within 15 business days

Null
Universe

NULL
UNIVERSE

DPD-162

A&G

Appeals Acknowledgement Letters Sent Timely (LA)

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Null
Universe

UNDER
DEV

DPD-163

A&G

Appeals Acknowledgement Letters Sent Timely (SD)

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Null
Universe

UNDER
DEV

DPD-166

A&G

Standard Cal MediConnect - Grievances TAT (CA-LA)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

Null
Universe

UNDER
DEV

DPD-167

A&G

Standard Cal MediConnect - Grievances TAT (CA-SD)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

N/A

UNDER
DEV


Schedule B-2-1		B-2-1-23		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Jan-2014

Feb-2014

Mar-2014

Apr-2014

RED
HI

YELLOW
LO

YELLOW
HI

GREEN
LO

DPD-158

A&G

Expedited Appeals TAT (Part D Pharmacy) (LA)

UNDER
DEV

NULL
UNIVERSE

94.99

DPD-159

A&G

Expedited Appeals TAT (Part D Pharmacy) (SD)

UNDER
DEV

NULL
UNIVERSE

94.99

DPD-160

A&G

IRE Appeals TAT (LA)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time

UNDER
DEV

NULL
UNIVERSE

94.99

CPD-161

A&G

Response to Regulator Inquiry about Claims TAT

% of responses to regulator inquiries about claims within 21 calendar days of receipt

100.00%

NULL
UNIVERSE

94.99

DPD-161

A&G

IRE Appeals TAT (SD)

Standard case is forwarded to IRE within 24 hours of the expiration of the applicable timeframe or when the decision is an ‘Uphold’ or ‘Partial Uphold’ - 100% of the time

UNDER
DEV

NULL
UNIVERSE

94.99

CPD-162

A&G

Response to Inquiry from Regulator Regarding a Claim TAT

% of responses submitted to the regulator from an inquiry involving a claim within 15 business days

NULL
UNIVERSE

NULL

UNIVERSE

NULL
UNIVERSE

94.99

DPD-162

A&G

Appeals Acknowledgement Letters Sent Timely (LA)

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

UNDER
DEV

NULL
UNIVERSE

94.99

DPD-163

A&G

Appeals Acknowledgement Letters Sent Timely (SD)

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

UNDER
DEV

NULL
UNIVERSE

94.99

DPD-166

A&G

Standard Cal MediConnect - Grievances TAT (CA-LA)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

UNDER
DEV

NULL
UNIVERSE

94.99

DPD-167

A&G

Standard Cal MediConnect - Grievances TAT (CA-SD)

Written notice must be provided to all concerned parties no later than 30 calendar days from the date the plan received the request - 100% of the time

UNDER
DEV

100.00%

94.99


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

DPD-170

A&G

Standard Part D - Grievances TAT (CA-LA)

Prime,
ODW

LA
COUNTY

CMS

Compliance

= 100%

DPD-171

A&G

Standard Part D - Grievances TAT (CA-SD)

Prime,
ODW

SD
COUNTY

CMS

Compliance

= 100%

DPD-172

A&G

Expedited Cal MediConnect - Grievances TAT (CA-LA)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Prime,
ODW

LA
COUNTY

CMS

Compliance

= 100%

DPD-173

A&G

Expedited Cal MediConnect - Grievances TAT (CA-SD)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Prime,
ODW

SD
COUNTY

CMS

Compliance

= 100%

DPD-176

A&G

Expedited Grievances TAT (Part D Pharmacy) (LA)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Prime,
ODW

LA
COUNTY

CMS,DHCS

Compliance

= 100%

DPD-177

A&G

Expedited Grievances TAT (Part D Pharmacy) (SD)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Prime,
ODW

SD
COUNTY

CMS,DHCS

Compliance

= 100%

DPD-186

A&G

Grievance Acknowledgement Letters Sent Timely (LA)

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

LA
COUNTY

CMS,DHCS

Compliance

= 100%

DPD-187

A&G

Grievance Acknowledgement Letters Sent Timely (SD)

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

SD
COUNTY

CMS,DHCS

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇▇-▇▇▇ ▇▇▇: Expedited Appeals Resolution Rate

within 3 calendar days

Prime,
ODW

DMHC

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇▇-▇▇▇ ▇▇▇: Standard Appeals Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇▇-▇▇▇ ▇▇▇: Expedited Grievances Resolution Rate

within 3 calendar days

Prime,
ODW

•

DMHC

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇▇-▇▇▇ ▇▇▇: Standard Grievances Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

DPD-170

A&G

Standard Part D - Grievances TAT (CA-LA)

Null
Universe

UNDER
DEV

DPD-171

A&G

Standard Part D - Grievances TAT (CA-SD)

Null
Universe

UNDER
DEV

DPD-172

A&G

Expedited Cal MediConnect - Grievances TAT (CA-LA)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Null
Universe

UNDER
DEV

DPD-173

A&G

Expedited Cal MediConnect - Grievances TAT (CA-SD)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Null
Universe

UNDER
DEV

DPD-176

A&G

Expedited Grievances TAT (Part D Pharmacy) (LA)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Null
Universe

UNDER
DEV

DPD-177

A&G

Expedited Grievances TAT (Part D Pharmacy) (SD)

Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time

Null
Universe

UNDER
DEV

DPD-186

A&G

Grievance Acknowledgement Letters Sent Timely (LA)

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Null
Universe

UNDER
DEV

DPD-187

A&G

Grievance Acknowledgement Letters Sent Timely (SD)

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

N/A

UNDER
DEV

SHP-266

A&G

Medi-Cal SPD: Expedited Appeals Resolution Rate

within 3 calendar days

N/A

NULL
UNIVERSE

NULL

UNIVERSE

100.00%

87.50%

100.00%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇▇-▇▇▇ ▇▇▇: Standard Appeals Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

N/A

100.00%

95.45%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇▇-▇▇▇ ▇▇▇: Expedited Grievances Resolution Rate

within 3 calendar days

N/A

NULL
UNIVERSE

NULL

UNIVERSE

100.00%

90.00%

84.62%

100.00%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇▇-▇▇▇ ▇▇▇: Standard Grievances Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

118

N/A

100.00%

98.96%

100.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
DPD-170	A&G	7	Standard Part D - Grievances TAT (CA- LA)	Written notice must be provided to all concerned parties, as expeditiously as the enrollee’s health condition requires, but no later than 30 calendar days from the date the plan received the request - 100% of the time	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-171	A&G	7	Standard Part D - Grievances TAT (CA- SD)	Written notice must be provided to all concerned parties, as expeditiously as the enrollee’s health condition requires, but no later than 30 calendar days from the date the plan received the request - 100% of the time	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-172	A&G	7	Expedited Cal MediConnect - Grievances TAT (CA-LA)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-173	A&G	7	Expedited Cal MediConnect - Grievances TAT (CA-SD)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-176	A&G	7	Expedited Grievances TAT (Part D Pharmacy) (LA)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-177	A&G	7	Expedited Grievances TAT (Part D Pharmacy) (SD)	Notification either orally or written, when mandated within 24 hours of receipt. 100% of the time	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-186	A&G	7	Grievance Acknowledgement Letters Sent Timely (LA)	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-187	A&G	7	Grievance Acknowledgement Letters Sent Timely (SD)	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	UNDER DEV	UNDER DEV	UNDER DEV	100.00%	94.99	0	0	95

SHP-266	A&G	5	Medi-Cal SPD: Expedited Appeals Resolution Rate	within 3 calendar days	100.00%	100.00%	100.00%	81.82%	94.99	0	0	95

SHP-267	A&G	5	Medi-Cal SPD: Standard Appeals Resolution Rate	Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	100.00%	100.00%	100.00%	97.30%	94.99	0	0	95

SHP-268	A&G	5	Medi-Cal SPD: Expedited Grievances Resolution Rate	within 3 calendar days	100.00%	95.24%	96.43%	100.00%	94.99	0	0	95

SHP-269	A&G	5	Medi-Cal SPD: Standard Grievances Resolution Rate	Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	98.57%	100.00%	100.00%	100.00%	94.99	0	0	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

SHP-270

A&G

Medi-Cal SPD: Appeals Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇▇-▇▇▇ ▇▇▇: Grievance Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Expedited Appeals Resolution Rate

within 3 calendar days

Prime,
ODW

DMHC

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Standard Appeals Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measure from date of receipt to letter date.

Prime,
ODW

DMHC

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Expedited Grievances Resolution Rate

within 3 calendar days

Prime,
ODW

•

DMHC

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Standard Grievances Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

•

DMHC

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Appeals Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

DMHC

Compliance

= 100%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Grievance Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

Prime,
ODW

DMHC

Compliance

= 100%

SHP-382

A&G

Member Appeal Acknowledgment Letter TAT (Standard)

Contractor shall acknowledge receipt of standard appeals in writing within 5 business days of receipt

SHP
database
(current),
Prime
(future),
ODW

•

AHCCCS

Compliance

= 100%

SHP-383

A&G

Member Appeal Acknowledgment Letter TAT (Expedited)

Contractor shall acknowledge receipt of expedited appeals with 1 business day of receipt.

SHP
database
(current),
Prime
(future),
ODW

•

AHCCCS

Compliance

= 100%

SHP-384

A&G

Member Appeal TAT (Expedited Denial Notice)

If the Contractor denies a request for expedited resolution, it must transfer the appeal to the 30-day timeframe for a standard appeal. The Contractor must make reasonable efforts to give the enrollee prompt oral notice and follow-up within 2 days with a written notice of the denial of expedited resolution.

SHP
database
(current),
Prime
(future),
ODW

AHCCCS

Compliance

= 100%

SHP-385

A&G

Member Appeal Resolution TAT (Standard)

Contractor shall resolve standard appeals no later than 30 days from the date of receipt of the appeal unless an extension is in effect.

SHP
database
(current),
Prime
(future),
ODW

•

AHCCCS

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇▇-▇▇▇ ▇▇▇: Appeals Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

N/A

96.97%

100.00%

96.30%

100.00%

95.45%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇▇-▇▇▇ ▇▇▇: Grievance Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

118

N/A

100.00%

98.96%

100.00%

96.47%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Expedited Appeals Resolution Rate

within 3 calendar days

Null
Universe

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Standard Appeals Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measure from date of receipt to letter date.

N/A

100.00%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Expedited Grievances Resolution Rate

within 3 calendar days

N/A

NULL
UNIVERSE

100.00%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Standard Grievances Resolution Rate

Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

N/A

100.00%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Appeals Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

N/A

100.00%

▇▇▇-▇▇▇

▇&▇

▇

▇▇▇-▇▇▇▇ ▇▇▇: Grievance Acknowledgement Letters Sent Timely

Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.

N/A

100.00%

84.62%

100.00%

SHP-382

A&G

Member Appeal Acknowledgment Letter TAT (Standard)

Contractor shall acknowledge receipt of standard appeals in writing within 5 business days of receipt

N/A

NULL
UNIVERSE

100.00%

SHP-383

A&G

Member Appeal Acknowledgment Letter TAT (Expedited)

Contractor shall acknowledge receipt of expedited appeals with 1 business day of receipt.

N/A

NULL
UNIVERSE

SHP-384

A&G

Member Appeal TAT (Expedited Denial Notice)

Null
Universe

NULL
UNIVERSE

SHP-385

A&G

Member Appeal Resolution TAT (Standard)

Contractor shall resolve standard appeals no later than 30 days from the date of receipt of the appeal unless an extension is in effect.

N/A

NULL
UNIVERSE


Schedule B-2-1		B-2-1-29		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
SHP-270	A&G	5	Medi-Cal SPD: Appeals Acknowledgement Letters Sent Timely	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95

SHP-271	A&G	5	Medi-Cal SPD: Grievance Acknowledgement Letters Sent Timely	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	98.57%	98.88%	97.22%	100.00%	94.99	0	0	95

SHP-272	A&G	5	Cal-Viva SPD: Expedited Appeals Resolution Rate	within 3 calendar days	100.00%	100.00%	100.00%	NULL UNIVERSE	94.99	0	0	95

SHP-273	A&G	5	Cal-Viva SPD: Standard Appeals Resolution Rate	Resolution letters are sent within 30 calendar days of receipt. Timeliness is measure from date of receipt to letter date.	100.00%	100.00%	100.00%	83.33%	94.99	0	0	95

SHP-274	A&G	5	Cal-Viva SPD: Expedited Grievances Resolution Rate	within 3 calendar days	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95

SHP-275	A&G	5	Cal-Viva SPD: Standard Grievances Resolution Rate	Resolution letters are sent within 30 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	100.00%	100.00%	100.00%	100.00%	94.99	0	0	95

SHP-276	A&G	5	Cal-Viva SPD: Appeals Acknowledgement Letters Sent Timely	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	100.00%	100.00%	80.00%	83.33%	94.99	0	0	95

SHP-277	A&G	5	Cal-Viva SPD: Grievance Acknowledgement Letters Sent Timely	Acknowledgement letters are sent within 5 calendar days of receipt. Timeliness is measured from date of receipt to letter date.	100.00%	100.00%	100.00%	92.31%	94.99	0	0	95

SHP-382	A&G	6	Member Appeal Acknowledgment Letter TAT (Standard)	Contractor shall acknowledge receipt of standard appeals in writing within 5 business days of receipt	100.00%	100.00%	NULL UNIVERSE	100.00%	94.99	95	96.99	97

SHP-383	A&G	6	Member Appeal Acknowledgment Letter TAT (Expedited)	Contractor shall acknowledge receipt of expedited appeals with 1 business day of receipt.	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%	94.99	95	96.99	97

SHP-384	A&G	6	Member Appeal TAT (Expedited Denial Notice)	If the Contractor denies a request for expedited resolution, it must transfer the appeal to the 30-day timeframe for a standard appeal. The Contractor must make reasonable efforts to give the enrollee prompt oral notice and follow-up within 2 days with a written notice of the denial of expedited resolution.	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	95	96.99	97

SHP-385	A&G	6	Member Appeal Resolution TAT (Standard)	Contractor shall resolve standard appeals no later than 30 days from the date of receipt of the appeal unless an extension is in effect.	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	100.00%	94.99	95	96.99	97


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement
Tools

Comment

Status

Location

Regulator

Metric
Type

Target

SHP-386

A&G

Member Appeal Resolution TAT (Expedited)

Contractor shall resolve all expedited appeals no later than 3 business days from the date the Contractor receives the appeal unless an extension is in effect.

SHP database
(current), Prime
(future), ODW

•

AHCCCS

Compliance

= 100%

SHP-387

A&G

Member Grievance Resolution TAT

Contractor must resolve each grievance within 10 business days of receipt. No grievances shall exceed 90 days for resolution

SHP database
(current), Prime
(future), ODW

•

AHCCCS

Compliance

= 100%

SHP-388

A&G

Member State Fair Hearing TAT

Request for State Fair Hearings are forwarded within 5 days of receipt

SHP database
(current), Prime
(future), ODW

AHCCCS

Compliance

= 100%

CPD-685

A&G

PPO/EPO Appeals Notification TAT

% of non-expedited appeals with letters sent within 15 calendar days of receipt if appeal not resolved at that time (to include known facts regarding the specific case)

Macess/Magic
(current), Prime
(future), ODW

CDI

Compliance

= 100%

Customer Call Center Metrics

Metric Data as of Apr-2014

SHP-130

Customer Call Center Abandonment Rate (Medi-Cal)

Call abandonment rate of less than or equal to 5%. (Medi-cal without CalViva).

Aspect ACD,
database

•

DMHC

Compliance

<= 5%

SHP-131

Customer Call Center Abandonment Rate (CalViva)

Call abandonment rate of less than or equal to 5%.

Aspect ACD,
database

•

DMHC

Compliance

<= 5%

SHP-133

Customer Call Center Service Level Rate (Medi-Cal)

Service level greater than or equal to 80% of phone calls answered by a recorded voice within 30 seconds. (Medi-cal without CalViva)

Aspect ACD,
database

DMHC

Compliance

>= 80%

SHP-134

Customer Call Center Service Level Rate (CalViva)

Service level greater than or equal to 80% of phone calls answered by a recorded voice within 30 seconds.

Aspect ACD,
database

•

DMHC

Compliance

>= 80%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ (▇▇)

Ratio of calls abandoned to calls offered

Aspect ACD,
database

LA
COUNTY

CMS,
DHCS

Compliance

<= 5%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ (SD)

Ratio of calls abandoned to calls offered

Aspect ACD,
database

•

SD
COUNTY

CMS,
DHCS

Compliance

<= 5%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ (▇▇)

Percentage of calls answered in 30 seconds or less

Aspect ACD,
database

LA
COUNTY

CMS,
DHCS

Compliance

= 80%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ (SD)

Percentage of calls answered in 30 seconds or less

Aspect ACD,
database

•

SD
COUNTY

CMS,
DHCS

Compliance

= 80%

DPD-142

Wait to Speak to Live Rep (LA)

Hold time <2 mins (average)

Aspect ACD,
database

LA
COUNTY

CMS,
DHCS

Compliance

>= 95%

DPD-143

Wait to Speak to Live Rep (SD)

Hold time <2 mins (average)

Aspect ACD,
database

SD
COUNTY

CMS,
DHCS

Compliance

>= 95%

SHP-163

CalViva Medi-Cal Call Center Wait to Speak to Live Rep

non recorded voice within 10 mins

Aspect ACD,
database

DHCS

Compliance

>= 95%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ Speed to Answer Calls

% of calls answered within 10 minutes

Aspect ACD,
database

DMHC

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

SHP-386

A&G

Member Appeal Resolution TAT (Expedited)

Contractor shall resolve all expedited appeals no later than 3 business days from the date the Contractor receives the appeal unless an extension is in effect.

N/A

NULL
UNIVERSE

SHP-387

A&G

Member Grievance Resolution TAT

Contractor must resolve each grievance within 10 business days of receipt. No grievances shall exceed 90 days for resolution

N/A

NULL
UNIVERSE

100.00%

SHP-388

A&G

Member State Fair Hearing TAT

Request for State Fair Hearings are forwarded within 5 days of receipt

Null
Universe

NULL
UNIVERSE

CPD-685

A&G

PPO/EPO Appeals Notification TAT

% of non-expedited appeals with letters sent within 15 calendar days of receipt if appeal not resolved at that time (to include known facts regarding the specific case)

103

N/A

UNDER
DEV

98.76%

99.14%

97.50%

Customer Call Center Metrics

Metric Data as of Apr-2014

SHP-130

Customer Call Center Abandonment Rate (Medi-Cal)

Call abandonment rate of less than or equal to 5%. (Medi-cal without CalViva).

75220

N/A

3.11%

3.14%

2.39%

2.52%

4.00%

2.99%

3.60%

NULL
UNIVERSE

11.89%

SHP-131

Customer Call Center Abandonment Rate (CalViva)

Call abandonment rate of less than or equal to 5%.

8857

N/A

4.09%

4.43%

4.33%

4.38%

4.96%

3.67%

5.34%

NULL
UNIVERSE

3.48%

SHP-133

Customer Call Center Service Level Rate (Medi-Cal)

Service level greater than or equal to 80% of phone calls answered by a recorded voice within 30 seconds. (Medi-cal without CalViva)

75220

N/A

85.49%

84.23%

88.36%

87.15%

79.23%

80.75%

80.36%

NULL
UNIVERSE

70.63%

SHP-134

Customer Call Center Service Level Rate (CalViva)

Service level greater than or equal to 80% of phone calls answered by a recorded voice within 30 seconds.

8857

N/A

92.07%

92.48%

92.61%

90.52%

89.54%

93.96%

87.57%

NULL
UNIVERSE

85.69%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ (▇▇)

Ratio of calls abandoned to calls offered

Null
Universe

UNDER
DEV

DPD-139

Abandonment Trend (SD)

Ratio of calls abandoned to calls offered

443

N/A

UNDER
DEV

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ (▇▇)

Percentage of calls answered in 30 seconds or less

Null
Universe

UNDER
DEV

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ (SD)

Percentage of calls answered in 30 seconds or less

443

N/A

UNDER
DEV

DPD-142

Wait to Speak to Live Rep (LA)

Hold time <2 mins (average)

Null
Universe

UNDER
DEV

DPD-143

Wait to Speak to Live Rep (SD)

Hold time <2 mins (average)

N/A

UNDER
DEV

SHP-163

CalViva Medi-Cal Call Center Wait to Speak to Live Rep

non recorded voice within 10 mins

Null
Universe

99.57%

99.47%

99.92%

99.00%

98.14%

97.97%

97.02%

NULL
UNIVERSE

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ Speed to Answer Calls

% of calls answered within 10 minutes

Null
Universe

96.52%

97.41%

93.83%

94.99%

97.09%

98.12%

94.48%

95.65%

90.48%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
SHP-386	A&G	6	Member Appeal Resolution TAT (Expedited)	Contractor shall resolve all expedited appeals no later than 3 business days from the date the Contractor receives the appeal unless an extension is in effect.	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%	94.99	95	96.99	97

SHP-387	A&G	6	Member Grievance Resolution TAT	Contractor must resolve each grievance within 10 business days of receipt. No grievances shall exceed 90 days for resolution	100.00%	100.00%	100.00%	100.00%	94.99	95	96.99	97

SHP-388	A&G	6	Member State Fair Hearing TAT	Request for State Fair Hearings are forwarded within 5 days of receipt	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	95	96.99	97

CPD-685	A&G	1	PPO/EPO Appeals Notification TAT	% of non-expedited appeals with letters sent within 15 calendar days of receipt if appeal not resolved at that time (to include known facts regarding the specific case)	89.29%	89.19%	89.61%	93.20%	94.99	0	0	95

Customer Call Center Metrics Metric Data as of Apr-2014

SHP-130	CC	5	Customer Call Center Abandonment Rate (Medi-Cal)	Call abandonment rate of less than or equal to 5%. (Medi-cal without CalViva).	14.50%	8.95%	10.03%	3.82%	4.99	0	0	5

SHP-131	CC	5	Customer Call Center Abandonment Rate (CalViva)	Call abandonment rate of less than or equal to 5%.	2.26%	1.52%	1.77%	0.89%	4.99	0	0	5

SHP-133	CC	5	Customer Call Center Service Level Rate (Medi-Cal)	Service level greater than or equal to 80% of phone calls answered by a recorded voice within 30 seconds. (Medi-cal without CalViva)	63.86%	63.62%	51.33%	75.44%	79.99	0	0	80

SHP-134	CC	5	Customer Call Center Service Level Rate (CalViva)	Service level greater than or equal to 80% of phone calls answered by a recorded voice within 30 seconds.	87.89%	90.77%	88.18%	93.03%	79.99	0	0	▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ (▇▇)	Ratio of calls abandoned to calls offered	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	5.1	0	0	5

DPD-139	CC	7	Abandonment Trend (SD)	Ratio of calls abandoned to calls offered	UNDER DEV	UNDER DEV	UNDER DEV	1.35%	5.1	0	0	▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ (▇▇)	Percentage of calls answered in 30 seconds or less	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	79.99	0	0	▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ (SD)	Percentage of calls answered in 30 seconds or less	UNDER DEV	UNDER DEV	UNDER DEV	87.13%	79.99	0	0	80

DPD-142	CC	7	Wait to Speak to Live Rep (LA)	Hold time <2 mins (average)	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	94.99	0	0	95

DPD-143	CC	7	Wait to Speak to Live Rep (SD)	Hold time <2 mins (average)	UNDER DEV	UNDER DEV	UNDER DEV	N/A	94.99	0	0	95

SHP-163	CC	5	CalViva Medi-Cal Call Center Wait to Speak to Live Rep	non recorded voice within 10 mins	84.83%	NULL UNIVERSE	NULL UNIVERSE	UNIVERSE NULL	94.99	0	0	95

CPD-167	CC	1	HMO/POS Speed to Answer Calls	% of calls answered within 10 minutes	91.62%	89.60%	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

SHP-223

Medi-Cal Call Center Wait to Speak to Live Rep

Non recorded voice within 10 mins

Aspect ACD, database

DHCS

Compliance

>= 95%

MPD-230

Abandonment Trend - Medicare CA Member

Ratio of calls abandoned to calls offered

Aspect ACD, database

—

CMS

Compliance

<= 5%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ - Medicare OR Member

Ratio of calls abandoned to calls offered

Aspect ACD, database

—

CMS

Compliance

<= 5%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ - ▇▇▇▇▇▇▇▇ ▇▇ Member

Ratio of calls abandoned to calls offered

Aspect ACD, database

—

CMS

Compliance

<= 5%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ - ▇▇▇▇▇▇▇▇ ▇▇ Member

Percentage of calls answered in 30 seconds or less

Aspect ACD, database

—

CMS

Compliance

= 80%

MPD-240

Service Level Trend - Medicare OR Member

Percentage of calls answered in 30 seconds or less

Aspect ACD, database

—

CMS

Compliance

= 80%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ - ▇▇▇▇▇▇▇▇ ▇▇ Member

Percentage of calls answered in 30 seconds or less

Aspect ACD, database

CMS

Compliance

= 80%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Dispute - Acknowledgment Letter TAT

Claim disputes are acknowledged in writing and within 5 business days of receipt.

NOTE- This metric is transitioning under the Claims tower. Removing from CCC tower.

—

AHCCCS

Compliance

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Dispute - Resolution TAT

Contractor’s Notice of Decision shall be mailed to all parties no later than 30 days after the provider files a claim dispute with the Contractor.

NOTE- This metric is transitioning under the Claims tower. Removing from CCC tower.

—

AHCCCS

Compliance

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Disputes - Overturned (Adjustments) TAT

If the claim dispute is overturned, in full or in part, the Contractor shall reprocess and pay the claim(s) in a manner consistent with the decision within 15 business days of the date of the Decision.

NOTE- This metric is transitioning under the Claims tower. Removing from CCC tower.

—

AHCCCS

Compliance

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Disputes - Request for State Fair Hearing TAT

Contractor must ensure that all supporting documentation is received by the AHCCCS Office of Administrative Legal Services (OALS), no later than 5 business days from the date the Contractor receives the provider’s written hearing request.

NOTE- This metric is transitioning under the Claims tower. Removing from CCC tower.

AHCCCS

Compliance

= 100%

SHP-389

Customer Call Center - Average Speed of Answer (ASOA)

The ASOA must be 45 seconds or less.

Aspect ACD, database

—

AHCCCS

Compliance

< = 45
Seconds

SHP-390

Customer Call Center - Monthly Average Abandnment Rate (MAAR)

The MAAR must be 5% or less. This is determined by the number of calls abandoned in a 24-hour period, divided by the total number of calls received in the same 24-hour period, summed for each day of the month and then divided by the number of days in the monthly reporting period.

Aspect ACD, database

—

AHCCCS

Compliance

< = 5%

SHP-391

Customer Call Center - Monthly First Contact Call Resolution Rate (MFCCCR)

The MFCCR must be 70% or better. This is the sum of the Daily FCCRs divided by the number of days in the reporting period.

Macess, Omni, ODW

—

AHCCCS

Compliance

> = 70%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample
Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

SHP-223

Medi-Cal Call Center Wait to Speak to Live Rep

Non recorded voice within 10 mins

Null
Universe

98.35%

98.45%

98.52%

98.14%

96.42%

96.08%

93.84%

NULL
UNIVERSE

MPD-230

Abandonment Trend - Medicare CA Member

Ratio of calls abandoned to calls offered

34479

N/A

1.45%

1.09%

1.72%

2.34%

2.63%

4.81%

18.53%

6.72%

8.52%

MPD-231

Abandonment Trend - Medicare OR Member

Ratio of calls abandoned to calls offered

11013

N/A

1.74%

2.83%

2.13%

4.65%

4.08%

2.82%

5.74%

4.51%

10.79%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇ - ▇▇▇▇▇▇▇▇ ▇▇ Member

Ratio of calls abandoned to calls offered

14020

N/A

2.81%

2.99%

3.14%

3.80%

3.61%

3.04%

6.44%

6.70%

7.65%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ - ▇▇▇▇▇▇▇▇ ▇▇ Member

Percentage of calls answered in 30 seconds or less

34479

N/A

82.12%

84.06%

83.56%

81.51%

81.68%

73.66%

31.67%

68.22%

68.89%

MPD-240

Service Level Trend - Medicare OR Member

Percentage of calls answered in 30 seconds or less

11013

N/A

86.94%

88.62%

84.02%

78.24%

85.63%

79.43%

66.67%

75.12%

62.51%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇ - ▇▇▇▇▇▇▇▇ ▇▇ Member

Percentage of calls answered in 30 seconds or less

14020

N/A

83.46%

84.28%

81.79%

76.11%

76.67%

80.39%

64.76%

65.53%

61.60%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Dispute - Acknowledgment Letter TAT

Claim disputes are acknowledged in writing and within 5 business days of receipt.

N/A

UNDER
DEV

NULL
UNIVERSE

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Dispute - Resolution TAT

Contractor’s Notice of Decision shall be mailed to all parties no later than 30 days after the provider files a claim dispute with the Contractor.

N/A

UNDER
DEV

NULL
UNIVERSE

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Disputes - Overturned (Adjustments) TAT

N/A

UNDER
DEV

NULL
UNIVERSE

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ Disputes - Request for State Fair Hearing TAT

Null
Universe

UNDER
DEV

NULL
UNIVERSE

SHP-389

Customer Call Center - Average Speed of Answer (ASOA)

The ASOA must be 45 seconds or less.

11855

N/A

NULL
UNIVERSE

23.00

10.00

26.00

SHP-390

Customer Call Center - Monthly Average Abandnment Rate (MAAR)

11855

N/A

NULL
UNIVERSE

3.04%

1.62%

2.11%

SHP-391

Customer Call Center - Monthly First Contact Call Resolution Rate (MFCCCR)

The MFCCR must be 70 % or better. This is the sum of the Daily FCCRs divided by the number of days in the reporting period.

13032

N/A

NULL
UNIVERSE

96.99%

97.02%

96.99%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
SHP-223	CC	5	Medi-Cal Call Center Wait to Speak to Live Rep	Non recorded voice within 10 mins	85.86%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95

MPD-230	CC	4	Abandonment Trend - Medicare CA Member	Ratio of calls abandoned to calls offered	16.01%	5.81%	6.57%	3.03%	4.99	0	0	5

MPD-231	CC	4	Abandonment Trend - Medicare OR Member	Ratio of calls abandoned to calls offered	10.49%	4.19%	4.34%	1.72%	4.99	0	0	5

MPD-233	CC	4	Abandonment Trend - Medicare AZ Member	Ratio of calls abandoned to calls offered	14.40%	9.13%	4.57%	1.89%	4.99	0	0	5

MPD-239	CC	4	Service Level Trend - Medicare CA Member	Percentage of calls answered in 30 seconds or less	54.09%	80.46%	67.43%	81.04%	79.99	0	0	80

MPD-240	CC	4	Service Level Trend - Medicare OR Member	Percentage of calls answered in 30 seconds or less	49.34%	80.34%	72.09%	81.50%	79.99	0	0	80

MPD-242	CC	4	Service Level Trend - Medicare AZ Member	Percentage of calls answered in 30 seconds or less	54.42%	79.31%	69.26%	77.08%	79.99	0	0	80

SHP-369	CC	6	Provider Claims Dispute - Acknowledgment Letter TAT	Claim disputes are acknowledged in writing and within 5 business days of receipt.	NULL UNIVERSE	100.00%	100.00%	97.30%	94.99	95	96.99	97

SHP-370	CC	6	Provider Claims Dispute - Resolution TAT	Contractor’s Notice of Decision shall be mailed to all parties no later than 30 days after the provider files a claim dispute with the Contractor.	NULL UNIVERSE	NULL UNIVERSE	100.00%	97.56%	94.99	95	96.99	97

SHP-371	CC	6	Provider Claims Disputes - Overturned (Adjustments) TAT	If the claim dispute is overturned, in full or in part, the Contractor shall reprocess and pay the claim(s) in a manner consistent with the decision within 15 business days of the date of the Decision.	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%	94.99	95	96.99	97

SHP-372	CC	6	Provider Claims Disputes - Request for State Fair Hearing TAT	Contractor must ensure that all supporting documentation is received by the AHCCCS Office of Administrative Legal Services (OALS), no later than 5 business days from the date the Contractor receives the provider’s written hearing request.	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	95	96.99	97

SHP-389	CC	6	Customer Call Center - Average Speed of Answer (ASOA)	The ASOA must be 45 seconds or less.	NULL UNIVERSE	NULL UNIVERSE	20.00	LAG MONTH	45.01	0	0	45

SHP-390	CC	6	Customer Call Center - Monthly Average Abandnment Rate (MAAR)	The MAAR must be 5% or less. This is determined by the number of calls abandoned in a 24-hour period, divided by the total number of calls received in the same 24-hour period, summed for each day of the month and then divided by the number of days in the monthly reporting period.	NULL UNIVERSE	NULL UNIVERSE	2.91%	LAG MONTH	4.99	0	0	5

SHP-391	CC	6	Customer Call Center - Monthly First Contact Call Resolution Rate (MFCCCR)	The MFCCR must be 70 % or better. This is the sum of the Daily FCCRs divided by the number of days in the reporting period.	NULL UNIVERSE	NULL UNIVERSE	95.20%	LAG MONTH	69.99	0	0	70


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

SHP-392

Customer Call Center - Monthly Average Service Level (MASL)

MASL must be 75 % or better. The total of the month?s calls answered within 45 seconds divided by the sum of the following: all calls answered in the month, all calls abandoned calls in the month and all calls receiving a busy signal in the month

Aspect ACD, database

—

AHCCCS

Compliance

> = 75%

CPD-655

TAT of Member Continuation of Coverage form request.

Upon member request, continuation of coverage form must be mailed to member within two business days.

Macess, Omni, ODW

OID

Compliance

= 100%

MPD

Average Speed to Answer-Medicare CA Member

Average speed in which a call is answered

Aspect ACD, database

New
SLA

CMS

Compliance

2 minutes

MPD

Average Speed to Answer-Medicare OR Member

Average speed in which a call is answered

Aspect ACD, database

New
SLA

CMS

Compliance

2 minutes

MPD

Average Speed to Answer-Medicare AZ Member

Average speed in which a call is answered

Aspect ACD, database

New
SLA

CMS

Compliance

2 minutes

CPD

Exempt Grievance (MHN)

Case resolved within one business day

Symposium

New
SLA

DMHC

Compliance

100.00%

CPD

Complete Provider Group Rollouts and notifications within 30 days for PCP’s and 60 days for PPG’s Complete Provider Rollouts and notifications (MediCal) within 30 days Complete Hospital Termination notifications 60 days prior to the termination effective date

The percentage of rollouts, member notifications completed within appropriate timeframes 30/60 days

Qcare, HNCS, Omni,
Page Center

New
SLA

DMHC,
CDI

Compliance

100.00%

▇▇▇

▇▇

▇

▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ Group Rollouts and notifications within 30 days for PCP’s and 60 days for PPG’s Complete Provider Rollouts and notifications (MediCal) within 30 days Complete Hospital Termination notifications 60 days prior to the termination effective date

The percentage of rollouts, member notifications completed within appropriate timeframes 30/60 days

Qcare, HNCS, Omni,
Page Center

New
SLA

DHCS

Compliance

100.00%

CPD

Respond to DMHC calls after hours within 60 minutes

Percentage of calls responded to within 60 minutes

Macess, Omni, ODW

New
SLA

DMHC

Compliance

100.00%

CPD

Respond to DMHC calls during business hours within 30 minutes

Percentage of calls responded to within 30 minutes

Macess, Omni, ODW

New
SLA

DMHC

Compliance

100.00%

CPD

After hours post stabilization

Percentage of calls responded to within 30 minutes

Macess, Omni, ODW

New
SLA

DMHC

Compliance

100.00%

CPD

Provide a member cost estimate within 1 BD

Percentage of cost estimates completed in ▇ ▇▇

▇▇▇▇▇▇, ▇▇▇▇, ▇▇▇

New
SLA

OID

Complance

100.00%

CPD

Oregon continuation form requests to portability members within 2 business days

Percentage of requests completed within 2 business days

Macess, Omni, ODW

New
SLA

OID

Compliance

100.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

SHP-392

Customer Call Center - Monthly Average Service Level (MASL)

11855

N/A

NULL

UNIVERSE

NULL

UNIVERSE

NULL

UNIVERSE

NULL

UNIVERSE

NULL

UNIVERSE

NULL
UNIVERSE

89.68%

96.22%

90.75%

CPD-655

TAT of Member Continuation of Coverage form request.

Upon member request, continuation of coverage form must be mailed to member within two business days.

Null
Universe

NULL
UNIVERSE

MPD

Average Speed to Answer - Medicare CA Member

Average speed in which a call is answered

N/a

MPD

Average Speed to Answer - Medicare OR Member

Average speed in which a call is answered

N/a

MPD

Average Speed to Answer - Medicare AZ Member

Average speed in which a call is answered

N/a

CPD

Exempt Grievance (MHN)

Case resolved within one business day

N/a

CPD

The percentage of rollouts, member notifications completed within appropriate timeframes 30/60 days

▇▇▇

▇▇

▇

The percentage of rollouts, member notifications completed within appropriate timeframes 30/60 days

CPD

Respond to DMHC calls after hours within 60 minutes

Percentage of calls responded to within 60 minutes

CPD

Respond to DMHC calls during business hours within 30 minutes

Percentage of calls responded to within 30 minutes

CPD

After hours post stabilization

Percentage of calls responded to within 30 minutes

CPD

Provide a member cost estimate within 1 BD

Percentage of cost estimates completed in 1 BD

CPD

Oregon continuation form requests to portability members within 2 business days

Percentage of requests completed within 2 business days


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
SHP-392	CC	6	Customer Call Center - Monthly Average Service Level (MASL)	MASL must be 75 % or better. The total of the month?s calls answered within 45 seconds divided by the sum of the following: all calls answered in the month, all calls abandoned calls in the month and all calls receiving a busy signal in the month	NULL UNIVERSE	NULL UNIVERSE	89.00%	LAG MONTH	74.99	0	0	75

CPD-655	CC	2	TAT of Member Continuation of Coverage form request.	Upon member request, continuation of coverage form must be mailed to member within two business days.	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	0	0	95

MPD	CC	4	Average Speed to Answer- Medicare CA Member	Average speed in which a call is answered					2.01	0	0	2

MPD	CC	4	Average Speed to Answer- Medicare OR Member	Average speed in which a call is answered					2.01	0	0	2

MPD	CC	4	Average Speed to Answer- Medicare AZ Member	Average speed in which a call is answered					2.01	0	0	2

CPD	CC	1	Exempt Grievance (MHN)	Case resolved within one business day					99.99	0	0	100

CPD	CC	1	Complete Provider Group Rollouts and notifications within 30 days for PCP’s and 60 days for PPG’s Complete Provider Rollouts and notifications (MediCal) within 30 days Complete Hospital Termination notifications 60 days prior to the termination effective date	The percentage of rollouts, member notifications completed within appropriate timeframes 30/60 days					99.99	0	0	100

SHP	CC	5	Complete Provider Group Rollouts and notifications within 30 days for PCP’s and 60 days for PPG’s Complete Provider Rollouts and notifications (MediCal) within 30 days Complete Hospital Termination notifications 60 days prior to the termination effective date	The percentage of rollouts, member notifications completed within appropriate timeframes 30/60 days					99.99	0	0	100

CPD	CC	1	Respond to DMHC calls after hours within 60 minutes	Percentage of calls responded to within 60 minutes					99.99	0	0	100

CPD	CC	1	Respond to DMHC calls during business hours within 30 minutes	Percentage of calls responded to within 30 minutes					99.99	0	0	100

CPD	CC	1	After hours post stabilization	Percentage of calls responded to within 30 minutes					99.99	0	0	100

CPD	CC	2	Provide a member cost estimate within 1 BD	Percentage of cost estimates completed in 1 BD					99.99	0	0	100

CPD	CC	2	Oregon continuation form requests to portability members within 2 business days	Percentage of requests completed within 2 business days					99.99	0	0	100


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

SHP

Silver Link Welcome Calls

Welcome calls must be done within the same month the member became active. The purpose of the call is to advise them to make apt with doctor for IHA (initial health assessment) within 90 days of being enrolled.

Qcare, HNCS, Omni,
Page Center

New
SLA

ALL

DHCS,
AHCCCS

Compliance

100.00%

Claims Metrics

Metric Data as of Apr-2014

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇ Acknowledgement TAT

Average speed in which a call is answered

Qcare, HNCS, Omni,
Page Center

—

CDI

Compliance

=100%

CPD-101

Claims

Interest on Clean Claims Paid Late

Interest shall be calculated beginning on the date that the payment to the health care provider is due

Quality Audit and
Training (Monthly)

—

ADOI

Compliance

100%

CPD-102

Claims

HMO/PPO Correct Claim Determination-Non-contracted Emergent Svcs

% of non-contracted emergent services NOT denied for lack of prior authorization

Quality Audit and
Training (Monthly)

—

ADOI

Compliance

100%

CPD-103

Claims

HMO/PPO Correct Claim Determination-Non-contracted Ambulance Svcs

% of non-contracted emergency ambulance services NOT denied for lack of prior authorization

Quality Audit and
Training (Monthly)

—

ADOI

Compliance

100%

CPD-104

Claims

‘Clean’ New Day Claims Resolution TAT (PG)

% of clean new day claims resolved within 30 calendar days

ABS -Monthly
Adhoc Report

—

OID

Compliance

100%

CPD-106

Claims

Initial Notification Regarding ‘Unclean’ New Day Claims TAT

% of notices sent for ‘unclean’ new day claims requesting additional information within 30 calendar days

ABS - Monthly
Adhoc Report

OID

Compliance

100%

CPD-107

Claims

Claims Interest Payment Accuracy

% of claims requiring interest that include accurate interest payment

Quality Audit and
Training (Monthly)

—

OID

Compliance

100%

CPD-109

Claims

Claims Correct Date of Receipt Recorded

% of claims with accurate date of receipt recorded in system

Quality Audit and
Training (Monthly)

—

OID

Compliance

100%

CPD-111

Claims

New Day Claims TAT (for contracted providers ONLY) (PG)

% of ‘clean’ new day claims resolved within 30 calendar days of receipt

ABS - Monthly
Adhoc Report

—

OIC

Compliance

>= 95%

CPD-112

Claims

‘Unclean’ New Day Claims TAT (for contracted providers ONLY) (PG)

% of ALL claims resolved within 60 calendar days of receipt

ABS - Monthly
Adhoc Report

OIC

Compliance

>= 95%

CPD-113

Claims

WA Interest Payment Accuracy

Accurate interest payment starting day 61 after the date of receipt

Quality Audit and
Training (Monthly)

OIC

Compliance

100%

CPD-115

Claims

Claims Acknowledgement TAT (under group insurance contracts)

% of claims acknowledged within 15 business days of receipt

ABS - Monthly
Adhoc Report

—

OIC

Compliance

100%

CPD-116

Claims

Record Correct Date of Claims Receipt

% of claims recorded with accurate date of receipt

Quality Audit and
Training (Monthly)

OIC

Compliance

100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
SHP	CC	5	Silver Link Welcome Calls	Welcome calls must be done within the same month the member became active. The purpose of the call is to advise them to make apt with doctor for IHA (initial health assessment) within 90 days of being enrolled.

Claims Metrics Metric Data as of Apr-2014

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Acknowledgement TAT	Average speed in which a call is answered	2798	N/A	98.99%	99.00%	99.99%	99.10%	99.00%	99.00%	99.00%	99.00%	99.00%

CPD-101	Claims	3	Interest on Clean Claims Paid Late	Interest shall be calculated beginning on the date that the payment to the health care provider is due	1656	25	100.00%	100.00%	100.00%	100.00%	84.00%	100.00%	100.00%	100.00%	100.00%

CPD-102	Claims	3	HMO/PPO Correct Claim Determination- Non-contracted Emergent Svcs	% of non-contracted emergent services NOT denied for lack of prior authorization	1883	N/A	100.00%	100.00%	100.00%	99.94%	98.82%	99.75%	99.81%	99.78%	99.90%

CPD-103	Claims	3	HMO/PPO Correct Claim Determination- Non-contracted Ambulance Svcs	% of non-contracted emergency ambulance services NOT denied for lack of prior authorization	1883	N/A	100.00%	100.00%	100.00%	99.94%	99.53%	100.00%	100.00%	100.00%	100.00%

CPD-104	Claims	2	‘Clean’ New Day Claims Resolution TAT (PG)	% of clean new day claims resolved within 30 calendar days	41976	N/A	98.40%	99.30%	99.40%	99.70%	99.60%	99.60%	99.80%	99.90%	99.70%

CPD-106	Claims	2	Initial Notification Regarding ‘Unclean’ New Day Claims TAT	% of notices sent for ‘unclean’ new day claims requesting additional information within 30 calendar days	106	N/A	98.15%	100.00%	99.49%	98.97%	98.72%	97.25%	98.00%	96.84%	94.29%

CPD-107	Claims	2	Claims Interest Payment Accuracy	% of claims requiring interest that include accurate interest payment	219	25	84.21%	100.00%	100.00%	100.00%	100.00%	94.44%	100.00%	75.00%	100.00%

CPD-109	Claims	2	Claims Correct Date of Receipt Recorded	% of claims with accurate date of receipt recorded in system	219	25	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-111	Claims	2	New Day Claims TAT (for contracted providers ONLY) (PG)	% of ‘clean’ new day claims resolved within 30 calendar days of receipt	1029	N/A	99.60%	99.90%	99.40%	100.00%	99.40%	99.90%	99.90%	99.80%	99.90%

CPD-112	Claims	2	‘Unclean’ New Day Claims TAT (for contracted providers ONLY) (PG)	% of ALL claims resolved within 60 calendar days of receipt	Null Universe	Null Universe	99.40%	100.00%	100.00%	100.00%	100.00%	99.50%	100.00%	100.00%	100.00%

CPD-113	Claims	2	WA Interest Payment Accuracy	Accurate interest payment starting day 61 after the date of receipt	Null Universe	Null Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

CPD-115	Claims	2	Claims Acknowledgement TAT (under group insurance contracts)	% of claims acknowledged within 15 business days of receipt	6369	N/A	95.52%	99.40%	99.67%	99.50%	99.40%	99.40%	99.40%	98.99%	99.50%

CPD-116	Claims	2	Record Correct Date of Claims Receipt	% of claims recorded with accurate date of receipt	Null Universe	Null Universe	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE


Schedule B-2-1		B-2-1-41		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI		YELLOW LO		YELLOW HI		GREEN LO
SHP	CC	5	Silver Link Welcome Calls	Welcome calls must be done within the same month the member became active. The purpose of the call is to advise them to make apt with doctor for IHA (initial health assessment) within 90 days of being enrolled.						99.99				0		0 100

Claims Metrics
Metric Data as of Apr-2014

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Acknowledgement TAT	Average speed in which a call is answered	99.00%	99.00%	99.00%	100%		89.99		90		94.99		95

CPD-101	Claims	3	Interest on Clean Claims Paid Late	Interest shall be calculated beginning on the date that the payment to the health care provider is due	100.00%	100.00%	96.00%	LAG MONTH		89.99		90		94.99		95

CPD-102	Claims	3	HMO/PPO Correct Claim Determination- Non-contracted Emergent Svcs	% of non-contracted emergent services NOT denied for lack of prior authorization	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		95

CPD-103	Claims	3	HMO/PPO Correct Claim Determination- Non-contracted Ambulance Svcs	% of non-contracted emergency ambulance services NOT denied for lack of prior authorization	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		95

CPD-104	Claims	2	‘Clean’ New Day Claims Resolution TAT (PG)	% of clean new day claims resolved within 30 calendar days	99.70%	99.03%	98.61%	98.80%		89.99		90		94.99		95

CPD-106	Claims	2	Initial Notification Regarding ‘Unclean’ New Day Claims TAT	% of notices sent for ‘unclean’ new day claims requesting additional information within 30 calendar days	96.26%	97.62%	96.88%	93.20%		89.99		90		94.99		95

CPD-107	Claims	2	Claims Interest Payment Accuracy	% of claims requiring interest that include accurate interest payment	100.00%	100.00%	100.00%	LAG MONTH		89.99		90		94.99		95

CPD-109	Claims	2	Claims Correct Date of Receipt Recorded	% of claims with accurate date of receipt recorded in system	100.00%	100.00%	100.00%	LAG MONTH		89.99		90		94.99		95

CPD-111	Claims	2	New Day Claims TAT (for contracted providers ONLY) (PG)	% of ‘clean’ new day claims resolved within 30 calendar days of receipt	99.50%	97.80%	98.50%	98.40%		94.99		0		0		95

CPD-112	Claims	2	‘Unclean’ New Day Claims TAT (for contracted providers ONLY) (PG)	% of ALL claims resolved within 60 calendar days of receipt	100.00%	100.00%	100.00%	NULL UNIVERSE		94.99		0		0		95

CPD-113	Claims	2	WA Interest Payment Accuracy	Accurate interest payment starting day 61 after the date of receipt	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	LAG MONTH		89.99		90		94.99		95

CPD-115	Claims	2	Claims Acknowledgement TAT (under group insurance contracts)	% of claims acknowledged within 15 business days of receipt	98.40%	98.40%	99.80%	LAG MONTH		89.99		90		94.99		95

CPD-116	Claims	2	Record Correct Date of Claims Receipt	% of claims recorded with accurate date of receipt	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	LAG MONTH		89.99		90		94.99		95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

CPD-117

Claims

Provider Claims Dispute Resolution TAT (PG)

% of provider claims disputes resolved within 30 calendar days of receipt

ABS - Monthly
Adhoc Report

—

OIC

Compliance

100%

CPD-664

Claims

HIPAA Eligibility Verification Real Time 20 second Rule

Real Time (Core Rule 156) 270/271 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.

Monthly Reports
from both HN IT
and our
Clearing Houses.

—

ALL

HHS

Compliance

=> 90%

CPD-665

Claims

HIPAA Claims Status Real Time 20 Second Response Time Rule

Real Time (Core Rule 156) 276/277 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.

Monthly Reports
from both HN IT
and our Clearing
Houses.

—

ALL

HHS

Compliance

=> 90%

CPD-666

Claims

Eligibility Verification System Availability 86% Rule

Core Rule 157 Eligibility and Benefits System Availability Rule: Real Time Transaction 270/271 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 270 inquiry and returning a response. Calendar week is defined as 12:01 am Sunday to 12:01 am the following Sunday.

Monthly Reports
from both HN IT
and our Clearing
Houses.

—

ALL

HHS

Compliance

=> 86%

▇▇▇-▇▇▇

▇▇▇▇▇▇

▇

▇▇▇▇▇▇ ▇▇▇▇▇▇ System Availability 86% Rule

Core Rule 250 Claims status rule (276/277) refers to Core Rule 157 for system availability requirements. Real Time Transaction 276/277 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 276 inquiry and returning a 277 response. Calendar week is defined as 12:01 am Sunday to 12:01 am the following Sunday

Monthly Reports
from both HN IT
and our Clearing
Houses.

—

ALL

HHS

Compliance

=> 86%

CPD-691

Claims

PPO/EPO Initial Notification Regarding Contested New Day Claims TAT

% of notices sent for contested new day claims requesting additional information within 30 working days of receipt

ABS - Monthly
Adhoc Report

—

CDI

Compliance

100%

CPD-708

Claims

HMO/PPO Clean Claims - Contracted/Non-contracted processed TAT

% of clean claims processed within 30 calendar days

ABS - Monthly
Adhoc Report

—

ADOI

Compliance

100%

CPD-709

Claims

HMO/PPO Clean Claims - Contracted/Non-contracted paid TAT

% of clean claims paid within 30 calendar days of processed date

ABS - Monthly
Adhoc Report

—

ADOI

Compliance

100%


Schedule B-2-1		B-2-1-43		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
CPD-117	Claims	2	Provider Claims Dispute Resolution TAT (PG)	% of provider claims disputes resolved within 30 calendar days of receipt	7	N/A	91.67%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	90.90%

CPD-664	Claims	1	HIPAA Eligibility Verification Real Time 20 second Rule	Real Time (Core Rule 156) 270/271 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.	887875	N/A	97.60%	100.00%	98.19%	98.39%	97.04%	98.57%	97.65%	99.28%	93.15%

CPD-665	Claims	1	HIPAA Claims Status Real Time 20 Second Response Time Rule	Real Time (Core Rule 156) 276/277 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.	38179	N/A	100.00%	100.00%	100.00%	98.48%	99.28%	93.66%	98.06%	99.90%	69.48%

CPD-666	Claims	1	Eligibility Verification System Availability 86% Rule	Core Rule 157 Eligibility and Benefits System Availability Rule: Real Time Transaction 270/271 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 270 inquiry and returning a response. Calendar week is defined as 12:01 am Sunday to 12:01 am the following Sunday.	972127	N/A	99.00%	96.00%	99.00%	99.00%	96.00%	97.00%	99.00%	98.00%	98.00%

▇▇▇-▇▇▇	▇▇▇▇▇▇	▇	▇▇▇▇▇▇ ▇▇▇▇▇▇ System Availability 86% Rule	Core Rule 250 Claims status rule (276/277) refers to Core Rule 157 for system availability requirements. Real Time Transaction 276/277 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 276 inquiry and returning a 277 response. Calendar week is defined as 12:01 am Sunday to 12:01 am the following Sunday	34932	N/A	N/A	98.00%	99.00%	100.00%	98.00%	99.00%	100.00%	100.00%	100.00%

CPD-691	Claims	1	PPO/EPO Initial Notification Regarding Contested New Day Claims TAT	% of notices sent for contested new day claims requesting additional information within 30 working days of receipt	1088	N/A	94.06%	95.67%	95.91%	93.95%	92.79%	91.60%	89.98%	90.19%	82.37%

CPD-708	Claims	3	HMO/PPO Clean Claims - Contracted/Non-contracted processed TAT	% of clean claims processed within 30 calendar days	113989	N/A	97.05%	98.12%	98.52%	98.64%	98.76%	98.43%	98.08%	96.62%	97.41%

CPD-709	Claims	3	HMO/PPO Clean Claims - Contracted/Non-contracted paid TAT	% of clean claims paid within 30 calendar days of processed date	101925	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
CPD-117	Claims	2	Provider Claims Dispute Resolution TAT (PG)	% of provider claims disputes resolved within 30 calendar days of receipt	87.50%	100.00%	100.00%	100.00%	89.99	90	94.99	95

CPD-664	Claims	1	HIPAA Eligibility Verification Real Time 20 second Rule	Real Time (Core Rule 156) 270/271 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.	98.26%	98.43%	99.22%	98.46%	89.99	0	0	89.99

CPD-665	Claims	1	HIPAA Claims Status Real Time 20 Second Response Time Rule	Real Time (Core Rule 156) 276/277 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.	97.00%	99.35%	99.97%	98.35%	89.99	0	0	89.99

CPD-666	Claims	1	Eligibility Verification System Availability 86% Rule	Core Rule 157 Eligibility and Benefits System Availability Rule: Real Time Transaction 270/271 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 270 inquiry and returning a response. Calendar week is defined as 12:01 am Sunday to 12:01 am the following Sunday.	99.00%	98.00%	99.00%	99.00%	85.99	0	0	85.99

CPD-667	Claims	1	Claims Status System Availability 86% Rule	Core Rule 250 Claims status rule (276/277) refers to Core Rule 157 for system availability requirements. Real Time Transaction 276/277 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 276 inquiry and returning a 277 response. Calendar week is defined as 12:01 am Sunday to 12:01 am the following Sunday	99.00%	98.00%	99.00%	99.00%	85.99	0	0	85.99

CPD-691	Claims	1	PPO/EPO Initial Notification Regarding Contested New Day Claims TAT	% of notices sent for contested new day claims requesting additional information within 30 working days of receipt	73.22%	96.64%	89.99%	96.21%	89.99	90	94.99	95

CPD-708	Claims	3	HMO/PPO Clean Claims - Contracted/Non-contracted processed TAT	% of clean claims processed within 30 calendar days	98.23%	98.23%	98.19%	98.70%	89.99	90	94.99	95

CPD-709	Claims	3	HMO/PPO Clean Claims - Contracted/Non-contracted paid TAT	% of clean claims paid within 30 calendar days of processed date	100.00%	100.00%	100.00%	100.00%	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

CPD-711

Claims

90% Reassociation EFT & ERA within 3 days

Core Rule 370 A health plan must release for transmission to the healthcare provider the v5010 X12 835 corresponding to the Healthcare EFT Standards: No sooner than three business days, prior to the Effective Entry Date, and No later than three business days after the Effective Entry Date, 90% of the time as measured within a calendar month.

Monthly Reports
from both HN
IT and our
Clearing
Houses.

—

ALL

HHS

Compliance

>= 90%

CPD-74

Claims

HMO/POS New Day Claims Resolution TAT (PG)

% of new day claims resolved within 45 business days of receipt

ABS - Monthly
Adhoc Report

—

DMHC

Compliance

100%

CPD-75

Claims

PPO/EPO New Day Claims TAT (PG)

% of new day claims resolved within 30 working days of receipt

ABS - Monthly
Adhoc Report

—

CDI

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇ to Forward Claims to Delegated Entity

% of claims forwarded to delegated entity within 10 business days of receipt

ABS - Monthly
Adhoc Report

DMHC

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇ Payment Accuracy

% interest and penalties paid accurately when due

Quality Audit
and Training
(Monthly)

—

DMHC

Compliance

100%

CPD-78

Claims

PPO/EPO Interest & Penalty Payment Accuracy

% of claims paid requiring interest and penalties paid accurately

Quality Audit
and Training
(Monthly)

—

CDI

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇ Acknowledgement TAT - Electronic Claims/Paper Claims

% of electronic claims acknowledged within 2 business days of receipt and paper claims acknowledged within 15 business days of receipt

ABS - Monthly
Adhoc Report

—

DMHC

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇ Acknowledgement TAT

% of claims acknowledged within 15 calendar days

ABS - Monthly
Adhoc Report

—

CDI

Compliance

100%

CPD-82

Claims

HMO/POS Provider Dispute Resolution (PDR) TAT

% of PDRs resolved within 45 business days of receipt

ABS - Monthly
Adhoc Report

—

DMHC

Compliance

100%

CPD-83

Claims

PPO/EPO Provider Dispute Resolution (PDR) TAT

% of PDRs resolved within 45 business days of receipt

ABS - Monthly
Adhoc Report

—

CDI

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇ Acknowledgement TAT - Electronic/Paper

% of electronic PDRs acknowledged within 2 business days of receipt and paper PDRs acknowledged within 15 business days of receipt

ABS - Monthly
Adhoc Report

—

DMHC

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇ Paid Date TAT after Determination

% of PDRs paid within 5 business days of determination

ABS - Monthly
Adhoc Report

—

DMHC

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇ Reimbursement Accuracy

% of PDRs paid accurately, including interest & penalties

Quality Audit
and Training
(Monthly)

—

DMHC

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇ Correct Date of Receipt

% of PDRs with accurate date of receipt recorded in system

Quality Audit
and Training
(Monthly)

—

DMHC

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇ Determination Letter Sent to Provider with Dispute Determination Reason

% of time determination letter is sent to provider and/or dispute determination is included within the letter

Quality Audit
and Training
(Monthly)

—

DMHC

Compliance

100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
CPD-711	Claims	1	90% Reassociation EFT & ERA within 3 days	Core Rule 370 A health plan must release for transmission to the healthcare provider the v5010 X12 835 corresponding to the Healthcare EFT Standards: No sooner than three business days, prior to the Effective Entry Date, and No later than three business days after the Effective Entry Date, 90% of the time as measured within a calendar month.	70339	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A

CPD-74	Claims	1	HMO/POS New Day Claims Resolution TAT (PG)	% of new day claims resolved within 45 business days of receipt	700821	N/A	99.95%	100.00%	99.92%	97.56%	99.95%	99.99%	99.34%	99.69%	99.77%

CPD-75	Claims	1	PPO/EPO New Day Claims TAT (PG)	% of new day claims resolved within 30 working days of receipt	118084	N/A	98.60%	99.48%	97.26%	97.29%	97.13%	96.22%	98.07%	97.94%	95.30%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ to Forward Claims to Delegated Entity	% of claims forwarded to delegated entity within 10 business days of receipt	40303	N/A	95.40%	95.38%	95.57%	95.69%	95.01%	92.16%	93.44%	93.77%	93.70%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇ Payment Accuracy	% interest and penalties paid accurately when due	59	25	100.00%	100.00%	100.00%	100.00%	92.00%	100.00%	100.00%	100.00%	96.00%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇ & ▇▇▇▇▇▇▇ Payment Accuracy	% of claims paid requiring interest and penalties paid accurately	129	25	100.00%	96.00%	100.00%	100.00%	98.00%	92.00%	100.00%	95.65%	100.00%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇ Acknowledgement TAT - Electronic Claims/Paper Claims	% of electronic claims acknowledged within 2 business days of receipt and paper claims acknowledged within 15 business days of receipt	251	150	98.00%	99.33%	100.00%	100.00%	98.67%	100.00%	100.00%	100.00%	99.33%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇ Acknowledgement TAT	% of claims acknowledged within 15 calendar days	251	150	98.00%	99.33%	100.00%	100.00%	98.67%	100.00%	100.00%	100.00%	99.33%

CPD-82	Claims	1	HMO/POS Provider Dispute Resolution (PDR) TAT	% of PDRs resolved within 45 business days of receipt	3980	N/A	97.13%	96.57%	98.06%	96.83%	97.74%	98.64%	99.37%	98.87%	98.75%

CPD-83	Claims	1	PPO/EPO Provider Dispute Resolution (PDR) TAT	% of PDRs resolved within 45 business days of receipt	2043	N/A	97.20%	96.56%	98.12%	97.03%	99.03%	99.30%	99.44%	99.75%	99.44%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Acknowledgement TAT - Electronic/Paper	% of electronic PDRs acknowledged within 2 business days of receipt and paper PDRs acknowledged within 15 business days of receipt	251	150	98.00%	99.33%	100.00%	100.00%	98.67%	100.00%	100.00%	100.00%	99.33%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Paid Date TAT after Determination	% of PDRs paid within 5 business days of determination	2635	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Reimbursement Accuracy	% of PDRs paid accurately, including interest & penalties	251	150	97.33%	98.67%	98.67%	97.33%	99.33%	98.67%	99.33%	99.33%	98.00%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Correct Date of Receipt	% of PDRs with accurate date of receipt recorded in system	251	150	100.00%	98.67%	100.00%	100.00%	99.33%	99.33%	99.33%	99.33%	99.33%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Determination Letter Sent to Provider with Dispute Determination Reason	% of time determination letter is sent to provider and/or dispute determination is included within the letter	251	150	100.00%	98.67%	100.00%	100.00%	100.00%	100.00%	99.33%	100.00%	99.33%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
CPD-711	Claims	1	90% Reassociation EFT & ERA within 3 days	Core Rule 370 A health plan must release for transmission to the healthcare provider the v5010 X12 835 corresponding to the Healthcare EFT Standards: No sooner than three business days, prior to the Effective Entry Date, and No later than three business days after the Effective Entry Date, 90% of the time as measured within a calendar month.	93.00%	97.41%	99.38%	99.93%	89.99	0	0	89.99

CPD-74	Claims	1	HMO/POS New Day Claims Resolution TAT (PG)	% of new day claims resolved within 45 business days of receipt	99.80%	99.90%	99.90%	LAG MONTH	89.99	90	94.99	95

CPD-75	Claims	1	PPO/EPO New Day Claims TAT (PG)	% of new day claims resolved within 30 working days of receipt	99.00%	96.16%	96.95%	97.29%	89.99	90	94.99	95

CPD-76	Claims	1	HMO/POS TAT to Forward Claims to Delegated Entity	% of claims forwarded to delegated entity within 10 business days of receipt	96.42%	94.84%	95.60%	94.04%	89.99	90	94.99	95

CPD-77	Claims	1	HMO/POS Interest Payment Accuracy	% interest and penalties paid accurately when due	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

CPD-78	Claims	1	PPO/EPO Interest & Penalty Payment Accuracy	% of claims paid requiring interest and penalties paid accurately	100.00%	100.00%	96.00%	LAG MONTH	89.99	90	94.99	95

CPD-79	Claims	1	HMO/POS Claim Acknowledgement TAT - Electronic Claims/Paper Claims	% of electronic claims acknowledged within 2 business days of receipt and paper claims acknowledged within 15 business days of receipt	100.00%	99.33%	99.33%	LAG MONTH	89.99	90	94.99	95

CPD-81	Claims	1	PPO/EPO Claim Acknowledgement TAT	% of claims acknowledged within 15 calendar days	100.00%	99.33%	99.33%	LAG MONTH	89.99	90	94.99	95

CPD-82	Claims	1	HMO/POS Provider Dispute Resolution (PDR) TAT	% of PDRs resolved within 45 business days of receipt	96.35%	99.35%	99.00%	98.00%	89.99	90	94.99	95

CPD-83	Claims	1	PPO/EPO Provider Dispute Resolution (PDR) TAT	% of PDRs resolved within 45 business days of receipt	99.61%	99.34%	99.00%	96.80%	89.99	90	94.99	95

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Acknowledgement TAT - Electronic/Paper	% of electronic PDRs acknowledged within 2 business days of receipt and paper PDRs acknowledged within 15 business days of receipt	100.00%	99.33%	99.33%	LAG MONTH	89.99	90	94.99	95

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Paid Date TAT after Determination	% of PDRs paid within 5 business days of determination	100.00%	100.00%	100.00%	100.00%	89.99	90	94.99	95

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Reimbursement Accuracy	% of PDRs paid accurately, including interest & penalties	96.67%	98.67%	99.33%	LAG MONTH	89.99	90	94.99	95

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Correct Date of Receipt	% of PDRs with accurate date of receipt recorded in system	100.00%	99.33%	99.33%	LAG MONTH	89.99	90	94.99	95

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇ Determination Letter Sent to Provider with Dispute Determination Reason	% of time determination letter is sent to provider and/or dispute determination is included within the letter	100.00%	99.33%	100.00%	LAG MONTH	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇ Denial Accuracy

% of denied claims that are denied accurately

Quality Audit and
Training (Monthly)

—

DMHC

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇ Correct Date of Receipt

% claims dates of receipt recorded accurately in the system

Quality Audit and
Training (Monthly)

—

DMHC

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇ Explanation for Denials

% of denial letters with a clear explanation of denial reason

Quality Audit and
Training (Monthly)

—

DMHC

Compliance

100%

CPD-96

Claims

HMO/PPO Provider Grievance TAT

within 30 business days

ABS - Monthly
Adhoc Report

—

ADOI

Compliance

100%

CPD-97

Claims

HMO/PPO Provider Grievance Type Coding

HN must categorize each grievance it receives into one of eleven grievance types listed in Attachment A of Regulatory Bulletin 2006-2

ABS - Monthly
Adhoc Report

—

ADOI

Compliance

100%

CPD-99

Claims

HMO/PPO Request for additional information for Unclean Claims TAT

% of written requests for additional information on unclean claims to the contracted/noncontracted provided, enrollee or third party within thirty days of receipt.

ABS - Monthly
Adhoc Report

—

ADOI

Compliance

100%

CPD

Claims

Provider Acknowledgement Letter TAT (Self Funded ERISA)

Acknowledgement letters are sent within 15 business days of receipt.

Macess/Magic,
Prime, ODW

All

DOL

Compliance

=100%

CPD

Claims

Provider Appeal Resolution TAT (Self Funded)

Contractor shall resolve all standards appeals no later than 45 business days days from the date the Contractor receives the appeal.

Macess/Magic,
Prime, ODW

All

DOL

Compliance

=100%

CPD

Claims

Provider Acknowledgement Letter TAT (Self Funded ERISA) Post Service Clinical

Acknowledgement letters are sent within 5 calendar days of receipt.

Macess/Magic,
Prime, ODW

All

DOL

Compliance

=100%

CPD

Claims

Provider Appeal Resolution TAT (Self Funded) Post Service Clinical

Contractor shall resolve all standards appeals no later than 30 calendar days from the date the

Macess/Magic,
Prime, ODW

All

DOL

Compliance

=100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇-▇▇▇ ▇▇▇-▇▇▇▇▇ Claims TAT: MA (HNAZ)

Process non-clean, non-par provider claims within 60 calendar days of receipt 100% of the time.

ABS - Monthly
Adhoc Report

—

CMS

Compliance

100%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇-▇▇▇ ▇▇▇-▇▇▇▇▇ Claims TAT: MA (HNCA HMO, HNLCA PPO)

Process non-clean, non-par provider claims within 60 calendar days of receipt 100% of the time.

ABS - Monthly
Adhoc Report

—

CMS

Compliance

100%

MPD-14

Claims

Non-Par Clean Claims TAT: MA (HNCA HMO, HNLCA PPO)

Process non-par provider claims within 30 calendar days of receipt 95% of the time.

ABS - Monthly
Adhoc Report

—

CMS

Compliance

95%

MPD-146

Claims

OC03 - Timely Payment of Non-Contracting Provider Clean Claims (OR)

The MAO must pay 95% of ‘clean’ claims from non-contracting providers within 30 calendar days of receipt

ABS - Monthly
Adhoc Report

—

CMS

Compliance

95%

▇▇▇-▇▇

▇▇▇▇▇▇

▇

▇▇▇-▇▇▇ ▇▇▇-▇▇▇▇▇ Claims TAT: MA (HNOR)

Process non-clean, non-par provider claims within 60 calendar days of receipt 100% of the time.

ABS - Monthly
Adhoc Report

—

CMS

Compliance

100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Denial Accuracy	% of denied claims that are denied accurately	48302	25	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Correct Date of Receipt	% claims dates of receipt recorded accurately in the system	48302	25	100.00%	96.00%	100.00%	100.00%	100.00%	100.00%	100.00%	96.00%	100.00%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇ Explanation for Denials	% of denial letters with a clear explanation of denial reason	48302	25	96.00%	96.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-96	Claims	3	HMO/PPO Provider Grievance TAT	within 30 business days	956	N/A	92.55%	93.85%	92.09%	97.11%	79.52%	85.79%	71.12%	99.63%	99.85%

CPD-97	Claims	3	HMO/PPO Provider Grievance Type Coding	HN must categorize each grievance it receives into one of eleven grievance types listed in Attachment A of Regulatory Bulletin 2006-2	1241	70	98.84%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-99	Claims	3	HMO/PPO Request for additional information for Unclean Claims TAT	% of written requests for additional information on unclean claims to the contracted/noncontracted provided, enrollee or third party within thirty days of receipt.	1883	N/A	100.00%	100.00%	100.00%	99.94%	99.87%	100.00%	100.00%	100.00%	100.00%

CPD	Claims	1	Provider Acknowledgement Letter TAT (Self Funded ERISA)	Acknowledgement letters are sent within 15 business days of receipt.

CPD	Claims	1	Provider Appeal Resolution TAT (Self Funded)	Contractor shall resolve all standards appeals no later than 45 business days days from the date the Contractor receives the appeal.

CPD	Claims	1	Provider Acknowledgement Letter TAT (Self Funded ERISA) Post Service Clinical	Acknowledgement letters are sent within 5 calendar days of receipt.

CPD	Claims	1	Provider Appeal Resolution TAT (Self Funded) Post Service Clinical	Contractor shall resolve all standards appeals no later than 30 calendar days from the date the

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇-▇▇▇ ▇▇▇-▇▇▇▇▇ Claims TAT: MA (HNAZ)	Process non-clean, non-par provider claims within 60 calendar days of receipt 100% of the time.	4850	31	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	96.67%	100.00%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇-▇▇▇ ▇▇▇-▇▇▇▇▇ Claims TAT: MA (HNCA HMO, HNLCA PPO)	Process non-clean, non-par provider claims within 60 calendar days of receipt 100% of the time.	7484	30	96.67%	100.00%	100.00%	96.77%	96.67%	96.67%	96.67%	100.00%	100.00%

MPD-14	Claims	4	Non-Par Clean Claims TAT: MA (HNCA HMO, HNLCA PPO)	Process non-par provider claims within 30 calendar days of receipt 95% of the time.	6796	30	96.67%	93.33%	100.00%	96.55%	100.00%	100.00%	96.67%	100.00%	96.43%

MPD-146	Claims	4	OC03 - Timely Payment of Non- Contracting Provider Clean Claims (OR)	The MAO must pay 95% of ‘clean’ claims from non-contracting providers within 30 calendar days of receipt	10531	29	96.43%	96.67%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	96.67%

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇-▇▇▇ ▇▇▇-▇▇▇▇▇ Claims TAT: MA (HNOR)	Process non-clean, non-par provider claims within 60 calendar days of receipt 100% of the time.	12023	31	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	96.67%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
CPD-91	Claims	1	HMO/POS Claims Denial Accuracy	% of denied claims that are denied accurately	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Correct Date of Receipt	% claims dates of receipt recorded accurately in the system	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

▇▇▇-▇▇	▇▇▇▇▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇ Explanation for Denials	% of denial letters with a clear explanation of denial reason	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

CPD-96	Claims	3	HMO/PPO Provider Grievance TAT	within 30 business days	99.96%	98.90%	96.88%	99.12%	89.99	90	94.99	95

CPD-97	Claims	3	HMO/PPO Provider Grievance Type Coding	HN must categorize each grievance it receives into one of eleven grievance types listed in Attachment A of Regulatory Bulletin 2006-2	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

CPD-99	Claims	3	HMO/PPO Request for additional information for Unclean Claims TAT	% of written requests for additional information on unclean claims to the contracted/noncontracted provided, enrollee or third party within thirty days of receipt.	100.00%	100.00%	100.00%	100.00%	89.99	90	94.99	95

CPD	Claims	1	Provider Acknowledgement Letter TAT (Self Funded ERISA)	Acknowledgement letters are sent within 15 business days of receipt.					99.99	0	0	100

CPD	Claims	1	Provider Appeal Resolution TAT (Self Funded)	Contractor shall resolve all standards appeals no later than 45 business days days from the date the Contractor receives the appeal.					99.99	0	0	100

CPD	Claims	1	Provider Acknowledgement Letter TAT (Self Funded ERISA) Post Service Clinical	Acknowledgement letters are sent within 5 calendar days of receipt.					99.99	0	0	100

CPD	Claims	1	Provider Appeal Resolution TAT (Self Funded) Post Service Clinical	Contractor shall resolve all standards appeals no later than 30 calendar days from the date the					99.99	0	0	100

MPD-11	Claims	4	Non-Par Non-Clean Claims TAT: MA (HNAZ)	Process non-clean, non-par provider claims within 60 calendar days of receipt 100% of the time.	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

MPD-13	Claims	4	Non-Par Non-Clean Claims TAT: MA (HNCA HMO, HNLCA PPO)	Process non-clean, non-par provider claims within 60 calendar days of receipt 100% of the time.	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

MPD-14	Claims	4	Non-Par Clean Claims TAT: MA (HNCA HMO, HNLCA PPO)	Process non-par provider claims within 30 calendar days of receipt 95% of the time.	100.00%	93.33%	100.00%	LAG MONTH	94.99	0	0	95

MPD-146	Claims	4	OC03 - Timely Payment of Non- Contracting Provider Clean Claims (OR)	The MAO must pay 95% of ‘clean’ claims from non-contracting providers within 30 calendar days of receipt	100.00%	100.00%	100.00%	LAG MONTH	94.99	0	0	95

MPD-15	Claims	4	Non-Par Non-Clean Claims TAT: MA (HNOR)	Process non-clean, non-par provider claims within 60 calendar days of receipt 100% of the time.	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

MPD-533

Claims

90% Reassociation EFT & ERA within 3 days

ABS - Monthly Adhoc Report

—

ALL

HHS

Compliance

>= 90%

MPD-534

Claims

HIPAA Eligibility Verification Real Time 20 second Rule

Monthly Reports from both HN IT and our Clearing Houses.

—

ALL

HHS

Compliance

=> 90%

MPD-535

Claims

HIPAA Claims Status Real Time 20 Second Response Time Rule

Monthly Reports from both HN IT and our Clearing Houses.

—

ALL

HHS

Compliance

=> 90%

MPD-536

Claims

Eligibility Verification System Availability 86% Rule

Monthly Reports from both HN IT and our Clearing Houses.

—

ALL

HHS

Compliance

=> 86%

▇▇▇-▇▇▇

▇▇▇▇▇▇

▇

▇▇▇▇▇▇ ▇▇▇▇▇▇ System Availability 86% Rule

Monthly Reports from both HN IT and our Clearing Houses.

—

ALL

HHS

Compliance

=> 86%

MPD-9

Claims

Non-Par Clean Claims TAT: MA (HNAZ)

Process non-par provider claims within 30 calendar days of receipt 95% of the time

ABS - Monthly Adhoc Report

—

CMS

Compliance

95%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
MPD-533	Claims	4	90% Reassociation EFT & ERA within 3 days	Core Rule 370 A health plan must release for transmission to the healthcare provider the v5010 X12 835 corresponding to the Healthcare EFT Standards: No sooner than three business days, prior to the Effective Entry Date, and No later than three business days after the Effective Entry Date, 90% of the time as measured within a calendar month.	70339	N/A	N/A	▇/▇	▇/▇	▇/▇	▇/▇	▇/▇	▇/▇	▇/▇	▇/▇

MPD-534	Claims	4	HIPAA Eligibility Verification Real Time 20 second Rule	Real Time (Core Rule 156) 270/271 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.	887875	N/A	97.60%	100.00%	98.19%	98.39%	97.04%	98.57%	97.65%	99.28%	93.15%

MPD-535	Claims	4	HIPAA Claims Status Real Time 20 Second Response Time Rule	Real Time (Core Rule 156) 276/277 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.	38179	N/A	100.00%	100.00%	100.00%	98.48%	99.28%	93.66%	98.06%	99.90%	69.48%

MPD-536	Claims	4	Eligibility Verification System Availability 86% Rule	Core Rule 157 Eligibility and Benefits System Availability Rule: Real Time Transaction 270/271 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 270 inquiry and returning a response. Calendar week is defined as 12:01am Sunday to 12:01am the following Sunday.	972127	N/A	99.00%	96.00%	99.00%	99.00%	96.00%	97.00%	99.00%	98.00%	98.00%

▇▇▇-▇▇▇	▇▇▇▇▇▇	▇	▇▇▇▇▇▇ ▇▇▇▇▇▇ System Availability 86% Rule	Core Rule 250 Claims status rule (276/277) refers to Core Rule 157 for system availability requirements. Real Time Transaction 276/277 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 276 inquiry and returning a 277 response. Calendar week is defined as 12:01am Sunday to 12:01am the following Sunday	34932	N/A	N/A	98.00%	99.00%	100.00%	98.00%	99.00%	100.00%	100.00%	100.00%

MPD-9	Claims	4	Non-Par Clean Claims TAT: MA (HNAZ)	Process non-par provider claims within 30 calendar days of receipt 95% of the time	4108	29	100.00%	100.00%	93.10%	100.00%	96.55%	100.00%	96.67%	100.00%	100.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
MPD-533	Claims	4	90% Reassociation EFT & ERA within 3 days	Core Rule 370 A health plan must release for transmission to the healthcare provider the v5010 X12 835 corresponding to the Healthcare EFT Standards: No sooner than three business days, prior to the Effective Entry Date, and No later than three business days after the Effective Entry Date, 90% of the time as measured within a calendar month.	93.00%	97.41%	99.38%	99.93%	89.99	0	0	89.99

MPD-534	Claims	4	HIPAA Eligibility Verification Real Time 20 second Rule	Real Time (Core Rule 156) 270/271 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.	98.26%	98.43%	99.22%	98.46%	89.99	0	0	89.99

MPD-535	Claims	4	HIPAA Claims Status Real Time 20 Second Response Time Rule	Real Time (Core Rule 156) 276/277 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.	97.00%	99.35%	99.97%	98.35%	89.99	0	0	89.99

MPD-536	Claims	4	Eligibility Verification System Availability 86% Rule	Core Rule 157 Eligibility and Benefits System Availability Rule: Real Time Transaction 270/271 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 270 inquiry and returning a response. Calendar week is defined as 12:01 am Sunday to 12:01 am the following Sunday.	99.00%	98.00%	99.00%	99.00%	85.99	0	0	85.99

MPD-537	Claims	4	Claims Status System Availability 86% Rule	Core Rule 250 Claims status rule (276/277) refers to Core Rule 157 for system availability requirements. Real Time Transaction 276/277 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 276 inquiry and returning a 277 response. Calendar week is defined as 12:01 am Sunday to 12:01 am the following Sunday	99.00%	98.00%	99.00%	99.00%	85.99	0	0	85.99

MPD-9	Claims	4	Non-Par Clean Claims TAT: MA (HNAZ)	Process non-par provider claims within 30 calendar days of receipt 95% of the time	100.00%	100.00%	96.55%	LAG MONTH	94.99	0	0	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

SHP-1

Claims

New Day Claims (Medi-Cal)

Process 100%* of claims within 45 working days of receipt. Timeliness is measured from receipt date to check date. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

ABS - Monthly Adhoc Report

—

DMHC

Compliance

100%

SHP-8

Claims

Provider Dispute Resolution TAT (Medi-Cal)

100%* processed within 45 working days. Timeliness is measured from receipt date to check date. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Qcare, HNCS, Omni, Page Center

—

DMHC

Compliance

=100%

SHP-9

Claims

Provider Dispute Resolution Acknowledgement Letter TAT (Medi-Cal)

100%* within 2 working days (for Electronic) and within 15 working days (for Paper). Timeliness is measured from receipt date to letter date. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Qcare, HNCS, Omni, Page Center

—

DMHC

Compliance

=100%

SHP-11

Claims

Provider Dispute Resolution Correct Date of Receipt Recorded (Medi-Cal)

100%* accuracy of Received Date entered into the System. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Qcare, HNCS, Omni, Page Center

—

DMHC

Compliance

=100%

SHP-12

Claims

Provider Dispute Resolution Correct Determination Made (Medi-Cal)

100%* accuracy with correct determination made and letter being sent to Provider and/or Dispute Determination included within the Letter. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Qcare, HNCS, Omni, Page Center

DMHC

Compliance

=100%

SHP-20

Claims

Provider Dispute Resolution TAT (Molina Medi-Cal)

Timeliness is measured from receipt date to check date. 100%* processed within 45 working days. Molina Medi-Cal is in Riverside and San Bernardino counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Qcare, HNCS, Omni, Page Center

DMHC

Compliance

=100%

SHP-29

Claims

Provider Dispute Resolution TAT (CalViva Medi-Cal)

Timeliness is measured from receipt date to check date. 100%* processed within 45 working days. *CalViva Medi-Cal is in Fresno, Kings and Madera Counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Qcare, HNCS, Omni, Page Center

—

DMHC

Compliance

=100%

SHP-10

Claims

Provider Dispute Resolution Reimbursement Accuracy (Medi-Cal)

100%* accuracy of Reimbursement to Provider. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Quality Audit and Training (Monthly)

DMHC

Compliance

100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
SHP-1	Claims	5	New Day Claims (Medi-Cal)	Process 100%* of claims within 45 working days of receipt. Timeliness is measured from receipt date to check date. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	229217	N/A	98.80%	99.20%	99.40%	99.20%	99.25%	99.36%	99.60%	99.33%	99.11%

SHP-8	Claims	5	Provider Dispute Resolution TAT (Medi-Cal)	100%* processed within 45 working days. Timeliness is measured from receipt date to check date. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	988	N/A	98.16%	84.47%	93.72%	98.70%	99.07%	99.37%	99.34%	98.72%	98.29%

SHP-9	Claims	5	Provider Dispute Resolution Acknowledgement Letter TAT (Medi-Cal)	100%* within 2 working days (for Electronic) and within 15 working days (for Paper). Timeliness is measured from receipt date to letter date. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	1036	N/A	99.42%	98.76%	99.54%	99.53%	100.00%	99.74%	99.91%	100.00%	100.00%

SHP-11	Claims	5	Provider Dispute Resolution Correct Date of Receipt Recorded (Medi-Cal)	100%* accuracy of Received Date entered into the System. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	986	25	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	96.00%	100.00%	100.00%

SHP-12	Claims	5	Provider Dispute Resolution Correct Determination Made (Medi-Cal)	100%* accuracy with correct determination made and letter being sent to Provider and/or Dispute Determination included within the Letter. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	986	25	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	92.00%	100.00%

SHP-20	Claims	5	Provider Dispute Resolution TAT (Molina Medi-Cal)	Timeliness is measured from receipt date to check date. 100%* processed within 45 working days. Molina Medi-Cal is in Riverside and San Bernardino counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	25	N/A	89.66%	100.00%	97.56%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

SHP-29	Claims	5	Provider Dispute Resolution TAT (CalViva Medi-Cal)	Timeliness is measured from receipt date to check date. 100%* processed within 45 working days. CalViva Medi-Cal is in Fresno, Kings and Madera Counties. HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	912	N/A	98.26%	95.03%	98.12%	99.41%	99.40%	99.18%	99.06%	99.68%	99.50%

SHP-10	Claims	5	Provider Dispute Resolution Reimbursement Accuracy (Medi-Cal)	100%* accuracy of Reimbursement to Provider. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	986	25	100.00%	96.00%	96.00%	100.00%	100.00%	100.00%	84.00%	76.00%	92.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
SHP-1	Claims	5	New Day Claims (Medi-Cal)	Process 100%* of claims within 45 working days of receipt. Timeliness is measured from receipt date to check date. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	99.22%	99.38%	99.40%	99.50%	89.99	90	94.99	95

SHP-8	Claims	5	Provider Dispute Resolution TAT (Medi-Cal)	100%* processed within 45 working days. Timeliness is measured from receipt date to check date. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	87.31%	97.27%	96.10%	95.55%	89.99	90	94.99	95

SHP-9	Claims	5	Provider Dispute Resolution Acknowledgement Letter TAT (Medi-Cal)	100%* within 2 working days (for Electronic) and within 15 working days (for Paper). Timeliness is measured from receipt date to letter date. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	100.00%	100.00%	99.32%	99.71%	89.99	90	94.99	95

SHP-11	Claims	5	Provider Dispute Resolution Correct Date of Receipt Recorded (Medi-Cal)	100%* accuracy of Received Date entered into the System. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	100.00%	100.00%	96.00%	LAG MONTH	89.99	90	94.99	95

SHP-12	Claims	5	Provider Dispute Resolution Correct Determination Made (Medi-Cal)	100%* accuracy with correct determination made and letter being sent to Provider and/or Dispute Determination included within the Letter. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	100.00%	100.00%	92.00%	LAG MONTH	89.99	90	94.99	95

SHP-20	Claims	5	Provider Dispute Resolution TAT (Molina Medi-Cal)	Timeliness is measured from receipt date to check date. 100%* processed within 45 working days. Molina Medi-Cal is in Riverside and San Bernardino counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	86.67%	100.00%	100.00%	88.00%	89.99	90	94.99	95

SHP-29	Claims	5	Provider Dispute Resolution TAT (CalViva Medi-Cal)	Timeliness is measured from receipt date to check date. 100%* processed within 45 working days. CalViva Medi-Cal is in Fresno, Kings and Madera Counties. HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	91.70%	98.24%	98.27%	97.48%	89.99	90	94.99	95

SHP-10	Claims	5	Provider Dispute Resolution Reimbursement Accuracy (Medi-Cal)	100%* accuracy of Reimbursement to Provider. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	88.00%	92.00%	80.00%	LAG MONTH	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

SHP-17

Claims

New Day Claims (Molina Medi-Cal)

Process 90% of claims within 30 calendar days of receipt. Timeliness is measured from receipt date to check date plus 2 days.

ABS - Monthly Adhoc Report

—

DMHC

Compliance

>= 90%

SHP-18

Claims

New Day Claims (Molina Medi-Cal)

Timeliness is measured from receipt date to check date. Process 100%* of claims within 45 working days of receipt Molina Medi-Cal is in Riverside and San Bernardino counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

QCARE - Monthly Adhoc Report

—

DMHC

Compliance

100%

SHP-2

Claims

New Day Claims (Medi-Cal)

Process 90%* of claims within 30 calendar days of receipt. Timeliness is measured from receipt date to check date.

QCARE - Monthly Adhoc Report

—

DMHC

Compliance

90%

SHP-21

Claims

HNCA New Day Claims (CalViva Medi-Cal)

Process 90% of claims within 30 calendar days of receipt. Timeliness is measured from receipt date to check date.

QCARE - Monthly Adhoc Report

—

DMHC

Compliance

>= 90%

SHP-22

Claims

HNCA New Day Claims (CalViva Medi-Cal)

Process 100%* of claims within 45 working days of receipt. Timeliness is measured from receipt date to check date. CalViva Medi-Cal is in Fresno, Kings and Madera Counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Dispute

QCARE - Monthly Adhoc Report

—

DMHC

Compliance

100%

SHP-299

Claims

Provider Dispute Resolution Reimbursement Accuracy (CalViva Medi-Cal)

100%* accuracy of Reimbursement to Provider. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

PDR Database

DMHC

Compliance

100%

SHP-3

Claims

Interest Payment Accuracy (Medi-Cal)

Interest Payment is calculated and applied accurately 100%* of the time. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Quality Audit and Training (Monthly)

DMHC

Compliance

100%

SHP-116

Claims

CalViva Medi-Cal PDR Acknow. Letter TAT

100%* within 2 working days (for Electronic) and within 15 working days (for Paper). Timeliness is measured from receipt date to letter date.

Prime, ODW

—

DMHC

Compliance

=100%

SHP-300

Claims

Provider Dispute Resolution Correct Date of Receipt Recorded (CalViva Medi-Cal)

100%* accuracy of Received Date entered into the System. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Quality Audit and Training (Monthly)

—

DMHC

Compliance

100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
SHP-17	Claims	5	New Day Claims (Molina Medi-Cal)	Process 90% of claims within 30 calendar days of receipt. Timeliness is measured from receipt date to check date plus 2 days.	2002	N/A	93.44%	93.89%	93.79%	94.16%	94.83%	93.35%	96.24%	96.15%	95.78%

SHP-18	Claims	5	New Day Claims (Molina Medi-Cal)	Timeliness is measured from receipt date to check date. Process 100%* of claims within 45 working days of receipt Molina Medi-Cal is in Riverside and San Bernardino counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	2002	N/A	98.14%	98.09%	98.99%	98.91%	97.95%	97.88%	98.62%	99.07%	99.25%

SHP-2	Claims	5	New Day Claims (Medi-Cal)	Process 90%* of claims within 30 calendar days of receipt. Timeliness is measured from receipt date to check date.	229217	N/A	92.90%	96.03%	93.94%	94.90%	95.43%	93.73%	95.00%	95.40%	93.44%

SHP-21	Claims	5	HNCA New Day Claims (CalViva Medi- Cal)	Process 90% of claims within 30 calendar days of receipt. Timeliness is measured from receipt date to check date.	192380	N/A	95.10%	96.79%	95.60%	96.95%	95.49%	94.27%	96.12%	96.22%	94.29%

SHP-22	Claims	5	HNCA New Day Claims (CalViva Medi- Cal)	Process 100%* of claims within 45 working days of receipt. Timeliness is measured from receipt date to check date. CalViva Medi-Cal is in Fresno, Kings and Madera Counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Dispute	192380	N/A	99.43%	99.58%	99.63%	99.56%	98.97%	99.57%	99.87%	99.70%	99.04%

SHP-299	Claims	5	Provider Dispute Resolution Reimbursement Accuracy (CalViva Medi-Cal)	100%* accuracy of Reimbursement to Provider. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	708	25	100.00%	100.00%	76.00%	88.00%	92.00%	76.00%	84.00%	80.00%	92.00%

SHP-3	Claims	5	Interest Payment Accuracy (Medi-Cal)	Interest Payment is calculated and applied accurately 100%* of the time. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	247	25	100.00%	100.00%	92.00%	96.00%	100.00%	96.00%	100.00%	92.00%	84.00%

SHP-116	Claims	5	CalViva Medi-Cal PDR Acknow. Letter TAT	100%* within 2 working days (for Electronic) and within 15 working days (for Paper). Timeliness is measured from receipt date to letter date.	839	N/A	99.02%	99.94%	100.00%	96.99%	100.00%	99.49%	100.00%	99.89%	100.00%

SHP-300	Claims	5	Provider Dispute Resolution Correct Date of Receipt Recorded (CalViva Medi-Cal)	100%* accuracy of Received Date entered into the System. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	708	25	100.00%	100.00%	100.00%	92.00%	100.00%	100.00%	100.00%	100.00%	100.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
SHP-17	Claims	5	New Day Claims (Molina Medi-Cal)	Process 90% of claims within 30 calendar days of receipt. Timeliness is measured from receipt date to check date plus 2 days.	88.70%	90.02%	87.38%	92.40%	89.99	0	0	89.99

SHP-18	Claims	5	New Day Claims (Molina Medi-Cal)	Timeliness is measured from receipt date to check date. Process 100%* of claims within 45 working days of receipt Molina Medi-Cal is in Riverside and San Bernardino counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	98.64%	98.72%	97.61%	99.10%	89.99	90	94.99	95

SHP-2	Claims	5	New Day Claims (Medi-Cal)	Process 90%* of claims within 30 calendar days of receipt. Timeliness is measured from receipt date to check date.	90.79%	92.34%	99.70%	92.10%	89.99	0	0	89.99

SHP-21	Claims	5	HNCA New Day Claims (CalViva Medi-Cal)	Process 90% of claims within 30 calendar days of receipt. Timeliness is measured from receipt date to check date.	92.85%	94.07%	92.00%	92.70%	89.99	0	0	89.99

SHP-22	Claims	5	HNCA New Day Claims (CalViva Medi-Cal)	Process 100%* of claims within 45 working days of receipt. Timeliness is measured from receipt date to check date. CalViva Medi-Cal is in Fresno, Kings and Madera Counties. *HNCA is required to be compliant 100% of the time for Claims and Provider Dispute	99.67%	99.70%	99.65%	99.80%	89.99	90	94.99	95

SHP-299	Claims	5	Provider Dispute Resolution Reimbursement Accuracy (CalViva Medi-Cal)	100%* accuracy of Reimbursement to Provider. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	92.00%	92.00%	84.00%	LAG MONTH	89.99	90	94.99	95

SHP-3	Claims	5	Interest Payment Accuracy (Medi-Cal)	Interest Payment is calculated and applied accurately 100%* of the time. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	80.00%	56.00%	52.00%	LAG MONTH	89.99	90	94.99	95

SHP-116	Claims	5	CalViva Medi-Cal PDR Acknow. Letter TAT	100%* within 2 working days (for Electronic) and within 15 working days (for Paper). Timeliness is measured from receipt date to letter date.	100.00%	100.00%	100.00%	99.88%	89.99	90	94.99	95

SHP-300	Claims	5	Provider Dispute Resolution Correct Date of Receipt Recorded (CalViva Medi-Cal)	100%* accuracy of Received Date entered into the System. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

SHP-301

Claims

Provider Dispute Resolution Correct Determination Made (CalViva Medi-Cal)

Quality Audit and Training (Monthly)

—

DMHC

Compliance

100%

SHP-302

Claims

Interest Payment Accuracy (CalViva Medi-Cal)

Interest Payment is calculated and applied accurately 100%* of the time. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Quality Audit and Training (Monthly)

DMHC

Compliance

100%

SHP-303

Claims

Claims Denial Accuracy (CalViva Medi-Cal)

100%* Accuracy of Claims Denials. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Quality Audit and Training (Monthly)

—

DMHC

Compliance

100%

SHP-304

Claims

Denied Claims Correct Date of Receipt Recorded (CalViva Medi-Cal)

100%* accuracy of Date of Receipt recorded in the system. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Quality Audit and Training (Monthly)

—

DMHC

Compliance

100%

SHP-305

Claims

Explanation for Claim Denials (CalViva Medi-Cal)

100%* accuracy of Clear Explanation of Denial Reason being on Denial Letters. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Quality Audit and Training (Monthly)

DMHC

Compliance

100%

SHP-369

Claims

Provider Claims Dispute - Acknowledgment Letter TAT

Claim disputes are acknowledged in writing and within 5 business days of receipt.

Qcare, HNCS, Omni, Page Center

—

AHCCCS

Compliance

= 100%

SHP-370

Claims

Provider Claims Dispute - Resolution TAT

Contractor’s Notice of Decision shall be mailed to all parties no later than 30 days after the provider files a claim dispute with the Contractor.

Qcare, HNCS, Omni, Page Center

—

AHCCCS

Compliance

= 100%

SHP-371

Claims

Provider Claims Disputes - Overturned (Adjustments) TAT

Qcare, HNCS, Omni, Page Center

—

AHCCCS

Compliance

= 100%

SHP-372

Claims

Provider Claims Disputes - Request for State Fair Hearing TAT

Qcare, HNCS, Omni, Page Center

AHCCCS

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
SHP-301	Claims	5	Provider Dispute Resolution Correct Determination Made (CalViva Medi-Cal)	100%* accuracy with correct determination made and letter being sent to Provider and/or Dispute Determination included within the Letter. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	708	25	100.00%	100.00%	100.00%	96.00%	100.00%	100.00%	100.00%	88.00%	92.00%

SHP-302	Claims	5	Interest Payment Accuracy (CalViva Medi-Cal)	Interest Payment is calculated and applied accurately 100%* of the time. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	166	25	92.00%	100.00%	100.00%	96.00%	100.00%	100.00%	82.35%	84.00%	96.00%

SHP-303	Claims	5	Claims Denial Accuracy (CalViva Medi-Cal)	100%* Accuracy of Claims Denials. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	16715	25	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇▇▇▇▇	▇	▇▇▇▇▇▇ ▇▇▇▇▇▇ Correct Date of Receipt Recorded (CalViva Medi-Cal)	100%* accuracy of Date of Receipt recorded in the system. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	16715	25	100.00%	96.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

SHP-305	Claims	5	Explanation for Claim Denials (CalViva Medi-Cal)	100%* accuracy of Clear Explanation of Denial Reason being on Denial Letters. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	16715	25	96.00%	100.00%	96.00%	96.00%	100.00%	100.00%	92.00%	96.00%	100.00%

SHP-369	Claims	6	Provider Claims Dispute - Acknowledgment Letter TAT	Claim disputes are acknowledged in writing and within 5 business days of receipt.	36	N/A	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

SHP-370	Claims	6	Provider Claims Dispute - Resolution TAT	Contractor’s Notice of Decision shall be mailed to all parties no later than 30 days after the provider files a claim dispute with the Contractor.	41	N/A	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

SHP-371	Claims	6	Provider Claims Disputes - Overturned (Adjustments) TAT	If the claim dispute is overturned, in full or in part, the Contractor shall reprocess and pay the claim(s) in a manner consistent with the decision within 15 business days of the date of the Decision.	37	N/A	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

SHP-372	Claims	6	Provider Claims Disputes - Request for State Fair Hearing TAT	Contractor must ensure that all supporting documentation is received by the AHCCCS Office of Administrative Legal Services (OALS), no later than 5 business days from the date the Contractor receives the provider’s written hearing request.	Null Universe	Null Universe	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE


Schedule B-2-1		B-2-1-62		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
SHP-301	Claims	5	Provider Dispute Resolution Correct Determination Made (CalViva Medi-Cal)	100%* accuracy with correct determination made and letter being sent to Provider and/or Dispute Determination included within the Letter. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

SHP-302	Claims	5	Interest Payment Accuracy (CalViva Medi-Cal)	Interest Payment is calculated and applied accurately 100%* of the time. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	92.00%	60.00%	52.00%	LAG MONTH	89.99	90	94.99	95

SHP-303	Claims	5	Claims Denial Accuracy (CalViva Medi-Cal)	100%* Accuracy of Claims Denials. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

SHP-304	Claims	5	Denied Claims Correct Date of Receipt Recorded (CalViva Medi-Cal)	100%* accuracy of Date of Receipt recorded in the system. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

SHP-305	Claims	5	Explanation for Claim Denials (CalViva Medi-Cal)	100%* accuracy of Clear Explanation of Denial Reason being on Denial Letters. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	96.00%	96.00%	88.00%	LAG MONTH	89.99	90	94.99	95

SHP-369	Claims	6	Provider Claims Dispute - Acknowledgment Letter TAT	Claim disputes are acknowledged in writing and within 5 business days of receipt.	NULL UNIVERSE	100.00%	100.00%	97.30%	94.99	95	96.99	97

SHP-370	Claims	6	Provider Claims Dispute - Resolution TAT	Contractor’s Notice of Decision shall be mailed to all parties no later than 30 days after the provider files a claim dispute with the Contractor.	NULL UNIVERSE	NULL UNIVERSE	100.00%	97.56%	94.99	95	96.99	97

SHP-371	Claims	6	Provider Claims Disputes - Overturned (Adjustments) TAT	If the claim dispute is overturned, in full or in part, the Contractor shall reprocess and pay the claim(s) in a manner consistent with the decision within 15 business days of the date of the Decision.	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%	94.99	95	96.99	97

SHP-372	Claims	6	Provider Claims Disputes - Request for State Fair Hearing TAT	Contractor must ensure that all supporting documentation is received by the AHCCCS Office of Administrative Legal Services (OALS), no later than 5 business days from the date the Contractor receives the provider’s written hearing request.	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	94.99	95	96.99	97


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

SHP-373

Claims

90% Reassociation EFT & ERA within 3 days

ABS - Monthly Adhoc Report

—

ALL

HHS

Compliance

>= 90%

SHP-374

Claims

Claim Timeliness (0-30 days)

Contractor shall ensure that for each form type (Dental/Professional/Institutional), 95% of all clean claims are adjudicated within 30 days of receipt of the clean claim.

QCARE - Monthly Adhoc Report

—

AHCCCS

Compliance

>= 95%

SHP-375

Claims

Claim Timeliness (0-60 days)

Contractor shall ensure that for each form type (Dental/Professional/Institutional), 99% of all clean claims are adjudicated within 60 days of receipt of the clean claim.

QCARE - Monthly Adhoc Report

—

AHCCCS

Compliance

>= 99%

SHP-376

Claims

Claims - Electronic Submission (Professional, Intitutional, Dental)

Receive 60% of each claim type (professional, institutional and dental) based on volume of actual claims excluding claims processed by Pharmacy Benefit Managers (PBMs) electronically.

ABS - Monthly Adhoc Report

—

AHCCCS

Compliance

>= 60%

SHP-377

Claims

Claims - Electronic Remittance Advice

Produce and distribute 60% of remittances electronically

ABS - Monthly Adhoc Report

—

AHCCCS

Compliance

>= 60%

SHP-378

Claims

Claims Payment - Electronic Funds Transfer

60% of claims payments are via EFT

ABS - Monthly Adhoc Report

AHCCCS

Compliance

>= 60%

▇▇▇-▇▇▇

▇▇▇▇▇▇

▇

▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇ Verification Real Time 20 second Rule

Monthly Reports from both HN IT and our Clearing Houses.

—

ALL

HHS

Compliance

=> 90%

▇▇▇-▇▇▇

▇▇▇▇▇▇

▇

▇▇▇▇▇ ▇▇▇▇▇▇ Status Real Time 20 Second Response Time Rule

Monthly Reports from both HN IT and our Clearing Houses.

—

ALL

HHS

Compliance

=> 90%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample
Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

SHP-373

Claims

90% Reassociation EFT & ERA within 3 days

70339

N/A

▇/▇

SHP-374

Claims

Claim Timeliness (0-30 days)

Contractor shall ensure that for each form type (Dental/Professional/Institutional), 95% of all clean claims are adjudicated within 30 days of receipt of the clean claim.

27261

N/A

UNDER
DEV

100.00%

98.58%

96.34%

SHP-375

Claims

Claim Timeliness (0-60 days)

Contractor shall ensure that for each form type (Dental/Professional/Institutional), 99% of all clean claims are adjudicated within 60 days of receipt of the clean claim.

27261

N/A

UNDER
DEV

100.00%

SHP-376

Claims

Claims - Electronic Submission (Professional, Intitutional, Dental)

Receive 60% of each claim type (professional, institutional and dental) based on volume of actual claims excluding claims processed by Pharmacy Benefit Managers (PBMs) electronically.

33968

N/A

UNDER
DEV

93.75%

77.61%

71.20%

SHP-377

Claims

Claims - Electronic Remittance Advice

Produce and distribute 60% of remittances electronically

27261

N/A

UNDER
DEV

69.56%

63.15%

57.65%

SHP-378

Claims

Claims Payment - Electronic Funds Transfer

60% of claims payments are via EFT

27261

N/A

UNDER
DEV

28.50%

29.73%

34.38%

SHP-393

Claims

HIPAA Eligibility Verification Real Time 20 second Rule

887875

N/A

97.60%

100.00%

98.19%

98.39%

97.04%

98.57%

97.65%

99.28%

93.15%

▇▇▇-▇▇▇

▇▇▇▇▇▇

▇

▇▇▇▇▇ ▇▇▇▇▇▇ Status Real Time 20 Second Response Time Rule

38179

N/A

100.00%

98.48%

99.28%

93.66%

98.06%

99.90%

69.48%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014			Mar-2014			Apr-2014	RED HI		YELLOW LO		YELLOW HI		GREEN LO
SHP-373	Claims	5	90% Reassociation EFT & ERA within 3 days	Core Rule 370 A health plan must release for transmission to the healthcare provider the v5010 X12 835 corresponding to the Healthcare EFT Standards: No sooner than three business days, prior to the Effective Entry Date, and No later than three business days after the Effective Entry Date, 90% of the time as measured within a calendar month.	93.00%		97.41	%		99.38	%	99.93%		89.99		0		0		89.99

SHP-374	Claims	6	Claim Timeliness (0-30 days)	Contractor shall ensure that for each form type (Dental/Professional/Institutional), 95% of all clean claims are adjudicated within 30 days of receipt of the clean claim.	98.00%		99.40	%		99.60	%	98.80%		94.99		0		0		95

SHP-375	Claims	6	Claim Timeliness (0-60 days)	Contractor shall ensure that for each form type (Dental/Professional/Institutional), 99% of all clean claims are adjudicated within 60 days of receipt of the clean claim.	99.95%		99.90	%		99.90	%	99.70%		98.99		0		0		99

SHP-376	Claims	6	Claims - Electronic Submission (Professional, Intitutional, Dental)	Receive 60% of each claim type (professional, institutional and dental) based on volume of actual claims excluding claims processed by Pharmacy Benefit Managers (PBMs) electronically.	76.17%		78.70	%		84.00	%	81.20%		54.9		55		59.9		60

SHP-377	Claims	6	Claims - Electronic Remittance Advice	Produce and distribute 60% of remittances electronically	61.94%		66.10	%		63.20	%	61.10%		54.9		55		59.9		60

SHP-378	Claims	6	Claims Payment - Electronic Funds Transfer	60% of claims payments are via EFT	37.79%		47.50	%		50.20	%	48.00%		54.9		55		59.9		60

SHP-393	Claims	5	HIPAA Eligibility Verification Real Time 20 second Rule	Real Time (Core Rule 156) 270/271 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.	98.26%		98.43	%		99.22	%	98.46%		89.99		0		0		89.99

▇▇▇-▇▇▇	▇▇▇▇▇▇	▇	▇▇▇▇▇ ▇▇▇▇▇▇ Status Real Time 20 Second Response Time Rule	Real Time (Core Rule 156) 276/277 Transaction 20 second response time rule. This rule is achieved when 90 percent of all required requests and responses are within a 20 second turnaround time in a calendar month.	97.00%		99.35	%		99.97	%	98.35%		89.99		0		0		89.99


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

SHP-395

Claims

Eligibility Verification System Availability 86% Rule

Monthly Reports from both HN IT and our Clearing Houses.

—

ALL

HHS

Compliance

=> 86%

▇▇▇-▇▇▇

▇▇▇▇▇▇

▇

▇▇▇▇▇▇ ▇▇▇▇▇▇ System Availability 86% Rule

Monthly Reports from both HN IT and our Clearing Houses.

—

ALL

HHS

Compliance

=> 86%

SHP-4

Claims

Claim Forwarding TAT (Medi-Cal)

100%* within 10 working days. Timeliness measured from receipt date to date forwarded to the contracting provider group. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

ABS - Monthly Adhoc Report

—

DMHC

Compliance

100%

SHP-5

Claims

Claims Denial Accuracy (Medi-Cal)

100%* Accuracy of Claims Denials. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Quality Audit and Training (Monthly)

—

DMHC

Compliance

100%

SHP-6

Claims

Denied Claims Correct Date of Receipt Recorded (Medi-Cal)

100%* accuracy of Date of Receipt recorded in the system. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Quality Audit and Training (Monthly)

—

DMHC

Compliance

100%

SHP-7

Claims

Explanation for Claim Denials (Medi- Cal)

100%* accuracy of Clear Explanation of Denial Reason being on Denial Letters. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.

Quality Audit and Training (Monthly)

—

DMHC

Compliance

100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower		Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
SHP-395		Claims	5	Eligibility Verification System Availability 86% Rule	Core Rule 157 Eligibility and Benefits System Availability Rule: Real Time Transaction 270/271 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 270 inquiry and returning a response. Calendar week is defined as 12:01am Sunday to 12:01am the following Sunday.	972127	N/A	99.00%	96.00%	99.00%	99.00%	96.00%	97.00%	99.00%	98.00%	98.00%

▇▇▇-▇▇▇		▇▇▇▇▇▇	▇	▇▇▇▇▇▇ ▇▇▇▇▇▇ System Availability 86% Rule	Core Rule 250 Claims status rule (276/277) refers to Core Rule 157 for system availability requirements. Real Time Transaction 276/277 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 276 inquiry and returning a 277 response. Calendar week is defined as 12:01am Sunday to 12:01am the following Sunday	34932	N/A	N/A	98.00%	99.00%	100.00%	98.00%	99.00%	100.00%	100.00%	100.00%

▇▇▇-▇		▇▇▇▇▇▇	▇	▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇ (▇▇▇▇-▇▇▇)	100%* within 10 working days. Timeliness measured from receipt date to date forwarded to the contracting provider group. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	57945	N/A	97.78%	97.44%	97.68%	96.83%	97.04%	97.09%	97.17%	95.82%	97.06%

SHP-5		Claims	5	Claims Denial Accuracy (Medi-Cal)	100%* Accuracy of Claims Denials. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	37792	25	96.00%	92.00%	100.00%	96.00%	92.00%	96.00%	96.00%	92.00%	100.00%

SHP-6		Claims	5	Denied Claims Correct Date of Receipt Recorded (Medi-Cal)	100%* accuracy of Date of Receipt recorded in the system. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	37792	25	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

SHP-7		Claims	5	Explanation for Claim Denials (Medi-Cal)	100%* accuracy of Clear Explanation of Denial Reason being on Denial Letters. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	37792	25	96.00%	100.00%	100.00%	96.00%	100.00%	100.00%	92.00%	100.00%	92.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
SHP-395	Claims	5	Eligibility Verification System Availability 86% Rule	Core Rule 157 Eligibility and Benefits System Availability Rule: Real Time Transaction 270/271 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 270 inquiry and returning a response. Calendar week is defined as 12:01am Sunday to 12:01am the following Sunday.	99.00%	98.00%	99.00%	99.00%	85.99	0	0	85.99

▇▇▇-▇▇▇	▇▇▇▇▇▇	▇	▇▇▇▇▇▇ ▇▇▇▇▇▇ System Availability 86% Rule	Core Rule 250 Claims status rule (276/277) refers to Core Rule 157 for system availability requirements. Real Time Transaction 276/277 System availability must be no less then 86 percent per calendar week for both real time and batch processing modes. System is defined as having all necessary means of processing a 276 inquiry and returning a 277 response. Calendar week is defined as 12:01am Sunday to 12:01am the following Sunday	99.00%	98.00%	99.00%	99.00%	85.99	0	0	85.99

SHP-4	Claims	5	Claim Forwarding TAT (Medi-Cal)	100%* within 10 working days. Timeliness measured from receipt date to date forwarded to the contracting provider group. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	96.69%	96.85%	97.18%	97.02%	89.99	90	94.99	95

SHP-5	Claims	5	Claims Denial Accuracy (Medi-Cal)	100%* Accuracy of Claims Denials. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	92.00%	100.00%	96.00%	LAG MONTH	89.99	90	94.99	95

SHP-6	Claims	5	Denied Claims Correct Date of Receipt Recorded (Medi-Cal)	100%* accuracy of Date of Receipt recorded in the system. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	100.00%	100.00%	100.00%	LAG MONTH	89.99	90	94.99	95

SHP-7	Claims	5	Explanation for Claim Denials (Medi-Cal)	100%* accuracy of Clear Explanation of Denial Reason being on Denial Letters. *HNCA is required to be compliant 100% of the time for Claims and Provider Disputes TATs.	100.00%	100.00%	96.00%	LAG MONTH	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

DPD

Claims

Claim Timeliness (Duals)

90% of claims processed within 30 calendar days of receipt. Follow the current Medi-Cal claims TAT standards for CMC claims in order to meet the current and more stringent ▇▇▇▇-▇▇▇▇▇ and regulatory requirements as cited in the DHCS contract and as referenced in the 3 Way Contract 2.1.3. CMS and DHCS should accept that 100% of all claims will be processed within 45 working days under the more stringent ▇▇▇▇ ▇▇▇▇▇ requirement.

ABS - Monthly Adhoc Report

New SLA

CMS & DHCS

Compliance

DPD

Claims

Claim Timeliness (Duals)

100% of claims processed within 45 working days of receipt. Follow the current Medi-Cal claims TAT standards for CMC claims in order to meet the current and more stringent ▇▇▇▇-▇▇▇▇▇ and regulatory requirements as cited in the DHCS contract and as referenced in the 3 Way Contract 2.1.3. CMS and DHCS should accept that 100% of all claims will be processed within 45 working days under the more stringent ▇▇▇▇ ▇▇▇▇▇ requirement.

ABS - Monthly Adhoc Report

New SLA

CMS & DHCS

Compliance

▇▇▇

▇▇▇▇▇▇

▇

Date of Receipt (AHCCCS)

The receipt date of the claim is the date stamp on the claim or the date electronically received. The receipt date is the day the claim is received at the Contractor’s specified claim mailing address. The Contractor shall forward all claims received to the subcontractor responsible for claims adjudication.

Quality Audit and Training (Monthly)

New SLA

AHCCCS

Compliance


Schedule B-2-1		B-2-1-70		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

DPD

Claims

Claim Timeliness (Duals)

90% of claims processed within 30 calendar days of receipt. Follow the current Medi-Cal claims TAT standards for CMC claims in order to meet the current and more stringent ▇▇▇▇- ▇▇▇▇▇ and regulatory requirements as cited in the DHCS contract and as referenced in the 3 Way Contract 2.1.3. CMS and DHCS should accept that 100% of all claims will be processed within 45 working days under the more stringent ▇▇▇▇ ▇▇▇▇▇ requirement.

DPD

Claims

Claim Timeliness (Duals)

100% of claims processed within 45 working days of receipt. Follow the current Medi-Cal claims TAT standards for CMC claims in order to meet the current and more stringent ▇▇▇▇- ▇▇▇▇▇ and regulatory requirements as cited in the DHCS contract and as referenced in the 3 Way Contract 2.1.3. CMS and DHCS should accept that 100% of all claims will be processed within 45 working days under the more stringent ▇▇▇▇ ▇▇▇▇▇ requirement.

▇▇▇

▇▇▇▇▇▇

▇

Date of Receipt (AHCCCS)


Schedule B-2-1		B-2-1-71		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Jan-2014

Feb-2014

Mar-2014

Apr-2014

RED
HI

YELLOW
LO

YELLOW
HI

GREEN
LO

DPD

Claims

Claim Timeliness (Duals)

84.99

89.99

DPD

Claims

Claim Timeliness (Duals)

100% of claims processed within 45 working days of receipt. Follow the current Medi-Cal claims TAT standards for CMC claims in order to meet the current and more stringent ▇▇▇▇- ▇▇▇▇▇ and regulatory requirements as cited in the DHCS contract and as referenced in the 3 Way Contract 2.1.3. CMS and DHCS should accept that 100% of all claims will be processed within 45 working days under the more stringent ▇▇▇▇ ▇▇▇▇▇ requirement.

89.99

94.99

▇▇▇

▇▇▇▇▇▇

▇

Date of Receipt (AHCCCS)

89.99

94.99


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

SHP

Claims

Clean Claim Tineliness (AHCCCS)

95% within 30 days: Unless a subcontract specifies otherwise, Contractors shall ensure that for each form type (Dental/Professional/Institutional) 95% of all clean claims are adjudicated within 30 days of receipt of the clean claim. The Contractor shall not pay: 1. Claims initially submitted more than six months after date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later; or 2. Claims that are submitted as clean claims more than 12 months after date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later (A.R.S.§36-2904.G). Claim payment requirements pertain to both contracted and non-contracted providers

ABS - Monthly Adhoc Report

New SLA

AHCCCS

Compliance

SHP

Claims

Clean Claim Tineliness (AHCCCS)

99% within 60 days: Unless a subcontract specifies otherwise, Contractors shall ensure that for each form type (Dental/Professional/Institutional) 99% are adjudicated within 60 days of receipt of the clean claim. The Contractor shall not pay:

1. Claims initially submitted more than six months after date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later; or

2. Claims that are submitted as clean claims more than 12 months after date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later (A.R.S.§36-2904.G). Claim payment requirements pertain to both contracted and non-contracted

ABS - Monthly Adhoc Report

New SLA

AHCCCS

Compliance

MPD

Claims

Medicare NDP Letters

30 days from denial date

Monthly report from OPUS that is sample audited for timeliness.

Measured at time of audit. Regulation is 30 days for contracted and 60 days for non-contracted. (The internal target is to process within 1 day of determination but has not been tracked for historical purposes). This measurment needs to be tracked going forward.

CMS

Compliance

95% > within the stated time frames


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

▇▇▇

▇▇▇▇▇▇

▇

Clean Claim Tineliness (AHCCCS)

1. Claims initially submitted more than six months after date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later; or

▇▇▇

▇▇▇▇▇▇

▇

Clean Claim Tineliness (AHCCCS)

1. Claims initially submitted more than six months after date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later; or

MPD

Claims

Medicare NDP Letters

30 days from denial date


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Jan-2014

Feb-2014

Mar-2014

Apr-2014

RED
HI

YELLOW
LO

YELLOW
HI

GREEN
LO

SHP

Claims

Clean Claim Tineliness (AHCCCS)

1. Claims initially submitted more than six months after date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later; or

89.99

94.99

▇▇▇

▇▇▇▇▇▇

▇

Clean Claim Tineliness (AHCCCS)

1. Claims initially submitted more than six months after date of service for which payment is claimed or after the date that eligibility is posted, whichever date is later; or

94.99

98.99

MPD

Claims

Medicare NDP Letters

30 days from denial date

89.99

94.99


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

MPD

Claims

Medicare NDP Letters

30 days from denial date

Monthly report from OPUS that is sample audited for timeliness.

CMS

Compliance

95% > within the stated time frames

MPD

Claims

Medicare NDP Letters

30 days from denial date

Monthly report from OPUS that is sample audited for timeliness.

CMS

Compliance

95% > within the stated time frames

CPD

Claims

AZ Development Letters

every 30 days from contested date

ACCESS Data Base

Measured at time of audit. Must be within 30 days with minimum of 2 attempts made. This measurement needs to be tracked going forward.

ADOI

Compliance

95% > within the stated time frames

CPD

Claims

OR Development Letters

sent once within 30 days from contested date

ACCESS Data Base

Measured at time of audit. Must be within 30 days with minimum of 2 attempts made. This measurement needs to be tracked going forward.

ORDOI

Compliance

95% > within the stated time frames

MPD

Claims

Medicare Development Letters

for non contracted providers, notification is sent of contested claim and claim must be finalized by 60th day from received date

ACCESS Data Base

Measured at time of audit. Must have a minimum of 2 attempts to get the required information within a 60 day period. This measurement needs to be tracked going forward.

CMS

Compliance

95% > within the stated time frames

MPD

Claims

Medicare Development Letters

for non contracted providers, notification is sent of contested claim and claim must be finalized by 60th day from received date

ACCESS Data Base

Measured at time of audit. Must have a minimum of 2 attempts to get the required information within a 60 day period. This measurement needs to be tracked going forward.

CMS

Compliance

95% > within the stated time frames

MPD

Claims

Medicare Development Letters

for non contracted providers, notification is sent of contested claim and claim must be finalized by 60th day from received date

ACCESS Data Base

Measured at time of audit. Must have a minimum of 2 attempts to get the required information within a 60 day period. This measurement needs to be tracked going forward.

CMS

Compliance

95% > within the stated time frames

CPD

Claims

CA Turn Around Time

99% of claims processed within 30 calendar days

Monthly report from OPUS

DMHC

Compliance

99%

CPD

Claims

OR Turn Around Time

99% of claims processed within 30 calendar days

Monthly report from OPUS

—

ORDOI

Compliance

99%

CPD

Claims

AZ Turn Around Time

99% of claims processed within 30 calendar days

Monthly report from OPUS

—

ADOI

Compliance

99%

Membership Accounting Compliance Metrics

Metric Data as of Apr-2014


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

MPD

Claims

Medicare NDP Letters

30 days from denial date

MPD

Claims

Medicare NDP Letters

30 days from denial date

CPD

Claims

AZ Development Letters

every 30 days from contested date

CPD

Claims

OR Development Letters

sent once within 30 days from contested date

MPD

Claims

Medicare Development Letters

for non contracted providers, notification is sent of contested claim and claim must be finalized by 60th day from received date

MPD

Claims

Medicare Development Letters

for non contracted providers, notification is sent of contested claim and claim must be finalized by 60th day from received date

MPD

Claims

Medicare Development Letters

for non contracted providers, notification is sent of contested claim and claim must be finalized by 60th day from received date

CPD

Claims

CA Turn Around Time

99% of claims processed within 30 calendar days

98.75%

99.39%

98.98%

99.37%

99.02%

98.40%

98.06%

96.04%

88.92%

CPD

Claims

OR Turn Around Time

99% of claims processed within 30 calendar days

98.43%

98.29%

98.54%

98.27%

97.24%

98.24%

98.40%

98.14%

98.09%

CPD

Claims

AZ Turn Around Time

99% of claims processed within 30 calendar days

98.71%

99.15%

98.42%

98.90%

96.00%

99.05%

99.43%

99.47%

98.93%

Membership Accounting Compliance Metrics

Metric Data as of Apr-2014


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
MPD	Claims	4	Medicare NDP Letters	30 days from denial date					89.99	90	94.99	95

MPD	Claims	4	Medicare NDP Letters	30 days from denial date					89.99	90	94.99	95

CPD	Claims	3	AZ Development Letters	every 30 days from contested date					89.99	90	94.99	95

CPD	Claims	2	OR Development Letters	sent once within 30 days from contested date					89.99	90	94.99	95

MPD	Claims	4	Medicare Development Letters	for non contracted providers, notification is sent of contested claim and claim must be finalized by 60th day from received date					89.99	90	94.99	95

MPD	Claims	4	Medicare Development Letters	for non contracted providers, notification is sent of contested claim and claim must be finalized by 60th day from received date					89.99	90	94.99	95

MPD	Claims	4	Medicare Development Letters	for non contracted providers, notification is sent of contested claim and claim must be finalized by 60th day from received date					89.99	90	94.99	95

CPD	Claims	1	CA Turn Around Time	99% of claims processed within 30 calendar days	84.27%	80.81%	90.44%	93.90%	89.99	90	94.99	95

CPD	Claims	2	OR Turn Around Time	99% of claims processed within 30 calendar days	97.40%	98.95%	95.07%	98.11%	89.99	90	94.99	95

CPD	Claims	3	AZ Turn Around Time	99% of claims processed within 30 calendar days	97.44%	98.94%	98.61%	98.88%	89.99	90	94.99	95

Membership Accounting Compliance Metrics

Metric Data as of Apr-2014


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

CPD

MAE

ACA- Processing ID Cards

ID cards sent within 10 business days of receiving complete and accurate enrollment information from the exchange and premium.

Manual Calculation between data from a future report extracted from ABS and data from the OCOE.

New SLA

CA/AZ

CMS/DMHC/CDI/AD OI

Compliance

99%

CPD

MAE

ACA- Processing ID Cards

The Exchange will receive the 999 file within one business day of receipt of the 834/820 file 85% of the time and within 3 business days of receiept of the 834/820 file 99% of the time within any given month.

ITG Extract

New SLA

CA/AZ

CMS/DMHC/CDI/AD OI

Compliance

99%

CPD

MAE

ACA- Effectuation of Enrollment

The exchange will receive the 834 file wthin one business day of receipt of the member’s initial payment file 85% of the time and within 3 business days of receipt of the member’s initial payment 99% of the time within any given month.

ITG Extract

New SLA

CA/AZ

CMS/DMHC/CDI/AD OI

Compliance

98%

CPD

MAE

ACA-Member Payment

The Exchange will receive the 820 file within one business day of receipt of the member’s payment file 95% of the time and within 3 business days of receipt of the member’s payment 99% of the time within any given month.

ITG Extract

New SLA

CA/AZ

CMS/DMHC/CDI/AD OI

Compliance

99%

CPD

MAE

ACA- Enrollment Change upon Non-receipt of member payment, 30 day notice and termination.

The Exchange will receive the 834 file within one business day of receipt of change of the member’s status 95% of the time and within 3 business days of reciept of the member’s status 99% of the time within any given month.

ITG Extract

New SLA

CA/AZ

CMS/DMHC/CDI/AD OI

Compliance

99%

CPD

MAE

HMO/POS Delinquency Notice

% of risk of termination notices sent to delinquent members 30 days prior to termination

Data from ODW & Access Database

New SLA, HSC 1365

DMHC

Compliance

100%

CPD

MAE

PPO/EPO Delinquency Notice

% of risk of termination notices sent to delinquent members 30 days prior to termination

Data from ODW & Access Database

New SLA, CIC 10273.4

CDI

Compliance

100%

CPD

MAE

On Exchange Delinquency Notice

% of notices sent to delinquent members with APTC three months prior to termination

Data from ODW & Access Database

New SLA, CFR 156.270

CMS, DMHC, CDI

Compliance

100%

CPD

MAE

On Exchange Delinquency Notice

% of notices sent to delinquent members with APTC three months prior to termination

Data from ODW & Access Database

New SLA, CFR 156.270

CMS/DMHC/CDI/AD OI

Compliance

100%

CPD

MAE

ACA- Reporting Cancellations

Reporting Cancellations for Non- Payment to the exchange by the 10th of the month

ITG Extract

New SLA

CMS/DMHC/CDI/AD OI

Compliance

100%

CPD

MAE

ACA- Reporting Cancellations

Reporting Cancellations for Non- Payments to the Federal Exchange by the 5th of the month

ITG Extract

New SLA

CMS/DMHC/CDI/AD OI

Compliance

100%


Schedule B-2-1		B-2-1-79		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

CPD

MAE

ACA- Processing ID Cards

ID cards sent within 10 business days of receiving complete and accurate enrollment information from the exchange and premium.

CPD

MAE

ACA- Processing ID Cards

CPD

MAE

ACA- Effectuation of Enrollment

CPD

MAE

ACA-Member Payment

CPD

MAE

ACA- Enrollment Change upon Non- receipt of member payment, 30 day notice and termination.

CPD

MAE

HMO/POS Delinquency Notice

% of risk of termination notices sent to delinquent members 30 days prior to termination

CPD

MAE

PPO/EPO Delinquency Notice

% of risk of termination notices sent to delinquent members 30 days prior to termination

CPD

MAE

On Exchange Delinquency Notice

% of notices sent to delinquent members with APTC three months prior to termination

CPD

MAE

On Exchange Delinquency Notice

% of notices sent to delinquent members with APTC three months prior to termination

CPD

MAE

ACA- Reporting Cancellations

Reporting Cancellations for Non- Payment to the exchange by the 10th of the month

CPD

MAE

ACA- Reporting Cancellations

Reporting Cancellations for Non- Payments to the Federal Exchange by the 5th of the month


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Jan-2014

Feb-2014

Mar-2014

Apr-2014

RED
HI

YELLOW
LO

YELLOW
HI

GREEN
LO

CPD

MAE

ACA- Processing ID Cards

ID cards sent within 10 business days of receiving complete and accurate enrollment information from the exchange and premium.

UNDER DEV

89.99

94.99

CPD

MAE

ACA- Processing ID Cards

UNDER DEV

89.99

94.99

CPD

MAE

ACA- Effectuation of Enrollment

UNDER DEV

89.99

94.99

CPD

MAE

ACA-Member Payment

UNDER DEV

89.99

94.99

CPD

MAE

ACA- Enrollment Change upon Non- receipt of member payment, 30 day notice and termination.

UNDER DEV

89.99

94.99

CPD

MAE

HMO/POS Delinquency Notice

% of risk of termination notices sent to delinquent members 30 days prior to termination

UNDER DEV

89.99

94.99

CPD

MAE

PPO/EPO Delinquency Notice

% of risk of termination notices sent to delinquent members 30 days prior to termination

UNDER DEV

89.99

94.99

CPD

MAE

On Exchange Delinquency Notice

% of notices sent to delinquent members with APTC three months prior to termination

UNDER DEV

89.99

94.99

CPD

MAE

On Exchange Delinquency Notice

% of notices sent to delinquent members with APTC three months prior to termination

UNDER DEV

89.99

94.99

CPD

MAE

ACA- Reporting Cancellations

Reporting Cancellations for Non- Payment to the exchange by the 10th of the month

UNDER DEV

89.99

94.99

CPD

MAE

ACA- Reporting Cancellations

Reporting Cancellations for Non- Payments to the Federal Exchange by the 5th of the month

UNDER DEV

89.99

94.99


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

CPD-663

MAE

TAT of Termination Notice due to non- payment of premium for life insurance policies

% of notices sent to the life insurance policy owner, and their designee (if individual) at least 30 days prior to the effective date of lapse or termination and within 30 days after premium is due and unpaid.

Genelco generated Report, manual tracking

—

ALL

CDI

Compliance

= 100%

CPD-673

MAE

MSP Input & TIN Reference Files - Submission Timeliness

TIN Reference File: Submitted by the assigned submission period each quarter. MSP Input File: Submitted within the assigned, 7-day submission period each quarter.

Health Net Data Warehouse automated FTP file to CMS with automated email verification from CMS of receipt

Quarterly

—

AZ & CA & OR & WA

CMS

Compliance

= 100%

CPD-674

MAE

MSP Response File Errors

Percentage of errors resolved prior to the next submission.

CMS Response file received from CMS used as a manual tracking file for % resolved.

Quarterly

AZ & CA & OR

CMS

Compliance

= 100%

DPD

MAE

ID Card Mailing Passive Enrollments

ID Cards to be in the members hands prior to their effective date

Tracked in Access Data Future report from ABS

New SLA

ALL

CMS/DHCS

Compliance

= 100%

DPD

MAE

ID Card Mailing Voluntary Enrollments

ID Cards to be mailed with in 10 days of the reciept of the TRR

Tracked in Access Data Future report from ABS

New SLA

ALL

CMS/DHCS

Compliance

= 100%

DPD-263

MAE

FIR Error transactions are corrected timely

Within 15 days, correct FIR issue so that Caremark is able to successfully transfer member’s financial Part D dollars to and from CMS’ Vendor.

SQL/Oracle back end with an Access database / front end

ALL

CMS

Compliance

100%

DPD-264

MAE

Coordination of Benefits (COB) loaded into Caremark’s system timely

During weekly processing, load COB file received from CMS into Caremark’s system for Part D claim adjudication. (NOTE: Special Business Process: Any new COB Medicare Secondary Payer (MSP) record for a member will first be validated prior to loading into Caremark and is included in the weekly processing and loading.)

SQL/Oracle back end with an Access database / front end

ALL

CMS

Compliance

= 100%

DPD-265

MAE

Prescription Drug Event (PDE) Timely Submissions to CMS

Within 30 days, ensure all Part D eligible claims are successfully submitted as a PDE to CMS.

SQL/Oracle back end with an Access database / front end

—

ALL

CMS

Compliance

= 98%

DPD-266

MAE

Prescription Drug Event (PDE) Error Timely Correction to CMS

Within 90 days, PDE Errors are corrected and submitted back to CMS and accepted by CMS. New requirement.

SQL/Oracle back end with an Access database / front end

—

ALL

CMS

Compliance

= 98%

MPD

MAE

ID Card Mailing

ID Cards to be mailed with in 10 days of the reciept of the TRR

Future report from ABS

New SLA

All

CMS

Compliance

= 100%

MPD

MAE

Member Refunds

Member refunds to be mailed with in 30 calander days

Future report from ABS

New SLA

ALL

CMS

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Universe

Sample Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

Dec-2013

▇▇▇-▇▇▇

▇▇▇

▇

▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇▇▇▇ Notice due to non- payment of premium for life insurance policies

N/A

100.00%

▇▇▇-▇▇▇

▇▇▇

▇

▇▇▇ ▇▇▇▇▇ & TIN Reference Files - Submission Timeliness

TIN Reference File: Submitted by the assigned submission period each quarter. MSP Input File: Submitted within the assigned, 7-day submission period each quarter.

N/A

50.00%

—

100.00%

—

100.00%

—

CPD-674

MAE

MSP Response File Errors

Percentage of errors resolved prior to the next submission.

7429

N/A

UNDER
DEV

49.87%

—

84.15%

—

61.70%

DPD

MAE

ID Card Mailing Passive Enrollments

ID Cards to be in the members hands prior to their effective date

DPD

MAE

ID Card Mailing Voluntary Enrollments

ID Cards to be mailed with in 10 days of the reciept of the TRR

DPD-263

MAE

FIR Error transactions are corrected timely

Within 15 days, correct FIR issue so that Caremark is able to successfully transfer member’s financial Part D dollars to and from CMS’ Vendor.

Null Universe

Null
Universe

UNDER
DEV

DPD-264

MAE

Coordination of Benefits (COB) loaded into Caremark’s system timely

Null Universe

UNDER DEV

DPD-265

MAE

Prescription Drug Event (PDE) Timely Submissions to CMS

Within 30 days, ensure all Part D eligible claims are successfully submitted as a PDE to CMS.

168

N/A

UNDER DEV

DPD-266

MAE

Prescription Drug Event (PDE) Error Timely Correction to CMS

Within 90 days, PDE Errors are corrected and submitted back to CMS and accepted by CMS. New requirement.

168

N/A

UNDER DEV

MPD

MAE

ID Card Mailing

ID Cards to be mailed with in 10 days of the reciept of the TRR

MPD

MAE

Member Refunds

Member refunds to be mailed with in 30 calander days


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
CPD-663	MAE	1	TAT of Termination Notice due to non-payment of premium for life insurance policies	% of notices sent to the life insurance policy owner, and their designee (if individual) at least 30 days prior to the effective date of lapse or termination and within 30 days after premium is due and unpaid.	100.00%	100.00%	100.00%	100.00%	89.99	90	94.99	95

CPD-673	MAE	1	MSP Input & TIN Reference Files - Submission Timeliness	TIN Reference File: Submitted by the assigned submission period each quarter. MSP Input File: Submitted within the assigned, 7-day submission period each quarter.	100.00%	—	—	100.00%	89.99	90	94.99	95

CPD-674	MAE	1	MSP Response File Errors	Percentage of errors resolved prior to the next submission.	—	—	25.58%	—	89.99	90	94.99	95

DPD	MAE	7	ID Card Mailing Passive Enrollments	ID Cards to be in the members hands prior to their effective date					94.99	0	0	95

DPD	MAE	7	ID Card Mailing Voluntary Enrollments	ID Cards to be mailed with in 10 days of the reciept of the TRR					94.99	0	0	95

DPD-263	MAE	7	FIR Error transactions are corrected timely	Within 15 days, correct FIR issue so that Caremark is able to successfully transfer member’s financial Part D dollars to and from CMS’ Vendor.	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	14	13	11	10

DPD-264	MAE	7	Coordination of Benefits (COB) loaded into Caremark’s system timely	During weekly processing, load COB file received from CMS into Caremark’s system for Part D claim adjudication. (NOTE: Special Business Process: Any new COB Medicare Secondary Payer (MSP) record for a member will first be validated prior to loading into Caremark and is included in the weekly processing and loading.)	UNDER DEV	UNDER DEV	UNDER DEV	NULL UNIVERSE	89.99	90	94.99	95

DPD-265	MAE	7	Prescription Drug Event (PDE) Timely Submissions to CMS	Within 30 days, ensure all Part D eligible claims are successfully submitted as a PDE to CMS.	UNDER DEV	UNDER DEV	UNDER DEV	100.00%	88.19	88.2	93.09	93.1

DPD-266	MAE	7	Prescription Drug Event (PDE) Error Timely Correction to CMS	Within 90 days, PDE Errors are corrected and submitted back to CMS and accepted by CMS. New requirement.	UNDER DEV	UNDER DEV	UNDER DEV	100.00%	88.19	88.2	93.09	93.1

MPD	MAE	4	ID Card Mailing	ID Cards to be mailed with in 10 days of the reciept of the TRR					94.99	0	0	95

MPD	MAE	4	Member Refunds	Member refunds to be mailed with in 30 calander days					94.99	0	0	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

MPD-1

MAE

Acknowledgment of Enrollment Request and Confirmation of Enrollment TAT, Audit Element ER05: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO, HNAZ HMO) (ABS)

Issue acknowledgment notice within 10 calendar days of receipt 100% of the time (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)

Manual using a Self Audit

•

OR & CA & AZ

CMS

Compliance

= 100%

MPD-3

MAE

Submission of Enrollment TAT: MA/Part D (H0562) (HNCA HMO) (ABS)

Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H0562)

Manual SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 90%

MPD-336

MAE

Submission of Enrollment TAT: MA/Part D (H5439) (HNCA PPO) (ABS)

Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H5439)

Manual SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 90%

MPD-337

MAE

Submission of Enrollment TAT: MA/Part D (H5520) (HNOR PPO) (ABS)

Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H5520)

Manual SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 90%

MPD-338

MAE

Submission of Enrollment TAT: MA/Part D (H6815) (HNOR HMO) (ABS)

Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H6815)

Manual SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 90%

MPD-345

MAE

LIS Processing Accuracy (H5439) (HNCA PPO) (ABS)

Greater than or equal to 95% (covers contract number: H5439)

Manual SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 95%

MPD-346

MAE

LIS Processing Accuracy (H5520) (HNOR PPO) (ABS)

Greater than or equal to 95% (covers contract number: H5520)

Manual SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 95%

MPD-347

MAE

LIS Processing Accuracy (H6815) (HNOR HMO) (ABS)

Greater than or equal to 95% (covers contract number: H6815)

Manual SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 95%

MPD-348

MAE

LIS Processing Accuracy (H0351) (HNAZ HMO) (ABS)

Greater than or equal to 95% (covers contract number: H0351)

Manual SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 95%

MPD-350

MAE

4RX Submission to CMS, Timeliness (H5439) (HNCA PPO) (ABS)

Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H5439)

Manual Reporting using TRR data via SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 99%

MPD-351

MAE

4RX Submission to CMS, Timeliness (H5520) (HNOR PPO) (ABS)

Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H5520)

Manual Reporting using TRR data via SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 99%

MPD-352

MAE

4RX Submission to CMS, Timeliness (H6815) (HNOR HMO) (ABS)

Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H6815)

Manual Reporting using TRR data via SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 99%

MPD-353

MAE

4RX Submission to CMS, Timeliness (H0351) (HNAZ HMO) (ABS)

Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H0351)

Manual Reporting using TRR data via SQL/Oracle back end with an Access database / front end

•

CMS

Compliance

>= 99%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
MPD-1	MAE	4	Acknowledgment of Enrollment Request and Confirmation of Enrollment TAT, Audit Element ER05: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO, HNAZ HMO) (ABS)	Issue acknowledgment notice within 10 calendar days of receipt 100% of the time (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)	5151	121	99.17%	100.00%	99.19%	98.23%	98.29%	100.00%	99.17%	97.67%	96.90%

MPD-3	MAE	4	Submission of Enrollment TAT: MA/Part D (H0562) (HNCA HMO) (ABS)	Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H0562)	3672	N/A	98.68%	99.10%	99.50%	99.30%	98.80%	100.00%	98.00%	97.20%	94.30%

MPD-336	MAE	4	Submission of Enrollment TAT: MA/Part D (H5439) (HNCA PPO) (ABS)	Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H5439)	52	N/A	100.00%	100.00%	100.00%	97.60%	100.00%	100.00%	94.20%	92.70%	90.10%

MPD-337	MAE	4	Submission of Enrollment TAT: MA/Part D (H5520) (HNOR PPO) (ABS)	Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H5520)	334	N/A	99.05%	97.90%	97.90%	99.10%	98.70%	100.00%	96.80%	96.50%	96.20%

MPD-338	MAE	4	Submission of Enrollment TAT: MA/Part D (H6815) (HNOR HMO) (ABS)	Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H6815)	377	N/A	98.31%	100.00%	98.20%	95.10%	100.00%	100.00%	98.70%	98.20%	96.90%

MPD-345	MAE	8	LIS Processing Accuracy (H5439) (HNCA PPO) (ABS)	Greater than or equal to 95% (covers contract number: H5439)	614	N/A	100.00%	100.00%	99.80%	99.80%	99.50%	99.30%	99.70%	99.20%	99.70%

MPD-346	MAE	8	LIS Processing Accuracy (H5520) (HNOR PPO) (ABS)	Greater than or equal to 95% (covers contract number: H5520)	5810	N/A	99.90%	99.90%	99.90%	99.80%	99.90%	99.90%	99.90%	99.50%	99.80%

MPD-347	MAE	8	LIS Processing Accuracy (H6815) (HNOR HMO) (ABS)	Greater than or equal to 95% (covers contract number: H6815)	1507	N/A	100.00%	100.00%	99.60%	100.00%	99.70%	100.00%	99.70%	99.70%	100.00%

MPD-348	MAE	8	LIS Processing Accuracy (H0351) (HNAZ HMO) (ABS)	Greater than or equal to 95% (covers contract number: H0351)	9038	N/A	99.80%	99.80%	99.70%	99.90%	99.80%	99.60%	100.00%	99.20%	99.80%

MPD-350	MAE	8	4RX Submission to CMS, Timeliness (H5439) (HNCA PPO) (ABS)	Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H5439)	3	N/A	100.00%	100.00%	N/A	100.00%	100.00%	100.00%	100.00%	0.00%	50.00%

MPD-351	MAE	8	4RX Submission to CMS, Timeliness (H5520) (HNOR PPO) (ABS)	Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H5520)	17	N/A	100.00%	N/A	N/A	100.00%	100.00%	100.00%	100.00%	83.33%	99.97%

MPD-352	MAE	8	4RX Submission to CMS, Timeliness (H6815) (HNOR HMO) (ABS)	Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H6815)	11	N/A	100.00%	100.00%	100.00%	N/A	N/A	100.00%	N/A	N/A	100.00%

MPD-353	MAE	8	4RX Submission to CMS, Timeliness (H0351) (HNAZ HMO) (ABS)	Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H0351)	26	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	99.98%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
MPD-1	MAE	4	Acknowledgment of Enrollment Request and Confirmation of Enrollment TAT, Audit Element ER05: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO, HNAZ HMO) (ABS)	Issue acknowledgment notice within 10 calendar days of receipt 100% of the time (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)	93.02%	97.46%	99.17%	LAG MONTH	94.99	0	0	95

MPD-3	MAE	4	Submission of Enrollment TAT: MA/Part D (H0562) (HNCA HMO) (ABS)	Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H0562)	97.70%	98.00%	97.00%	98.90%	89.99	0	0	90

MPD-336	MAE	4	Submission of Enrollment TAT: MA/Part D (H5439) (HNCA PPO) (ABS)	Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H5439)	93.20%	96.60%	97.60%	94.20%	89.99	0	0	90

MPD-337	MAE	4	Submission of Enrollment TAT: MA/Part D (H5520) (HNOR PPO) (ABS)	Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H5520)	92.30%	96.10%	93.30%	99.10%	89.99	0	0	90

MPD-338	MAE	4	Submission of Enrollment TAT: MA/Part D (H6815) (HNOR HMO) (ABS)	Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request. (covers contract number: H6815)	97.20%	99.00%	94.60%	98.40%	89.99	0	0	90

MPD-345	MAE	8	LIS Processing Accuracy (H5439) (HNCA PPO) (ABS)	Greater than or equal to 95% (covers contract number: H5439)	99.24%	99.40%	99.40%	99.50%	94.99	0	0	95

MPD-346	MAE	8	LIS Processing Accuracy (H5520) (HNOR PPO) (ABS)	Greater than or equal to 95% (covers contract number: H5520)	98.10%	99.00%	99.00%	98.90%	94.99	0	0	95

MPD-347	MAE	8	LIS Processing Accuracy (H6815) (HNOR HMO) (ABS)	Greater than or equal to 95% (covers contract number: H6815)	100.00%	99.60%	99.60%	99.80%	94.99	0	0	95

MPD-348	MAE	8	LIS Processing Accuracy (H0351) (HNAZ HMO) (ABS)	Greater than or equal to 95% (covers contract number: H0351)	98.96%	99.20%	99.20%	99.60%	94.99	0	0	95

MPD-350	MAE	8	4RX Submission to CMS, Timeliness (H5439) (HNCA PPO) (ABS)	Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H5439)	100.00%	N/A	100.00%	100.00%	89.99	0	0	90

MPD-351	MAE	8	4RX Submission to CMS, Timeliness (H5520) (HNOR PPO) (ABS)	Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H5520)	100.00%	100.00%	100.00%	100.00%	89.99	0	0	90

MPD-352	MAE	8	4RX Submission to CMS, Timeliness (H6815) (HNOR HMO) (ABS)	Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H6815)	100.00%	100.00%	100.00%	100.00%	89.99	0	0	90

MPD-353	MAE	8	4RX Submission to CMS, Timeliness (H0351) (HNAZ HMO) (ABS)	Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H0351)	100.00%	100.00%	100.00%	100.00%	89.99	0	0	90


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

MPD-36

MAE

Refund Timeliness, Audit Element DN04 when applicable (HNCA ▇▇▇, ▇▇▇▇ ▇▇▇, ▇▇▇▇ ▇▇▇, ▇▇▇▇ ▇▇▇, HNAZ HMO) (ABS)

Greater than or equal to 95% (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)

QA&T Monthly Self Audit

—

OR & CA & AZ

CMS

Compliance

= 100%

MPD-4

MAE

Submission of Enrollment TAT: MA/Part D (H0351) (HNAZ HMO) (ABS)

Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request (covers contract number: H0351)

QA&T Monthly Self Audit

—

CMS

Compliance

>= 90%

MPD-41

MAE

LIS Processing Accuracy (H0562) (HNCA HMO) (ABS)

Greater than or equal to 95% (covers contract number: H0562)

QA&T Monthly Self Audit

—

CMS

Compliance

>= 95%

MPD-435

MAE

Acknowledgment of Enrollment Request and Confirmation of Enrollment Notice Content Audit Element ER06: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO, HNAZ HMO) (ABS)

Notice Accuracy (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)

QA&T Monthly Self Audit

OR & CA & AZ

CMS

Compliance

= 100%

MPD-436

MAE

Acknowledgment of Disenrollment Request Notice Content , Audit Element DN03: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO) (ABS)

Submit disenrollment transaction within 7 calendar days of receipt. (covers contract numbers: H0562, H5439, H5520, H6815)

QA&T Monthly Self Audit

—

OR & CA & AZ

CMS

Compliance

= 100%

MPD-50

MAE

4RX Submission to CMS, Timeliness (H0562) (HNCA HMO) (ABS)

Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H0562)

Manual Reporting using TRR data via SQL/Oracle back end with an Access database / front end

—

CMS

Compliance

>= 99%

MPD-7

MAE

Acknowledgment of Disenrollment Request TAT, Audit Element DN02: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO, HNAZ HMO) (ABS)

Submit disenrollment transaction within 7 calendar days of receipt. (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)

QA&T Monthly Self Audit

—

OR & CA & AZ

CMS

Compliance

= 100%

MPD-79

MAE

FIR Error transactions are corrected timely

Within 30 days, correct FIR issue so that Caremark is able to successfully transfer member’s financial Part D dollars to and from CMS’ Vendor

SQL/Oracle back end with an Access database / front end

—

ALL

CMS

Compliance

= 100%

MPD-80

MAE

Coordination of Benefits (COB) loaded into Caremark’s system timely

Weekly process to load COB file received from CMS into Caremark’s system for Part D claim adjudication. NOTE Special Business Process: any new COB Medicare Secondary Payer (MSP) record for a member will first be validated prior to loading into Caremark.

SQL/Oracle back end with an Access database / front end

—

ALL

CMS

Compliance

= 100%

MPD-81

MAE

Prescription Drug Event (PDE) Timely Submissions to CMS

Within 30 days, ensure all Part D eligible claims are successfully submitted as a PDE to CMS. New requirement, developing for monthly

SQL/Oracle back end with an Access database / front end

—

ALL

CMS

Compliance

>= 98%

MPD-82

MAE

Prescription Drug Event (PDE) Error Timely Correction to CMS

Within 90 days, PDE Errors are corrected and submitted back to CMS and accepted by CMS. New requirement.

SQL/Oracle back end with an Access database / front end

ALL

CMS

Compliance

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
MPD-36	MAE	4	Refund Timeliness, Audit Element DN04 when applicable (HNCA ▇▇▇, ▇▇▇▇ ▇▇▇, ▇▇▇▇ ▇▇▇, ▇▇▇▇ ▇▇▇, HNAZ HMO) (ABS)	Greater than or equal to 95% (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)	▇▇▇	▇	▇/▇	▇/▇	▇/▇	100.00%	100.00%	N/A	100.00%	100.00%	0.00%

MPD-4	MAE	4	Submission of Enrollment TAT: MA/Part D (H0351) (HNAZ HMO) (ABS)	Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request (covers contract number: H0351)	621	N/A	98.98%	98.70%	98.90%	98.90%	98.20%	100.00%	98.10%	97.90%	95.20%

MPD-41	MAE	8	LIS Processing Accuracy (H0562) (HNCA HMO) (ABS)	Greater than or equal to 95% (covers contract number: H0562)	44695	N/A	99.90%	99.90%	99.70%	99.90%	99.90%	99.70%	99.90%	99.60%	99.50%

MPD-435	MAE	4	Acknowledgment of Enrollment Request and Confirmation of Enrollment Notice Content Audit Element ER06: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO, HNAZ HMO) (ABS)	Notice Accuracy (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)	5151	121	98.33%	96.55%	98.39%	98.23%	98.29%	96.46%	97.52%	63.57%	41.86%

MPD-436	MAE	4	Acknowledgment of Disenrollment Request Notice Content , Audit Element DN03: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO) (ABS)	Submit disenrollment transaction within 7 calendar days of receipt. (covers contract numbers: H0562, H5439, H5520, H6815)	261	30	66.67%	56.67%	100.00%	100.00%	100.00%	93.33%	100.00%	96.67%	90.00%

MPD-50	MAE	8	4RX Submission to CMS, Timeliness (H0562) (HNCA HMO) (ABS)	Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H0562)	56	N/A	100.00%	100.00%	100.00%	67.31%	100.00%	100.00%	100.00%	43.75%	99.95%

MPD-7	MAE	4	Acknowledgment of Disenrollment Request TAT, Audit Element DN02: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO, HNAZ HMO) H5439, H5520, H6815) (ABS)	Submit disenrollment transaction within 7 calendar days of receipt. (covers contract numbers: (H0351, H0562,	261	30	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	93.33%

MPD-79	MAE	8	FIR Error transactions are corrected timely	Within 30 days, correct FIR issue so that Caremark is able to successfully transfer member’s financial Part D dollars to and from CMS’ Vendor	473	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇	▇▇▇	▇	▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇ (▇▇▇) loaded into Caremark’s system timely	Weekly process to load COB file received from CMS into Caremark’s system for Part D claim adjudication. NOTE Special Business Process: any new COB Medicare Secondary Payer (MSP) record for a member will first be validated prior to loading into Caremark.	603	N/A	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-81	MAE	8	Prescription Drug Event (PDE) Timely Submissions to CMS	Within 30 days, ensure all Part D eligible claims are successfully submitted as a PDE to CMS. New requirement, developing for monthly	2577233	N/A	99.96%	99.99%	99.97%	99.97%	99.97%	99.98%	99.98%	99.98%	99.98%

MPD-82	MAE	8	Prescription Drug Event (PDE) Error Timely Correction to CMS	Within 90 days, PDE Errors are corrected and submitted back to CMS and accepted by CMS. New requirement.	65617	N/A	92.66%	91.00%	91.00%	N/A	88.00%	87.00%	87.50%	86.70%	86.70%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
MPD-36	MAE	4	Refund Timeliness, Audit Element DN04 when applicable (HNCA ▇▇▇, ▇▇▇▇ ▇▇▇, ▇▇▇▇ ▇▇▇, ▇▇▇▇ ▇▇▇, HNAZ HMO) (ABS)	Greater than or equal to 95% (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)	100.00%	N/A	100.00%	LAG MONTH	94.99	0	0	95
MPD-4	MAE	4	Submission of Enrollment TAT: MA/Part D (H0351) (HNAZ HMO) (ABS)	Submit enrollment to CMS within 7 calendar days of receipt of the completed enrollment request (covers contract number: H0351)	96.30%	98.30%	95.80%	97.40%	89.99	0	0	90
MPD-41	MAE	8	LIS Processing Accuracy (H0562) (HNCA HMO) (ABS)	Greater than or equal to 95% (covers contract number: H0562)	99.39%	99.60%	99.60%	99.70%	94.99	0	0	95
MPD-435	MAE	4	Acknowledgment of Enrollment Request and Confirmation of Enrollment Notice Content Audit Element ER06: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO, HNAZ HMO) (ABS)	Notice Accuracy (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)	33.33%	84.75%	73.55%	LAG MONTH	94.99	0	0	95
MPD-436	MAE	4	Acknowledgment of Disenrollment Request Notice Content , Audit Element DN03: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO) (ABS)	Submit disenrollment transaction within 7 calendar days of receipt. (covers contract numbers: H0562, H5439, H5520, H6815)	93.33%	96.67%	100.00%	LAG MONTH	94.99	0	0	95
MPD-50	MAE	8	4RX Submission to CMS, Timeliness (H0562) (HNCA HMO) (ABS)	Greater than or equal to 99% of the total CMS-generated enrollments are responded to within 72 hours (covers contract number: H0562)	100.00%	100.00%	100.00%	100.00%	89.99	0	0	99
MPD-7	MAE	4	Acknowledgment of Disenrollment Request TAT, Audit Element DN02: MA/Part D (HNCA HMO, HNCA PPO, HNOR PPO, HNOR HMO, HNAZ HMO) (ABS)	Submit disenrollment transaction within 7 calendar days of receipt. (covers contract numbers: (H0351, H0562, H5439, H5520, H6815)	93.33%	100.00%	100.00%	LAG MONTH	94.99	0	0	95
MPD-79	MAE	8	FIR Error transactions are corrected timely	Within 30 days, correct FIR issue so that Caremark is able to successfully transfer member’s financial Part D dollars to and from CMS’ Vendor	100.00%	100.00%	100.00%	100.00%	99.99	0	0	100
MPD-80	MAE	8	Coordination of Benefits (COB) loaded into Caremark’s system timely	Weekly process to load COB file received from CMS into Caremark’s system for Part D claim adjudication. NOTE Special Business Process: any new COB Medicare Secondary Payer (MSP) record for a member will first be validated prior to loading into Caremark.	100.00%	100.00%	100.00%	100.00%	99.99	0	0	100
MPD-81	MAE	8	Prescription Drug Event (PDE) Timely Submissions to CMS	Within 30 days, ensure all Part D eligible claims are successfully submitted as a PDE to CMS. New requirement, developing for monthly	99.98%	100.00%	100.00%	100.00%	97.99	0	0	98
MPD-82	MAE	8	Prescription Drug Event (PDE) Error Timely Correction to CMS	Within 90 days, PDE Errors are corrected and submitted back to CMS and accepted by CMS. New requirement.	100.00%	100.00%	100.00%	57.10%	99.99	0	0	100


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric
ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

MPD

MAE

OEV

The OEV letter must be mailed out to the beneficiary within fifteen (15) calendar days of receipt of the enrollment request.

OEV reporting and systems

Medicare all regions; New metric per new OEV regulations

All

MPD

Compliance

<= 15 calendar days

Medical Management Metrics

Metric Data as of Jun-2014

CPD-288

HMO/POS Routine Pre-Service Authorization Decision TAT (PG)

% of routine pre-service authorization requests decided within 5 business days of receipt of the info reasonably necessary and requested by plan to make the determination

Auditing Database

DMHC

N/A

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇ Concurrent Authorization Request Decision TAT

% of urgent concurrent authorization request decisions made within 72 hours of receipt of the info reasonably necessary and requested by plan to make the determination

Auditing Database

DMHC

N/A

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇ Pre-Service Authorization Request Decision TAT (PG)

% of urgent pre-service authorization decisions made within 72 hours of receipt of the info reasonably necessary and requested by plan to make the determination

Auditing Database

DMHC

N/A

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇ Pre-Service Authorization Request Decision TAT (PG)

% of urgent pre-service authorization requests decided within 72 hours of receipt

Auditing Database

CDI

N/A

= 100%

CPD-297

PPO/EPO Routine Pre-Service Authorization Request Initial Provider Communication

% of provider notified (communicated) within 24 hours after pre-service authorization request decision

Auditing Database

CDI

N/A

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇ Concurrent Authorization Request Resolution TAT

% of urgent concurrent authorization request decisions made within 72 hours of receipt

Auditing Database

CDI

N/A

= 100%

CPD-296

HMO/POS Notification to Provider of Decision on Pre-Service Authorization Reques

% of notifications (communications) to requesting providers of pre-service authorization decision made within 24 hours after decision

Auditing Database

—

DMHC

N/A

= 100%

CPD-290

HMO/POS Post-Service Authorization Request Resolution TAT

% of retrospective review (post-service authorization) decisions within 30 calendar days of receipt of the info reasonably necessary to make the determination

Auditing Database

—

DMHC

N/A

= 100%

CPD-311

HMO/POS Second Opinion Authorization Request Resolution TAT

% of second opinion urgent requests decided within 72 hours of receipt

Auditing Database

—

DMHC

N/A

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
MPD	MAE	4	OEV	The OEV letter must be mailed out to the beneficiary within fifteen (15) calendar days of receipt of the enrollment request.	N/ A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A

Medical Management Metrics
Metric Data as of Jun-2014

CPD-288	MM	1	HMO/POS Routine Pre-Service Authorization Decision TAT (PG)	% of routine pre-service authorization requests decided within 5 business days of receipt of the info reasonably necessary and requested by plan to make the determination	167	30	100.00%	97.00%		93.00%	100.00%	100.00%	80.00%	90.00%	73.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Concurrent Authorization Request Decision TAT	% of urgent concurrent authorization request decisions made within 72 hours of receipt of the info reasonably necessary and requested by plan to make the determination	76	30	100.00%	97.00%		100.00%	86.67%	97.00%	93.33%	93.00%	93.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Pre-Service Authorization Request Decision TAT (PG)	% of urgent pre-service authorization decisions made within 72 hours of receipt of the info reasonably necessary and requested by plan to make the determination	127	30	93.00%	100.00%		100.00%	100.00%	100.00%	100.00%	97.00%	87.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Pre-Service Authorization Request Decision TAT (PG)	% of urgent pre-service authorization requests decided within 72 hours of receipt	314	30	100.00%	100.00%		100.00%	100.00%	100.00%	93.33%	100.00%	97.00%

CPD-297	MM	1	PPO/EPO Routine Pre-Service Authorization Request Initial Provider Communication	% of provider notified (communicated) within 24 hours after pre-service authorization request decision	249	30	100.00%	100.00%		100.00%	96.67%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Concurrent Authorization Request Resolution TAT	% of urgent concurrent authorization request decisions made within 72 hours of receipt	253	30	97.00%	100.00%		100.00%	96.67%	97.00%	100.00%	97.00%	100.00%

CPD-296	MM		HMO/POS Notification to Provider of Decision on Pre-Service Authorization Reques	% of notifications (communications) to requesting providers of pre-service authorization decision made within 24 hours after decision	294	8	100.00%	100.00%		100.00%	96.67%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇-▇▇▇▇▇▇▇ Authorization Request Resolution TAT	% of retrospective review (post-service authorization) decisions within 30 calendar days of receipt of the info reasonably necessary to make the determination	8	N/A	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Opinion Authorization Request Resolution TAT	% of second opinion urgent requests decided within 72 hours of receipt	1	N/A	100.00%	0.00%		100.00%	NULL UNIVERSE	100.00%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE


Schedule B-2-1		B-2-1-92		Health Net / Cognizant Confidential

Final

Metric
ID

Tower

Group
Code

Metric
Name

Metric Measure

Jan-2014

Feb-2014

Mar-2014

Apr-2014

RED
HI

YELLOW
LO

YELLOW
HI

GREEN
LO

MPD

MAE

OEV

The OEV letter must be mailed out to the beneficiary within fifteen (15) calendar days of receipt of the enrollment request.

N/A

15.01

Medical Management Metrics

Metric Data as of Jun-2014


CPD-288	MM	1	HMO/POS Routine Pre-Service Authorization Decision TAT (PG)	% of routine pre-service authorization requests decided within 5 business days of receipt of the info reasonably necessary and requested by plan to make the determination	100.00%	80.00%	76.67%	90.00%	89.99	90	94.99	95
▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Concurrent Authorization Request Decision TAT	% of urgent concurrent authorization request decisions made within 72 hours of receipt of the info reasonably necessary and requested by plan to make the determination	93.33%	86.67%	76.67%	76.67%	89.99	90	94.99	95
▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Pre-Service Authorization Request Decision TAT (PG)	% of urgent pre-service authorization decisions made within 72 hours of receipt of the info reasonably necessary and requested by plan to make the determination	93.33%	96.67%	86.67%	93.33%	89.99	90	94.99	▇▇
▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Pre-Service Authorization Request Decision TAT (PG)	% of urgent pre-service authorization requests decided within 72 hours of receipt	93.33%	100.00%	100.00%	93.33%	89.99	90	94.99	95
CPD-297	MM	1	PPO/EPO Routine Pre-Service Authorization Request Initial Provider Communication	% of provider notified (communicated) within 24 hours after pre-service authorization request decision	96.67%	100.00%	96.67%	100.00%	89.99	90	94.99	▇▇
▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ Concurrent Authorization Request Resolution TAT	% of urgent concurrent authorization request decisions made within 72 hours of receipt	86.67%	96.67%	100.00%	93.33%	89.99	90	94.99	95
CPD-296	MM	1	HMO/POS Notification to Provider of Decision on Pre-Service Authorization Reques	% of notifications (communications) to requesting providers of pre-service authorization decision made within 24 hours after decision	96.67%	100.00%	100.00%	98.36%	89.99	90	94.99	95
CPD-290	MM	1	HMO/POS Post-Service Authorization Request Resolution TAT	% of retrospective review (post-service authorization) decisions within 30 calendar days of receipt of the info reasonably necessary to make the determination	92.31%	100.00%	100.00%	100.00%	89.99	90	94.99	▇▇
▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇ Authorization Request Resolution TAT	% of second opinion urgent requests decided within 72 hours of receipt	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric
ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

CPD-301

HMO/POS Written Notice to Member of Pre-Service Authorization Request Denial, De

% of written notices sent to members regarding pre-service authorization requests denials, delays or modifications within 2 business days of decision

Auditing Database

—

DMHC

N/A

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇ Notification to Provider of Denial, Delay or Modification of Pre

% of written notifications to providers of pre-service authorization request denial, delay or modifications within 2 business days of decision

Auditing Database

—

DMHC

N/A

= 100%

CPD-319

HMO/PPO Standard Pre-Service Auth TAT

within ten (10) business days after receipt of request

Auditing Database

—

ADOI

N/A

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Review Authorization Request Provider Communication TAT

% of providers notified within 24 hours after concurrent review authorization request decision

Auditing Database

—

CDI

N/A

= 100%

CPD-291

PPO/EPO Post-Service Authorization Request Resolution TAT

% of post-service authorization request decisions made within 30 calendar days of receipt

Auditing Database

—

CDI

N/A

= 100%

CPD-300

PPO/EPO Pre-Service Authorization Denial Member Communication TAT

% of written notices sent to members regarding pre-service authorization requests denials, delays or modifications within 2 business days of decision

Auditing Database

—

CDI

N/A

= 100%

CPD-289

PPO/EPO Routine Pre-Service Authorization Request Decision TAT (PG)

% of routine pre-service authorization requests decided within 5 business days of receipt of the info reasonably necessary and requested by plan to make the determination

Auditing Database

—

CDI

N/A

= 100%

CPD-298

PPO/EPO Routine Pre-Service Authorization Request Provider Written Communication

% of provider letters sent written notification within 2 business days after pre-service authorization request denial decision

Auditing Database

—

CDI

N/A

= 100%

CPD-322

Urgent Pre-Service Authorization Request Resolution TAT

% of urgent pre-service authorization request decision made within 72 hours or 2 business days, whichever is first, of receipt

Auditing Database

—

OID

N/A

= 100%

CPD-337

Authorization Request for Immediate Request Situations TAT

% of authorization request decisions for immediate request situations made within 1 business day when the lack of treatment may result in an emergency visit or emergency admission

Auditing Database

OIC

N/A

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇ to Enrollee with Terminal Illness of Reasons for Denying Authoriz

% of notices to enrollees with a terminal illness with reasons for denying authorization coverage request within 5 business days of receipt

Auditing Database

DMHC

N/A

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇ Notice to Member of Pre-Service Authorization Request Denial, De	% of written notices sent to members regarding pre-service authorization requests denials, delays or modifications within 2 business days of decision	35	8	100.00%	100.00%		97.00%	100.00%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇ Notification to Provider of Denial, Delay or Modification of Pre	% of written notifications to providers of pre-service authorization request denial, delay or modifications within 2 business days of decision	35	8	100.00%	100.00%		97.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-319	MM	3	HMO/PPO Standard Pre-Service Auth TAT	within ten (10) business days after receipt of request	2	N/A	100.00%	100.00%		100.00%	100.00%	100.00%	96.67%	100.00%	90.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Review Authorization Request Provider Communication TAT	% of providers notified within 24 hours after concurrent review authorization request decision	253	30	100.00%	100.00%		93.00%	100.00%	100.00%	100.00%	97.00%	100.00%

CPD-291	MM	1	PPO/EPO Post-Service Authorization Request Resolution TAT	% of post-service authorization request decisions made within 30 calendar days of receipt	16	8	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇-▇▇▇▇▇▇▇ Authorization Denial Member Communication TAT	% of written notices sent to members regarding pre-service authorization requests denials, delays or modifications within 2 business days of decision	32	8	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-289	MM	1	PPO/EPO Routine Pre-Service Authorization Request Decision TAT (PG)	% of routine pre-service authorization requests decided within 5 business days of receipt of the info reasonably necessary and requested by plan to make the determination	249	8	100.00%	100.00%		97.00%	100.00%	100.00%	100.00%	100.00%	100.00%

CPD-298	MM	1	PPO/EPO Routine Pre-Service Authorization Request Provider Written Communication	% of provider letters sent written notification within 2 business days after pre-service authorization request denial decision	17	8	100.00%	100.00%		100.00%	96.67%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇▇▇ Pre-Service Authorization Request Resolution TAT	% of urgent pre-service authorization request decision made within 72 hours or 2 business days, whichever is first, of receipt	1	N/A	93.00%	100.00%		100.00%	100.00%	97.00%	100.00%	100.00%	100.00%

CPD-337	MM	2	Authorization Request for Immediate Request Situations TAT	% of authorization request decisions for immediate request situations made within 1 business day when the lack of treatment may result in an emergency visit or emergency admission	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE		NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

CPD-306	MM	1	HMO/POS Notice to Enrollee with Terminal Illness of Reasons for Denying Authoriz	% of notices to enrollees with a terminal illness with reasons for denying authorization coverage request within 5 business days of receipt	NULL UNIVERSE	NULL UNIVERSE									NULL UNIVERSE


Schedule B-2-1		B-2-1-95		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
CPD-301	MM	1	HMO/POS Written Notice to Member of Pre-Service Authorization Request Denial, De	% of written notices sent to members regarding pre-service authorization requests denials, delays or modifications within 2 business days of decision	100.00%	100.00%	100.00%	100.00%	89.99	90	94.99	▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇ Notification to Provider of Denial, Delay or Modification of Pre	% of written notifications to providers of pre-service authorization request denial, delay or modifications within 2 business days of decision	100.00%	100.00%	100.00%	100.00%	89.99	90	94.99	95

CPD-319	MM	3	HMO/PPO Standard Pre-Service Auth TAT	within ten (10) business days after receipt of request	100.00%	NULL UNIVERSE	NULL UNIVERSE	100.00%	89.99	90	94.99	▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Review Authorization Request Provider Communication TAT	% of providers notified within 24 hours after concurrent review authorization request decision	100.00%	100.00%	90.00%	95.67%	89.99	90	94.99	95

CPD-291	MM	1	PPO/EPO Post-Service Authorization Request Resolution TAT	% of post-service authorization request decisions made within 30 calendar days of receipt	100.00%	100.00%	100.00%	100.00%	89.99	90	94.99	95

CPD-300	MM	1	PPO/EPO Pre-Service Authorization Denial Member Communication TAT	% of written notices sent to members regarding pre-service authorization requests denials, delays or modifications within 2 business days of decision	100.00%	100.00%	100.00%	100.00%	89.99	90	94.99	95

CPD-289	MM	1	PPO/EPO Routine Pre-Service Authorization Request Decision TAT (PG)	% of routine pre-service authorization requests decided within 5 business days of receipt of the info reasonably necessary and requested by plan to make the determination	100.00%	100.00%	90.00%	100.00%	89.99	90	94.99	95

CPD-298	MM	1	PPO/EPO Routine Pre-Service Authorization Request Provider Written Communication	% of provider letters sent written notification within 2 business days after pre-service authorization request denial decision	100.00%	100.00%	100.00%	100.00%	89.99	90	94.99	95

CPD-322	MM	2	Urgent Pre-Service Authorization Request Resolution TAT	% of urgent pre-service authorization request decision made within 72 hours or 2 business days, whichever is first, of receipt	100.00%	100.00%	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

CPD-337	MM	2	Authorization Request for Immediate Request Situations TAT	% of authorization request decisions for immediate request situations made within 1 business day when the lack of treatment may result in an emergency visit or emergency admission	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇ to Enrollee with Terminal Illness of Reasons for Denying Authoriz	% of notices to enrollees with a terminal illness with reasons for denying authorization coverage request within 5 business days of receipt	—	NULL UNIVERSE	—	—	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric
ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

CPD-307

HMO/POS TAT for Notice to Enrollee with Terminal Illness Providing Opportunity t

% of notices sent to enrollees with terminal illness notifying them of the opportunity for a conference within 30 calendar days of receipt of a complaint form

Auditing Database

DMHC

N/A

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇ Notice to Member of Concurrent Authorization Request Denial, Del

% of written notices sent to members regarding concurrent authorization requests denials, delays or modifications within 2 business days of decision

Auditing Database

DMHC

N/A

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇ Notification to Provider of Denial, Delay or Modification of Con

% of written notices sent to providers within 2 business days of denial, delay or modification for concurrent review authorization request

Auditing Database

DMHC

N/A

= 100%

CPD-320

HMO/PPO Expedited Service Auth TAT

within 72 hours of receipt of request

Auditing Database

ADOI

N/A

= 100%

CPD-334

Post-Service Authorization Request Resolution TAT

% of post-service authorization request decisions made within 30 calendar days of receipt of all nec info or expiration of the deadline to respond

Auditing Database

OIC

N/A

= 100%

CPD-324

Post-Service Authorization Resolution Request TAT

% of post-service review requests decided within 30 calendar days of receipt

Auditing Database

OID

N/A

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Review Authorization Denial Member Written Communication TAT

% of written notices sent to enrollees within 2 business days of denial for concurrent review authorization request

Auditing Database

CDI

N/A

= 100%

CPD-308

PPO/EPO TAT to provide the enrollee an opportunity to attend a conference after

% of reviews conducted for enrollees requesting review after denial for request for experimental treatment for enrollee with terminal illness within 30 calendar days of the request or within 5 business days if the treating physician and medical director

Auditing Database

CDI

N/A

= 100%

CPD-339

Pre-Service Authorization Request for Experimental/Investigational Service Resol

% of pre-service authorization requests for experimental/investigational services made within 20 business days of receipt of a fully documented request

Auditing Database

OIC

N/A

= 100%

CPD-323

Routine Pre-Service Authorization Request Resolution TAT

% of routine pre-service authorization request decision made within 2 business days of receipt

Auditing Database

OID

N/A

= 100%

CPD-333

Routine Pre-Service Authorization Request Resolution TAT

% of routine pre-service authorization requests decisions made within 5 calendar days of receipt of all nec info or expiration of the deadline to respond

Auditing Database

OIC

N/A

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric
ID

Tower

Group
Code

Metric Name

Metric
Measure

Universe

Sample
Size

Apr-2013

May-2013

Jun-2013

Jul-2013

Aug-2013

Sep-2013

Oct-2013

Nov-2013

▇▇▇-▇▇▇▇

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇ for Notice to Enrollee with Terminal Illness Providing Opportunity t

% of notices sent to enrollees with terminal illness notifying them of the opportunity for a conference within 30 calendar days of receipt of a complaint form

NULL
UNIVERSE

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇ Notice to Member of Concurrent Authorization Request Denial, Del

% of written notices sent to members regarding concurrent authorization requests denials, delays or modifications within 2 business days of decision

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇ Notification to Provider of Denial, Delay or Modification of Con

% of written notices sent to providers within 2 business days of denial, delay or modification for concurrent review authorization request

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

CPD-320

HMO/PPO Expedited Service Auth TAT

within 72 hours of receipt of request

NULL
UNIVERSE

100.00%

97.00%

100.00%

CPD-334

Post-Service Authorization Request Resolution TAT

% of post-service authorization request decisions made within 30 calendar days of receipt of all nec info or expiration of the deadline to respond

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

100.00%

CPD-324

Post-Service Authorization Resolution Request TAT

% of post-service review requests decided within 30 calendar days of receipt

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

100.00%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Review Authorization Denial Member Written Communication TAT

% of written notices sent to enrollees within 2 business days of denial for concurrent review authorization request

NULL
UNIVERSE

100.00%

NULL
UNIVERSE

CPD-308

PPO/EPO TAT to provide the enrollee an opportunity to attend a conference after

NULL
UNIVERSE

CPD-339

Pre-Service Authorization Request for Experimental/Investigational Service Resol

% of pre-service authorization requests for experimental/investigational services made within 20 business days of receipt of a fully documented request

NULL
UNIVERSE

CPD-323

Routine Pre-Service Authorization Request Resolution TAT

% of routine pre-service authorization request decision made within 2 business days of receipt

NULL
UNIVERSE

100.00%

97.00%

100.00%

97.00%

100.00%

CPD-333

Routine Pre-Service Authorization Request Resolution TAT

% of routine pre-service authorization requests decisions made within 5 calendar days of receipt of all nec info or expiration of the deadline to respond

NULL
UNIVERSE

100.00%

96.67%

100.00%

97.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
CPD-307	MM	1	HMO/POS TAT for Notice to Enrollee with Terminal Illness Providing Opportunity t	% of notices sent to enrollees with terminal illness notifying them of the opportunity for a conference within 30 calendar days of receipt of a complaint form	—	NULL UNIVERSE	—	—	89.99	90	94.99	95

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇ Notice to Member of Concurrent Authorization Request Denial, Del	% of written notices sent to members regarding concurrent authorization requests denials, delays or modifications within 2 business days of decision	100.00%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇ Notification to Provider of Denial, Delay or Modification of Con	% of written notices sent to providers within 2 business days of denial, delay or modification for concurrent review authorization request	100.00%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

CPD-320	MM	3	HMO/PPO Expedited Service Auth TAT	within 72 hours of receipt of request	100.00%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

CPD-334	MM	2	Post-Service Authorization Request Resolution TAT	% of post-service authorization request decisions made within 30 calendar days of receipt of all nec info or expiration of the deadline to respond	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

CPD-324	MM	2	Post-Service Authorization Resolution Request TAT	% of post-service review requests decided within 30 calendar days of receipt	100.00%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇/▇▇▇ ▇▇▇▇▇▇▇▇▇▇ Review Authorization Denial Member Written Communication TAT	% of written notices sent to enrollees within 2 business days of denial for concurrent review authorization request	100.00%	0.00%	100.00%	NULL UNIVERSE	89.99	90	94.99	95

CPD-308	MM	1	PPO/EPO TAT to provide the enrollee an opportunity to attend a conference after	% of reviews conducted for enrollees requesting review after denial for request for experimental treatment for enrollee with terminal illness within 30 calendar days of the request or within 5 business days if the treating physician and medical director	—	NULL UNIVERSE	—	—	89.99	90	94.99	95

CPD-339	MM	2	Pre-Service Authorization Request for Experimental/Investigational Service Resol	% of pre-service authorization requests for experimental/investigational services made within 20 business days of receipt of a fully documented request	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

CPD-323	MM	2	Routine Pre-Service Authorization Request Resolution TAT	% of routine pre-service authorization request decision made within 2 business days of receipt	100.00%	NULL UNIVERSE	100.00%	0.00%	89.99	90	94.99	95

CPD-333	MM	2	Routine Pre-Service Authorization Request Resolution TAT	% of routine pre-service authorization requests decisions made within 5 calendar days of receipt of all nec info or expiration of the deadline to respond	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

Metric
ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

CPD-335

Urgent Concurrent Authorization Decision TAT

% of urgent concurrent authorization request decisions made no later than 24 hours of receipt of all nec info or expiration of the deadline to respond

Auditing Database

OIC

N/A

= 100%

CPD-332

Urgent Pre-Service Authorization Request Resolution TAT

% of urgent pre-service authorization request decisions made within 48 hours of receipt of all nec info or expiration of the deadline to respond

Auditing Database

OIC

N/A

= 100%

CPD-336

Written Notification Provider and Enrollee of Urgent Denial TAT

% of authorization request decisions for immediate request situations made within 1 business day when the lack of treatment may result in an emergency visit or emergency admission

Auditing Database

OIC

N/A

= 100%

MPD-160

OP01 - Adverse Standard Pre-Service Organization Determinations (Timeliness) (AZ

% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing

Auditing Database

CMS

= 100%

MPD-175

OP04 - Requests for Expedited Organization Determinations (Timeliness) (CA)

% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing

Auditing Database

CMS

= 100%

MPD-212

OP15 - Detailed Notice of Discharge of Inpatient Hospital Care(OR)

% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification

Auditing Database

CMS

= 100%

MPD-162

OP04 - Requests for Expedited Organization Determinations (Timeliness) (AZ)

Auditing Database

CMS

= 100%

MPD-188

OP04 - Requests for Expedited Organization Determinations (Timeliness) (CA PPO)

Auditing Database

CMS

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
CPD-335	MM	2	Urgent Concurrent Authorization Decision TAT	% of urgent concurrent authorization request decisions made no later than 24 hours of receipt of all nec info or expiration of the deadline to respond	NULL UNIVERSE	NULL UNIVERSE	82.00%	86.00%		85.00%	78.57%	70.00%	90.00%	87.00%	60.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇▇▇ Pre-Service Authorization Request Resolution TAT	% of urgent pre-service authorization request decisions made within 48 hours of receipt of all nec info or expiration of the deadline to respond	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%		94.00%	94.74%	92.00%	96.43%	100.00%	100.00%

CPD-336	MM	2	Written Notification Provider and Enrollee of Urgent Denial TAT	% of authorization request decisions for immediate request situations made within 1 business day when the lack of treatment may result in an emergency visit or emergency admission	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE		100.00%	100.00%	NULL UNIVERSE	NULL UNIVERSE	0.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (AZ	% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	11	N/A	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-175	MM	4	OP04 - Requests for Expedited Organization Determinations (Timeliness) (CA)	% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	22	N/A	94.00%	100.00%		100.00%	100.00%	100.00%	100.00%	NULL UNIVERSE	81.00%

MPD-212	MM	4	OP15 - Detailed Notice of Discharge of Inpatient Hospital Care(OR)	% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification	1	N/A	NULL UNIVERSE	100.00%		NULL UNIVERSE	NULL UNIVERSE	100.00%	NULL UNIVERSE	NULL UNIVERSE	100.00%

MPD-162	MM	4	OP04 - Requests for Expedited Organization Determinations (Timeliness) (AZ)	% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	183	30	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-188	MM	4	OP04 - Requests for Expedited Organization Determinations (Timeliness) (CA PPO)	% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	41	30	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		▇▇▇▇▇▇ ▇▇▇ / ▇▇▇▇▇▇▇▇▇ Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
CPD-335	MM	2	Urgent Concurrent Authorization Decision TAT	% of urgent concurrent authorization request decisions made no later than 24 hours of receipt of all nec info or expiration of the deadline to respond	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

CPD-332	MM	2	Urgent Pre-Service Authorization Request Resolution TAT	% of urgent pre-service authorization request decisions made within 48 hours of receipt of all nec info or expiration of the deadline to respond	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

CPD-336	MM	2	Written Notification Provider and Enrollee of Urgent Denial TAT	% of authorization request decisions for immediate request situations made within 1 business day when the lack of treatment may result in an emergency visit or emergency admission	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (AZ	% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	100.00%	100.00%	100.00%	100.00%	89.99	90	94.99	95

MPD-175	MM	4	OP04 - Requests for Expedited Organization Determinations (Timeliness) (CA)	% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	85.71%	100.00%	85.71%	94.12%	89.99	90	94.99	95

MPD-212	MM	4	OP15 - Detailed Notice of Discharge of Inpatient Hospital Care(OR)	% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

MPD-162	MM	4	OP04 - Requests for Expedited Organization Determinations (Timeliness) (AZ)	% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	96.67%	96.67%	90.00%	90.00%	89.99	90	94.99	95

MPD-188	MM	4	OP04 - Requests for Expedited Organization Determinations (Timeliness) (CA PPO)	% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	100.00%	83.33%	100.00%	90.00%	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

MPD-173

OP01 - Adverse Standard Pre-Service Organization Determinations (Timeliness) (CA

Auditing Database

—

CMS

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (CA

Auditing Database

—

CMS

=
100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (OR

Auditing Database

—

CMS

=
100%

MPD-320

OP01 - Adverse Standard Pre-Service Organization Determinations (Timeliness) (OR

Auditing Database

—

CMS

=
100%

MPD-201

OP04 - Requests for Expedited Organization Determinations (Timeliness) (OR)

Auditing Database

—

CMS

=
100%

MPD-321

OP04 - Requests for Expedited Organization Determinations (Timeliness) (OR HMO)

Auditing Database

—

CMS

=
100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside

% requests correctly distinguished as an organization determination and not a reconsideration

Auditing Database

—

CMS

=
100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside

% requests correctly distinguished as an organization determination and not a reconsideration

Auditing Database

—

CMS

=
100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside

% requests correctly distinguished as an organization determination and not a reconsideration

Auditing Database

—

CMS

=
100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	▇▇▇-▇▇▇▇
▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (CA	% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	15	N/A	86.00%	100.00%		100.00%	100.00%	97.00%	93.00%	91.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (CA	% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	1	N/A	83.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (OR	% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	12	N/A	100.00%	100.00%		100.00%	96.67%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (OR	% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	4	N/A	100.00%	100.00%		100.00%	100.00%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	100.00%

MPD-201	MM	4	OP04 - Requests for Expedited Organization Determinations (Timeliness) (OR)	% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	223	30	93.00%	100.00%		NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	97.00%

MPD-321	MM	4	OP04 - Requests for Expedited Organization Determinations (Timeliness) (OR HMO)	% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	85	30	100.00%	100.00%		NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside	% requests correctly distinguished as an organization determination and not a reconsideration	194	41	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside	% requests correctly distinguished as an organization determination and not a reconsideration	37	N/A	100.00%	100.00%		100.00%	100.00%	100.00%	97.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside	% requests correctly distinguished as an organization determination and not a reconsideration	42	31	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		▇▇▇▇▇▇ ▇▇▇ / ▇▇▇▇▇▇▇▇▇ Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI		YELLOW LO		YELLOW HI		GREEN LO
MPD-173	MM	4	OP01 - Adverse Standard Pre-Service Organization Determinations (Timeliness) (CA	% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (CA	% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (OR	% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	100.00%	90.00%	100.00%	100.00%		89.99		90		94.99		▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇ Standard Pre-Service Organization Determinations (Timeliness) (OR	% Enrollee notification of an adverse determination no later than 14 calendar days after receiving the request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	100.00%	100.00%	100.00%	85.71%		89.99		90		94.99		95

MPD-201	MM	4	OP04 - Requests for Expedited Organization Determinations (Timeliness) (OR)	% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	96.67%	100.00%	83.33%	86.67%		89.99		90		94.99		95

MPD-321	MM	4	OP04 - Requests for Expedited Organization Determinations (Timeliness) (OR HMO)	% Enrollees notified of the expedited organization determination (favorable or adverse) within 72 hours of request Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	100.00%	100.00%	96.67%	83.33%		89.99		90		94.99		▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside	% requests correctly distinguished as an organization determination and not a reconsideration	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside	% requests correctly distinguished as an organization determination and not a reconsideration	100.00%	100.00%	96.88%	100.00%		89.99		90		94.99		▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside	% requests correctly distinguished as an organization determination and not a reconsideration	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		95


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		Health Net / Cognizant Confidential

Final

Metric
ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

MPD-205

OP08 - Correctly Distinguishes Between Organization Determinations and Reconside

% requests correctly distinguished as an organization determination and not a reconsideration

Auditing Database

—

CMS

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside

% requests correctly distinguished as an organization determination and not a reconsideration

Auditing Database

—

CMS

= 100%

MPD-168

OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (

% Enrollees notified of favorable determinations within 14 calendar days of request.

Auditing Database

—

CMS

= 100%

MPD-181

OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (

% Enrollees notified of favorable determinations within 14 calendar days of request.

Auditing Database

—

CMS

= 100%

MPD-194

OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (

% Enrollees notified of favorable determinations within 14 calendar days of request.

Auditing Database

—

CMS

= 100%

MPD-207

OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (

% Enrollees notified of favorable determinations within 14 calendar days of request.

Auditing Database

—

CMS

= 100%

MPD-323

OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (

% Enrollees notified of favorable determinations within 14 calendar days of request.

Auditing Database

—

CMS

= 100%

MPD-169

OP12 - Detailed Explanation of Non- Coverage of Provider Services (Timeliness) (A

Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing

Auditing Database

—

CMS

= 100%

MPD-182

OP12 - Detailed Explanation of Non- Coverage of Provider Services (Timeliness) (C

% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received

Auditing Database

—

CMS

= 100%

MPD-195

OP12 - Detailed Explanation of Non- Coverage of Provider Services (Timeliness) (C

% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received

Auditing Database

—

CMS

= 100%

MPD-209

OP12 - Detailed Explanation of Non- Coverage of Provider Services (Timeliness) (O

% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received

Auditing Database

—

CMS

= 100%

MPD-324

OP12 - Detailed Explanation of Non- Coverage of Provider Services (Timeliness) (O

% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received

Auditing Database

—

CMS

= 100%

MPD-172

OP15 - Detailed Notice of Discharge of Inpatient Hospital Care (AZ)

% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification

Auditing Database

—

CMS

= 100%

MPD-185

OP15 - Detailed Notice of Discharge of Inpatient Hospital Care (CA)

% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification

Auditing Database

CMS

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	▇▇▇-▇▇▇▇
▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside	% requests correctly distinguished as an organization determination and not a reconsideration	235	42	100.00%	100.00%		100.00%	97.67%	100.00%	97.00%	100.00%	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside	% requests correctly distinguished as an organization determination and not a reconsideration	89	34	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-168	MM	4	OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (	% Enrollees notified of favorable determinations within 14 calendar days of request.	1090	30	97.00%	97.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-181	MM	4	OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (	% Enrollees notified of favorable determinations within 14 calendar days of request.	42	30	90.00%	93.00%		NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	100.00%

MPD-194	MM	4	OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (	% Enrollees notified of favorable determinations within 14 calendar days of request.	75	30	100.00%	100.00%		100.00%	100.00%	100.00%	NULL UNIVERSE	100.00%	100.00%

MPD-207	MM	4	OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (	% Enrollees notified of favorable determinations within 14 calendar days of request.	1391	30	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

MPD-323	MM	4	OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (	% Enrollees notified of favorable determinations within 14 calendar days of request.	423	30	93.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	97.00%

MPD-169	MM	4	OP12 - Detailed Explanation of Non-Coverage of Provider Services (Timeliness) (A	Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	1	N/A	100.00%	100.00%		100.00%	100.00%	97.00%	100.00%	100.00%	100.00%

MPD-182	MM	4	OP12 - Detailed Explanation of Non-Coverage of Provider Services (Timeliness) (C	% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received	23	N/A	100.00%	94.00%		NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	100.00%

MPD-195	MM	4	OP12 - Detailed Explanation of Non-Coverage of Provider Services (Timeliness) (C	% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received	2	N/A	100.00%	100.00%		NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	100.00%

MPD-209	MM	4	OP12 - Detailed Explanation of Non-Coverage of Provider Services (Timeliness) (O	% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received	18	N/A	100.00%	100.00%		NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	100.00%

MPD-324	MM	4	OP12 - Detailed Explanation of Non-Coverage of Provider Services (Timeliness) (O	% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received	2	N/A	NULL UNIVERSE	NULL UNIVERSE		94.75%	94.20%	96.21%	96.12%	96.35%	UNIVERSE NULL

MPD-172	MM	4	OP15 - Detailed Notice of Discharge of Inpatient Hospital Care (AZ)	% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification	1	N/A	NULL UNIVERSE	NULL UNIVERSE		13.61%	13.28%	15.67%	14.66%	13.64%	UNIVERSE NULL

MPD-185	MM	4	OP15 - Detailed Notice of Discharge of Inpatient Hospital Care (CA)	% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%		1.40%	184.00%	1.25%	1.97%	2.32%	100.00%


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI		YELLOW LO		YELLOW HI		GREEN LO
MPD-205	MM	4	OP08 - Correctly Distinguishes Between Organization Determinations and Reconside	% requests correctly distinguished as an organization determination and not a reconsideration	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		▇▇

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇ - ▇▇▇▇▇▇▇▇▇ Distinguishes Between Organization Determinations and Reconside	% requests correctly distinguished as an organization determination and not a reconsideration	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		95

MPD-168	MM	4	OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (	% Enrollees notified of favorable determinations within 14 calendar days of request.	100.00%	96.67%	100.00%	96.67%		89.99		90		94.99		95

MPD-181	MM	4	OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (	% Enrollees notified of favorable determinations within 14 calendar days of request.	100.00%	96.67%	96.43%	100.00%		89.99		90		94.99		95

MPD-194	MM	4	OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (	% Enrollees notified of favorable determinations within 14 calendar days of request.	100.00%	96.67%	100.00%	96.67%		89.99		90		94.99		95

MPD-207	MM	4	OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (	% Enrollees notified of favorable determinations within 14 calendar days of request.	96.67%	100.00%	96.67%	100.00%		89.99		90		94.99		95

MPD-323	MM	4	OP09 - Favorable Standard Pre-Service Organization Determinations (Timeliness) (	% Enrollees notified of favorable determinations within 14 calendar days of request.	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		95

MPD-169	MM	4	OP12 - Detailed Explanation of Non-Coverage of Provider Services (Timeliness) (A	Decision TAT is all inclusive of Reciept date until member is notified by oral or in writing	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		95

MPD-182	MM	4	OP12 - Detailed Explanation of Non-Coverage of Provider Services (Timeliness) (C	% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received	96.67%	96.43%	100.00%	100.00%		89.99		90		94.99		95

MPD-195	MM	4	OP12 - Detailed Explanation of Non-Coverage of Provider Services (Timeliness) (C	% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE		89.99		90		94.99		95

MPD-209	MM	4	OP12 - Detailed Explanation of Non-Coverage of Provider Services (Timeliness) (O	% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received	100.00%	100.00%	100.00%	100.00%		89.99		90		94.99		95

MPD-324	MM	4	OP12 - Detailed Explanation of Non-Coverage of Provider Services (Timeliness) (O	% of cases in which a written DENC notice is issued to the enrollee by the close of business on the day the QIO notification is received	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE		89.99		90		94.99		95

MPD-172	MM	4	OP15 - Detailed Notice of Discharge of Inpatient Hospital Care (AZ)	% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification	NULL UNIVERSE	100.00%	NULL UNIVERSE	100.00%		89.99		90		94.99		95

MPD-185	MM	4	OP15 - Detailed Notice of Discharge of Inpatient Hospital Care (CA)	% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification	75.00%	100.00%	100.00%	100.00%		89.99		90		94.99		95


Schedule B-2-1		B-2-1-108		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric
Type

Target

MPD-198

OP15 - Detailed Notice of Discharge of Inpatient Hospital Care (CA PPO)

% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification

Auditing Database

CMS

= 100%

MPD-326

OP15 - Detailed Notice of Discharge of Inpatient Hospital Care(OR HMO)

% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification

Auditing Database

CMS

= 100%

SHP-181

CalViva Medi-Cal Expedited Authorizations-extension needed TAT

Decision to pend within 3 calendar days of receipt of request and decision to approve, deny or modify within 1 working day (24 hrs) of receipt of requested info necessary to render decision.

Auditing Database

DMHC,
NCQA,
DHS

CalViva

= 100%

SHP-173

Medi-Cal Expedited Authorizations-extension needed TAT

Within 3 calendar days of receipt of a request, a decision must be made to approve, deny, or note the decision is ‘pending’. Decisions noted as ‘pending’ require further information from the provider. For requests noted as ‘pending’, a decision to approve, deny or modify must be done within 1 business day of receipt of the additional information.

Excel TAT report

DMHC,
NCQA,
DHS

Medi-Cal

= 100%

SHP-179

CalViva Medi-Cal Routine Authorizations-extension needed TAT

Decision to pend within 5 working days. Decision to approve, deny or modify no longer than 28 calendar days of receipt of request if additional info is necessary to render decision

Excel TAT report

DMHC,
NCQA,
DHS

CalViva

= 100%

SHP-381

AHCCCS Prior Authorization TAT (Expedited)

A request for the authorization of services which the provider or a Contractor determines that using the standard timeframe could seriously jeopardize the member’s life or health or the ability to attain, maintain or regain maximum function. The Contractor must make an expedited authorization decision and provide notice as expeditiously as the member’s health condition requires but no later than 3 working days following the receipt of the authorization request.

Excel TAT report

—

AHCCCS

= 100%

SHP-380

AHCCCS Prior Authorization TAT (Standard)

A request for the authorization of services for which a Contractor must provide a decision as expeditiously as the member’s health condition requires, but not later than 14 calendar days following the receipt of the authorization request.

Excel TAT report

—

AHCCCS

= 100%


Schedule B-2-1		B-2-1-109		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
MPD-198	MM	4	OP15 - Detailed Notice of Discharge of Inpatient Hospital Care (CA PPO)	% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification	NULL UNIVERSE	NULL UNIVERSE	100.00%	NULL UNIVERSE		21.34%	15.63%	18.90%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

MPD-326	MM	4	OP15 - Detailed Notice of Discharge of Inpatient Hospital Care(OR HMO)	% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE		17.90%	19.19%	16.50%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

SHP-181	MM	5	CalViva Medi-Cal Expedited Authorizations-extension needed TAT	Decision to pend within 3 calendar days of receipt of request and decision to approve, deny or modify within 1 working day (24 hrs) of receipt of requested info necessary to render decision.	10	N/A	100.00%	100.00%		100.00%	100.00%	NULL UNIVERSE	100.00%	100.00%	100.00%

SHP-173	MM	5	Medi-Cal Expedited Authorizations- extension needed TAT	Within 3 calendar days of receipt of a request, a decision must be made to approve, deny, or note the decision is ‘pending’. Decisions noted as ‘pending’ require further information from the provider. For requests noted as ‘pending’, a decision to approve, deny or modify must be done within 1 business day of receipt of the additional information.	10	N/A	50.00%	100.00%		NULL UNIVERSE	100.00%	100.00%	100.00%	100.00%	100.00%

SHP-179	MM	5	CalViva Medi-Cal Routine Authorizations-extension needed TAT	Decision to pend within 5 working days. Decision to approve, deny or modify no longer than 28 calendar days of receipt of request if additional info is necessary to render decision	45	30	100.00%	98.50%		100.00%	100.00%	100.00%	100.00%	97.40%	100.00%

SHP-381	MM	6	AHCCCS Prior Authorization TAT (Expedited)	A request for the authorization of services which the provider or a Contractor determines that using the standard timeframe could seriously jeopardize the member’s life or health or the ability to attain, maintain or regain maximum function. The Contractor must make an expedited authorization decision and provide notice as expeditiously as the member’s health condition requires but no later than 3 working days following the receipt of the authorization request.	98	N/A	-	-		-	-	-	-	-	-

SHP-380	MM	6	AHCCCS Prior Authorization TAT (Standard)	A request for the authorization of services for which a Contractor must provide a decision as expeditiously as the member’s health condition requires, but not later than 14 calendar days following the receipt of the authorization request.	278	N/A	-	-		-	-	-	-	-	-


Schedule B-2-1		B-2-1-110		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
MPD-198	MM	4	OP15—Detailed Notice of Discharge of Inpatient Hospital Care (CA PPO)	% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification	NULL UNIVERSE	100.00%	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

MPD-326	MM	4	OP15—Detailed Notice of Discharge of Inpatient Hospital Care(OR HMO)	% of cases in which the Detailed Notice of Discharge was provided to the enrollee no later than noon of the day after QIO’s notification	NULL UNIVERSE	100.00%	100.00%	NULL UNIVERSE	89.99	90	94.99	95

SHP-181	MM	5	CalViva Medi-Cal Expedited Authorizations-extension needed TAT	Decision to pend within 3 calendar days of receipt of request and decision to approve, deny or modify within 1 working day (24 hrs) of receipt of requested info necessary to render decision.	87.50%	100.00%	100.00%	100.00%	89.99	90	94.99	95

SHP-173	MM	5	Medi-Cal Expedited Authorizations- extension needed TAT	Within 3 calendar days of receipt of a request, a decision must be made to approve, deny, or note the decision is ‘pending’. Decisions noted as ‘pending’ require further information from the provider. For requests noted as ‘pending’, a decision to approve, deny or modify must be done within 1 business day of receipt of the additional information.	100.00%	100.00%	100.00%	80.00%	89.99	90	94.99	95

SHP-179	MM	5	CalViva Medi-Cal Routine Authorizations-extension needed TAT	Decision to pend within 5 working days. Decision to approve, deny or modify no longer than 28 calendar days of receipt of request if additional info is necessary to render decision	92.00%	97.50%	97.62%	93.75%	89.99	90	94.99	95

SHP-381	MM	6	AHCCCS Prior Authorization TAT (Expedited)	A request for the authorization of services which the provider or a Contractor determines that using the standard timeframe could seriously jeopardize the member’s life or health or the ability to attain, maintain or regain maximum function. The Contractor must make an expedited authorization decision and provide notice as expeditiously as the member’s health condition requires but no later than 3 working days following the receipt of the authorization request.	100.00%	97.92%	100.00%	100.00%	94.99	95	96.99	97

SHP-380	MM	6	AHCCCS Prior Authorization TAT (Standard)	A request for the authorization of services for which a Contractor must provide a decision as expeditiously as the member’s health condition requires, but not later than 14 calendar days following the receipt of the authorization request.	100.00%	100.00%	99.49%	100.00%	94.99	95	96.99	97


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		Health Net / Cognizant Confidential

Final

Metric ID

Tower

Group
Code

Metric Name

Metric Measure

Measurement Tools

Comment

Status

Location

Regulator

Metric Type

Target

SHP-185

CalViva Medi-Cal Concurrent expedited Auth Resolution TAT

Decision within 1 calendar day (24 hrs) of receipt of the request.

Excel TAT report

—

DMHC, NCQA, DHS

CalViva

= 100%

SHP-180

CalViva Medi-Cal Expedited Authorizations TAT

Decision within 3 calendar days (72 hours) of recpt of request

Excel TAT report

—

DMHC, NCQA, DHS

CalViva

= 100%

SHP-178

CalViva Medi-cal Routine Authorizations TAT

decision within 5 working days of recpt of request

Excel TAT report

—

DMHC, NCQA, DHS

CalViva

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇-▇▇▇ ▇▇▇▇▇▇▇▇▇▇ expedited Auth Resolution TAT

Decision within 1 calendar days (24 hrs) of receipt of the request

Excel TAT report

—

DMHC, NCQA, DHS

Medi-Cal

= 100%

SHP-172

Medi-Cal Expedited Authorizations TAT

Decision within 3 calendar days (72 hours) of recpt of request

Excel TAT report

—

DMHC, NCQA, DHS

Medi-Cal

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇-▇▇▇ ▇▇▇▇-▇▇▇▇▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇ Review Auth Resolution TAT

Decision within 30 calendar days of receipt of request

Excel TAT report

—

DMHC, NCQA, DHS

Medi-Cal

= 100%

SHP-171

Medi-Cal Routine Authorizations- extension needed TAT

Decision to pend within 5 working days. Decision to approve, deny or modify no longer than 28 calendar days of receipt of request if additional info is necessary to render decision

Excel TAT report

—

DMHC, NCQA, DHS

Medi-Cal

= 100%

SHP-170

Medi-Cal Routine Authorizations TAT

Decision within 5 working days of recpt of request

Excel TAT report

—

DMHC, NCQA, DHS

Medi-Cal

= 100%

SHP-183

CalViva Medi-Cal Post- Service/Retrospective Review Auth Resolution-extension nee

Decision to pend within 30 calendar days of receipt of requested info necessary to render decision

Excel TAT report

DMHC, NCQA, DHS

CalViva

= 100%

SHP-182

CalViva Medi-Cal Post- Service/Retrospective Review Auth Resolution TAT

Decision within 30 calendar days of receipt of request

Excel TAT report

DMHC, NCQA, DHS

CalViva

= 100%

▇▇▇-▇▇▇

▇▇

▇

▇▇▇▇-▇▇▇ ▇▇▇▇-▇▇▇▇▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇ Review Auth Resolution-extension needed TAT

Decision within 30 calendar days of receipt of requested info necessary to render decision

Excel TAT report

DMHC, NCQA, DHS

Medi-Cal

= 100%


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		Health Net / Cognizant Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Universe	Sample Size	Apr-2013	May-2013	Jun-2013	Jul-2013	Aug-2013	Sep-2013	Oct-2013	Nov-2013	Dec-2013
SHP-185	MM	5	CalViva Medi-Cal Concurrent expedited Auth Resolution TAT	Decision within 1 calendar day (24 hrs) of receipt of the request.	1	N/A	63.60%	100.00%		87.50%	100.00%	91.70%	100.00%	100.00%	100.00%

SHP-180	MM	5	CalViva Medi-Cal Expedited Authorizations TAT	Decision within 3 calendar days (72 hours) of recpt of request	521	31	99.50%	99.10%		98.70%	99.30%	99.80%	99.50%	96.90%	99.20%

SHP-178	MM	5	CalViva Medi-cal Routine Authorizations TAT	decision within 5 working days of recpt of request	2201	31	99.40%	99.60%		99.20%	99.50%	99.50%	99.70%	100.00%	99.50%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇-▇▇▇ ▇▇▇▇▇▇▇▇▇▇ expedited Auth Resolution TAT	Decision within 1 calendar days (24 hrs) of receipt of the request	67	N/A	76.10%	97.70%		97.20%	100.00%	97.30%	98.00%	100.00%	98.10%

SHP-172	MM	5	Medi-Cal Expedited Authorizations TAT	Decision within 3 calendar days (72 hours) of recpt of request	394	33	98.50%	99.10%		99.40%	98.00%	99.70%	98.70%	100.00%	99.20%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇-▇▇▇ ▇▇▇▇-▇▇▇▇▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇ Review Auth Resolution TAT	Decision within 30 calendar days of receipt of request	2	N/A	100.00%	100.00%		100.00%	100.00%	100.00%	100.00%	100.00%	100.00%

SHP-171	MM	5	Medi-Cal Routine Authorizations- extension needed TAT	Decision to pend within 5 working days. Decision to approve, deny or modify no longer than 28 calendar days of receipt of request if additional info is necessary to render decision	58	30	100.00%	100.00%		98.40%	100.00%	100.00%	98.60%	98.30%	100.00%

SHP-170	MM	5	Medi-Cal Routine Authorizations TAT	Decision within 5 working days of recpt of request	1724	31	99.60%	99.70%		99.40%	99.70%	99.90%	99.70%	99.80%	99.80%

SHP-183	MM	5	CalViva Medi-Cal Post- Service/Retrospective Review Auth Resolution-extension nee	Decision to pend within 30 calendar days of receipt of requested info necessary to render decision	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE		NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE

SHP-182	MM	5	CalViva Medi-Cal Post- Service/Retrospective Review Auth Resolution TAT	Decision within 30 calendar days of receipt of request	NULL UNIVERSE	NULL UNIVERSE	100.00%	100.00%		100.00%	100.00%	100.00%	NULL UNIVERSE	NULL UNIVERSE	100.00%

▇▇▇-▇▇▇	▇▇	▇	▇▇▇▇-▇▇▇ ▇▇▇▇-▇▇▇▇▇▇▇/▇▇▇▇▇▇▇▇▇▇▇▇▇ Review Auth Resolution-extension needed TAT	Decision within 30 calendar days of receipt of requested info necessary to render decision	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE		NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		▇▇▇▇▇▇ ▇▇▇ / ▇▇▇▇▇▇▇▇▇ Confidential

Final


Metric ID	Tower	Group Code	Metric Name	Metric Measure	Jan-2014	Feb-2014	Mar-2014	Apr-2014	RED HI	YELLOW LO	YELLOW HI	GREEN LO
SHP-185	MM	5	CalViva Medi-Cal Concurrent expedited Auth Resolution TAT	Decision within 1 calendar day (24 hrs) of receipt of the request.	100.00%	90.00%	75.00%	50.00%	89.99	90	94.99	95

SHP-180	MM	5	CalViva Medi-Cal Expedited Authorizations TAT	Decision within 3 calendar days (72 hours) of recpt of request	97.71%	98.66%	97.36%	98.44%	89.99	90	94.99	95

SHP-178	MM	5	CalViva Medi-cal Routine Authorizations TAT	decision within 5 working days of recpt of request	99.23%	98.81%	98.77%	98.17%	89.99	90	94.99	95

SHP-177	MM	5	Medi-Cal Concurrent expedited Auth Resolution TAT	Decision within 1 calendar days (24 hrs) of receipt of the request	94.00%	100.00%	91.43%	83.33%	89.99	90	94.99	95

SHP-172	MM	5	Medi-Cal Expedited Authorizations TAT	Decision within 3 calendar days (72 hours) of recpt of request	95.97%	98.88%	98.46%	94.35%	89.99	90	94.99	95

SHP-174	MM	5	Medi-Cal Post-Service/Retrospective Review Auth Resolution TAT	Decision within 30 calendar days of receipt of request	100.00%	100.00%	NULL UNIVERSE	100.00%	89.99	90	94.99	95

SHP-171	MM	5	Medi-Cal Routine Authorizations- extension needed TAT	Decision to pend within 5 working days. Decision to approve, deny or modify no longer than 28 calendar days of receipt of request if additional info is necessary to render decision	96.30%	90.24%	97.62%	91.18%	89.99	90	94.99	95

SHP-170	MM	5	Medi-Cal Routine Authorizations TAT	Decision within 5 working days of recpt of request	98.98%	97.94%	98.39%	97.41%	89.99	90	94.99	95

SHP-183	MM	5	CalViva Medi-Cal Post- Service/Retrospective Review Auth Resolution-extension nee	Decision to pend within 30 calendar days of receipt of requested info necessary to render decision	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

SHP-182	MM	5	CalViva Medi-Cal Post- Service/Retrospective Review Auth Resolution TAT	Decision within 30 calendar days of receipt of request	100.00%	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95

SHP-175	MM	5	Medi-Cal Post-Service/Retrospective Review Auth Resolution-extension needed TAT	Decision within 30 calendar days of receipt of requested info necessary to render decision	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	NULL UNIVERSE	89.99	90	94.99	95


Schedule ▇-▇-▇		▇-▇-▇-▇▇▇		Health Net / Cognizant Confidential

MSA Schedule B-2-2

SCHEDULE B-2-2

PAYMENT OF FINES THAT COVER CRITICAL COMPLIANCE SERVICE LEVEL

FAILURES

***

[Represents 1 page of material pursuant to a request for confidential treatment under Rule 24b-2 of the Securities Exchange Act of 1934 which has been filed separately with the Securities and Exchange Commission]

MSA Schedule B-3

SCHEDULE B-3

*** Measures

***

[Represents 13 pages of material pursuant to a request for confidential treatment under Rule 24b-2 of the Securities Exchange Act of 1934 which has been filed separately with the Securities and Exchange Commission]

Final

SCHEDULE B-3-1

STANDARDS FOR NEW OR MODIFIED

*** SERVICE LEVELS


Schedule B-3-1				Health Net / Cognizant Confidential

Final

TABLE OF CONTENTS


HNAZ CORPORATE PERFORMANCE STANDARDS FOR OPERATIONS			2

1.	DISTRIBUTION OF ID CARDS		3
	1.1	PROPOSED PERFORMANCE STANDARD	3
	1.2	PERFORMANCE STANDARD METHODOLOGY	3
	1.3	NOTES	3

2.	ID CARD ACCURACY RATE		4
	2.1	PROPOSED PERFORMANCE STANDARD	4
	2.2	PERFORMANCE STANDARD METHODOLOGY	4
	2.3	NOTES	4

3.	ELIGIBILITY DATA		5
	3.1	PROPOSED PERFORMANCE STANDARD	5
	3.2	PERFORMANCE STANDARD METHODOLOGY	5
	3.3	NOTES	5

4.	CLAIMS PROCESSING TURNAROUND TIME		6
	4.1	PROPOSED PERFORMANCE STANDARDS	6
	4.2	PERFORMANCE STANDARD METHODOLOGY	6
	4.3	NOTES	6

5.	CLAIM FINANCIAL ACCURACY		7
	5.1	PROPOSED PERFORMANCE STANDARD	7
	5.2	PERFORMANCE STANDARD METHODOLOGY	7
	5.3	NOTES	7

6.	CLAIM PROCEDURAL ACCURACY		8
	6.1	PROPOSED PERFORMANCE STANDARD	8
	6.2	PERFORMANCE STANDARD METHODOLOGY	8
	6.3	NOTES	8

7.	CLAIM PAYMENT ACCURACY		9
	7.1	PROPOSED PERFORMANCE STANDARD	9
	7.2	PERFORMANCE STANDARD METHODOLOGY	9
	7.3	NOTES	9

8.	CLAIM OVERALL PROCESSING		10
	8.1	PROPOSED PERFORMANCE STANDARD	10
	8.2	PERFORMANCE STANDARD METHODOLOGY	10
	8.3	NOTES	10


Schedule B-3-1		B-3-1-i		Health Net / Cognizant Confidential

Final



9.	RESPONSE TO TELEPHONE INQUIRIES		11
	9.1	PROPOSED PERFORMANCE STANDARD	11
	9.2	PERFORMANCE STANDARD METHODOLOGY	11
	9.3	NOTES	11

10.	TELEPHONE ABANDONMENT RATE		12
	10.1	PROPOSED PERFORMANCE STANDARD	12
	10.2	PERFORMANCE STANDARD METHODOLOGY	12
	10.3	NOTES	12

11.	INITIAL CALL RESOLUTION		13
	11.1	PROPOSED PERFORMANCE STANDARD	13
	11.2	PERFORMANCE STANDARD METHODOLOGY	13
	11.3	NOTES	13

12.	RESPONSE TO WRITTEN INQUIRIES		14
	12.1	PROPOSED PERFORMANCE STANDARDS	14
	12.2	PERFORMANCE STANDARD METHODOLOGY	14
	12.3	NOTES	14

13.	RESPONSE TIME TO APPEALS		15
	13.1	PROPOSED PERFORMANCE STANDARDS	15
	13.2	PERFORMANCE STANDARD METHODOLOGY	15
	13.3	NOTES	15

14.	RESPONSE TIME TO GRIEVANCES		16
	14.1	PROPOSED PERFORMANCE STANDARDS	16
	14.2	PERFORMANCE STANDARD METHODOLOGY	16
	14.3	NOTES	16

HNCA CORPORATE PERFORMANCE STANDARDS FOR OPERATIONS			17

15.	DISTRIBUTION OF ID CARDS		18
	15.1	PROPOSED PERFORMANCE STANDARD	18
	15.2	PERFORMANCE STANDARD METHODOLOGY	18
	15.3	NOTES	18

16.	ID CARD ACCURACY RATE		19
	16.1	PROPOSED PERFORMANCE STANDARD	19
	16.2	PERFORMANCE STANDARD METHODOLOGY	19
	16.3	NOTES	19

17.	ELIGIBILITY DATA		20
	17.1	PROPOSED PERFORMANCE STANDARD	20


Schedule B-3-1		B-3-1-ii		Health Net / Cognizant Confidential

Final


	17.2	PERFORMANCE STANDARD METHODOLOGY	20
	17.3	NOTES	20

18.	CLAIMS PROCESSING TURNAROUND TIME		21
	18.1	PROPOSED PERFORMANCE STANDARDS	21
	18.2	PERFORMANCE STANDARD METHODOLOGY	21
	18.3	NOTES	21

19.	CLAIM FINANCIAL ACCURACY		22
	19.1	PROPOSED PERFORMANCE STANDARD	22
	19.2	PERFORMANCE STANDARD METHODOLOGY	22
	19.3	NOTES	22

20.	CLAIM PROCEDURAL ACCURACY		23
	20.1	PROPOSED PERFORMANCE STANDARD	23
	20.2	PERFORMANCE STANDARD METHODOLOGY	23
	20.3	NOTES	23

21.	CLAIM PAYMENT ACCURACY		24
	21.1	PROPOSED PERFORMANCE STANDARD	24
	21.2	PERFORMANCE STANDARD METHODOLOGY	24
	21.3	NOTES	24

22.	CLAIM OVERALL PROCESSING		25
	22.1	PROPOSED PERFORMANCE STANDARD	25
	22.2	PERFORMANCE STANDARD METHODOLOGY	25
	22.3	NOTES	25

23.	RESPONSE TO TELEPHONE INQUIRIES		26
	23.1	PROPOSED PERFORMANCE STANDARD	26
	23.2	PERFORMANCE STANDARD METHODOLOGY	26
	23.3	NOTES	26

24.	TELEPHONE ABANDONMENT RATE		27
	24.1	PROPOSED PERFORMANCE STANDARD	27
	24.2	PERFORMANCE STANDARD METHODOLOGY	27
	24.3	NOTES	27

25.	INITIAL CALL RESOLUTION		28
	25.1	PROPOSED PERFORMANCE STANDARD	28
	25.2	PERFORMANCE STANDARD METHODOLOGY	28
	25.3	NOTES	28


Schedule B-3-1		B-3-1-iii		Health Net / Cognizant Confidential

Final



26.	RESPONSE TO WRITTEN INQUIRIES		29
	26.1	PROPOSED PERFORMANCE STANDARDS	29
	26.2	PERFORMANCE STANDARD METHODOLOGY	29
	26.3	NOTES	29

27.	RESPONSE TO WRITTEN INQUIRIES - MEDICARE		30
	27.1	PROPOSED PERFORMANCE STANDARDS	30
	27.2	PERFORMANCE STANDARD METHODOLOGY	30
	27.3	NOTES	30

28.	RESPONSE TIME TO APPEALS		31
	28.1	PROPOSED PERFORMANCE STANDARDS	31
	28.2	PERFORMANCE STANDARD METHODOLOGY	31
	28.3	NOTES	31

29.	RESPONSE TIME TO APPEALS - MEDICARE		32
	29.1	PROPOSED PERFORMANCE STANDARDS	32
	29.2	PERFORMANCE STANDARD METHODOLOGY	32
	29.3	NOTES	32

30.	RESPONSE TIME TO GRIEVANCES		33
	30.1	PROPOSED PERFORMANCE STANDARDS	33
	30.2	PERFORMANCE STANDARD METHODOLOGY	33
	30.3	NOTES	33

31.	RESPONSE TIME TO GRIEVANCES - MEDICARE		34
	31.1	PROPOSED PERFORMANCE STANDARDS	34
	31.2	PERFORMANCE STANDARD METHODOLOGY	34
	31.3	NOTES	34

HNOR CORPORATE PERFORMANCE STANDARDS FOR OPERATIONS			35

32.	DISTRIBUTION OF ID CARDS		36
	32.1	PROPOSED PERFORMANCE STANDARD	36
	32.2	PERFORMANCE STANDARD METHODOLOGY	36
	32.3	NOTES	36

33.	ID CARD ACCURACY RATE		37
	33.1	PROPOSED STANDARD PERFORMANCE	37
	33.2	PERFORMANCE STANDARD METHODOLOGY	37
	33.3	NOTES	37

34.	ELIGIBILITY DATA		38
	34.1	PROPOSED STANDARD METHODOLOGY	38


Schedule B-3-1		B-3-1-iv		Health Net / Cognizant Confidential

Final


	34.2	PERFORMANCE STANDARD METHODOLOGY	38
	34.3	NOTES	38

35.	CLAIMS PROCESSING TURNAROUND TIME		39
	35.1	PROPOSED PERFORMANCE STANDARDS	39
	35.2	PERFORMANCE STANDARD METHODOLOGY	39
	35.3	NOTES	39

36.	CLAIM FINANCIAL ACCURACY		40
	36.1	PROPOSED PERFORMANCE STANDARD	40
	36.2	PERFORMANCE STANDARD METHODOLOGY	40
	36.3	NOTES	40

37.	CLAIM PROCEDURAL ACCURACY		41
	37.1	PROPOSED PERFORMANCE STANDARD	41
	37.2	PERFORMANCE STANDARD METHODOLOGY	41
	37.3	NOTES	41

38.	CLAIM PAYMENT ACCURACY		42
	38.1	PROPOSED PERFORMANCE STANDARD	42
	38.2	PERFORMANCE STANDARD METHODOLOGY	42
	38.3	NOTES	42

39.	CLAIM OVERALL PROCESSING		43
	39.1	PROPOSED PERFORMANCE STANDARD	43
	39.2	PERFORMANCE STANDARD METHODOLOGY	43
	39.3	NOTES	43

40.	RESPONSE TO TELEPHONE INQUIRIES		44
	40.1	PROPOSED PERFORMANCE STANDARD	44
	40.2	PERFORMANCE STANDARD METHODOLOGY	44
	40.3	NOTES	44

41.	TELEPHONE ABANDONMENT RATE		45
	41.1	PROPOSED PERFORMANCE STANDARD	45
	41.2	PERFORMANCE STANDARD METHODOLOGY	45
	41.3	NOTES	45

42.	INITIAL CALL RESOLUTION		46
	42.1	PROPOSED PERFORMANCE STANDARD	46
	42.2	PERFORMANCE STANDARD METHODOLOGY	46
	42.3	NOTES	46


Schedule B-3-1		B-3-1-v		Health Net / Cognizant Confidential

Final



43.	RESPONSE TO WRITTEN INQUIRIES		47
	43.1	PROPOSED PERFORMANCE STANDARDS	47
	43.2	PERFORMANCE STANDARD METHODOLOGY	47
	43.3	NOTES	47

[2015] MHN * PRODUCT: BEHAVIORAL HEALTH**

[2015] MHN * PRODUCT: EAP**


Schedule B-3-1		B-3-1-vi		Health Net / Cognizant Confidential

DRAFT

SCHEDULE B-3-1

STANDARDS FOR NEW OR MODIFIED

*** SERVICE LEVELS

CONTENTS

This Schedule B-3-1 (Standards for New or Modified *** Group Service Levels) consists of the following standards:

•

HNAZ Corporate Performance Standards for Operations - August 2014

•

HNCA Corporate Performance Standards for Operations - August 2014

•

HNOR Corporate Performance Standards for Operations - August 2014

•

MHN Behavioral Health *** Template for Operations - August 2014

•

MHN EAP *** Template for Operations - August 2014


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

HNAZ CORPORATE PERFORMANCE STANDARDS FOR OPERATIONS

(Membership, Claims, Customer Service, A&G, Correspondence)

August 2014


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

1. DISTRIBUTION OF ID CARDS

1.1

PROPOSED PERFORMANCE STANDARD

***

1.2

PERFORMANCE STANDARD METHODOLOGY

***

1.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

2. ID CARD ACCURACY RATE

2.1

PROPOSED PERFORMANCE STANDARD

***

2.2

PERFORMANCE STANDARD METHODOLOGY

***

2.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

3. ELIGIBILITY DATA

3.1

PROPOSED PERFORMANCE STANDARD

***

3.2

PERFORMANCE STANDARD METHODOLOGY

***

3.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

4. CLAIMS PROCESSING TURNAROUND TIME

4.1

PROPOSED PERFORMANCE STANDARDS

***

4.2

PERFORMANCE STANDARD METHODOLOGY

***

4.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

▇▇▇▇▇

▇. CLAIM FINANCIAL ACCURACY

5.1

PROPOSED PERFORMANCE STANDARD

***

5.2

PERFORMANCE STANDARD METHODOLOGY

***

5.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

6. CLAIM PROCEDURAL ACCURACY

6.1

PROPOSED PERFORMANCE STANDARD

***

6.2

PERFORMANCE STANDARD METHODOLOGY

***

6.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

7. CLAIM PAYMENT ACCURACY

7.1

PROPOSED PERFORMANCE STANDARD

***

7.2

PERFORMANCE STANDARD METHODOLOGY

***

7.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇		Health Net / Cognizant Confidential

Final

8. CLAIM OVERALL PROCESSING

8.1

PROPOSED PERFORMANCE STANDARD

***

8.2

PERFORMANCE STANDARD METHODOLOGY

***

8.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

9. RESPONSE TO TELEPHONE INQUIRIES

9.1

PROPOSED PERFORMANCE STANDARD

***

9.2

PERFORMANCE STANDARD METHODOLOGY

***

9.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

10. TELEPHONE ABANDONMENT RATE

10.1

PROPOSED PERFORMANCE STANDARD

***

10.2

PERFORMANCE STANDARD METHODOLOGY

***

10.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

11. INITIAL CALL RESOLUTION

11.1

PROPOSED PERFORMANCE STANDARD

***

11.2

PERFORMANCE STANDARD METHODOLOGY

***

11.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

12. RESPONSE TO WRITTEN INQUIRIES

12.1

PROPOSED PERFORMANCE STANDARDS

***

12.2

PERFORMANCE STANDARD METHODOLOGY

***

12.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

13. RESPONSE TIME TO APPEALS

13.1

PROPOSED PERFORMANCE STANDARDS

***

13.2

PERFORMANCE STANDARD METHODOLOGY

***

13.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

14. RESPONSE TIME TO GRIEVANCES

14.1

PROPOSED PERFORMANCE STANDARDS

***

14.2

PERFORMANCE STANDARD METHODOLOGY

***

14.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

HNCA CORPORATE PERFORMANCE STANDARDS FOR OPERATIONS

(Membership, Claims, Customer Service, A&G, Correspondence)

August 2014


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

15. DISTRIBUTION OF ID CARDS

15.1

PROPOSED PERFORMANCE STANDARD

***

15.2

PERFORMANCE STANDARD METHODOLOGY

***

15.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

16. ID CARD ACCURACY RATE

16.1

PROPOSED PERFORMANCE STANDARD

***

16.2

PERFORMANCE STANDARD METHODOLOGY

***

16.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

17. ELIGIBILITY DATA

17.1

PROPOSED PERFORMANCE STANDARD

***

17.2

PERFORMANCE STANDARD METHODOLOGY

***

17.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

18. CLAIMS PROCESSING TURNAROUND TIME

18.1

PROPOSED PERFORMANCE STANDARDS

***

18.2

PERFORMANCE STANDARD METHODOLOGY

***

18.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

DRAFT

19. CLAIM FINANCIAL ACCURACY

19.1

PROPOSED PERFORMANCE STANDARD

***

19.2

PERFORMANCE STANDARD METHODOLOGY

***

19.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

20. CLAIM PROCEDURAL ACCURACY

20.1

PROPOSED PERFORMANCE STANDARD

***

20.2

PERFORMANCE STANDARD METHODOLOGY

***

20.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

21. CLAIM PAYMENT ACCURACY

21.1

PROPOSED PERFORMANCE STANDARD

***

21.2

PERFORMANCE STANDARD METHODOLOGY

***

21.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

22. CLAIM OVERALL PROCESSING

22.1

PROPOSED PERFORMANCE STANDARD

***

22.2

PERFORMANCE STANDARD METHODOLOGY

***

22.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

23. RESPONSE TO TELEPHONE INQUIRIES

23.1

PROPOSED PERFORMANCE STANDARD

***

23.2

PERFORMANCE STANDARD METHODOLOGY

***

23.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

24. TELEPHONE ABANDONMENT RATE

24.1

PROPOSED PERFORMANCE STANDARD

***

24.2

PERFORMANCE STANDARD METHODOLOGY

***

24.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

25. INITIAL CALL RESOLUTION

25.1

PROPOSED PERFORMANCE STANDARD

***

25.2

PERFORMANCE STANDARD METHODOLOGY

***

25.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

26. RESPONSE TO WRITTEN INQUIRIES

26.1

PROPOSED PERFORMANCE STANDARDS

***

26.2

PERFORMANCE STANDARD METHODOLOGY

***

26.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

27. RESPONSE TO WRITTEN INQUIRIES - MEDICARE

27.1

PROPOSED PERFORMANCE STANDARDS

***

27.2

PERFORMANCE STANDARD METHODOLOGY

***

27.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

28. RESPONSE TIME TO APPEALS

28.1

PROPOSED PERFORMANCE STANDARDS

***

28.2

PERFORMANCE STANDARD METHODOLOGY

***

28.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

29. RESPONSE TIME TO APPEALS - MEDICARE

29.1

PROPOSED PERFORMANCE STANDARDS

***

29.2

PERFORMANCE STANDARD METHODOLOGY

***

29.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

30. RESPONSE TIME TO GRIEVANCES

30.1

PROPOSED PERFORMANCE STANDARDS

¿ ***

30.2

PERFORMANCE STANDARD METHODOLOGY

***

30.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

31. RESPONSE TIME TO GRIEVANCES - MEDICARE

31.1

PROPOSED PERFORMANCE STANDARDS

***

31.2

PERFORMANCE STANDARD METHODOLOGY

***

31.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

HNOR CORPORATE PERFORMANCE STANDARDS FOR OPERATIONS

(Membership, Claims, Customer Service, A&G, Correspondence)

August 2014


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

32. DISTRIBUTION OF ID CARDS

32.1

PROPOSED PERFORMANCE STANDARD

***

32.2

PERFORMANCE STANDARD METHODOLOGY

***

32.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

33. ID CARD ACCURACY RATE

33.1

PROPOSED STANDARD PERFORMANCE

***

33.2

PERFORMANCE STANDARD METHODOLOGY

***

33.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

34. ELIGIBILITY DATA

34.1

PROPOSED PERFORMANCE STANDARD

***

34.2

PERFORMANCE STANDARD METHODOLOGY

***

34.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

35. CLAIMS PROCESSING TURNAROUND TIME

35.1

PROPOSED PERFORMANCE STANDARDS

***

35.2

PERFORMANCE STANDARD METHODOLOGY

***

35.3

NOTES

¿ ***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

36. CLAIM FINANCIAL ACCURACY

36.1

PROPOSED PERFORMANCE STANDARD

***

36.2

PERFORMANCE STANDARD METHODOLOGY

***

36.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

37. CLAIM PROCEDURAL ACCURACY

37.1

PROPOSED PERFORMANCE STANDARD

***

37.2

PERFORMANCE STANDARD METHODOLOGY

***

37.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

38. CLAIM PAYMENT ACCURACY

38.1

PROPOSED PERFORMANCE STANDARD

***

38.2

PERFORMANCE STANDARD METHODOLOGY

***

38.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

39. CLAIM OVERALL PROCESSING

39.1

PROPOSED PERFORMANCE STANDARD

***

39.2

PERFORMANCE STANDARD METHODOLOGY

***

39.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

40. RESPONSE TO TELEPHONE INQUIRIES

40.1

PROPOSED PERFORMANCE STANDARD

***

40.2

PERFORMANCE STANDARD METHODOLOGY

***

40.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

41. TELEPHONE ABANDONMENT RATE

41.1

PROPOSED PERFORMANCE STANDARD

***

41.2

PERFORMANCE STANDARD METHODOLOGY

***

41.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

42. INITIAL CALL RESOLUTION

42.1

PROPOSED PERFORMANCE STANDARD

***

42.2

PERFORMANCE STANDARD METHODOLOGY

***

42.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

43. RESPONSE TO WRITTEN INQUIRIES

43.1

PROPOSED PERFORMANCE STANDARDS

***

43.2

PERFORMANCE STANDARD METHODOLOGY

***

43.3

NOTES

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

***


Schedule ▇-▇-▇		▇-▇-▇-▇▇		Health Net / Cognizant Confidential

Final

SCHEDULE B-4

STAKEHOLDER SAT SURVEY


Schedule B-4				Health Net / Cognizant Confidential

Final

SCHEDULE B-4

STAKEHOLDER SATISFACTION SURVEY

Scoring

5	Regularly exceeding expectations and perceived to be adding significant value above and beyond requirements or SLAs.

4	Consistently meeting expectations and occasionally exceeding expectations by adding value above requirements or SLAs.

3	Consistently meeting expectations and perceived to be contributing to client success within the scope of services contracted for.

2	Some inconsistency in meeting expectations and perceptions that client is having to intervene to ensure performance - improvement required.

1	Consistently not meeting expectations - situation requires immediate and substantial improvement.

Stakeholder Scoring Matrix


Category	Score
Account Management		3
Operational Management		3
Knowledge Management		3
Business Enablement & Innovation		3
Value of Services		3
Customer Experience		3
Brand Impact		3
Overall Score		3

Please provide specific comments, observations, concerns, recommendations for improvement, etc. of any ratings less than 3

Considerations for Category Scoring (Note: each consideration does not have to be demonstrated in each quarter to achieve a 3 or higher.)

Account Management Team

Account Management Team leadership skills.

Timely and informative reporting and communications.

Openness to suggestions / criticism and responsiveness to Client Leadership concerns.

Attitude and responsiveness for dealing with unforeseen business needs or events, as approptiate for Supplier’s scope.

Ability to manage up and out across the Supplier’s delivery organization(s) (e.g. , foreign delivery locations or business units).

Tracking and resolution of Client issues that have been referred within Supplier’s delivery organization.

Ability to identify and leverage the “right” people from Supplier to support Client’s needs.

Ease of interaction with Account Management Team.

Operational Management

Operational excellence of Supplier (the achievement of SLAs without material Client intervention or attention).

Quality of change execution.

Proactive in addressing potential or actual operational failures (e.g. , incident avoidance, attention of resources to recurring problems).

Openness and communication of operational problems (v. failing to inform or attempting to cover over problems).

Knowledge of Client policies, procedures and methodologies and training of client personnel.

Ability to recover upon a service failure.

Supplier management of turnover of Key Resources and/or “Knowledge Critical” resources.

Knowledge Management

Availability and ease of use of Supplier’s Knowledge Management solution including access by all appropriate Client and other necessary supplier resources.

Quality of material contained in Knowledge Management System.

Proactive updating and improvement of the information contained in the Knowledge Management System by Supplier resources.

Value of Knowledge Management to speed of resolution, improvements in client experience and/or operational hand-offs between delivery centers.

Business Enablement and Innovation

Supplier’s knowledge of Client’s business and industry.

Supplier’s knowledge of current and trending technology and proactive communication of potential value/threat to Client’s business.

Supplier observations and recommendations to improve Client performance both within and around Supplier’s Services.

Supplier’s proactive delivery of Supplier subject matter experts (industry, technical, operational, etc.) to inform and improve Supplier Services.

Value of Services

Perceived value of ongoing efforts by Supplier to improve quality of Services after Supplier transition.

Value of Supplier’s integration, tools, process best practices, methodologies and effective leverage of same in delivery of Services.

Customer Experience

Overall perception of value of Supplier’s delivery on Customer experience.

Quality and effectiveness of communications to Customers as appropriate for Supplier’s scope.

Perception of Business Stakeholder’s satisfaction as obtained by Customer surveys and other feedback from the businesses.

Ease of Customer interaction with Supplier as appropriate for Supplier scope.

Brand Impact

Stakeholder’s perception of Supplier’s efforts to protect the Client’s brand.

Supplier’s impact on brand through proactive management of quality and compliance challenges.

Supplier’s impact on brand through proactive avoidance of information or other security breaches.

Outcome of industry and other surveys based on Customer experiences associated with Supplier’s delivery of Services.


Schedule B-4		B-4-1		Health Net / Cognizant Confidential

MSA Schedule C

SCHEDULE C

CHARGES

***

[Represents 54 pages of material pursuant to a request for confidential treatment under Rule 24b-2 of the Securities Exchange Act of 1934 which has been filed separately with the Securities and Exchange Commission]

MSA Schedule C Subschedules

SCHEDULES C SUBSCHEDULES

(C-1 THROUGH C-17)

***

[Represents 172 pages of material pursuant to a request for confidential treatment under Rule 24b-2 of the Securities Exchange Act of 1934 which has been filed separately with the Securities and Exchange Commission]

Final

SCHEDULE D

KEY SUPPLIER POSITIONS


Schedule D				Health Net / Cognizant Confidential

Final

SCHEDULE D

KEY SUPPLIER POSITIONS


Key Cognizant Position	Name	Rebadge (Y/N)	Comments
Operating Officer	TBD	N

Business Process Services - Head	TBD	Y

Transition & Transformation Head	TBD	N

Claims – Lead	TBD	Y

Membership – Lead	TBD	Y

Business Configuration – Lead	TBD	Y

Medical Management Intake – Lead	TBD	N

Customer Care – Lead	TBD	Y

Appeals & Grievances – Lead	TBD	Y

QA & Training – Lead	TBD	Y

Chief Information Officer	TBD	Y

IT Applications Development & Maintenance – Head	TBD (Onshore)	N

IT Applications Development & Maintenance – Head	TBD (Offshore)	N

PPMO Lead	TBD	Y


Schedule D		D-1		Health Net / Cognizant Confidential

Final


Key Cognizant Position	Name	Rebadge (Y/N)	Comments
Infrastructure Services - Head	TBD	Y

Technology Transformation Lead	▇▇▇	▇▇▇

Head of IT Security & Compliance (CSO)	TBD	N

P5 Operations Transition Lead	▇▇▇	▇	▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇

▇▇ ▇▇ Transition Lead	TBD	Y	Up until Steady State

Relationship Executive	TBD	N

Teleperformance			Placeholder for key personnel above the SOW level for TP

Note 1: Cognizant shall propose individuals to occupy these Key Supplier Positions for Health Net’s approval within thirty (30) days after the Effective Date, and the approved individuals shall be appointed to fill these Key Supplier Positions within Ninety (90) days after the Effective Date.

Note 2: Health Net shall have the right to designate five (5) additional full time Key Supplier Positions to address Service quality concerns by giving written notice to Supplier.


Schedule D		D-2		Health Net / Cognizant Confidential

MSA Schedule E

SCHEDULE E

TRANSITIONED EMPLOYEES

***

[Represents 15 pages of material pursuant to a request for confidential treatment under Rule 24b-2 of the Securities Exchange Act of 1934 which has been filed separately with the Securities and Exchange Commission]

MSA Schedule E Annex 1

ANNEX TO SCHEDULE E

SEVERANCE TERMS

***

[Represents 7 pages of material pursuant to a request for confidential treatment under Rule 24b-2 of the Securities Exchange Act of 1934 which has been filed separately with the Securities and Exchange Commission]

Final

SCHEDULE F

SUPPLIER FACILITIES


Schedule F				Health Net / Cognizant Confidential

Final

SCHEDULE F

SUPPLIER FACILITIES

1.	OFFSHORE SUPPLIER FACILITIES

This section sets forth the offshore Supplier Facilities from which Supplier will perform the Services. A “Primary” classification indicates a facility from which Supplier will normally perform the Services, and a “Secondary” classification indicates a disaster recovery facility.

Supplier Facility
Name

Supplier Facility Address

Approved Services to
be Performed

Classification

May Health
Net Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Stored at
this
Facility?

MEPZ

Cognizant Technology Solutions Pvt. Ltd.

▇▇▇▇ ▇▇ ▇▇▇,▇▇,▇▇ ▇▇▇,▇▇▇,▇▇ &▇▇ ▇▇ ▇▇ ,▇▇▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇ -▇▇▇▇▇▇, ▇▇▇▇▇

IT Applications Development & Testing, Application Maintenance

BPS – Claims, A&G, Quality Assurance

Primary, except for BPS-A&G. For BPS A&G this will be a Secondary site.

YES

GMR

Cognizant Technology Solutions Pvt. Ltd.

Varalakshmi Tech Park, ▇/▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇-▇▇▇▇▇▇, ▇▇▇▇▇

IT Applications Development & Testing, Application Maintenance

Primary

YES


Schedule F		F-1		Health Net / Cognizant Confidential

Final

Supplier Facility
Name

Supplier Facility Address

Approved Services to
be Performed

Classification

May Health
Net Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Stored at
this
Facility?

CKC

Cognizant Technology Solutions India Pvt. Ltd, ▇▇▇▇ ▇▇. ▇ & ▇, ▇▇▇▇▇ ▇▇ Park, Survey ▇▇. ▇▇▇/▇, ▇▇▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ - ▇▇▇▇▇▇, ▇▇▇▇▇

IT Applications Development & Testing, Application Maintenance

Primary,

YES

PKN

Cognizant Technology Solutions Pvt. Ltd.

Cee Dee Yes Software Technology Park, ▇▇ ▇▇/▇▇, ▇▇, ▇▇, ▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇, Pallvaram ▇▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇ – ▇▇▇▇▇▇, ▇▇▇▇▇

BPS Claims, Membership, Configuration, Quality Assurance

Secondary

YES

CRC

Cognizant Technology Solutions Pvt. Ltd.

▇▇▇▇ Tower, Ramanujan IT, SEZ, ▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ (▇▇▇), ▇▇▇▇▇▇▇- ▇▇▇▇▇▇,

▇▇▇▇▇

IT Applications Development & Testing, Application Maintenance

BPS Claims, Membership, Configuration, Quality Assurance

Primary, except for BPS-Claims. For BPS-Claims, this will be a Secondary site

YES


Schedule F		F-2		Health Net / Cognizant Confidential

Final

Supplier Facility
Name

Supplier Facility Address

Approved Services to
be Performed

Classification

May Health
Net Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Stored at
this
Facility?

CBE-SEZ

Cognizant -Delivery Center, Coimbatore C3 — Chill Special Economic ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇,

▇▇▇▇▇▇▇▇▇▇ 641 035

TamilNadu

India

ITO L1, L2 & L3 Services Delivery & Operations BPS – Claims, Quality Assurance

Primary, except for BPS-Claims and ▇▇▇ ▇▇ & ▇▇ ▇▇▇▇▇▇▇▇. ▇▇▇ ▇▇▇- Claims, ITO L2 & L3 Services this will be a Secondary site

YES

CBE - Mountain View Campus

Cognizant Technology Solutions Pvt. Ltd.

Unit I, STPI IT Park, Kumaraguru College of Technology Campus, Saravanampatti, Coimbatore – 641006, India

IT Applications Development & Testing, Application Maintenance

Primary

YES

Manyata Embassy Business(MBP) Park

Cognizant Technology Solutions Pvt. Ltd.

▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇ -

IT Applications Development & Testing, Application Maintenance, ITO L1, L2 & L3 Services

Primary, except for BPS- Configuration and Membership and ITO L1 Services. For BPS-

YES


Schedule F		F-3		Health Net / Cognizant Confidential

Final

Supplier Facility
Name

Supplier Facility Address

Approved Services to
be Performed

Classification

May Health
Net Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Stored at
this
Facility?

▇▇▇▇▇▇

▇▇▇▇▇

Delivery & Operations

BPS Configuration, Membership, Quality Assurance

Configuration and, Membership , ITO L1 Services this will be a Secondary site

KOL - ITP - STZ

Cognizant Technology Solutions Pvt. Ltd.

InfoSpace Unitech Hi-tech Structures Ltd., IT/ITeS SEZ, Tower G2, 6th floor, SEZ ▇▇▇▇ ▇, ▇▇▇▇ ▇▇.▇▇- ▇, ▇▇-▇, DH-3 & ▇▇-▇/▇, ▇▇▇▇▇ ▇▇. ▇▇, ▇▇▇▇▇▇ ▇▇▇▇ ▇, ▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇- ▇▇▇▇▇▇

▇▇▇▇▇

IT Applications Development & Testing, Application Maintenance

Primary

YES

HYD - DLF - PH1/2/3

Cognizant Technology Solutions Pvt. Ltd.

Floors Ground,I,II, Plot No: 129,130,131,132-SEZ, ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇.- ▇▇▇▇▇▇,

▇▇▇▇▇

IT Applications Development & Testing, Application Maintenance

BPS Claims, Quality Assurance

Primary, except for BPS-Claims. For BPS-Claims this will be a Secondary site

YES


Schedule F		F-4		Health Net / Cognizant Confidential

Final

Supplier Facility
Name

Supplier Facility Address

Approved Services to
be Performed

Classification

May Health
Net Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Stored at
this
Facility?

HYD -▇▇▇▇▇▇

Cognizant Technology Solutions Pvt. Ltd Mind space Hyderabad Plot No. 64, APIIC layout, ▇▇▇▇▇▇▇ ▇▇▇▇ & ▇▇▇▇▇▇▇▇ ▇▇-▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇▇ - ▇▇▇▇▇▇

BPS Claims, Quality Assurance

Secondary

YES

Manila - Taguig

Cognizant Technology Solutions Pvt. Ltd. -▇/▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇

▇▇. ▇▇, ▇▇▇▇▇ 5 & 6, Upper ▇▇▇▇▇▇▇▇ Road, ▇▇▇▇▇▇▇▇ Hills, ▇▇▇▇ ▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇, ▇▇▇▇▇▇- ▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇

IT Testing

BPS A&G, Membership, Medical Management & Quality Assurance

Primary

YES

-Cebu

Cognizant Technology Solutions Pvt. Ltd.

11th - 12th Flr, Skyrise 4 (Block 2, ▇▇▇ ▇ ▇▇▇▇▇▇▇ ▇▇. ▇▇▇▇ ▇▇ ▇▇▇▇), ▇▇▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇

ITO – Commercial Service Desk Operations

BPS- A&G, Membership, Medical Management, Quality Assurance

Primary, except for BPS-A&G, Membership & Medical Management. For BPS-A&G, Membership, & Medical Management, this will be a Secondary site

YES


Schedule F		F-5		Health Net / Cognizant Confidential

Final

Supplier Facility
Name

Supplier Facility Address

Approved Services to
be Performed

Classification

May Health
Net Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Stored at
this
Facility?

Manila-Pasig

Cognizant Technology Solutions Pvt. Ltd.

11th, 12th, 14th & 15th Floor, No. 17 Hanston Square Building, San ▇▇▇▇▇▇ Ave.,Ortigas Center, Pasig City 1605, Philippines

ITO – Commercial Service Desk Operations

BPS A&G, Membership ,Medical Management, Quality Assurance

Secondary

YES

Manila – Makati

Cognizant Technology Solutions Pvt. Ltd.

4th & 5th Floor, Paseo Centre Building, 8757 ▇▇▇▇▇ ▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇

BPS A&G, Membership, Medical Management, Quality Assurance

Primary

YES

CHIH-PS

▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, ▇▇▇▇, ▇▇▇▇▇▇

Contact Center Operations

Secondary

YES

Davao, Philippines

Davao, Philippines 2nd Floor, SM City Davao

IB/OB call, off phone case follow up and

Primary

YES


Schedule F		F-6		Health Net / Cognizant Confidential

Final

Supplier Facility
Name

Supplier Facility Address

Approved Services to
be Performed

Classification

May Health
Net Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Stored at
this
Facility?

Annex, Quimpo Blvd, Dabao 8000

correspondence

Fairview, Quezon City, Philippines

Fairview Facility, Quezon City: ▇/▇ ▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇▇

IB/OB call, off phone case follow up and correspondence

Primary

YES

Chihuahua, Mexico

Teleperformance Mexico S.A. ▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ 100, Complejo

IB/OB call, off phone case follow up and correspondence

Primary

YES


Schedule F		F-7		Health Net / Cognizant Confidential

Final

3.	ONSHORE SUPPLIER FACILITIES

This section sets forth the onshore Supplier Facilities from which Supplier will perform the Services. A “Primary” classification indicates a facility from which Supplier will normally perform the Services, and a “Secondary” classification indicates a disaster recovery facility.

Supplier Facility
Name

Supplier Facility
Address

Services to be
Performed

Classification

May Health Net
Data be
Accessed from
this Facility?

May
Department
of Defense
Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Stored at this
Facility?

CO-DC

Cognizant Data Center – Colorado (Latisys) ▇▇▇▇ ▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ , ▇▇ ▇▇▇▇▇

ITO - Datacenter Hosting Services

Primary

YES

AZ-DC

Cognizant Data Center – Arizona ▇▇▇▇ ▇ ▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

ITO – Datacenter Hosting Services

Secondary

YES

AZ-DL

Cognizant – Delivery Center, Arizona ▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇ 8502

ITO –Federal Service Desk, ITO Services Delivery & Operations, BPS - Claims

Primary, except for ITO Services Delivery & Operations and BPS - Claims

YES

FL-DL

Cognizant – Delivery Center, ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇, ▇▇ ▇▇▇▇▇

ITO – Federal Service Desk

Secondary

YES

▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇, ▇▇▇

▇▇▇▇▇ & ▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇

ITO Services Delivery & Operations, Security Services

Primary

YES


Schedule F		F-8		Health Net / Cognizant Confidential

Final

Supplier Facility
Name

Supplier Facility
Address

Services to be
Performed

Classification

May Health Net
Data be
Accessed from
this Facility?

May
Department
of Defense
Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Stored at this
Facility?

Aerojet-Rancho Cordova, CA, USA

▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇, ▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

ITO Services Delivery & Operations, Security Services

Primary

YES

Woodland Hills, CA, USA

▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇, ▇▇

ITO Services Delivery & Operations, Security Services

Secondary

YES

LAX-PS

▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇, ▇▇, ▇▇▇

Contact Center Operations

Primary

YES

▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇, ▇▇▇

▇▇▇▇▇ & ▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇

BPS Services (Contact Center, Claims, Membership & Configuration, Quality Assurance, Training & Medical Management)

Primary

YES

Woodland Hills, CA, USA

▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇, ▇▇

BPS Services Contact Center, Claims, Membership & Configuration, A&G, Quality Assurance, Training & Medical

Primary

YES


Schedule F		F-9		Health Net / Cognizant Confidential

Final

Supplier Facility
Name

Supplier Facility
Address

Services to be
Performed

Classification

May Health Net
Data be
Accessed from
this Facility?

May
Department
of Defense
Data be
Accessed
from this
Facility?

May
Department
of Defense
Data be
Stored at
this
Facility?

Management)

San ▇▇▇▇▇▇

▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇. ▇▇▇ ▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

BPS Services (Membership & Quality Assurance)

Primary

YES

Huntington Beach

▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇, ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇, ▇▇ ▇▇▇▇▇

BPS Services (Quality Assurance, Contact Center)

Primary

YES

Glendale

▇▇▇ ▇ ▇▇▇▇▇ ▇▇▇▇ ▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇

BPS Services (Medical Management)

Primary

YES

Shreveport, LA

Shreveport, LA, USA TPUSA, Inc. ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇

IB/OB call, off phone case follow up

Primary

YES

Irving, TX

▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ # ▇▇▇. Irving, TX

IB/OB call, off phone case follow up

Primary

YES

Tempe, AZ

1230 ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇

A&G

Primary

YES


Schedule F		F-10		Health Net / Cognizant Confidential

Final

SCHEDULE G

GOVERNANCE


Schedule G				Health Net / Cognizant Confidential

Final

SCHEDULE G

GOVERNANCE

1.	GENERAL

(a)

This Schedule G (Governance) sets forth an integrated set of resources, committees, meetings, processes, plans and tools (“Contract Governance”). The purpose of Contract Governance is to monitor and control all aspects of the Services in order to promote smooth operation of the Services in accordance with the Agreement. This Schedule G (Governance) describes the Contract Governance plan (“Contract Governance Plan”), including Health Net’s and Supplier’s roles and responsibilities in Contract Governance, the relationship management structure, the decision making processes related to the Services, and other aspects of the Contract Governance.

(b)

The following Schedules are included as part of this Schedule G (Governance):

(i)

Schedule G-1 (Supplier Organization) contains a description of Supplier’s management-level organizational unit involved in the performance of this Agreement.

(ii)

Schedule G-2 (Committee and Meeting Framework) describes the committee and meeting framework to be used by Health Net and Supplier to operationalize Contract Governance.

(iii)

Schedule G-3 (Management Reports) contains a list of certain of the management reports that will be provided by Supplier to Health Net as part of Contract Governance.

2.	CONTRACT GOVERNANCE PLAN

2.1

Development of Contract Governance Plan

Health Net and Supplier will jointly finalize and implement the Contract Governance Plan within ninety (90) days, or as mutually agreed, following the Effective Date. The Contract Governance Plan will, at a minimum:

(a)

Specify the formal organizations, processes, and practices for managing Health Net’s and Supplier’s relationship under the Agreement;

(b)

Establish organizational interfaces for management and operation of the Agreement including:

(i)

the organization charts for Health Net and Supplier identifying the roles involved in Contract Governance;

(ii)

framework for governance reports and meetings, including those reports and meetings described in Section 3, below; and

(iii)

the operational and contractual authority and authorization levels of the Health Net and Supplier resources involved in Contract Governance;


Schedule G		G-1		Health Net / Cognizant Confidential

Final

(c)

Specify the following Contract Governance processes:

(i)

Process to receive, qualify, identify, manage, and track Deliverables to completion; and

(ii)

Protocol for formal communications between Health Net and Supplier;

(d)

Establish a strategy for gathering appropriate inputs to Contract Governance and communicating appropriate outputs from Contract Governance to appropriate Health Net and Supplier resources; and

(e)

Include such other information as requested by Health Net to support the purpose of Contract Governance.

2.2

Other Governance-Related Processes

In addition to any other processes necessary to support Contract Governance, the role of the Governance organization in the following processes (e.g., as the body to hear escalations, etc.) will be incorporated in the Contract Governance Plan:

(a)

Change Control Process, as defined and further described in Section 17.5 of the Terms and Conditions and Schedule H (Change Control);

(b)

The Action Plan and Step In Rights processes described in Section 17.4 of the Terms and Conditions;

(c)

The processes for determining end user and stakeholder satisfaction, as described in Schedule B (Service Levels);

(d)

The process for managing and evaluating performance against the Service Levels and remediating Service Level Failures, as described in Schedule B (Service Levels);

(e)

The dispute resolution process described in Section 26 of the Terms and Conditions;

(f)

The indemnification process and procedures described in Section 23 of the Terms and Conditions;

(g)

The process for the development and maintenance of the Procedures Manual described in Section 17.2 of the Terms and Conditions;

(h)

The Demand Intake Process consistent with Schedule J (Project Framework), Schedule C (Charges), and Schedule H (Change Control);

(i)

Processes related to the establishment of the BPaaS and non-BPaaS Road Map; and

(j)

Any other processes and procedures described in this Agreement that relate to how the Parties will interact with one another to govern and manage performance under and compliance with the Agreement.


Schedule G		G-2		Health Net / Cognizant Confidential

Final

2.3

Responsibilities

(a)

Within ninety (90) days after the Effective Date (or as otherwise specified below), Supplier will:

(i)

assign an individual to be the single point of contact to Health Net for the Contract Governance Structure development and maintenance;

(ii)

identify the Supplier attendees for the meetings reflected in Schedule G-2 (Committee and Meeting Framework) and any updates as they occur;

(iii)

develop the Contract Governance Plan in collaboration with Health Net;

(iv)

review Health Net comments and feedback and revise the draft Contract Governance Plan and submit to Health Net for Health Net review and approval within ten (10) Business Days of receipt of Health Net’s comments. For the avoidance of doubt, this process will be repeated until the Contract Governance Plan is approved by Health Net; and

(v)

provide appropriate Supplier Personnel access to the Contract Governance Plan, as needed.

(b)

Within ninety (90) days after the Effective Date (or as otherwise specified below), Health Net will:

(i)

assign an individual to be the single point of contact to Supplier for the Contract Governance Plan development and maintenance;

(ii)

provide a list of Health Net attendees for the meetings reflected in the meetings plan and any updates as they occur;

(iii)

collaborate with the Supplier on the development of the Contract Governance Plan;

(iv)

review and provide to Supplier, in writing, Health Net’s comments, questions and proposed changes to the draft plan within thirty (30) days following Health Net’s acknowledged receipt of the draft Contract Governance Plan; and

(v)

provide the Contract Governance Plan to appropriate Health Net employees, as appropriate.

(c)

Within ninety (90) days after the Effective Date and regularly thereafter, Supplier will identify process inhibitors, and propose process improvements to Health Net, as required.

(d)

In accordance with Schedule R (Critical Milestones), Supplier will draft and deliver to Health Net the initial Contract Governance Plan.

(e)

The Parties will jointly review, on an annual basis or more frequently as requested by a Party, the Contract Governance Plan and update and/or maintain the Contract Governance Plan accordingly.


Schedule G		G-3		Health Net / Cognizant Confidential

Final

3.	GOVERNANCE ORGANIZATION

Health Net and Cognizant will implement a governance organization that continues to evolve from the Effective Date through to steady state. Diagram 1 below illustrates the phases of governance evolution as well as the targeted dates for each phase.

Diagram 1

3.1

Governance Structure in Phases 1 and 2

Health Net and Supplier will organize their joint governance during Phases 1 and 2 as illustrated in Diagram 2 below and described in this Section 3.1.

Diagram 2


Schedule G		G-4		Health Net / Cognizant Confidential

Final

(a)

Board of Supervisors and Executive Council

Supplier will create and chair an executive forum responsible for the overall strategic direction and decision making related to the go-to-market strategy for the Technology Platform and related services (the “Go to Market Forum”). Health Net will be a member of the Go To Market Forum and will provide strategic advice and industry expertise in connection with the various service offerings and associated technology. The focus and overall strategy of the Go To Market Forum will include addressing the need to increase membership on the Technology Platform in order to reduce overall cost, leveraging and further developing the Technology Platform, leveraging synergies with other Supplier products, and to build and market a product that has highly attractive distinguishing features for the target market.

(b)

Governance Committee

The parties will jointly form a Governance Committee consisting of three (3) senior executives from Health Net and three (3) senior executives from Cognizant who will:

(i)

Provide guidance to the Transformation Management Office;

(ii)

Oversee performance reviews (operational and financial);

(iii)

Oversee Service Levels including compliance and transformation metrics;

(iv)

Resolve escalations;

(v)

Decide resource allocations; and

(vi)

Address within their respective organizations and provide guidance to their respective organization on:

(A)

Portfolio/IT roadmap

(B)

Innovation oversight

(C)

Strategic Planning

(D)

Customer experience

(c)

Co-Operating Officers

The parties will each nominate a senior executive from their organization to serve as the Co-Operating Officers through Phase 2 who will:

(i)

Set strategy/structure for the Transformation Management Organization;

(ii)

Manage the Transition;

(iii)

Ensure that Health Net achieves the desired performance levels, cost reduction objectives and builds enhanced capacities;


Schedule G		G-5		Health Net / Cognizant Confidential

Final

(iv)

Ensure that Supplier achieves targeted operational goals and metrics associated with delivery of the Services to Health Net; and

(v)

Ensure that Supplier builds and executes a viable line of business targeting acquisition of other health care clients.

The Supplier Operating Officer’s overall responsibilities for the Term are set forth in Section 5.2 below.

The Health Net Operating Officer will coach the Supplier Operating Officer on all aspects of health plan operations to enable the Supplier Operating Officer to assume greater responsibilities over time related to the oversight of the Services. The Health Net Operating Officer will also have Transition related authority set forth in Section 13.3 of the Terms and Conditions. During Phases 1 and 2, the Health Net Operating Officer will have sole authority for approving or denying each phase of the Transition as they become due (including whether Acceptance Criteria for Transition Deliverables and Transition Milestones have been met) in accordance with Section 1 of Schedule Z (High Level Transition Information) and Section 13.4 of the Terms and Conditions. The governance of certain other Transition-related matters is set forth in Section 13.3 of the Terms and Conditions. For the avoidance of any doubt, Transition shall mean each wave within each Statement of Work.

3.2

Governance Structure in Phase 3

Health Net and Supplier will organize their governance during Phase 3 as illustrated in Diagram 3 below and described in this Section.

Diagram 3


Schedule G		G-6		Health Net / Cognizant Confidential

Final

(a)

Supplier Board of Supervisors and Health Net Executive Council The Supplier Board of Supervisors and Health Net Executive Council will continue to operate during Phase 3 as set forth in Section 3.1(a).

(b)

Governance Committee

The Governance Committee will continue to operate during steady state with responsibilities as set forth in Section 3.1(b)(ii)—3.1(b)(vi).

(c)

Supplier Operating Officer and the Health Net Oversight Officer (or designee)

At the end of Phase 2, (i) the Health Net Operating Officer will disengage and the Health Net Oversight Officer (or designee) will assume responsibility for representing Health Net in Phase 3/steady state, and (ii) the Supplier Operating Officer will assume responsibility for functional oversight of the day-to-day operations. The Supplier Operating Officer’s overall responsibilities for the Term are set forth in Section 5.2 below and also include the responsibilities set forth in Section 3.1(c)(iii)—3.1(c)(v). ▇▇▇▇▇▇ ▇▇▇▇▇ ▇, if there is a disagreement between the Health Net Oversight Officer and the Supplier Operating Officer, the parties will escalate the dispute to the Governance Committee for resolution.

4.	GOVERNANCE MEETINGS & REPORTS

Governance meetings and management reporting will be critical aspects of the Services provided by Supplier under this Agreement, as they will be the principal means by which Health Net’s management and overseers will continue to have the requisite visibility into the operation of those aspects of Health Net’s business that are comprised by the Functions outsourced to Supplier pursuant to this Agreement.

4.1

Meetings

As part of the Contract Governance Plan, the Parties will set up the governance meetings (“Governance Meetings”) listed in Schedule G-2 (Committee and Meeting Framework). Unless otherwise agreed by the Parties, Supplier will prepare and circulate a list of topics to be discussed for each agenda item for each meeting sufficiently in advance of each meeting to give the participants an opportunity to prepare for the meeting. Supplier and Health Net will agree on a final agenda. The Parties will ensure that representatives with appropriate knowledge and authority will participate in each Governance Meeting. Supplier will prepare and circulate a documented list of outcomes and action items after each meeting, which will not be binding on either Party if they are in any way inconsistent with this Agreement. At any time during the Term, Health Net may reasonably request additional Governance Meetings or modifications to the type, frequency, purpose or attendance at existing Governance Meetings, and if it does, Supplier shall reasonably consent to such modifications at no charge.

The framework for Governance Meetings and specific Governance Meetings are set forth in Schedule G-2 (Committee and Meeting Framework).

4.2

Reports

(a)

During the Term, Supplier will be responsible for continuing to generate all reports (governance, operational, and management reports) produced by the Affected Employees at no additional Charge.


Schedule G		G-7		Health Net / Cognizant Confidential

Final

(b)

Schedule A of the Agreement and each Statement of Work addresses the Supplier’s responsibilities to provide operational reporting as an integral part of the Services to be provided under this Agreement. This Schedule G (Governance) addresses Supplier’s responsibilities with respect to “Management Reporting,” which means reporting by Supplier to Health Net management and external entities, such as Regulators, with respect to the Functions outsourced to Supplier, in order to provide them with the requisite visibility into the relevant aspects of Health Net’s business. Management Reporting includes any reporting required by Regulators or applicable Laws. The Parties have prepared a preliminary list of the Management Reporting to be provided by Supplier to Health Net on an ongoing basis, which is set forth in Schedule G-3 (Management Reports). Supplier will deliver all reports listed in Schedule G-3 (Management Reports) at no additional charge to Health Net. If it is determined that any report listed in Schedule G-3 (Management Reports) is not yet being generated by Health Net as of the BPaaS Services Commencement Date, the Parties will mutually agree to a schedule and process for implementing the report (at no additional charge to Health Net) or the Parties will mutually agree to remove the report from Schedule G-3 (Management Reports). No later than six months after the BPaaS Services Commencement Date, Health Net may within reason update the list of Management Reports set forth in Schedule G-3 (Management Reports). As part of the Contract Governance Plan, the Parties will work together during the Term to refine Schedule G- 3(Management Reports) from time to time as may be necessary so that Supplier’s Management Reporting meets the objective of providing Health Net’s management and overseers with the requisite degree of visibility into the conduct of Health Net’s Functions that have been outsourced to Supplier, as they may change and evolve during the Term. Such Management Reporting will be no less comprehensive than (1) the Management Reporting of Health Net’s outsourced Functions as of the Effective Date and (2) the Management Reporting provided to Health Net (x) by Supplier under the Original BPO Agreement and Original AO Agreement or (y) by other Health Net outsourcing suppliers, as of the Effective Date, performing services similar to the Services prior to the Effective Date.

(i)

In addition to the Management Reporting described in this Section 4.2(b), Supplier will produce a monthly performance report describing Supplier’s performance of the Services in the preceding month (the “Monthly Performance Report”). The Monthly Performance Report will be delivered to Health Net not later than the fifteenth (15th) day of each month. Each Monthly Performance Report will (A) assess the degree to which Supplier has attained or failed to attain the pertinent objectives for the prior month, including the Service Levels and measurements with respect to metrics other than the Service Levels as specified by Health Net, if applicable; (B) describe the status of each ongoing problem resolution effort and any other initiative; (C) explain deviations from the Service Levels in the prior month and include for each deviation a plan for corrective action; (D) set forth a record of the Services, personnel changes and any other changes made during the reporting period that affect, or could affect, the Services and describe the planned changes during the upcoming month that may affect the Services; (E) set forth utilization of each Supplier resource (e.g., hour, FTE, etc.) for which a charge is made under this Agreement; (F) include all documentation and other information that Health Net reasonably requests to verify compliance with this Agreement; and (G) provide Health Net with a monthly financial projection of Supplier’s charges for the following month.


Schedule G		G-8		Health Net / Cognizant Confidential

Final

(c)

At any time during the Term, Health Net may request additional reports or modifications to the type, frequency, or format of existing reports, and if it does, Supplier shall reasonably consent to such modifications at no charge.

(d)

Supplier understands and agrees that a number of Affected Personnel, perform ad hoc reporting as a matter of course in their daily duties. With the transition of such Affected Personnel, Supplier shall continue to provide such ad hoc reporting as may be requested by Health Net at no charge.

5.	RELATIONSHIP MANAGEMENT STRUCTURE

5.1

Relationship Executive

Within fifteen (15) days after the Effective Date, Health Net and Supplier will each identify its own relationship executive (“Relationship Executive”) who will focus on Health Net’s and Supplier’s long-term strategic relationship and the mission, vision, and innovation as they relate to the Services. Supplier’s Relationship Executive will be responsible for the achievement of the goals and the implementation of the Agreement, and will be Health Net’s single point of contact for executive issues and escalation management. The Relationship Executives may not delegate execution of their role, but may involve other Health Net or Supplier resources as needed to facilitate execution of their role.

5.2

Supplier Operating Officer

For the Term, Supplier will identify an account executive (the “Supplier Operating Officer”) who will focus on the day-to-day operations and delivery of the Services. The Supplier Operating Officer’s role will evolve during the Term as detailed in Sections 3.1(c) and 3.2(c) above. Regardless of the Phase, during the Term the Supplier Operating Officer’s responsibilities include:

(a)

serving as the single point of accountability for Supplier for the Services, including all aspects of service delivery and the Supplier delivery organization, and have overall responsibility to ensure Health Net satisfaction. The Supplier Operating Officer will also review all Transition activities to verify that critical processes and systems are smoothly and efficiently integrated or transitioned;

(b)

being the executive contact for Health Net on daily delivery performance and Supplier service delivery commitments, including managing performance and efficiency of Supplier’s third party delivery vendors;

(c)

providing service management processes and reporting while being responsible for continuous delivery service improvement; and

(d)

working with the Health Net Co-Operating Officer or Health Net Oversight Executive or Designee to ensure client satisfaction and to support new strategies and Health Net business directions.

Health Net leadership that serve on the Governance Committee and the Board of Supervisors will provide Supplier feedback relating to performance of the Supplier Operating Officer. Health Net’s feedback will be used by Supplier as input for the overall performance appraisals for such individual.


Schedule G		G-9		Health Net / Cognizant Confidential

Final

SCHEDULE G-1 – SUPPLIER ORGANIZATION

1	SUPPLIER ORGANIZATION


Schedule G-1 (Supplier Organization)		G-1-1		Health Net / Cognizant Confidential

Final


Schedule G-1 (Supplier Organization)		G-1-2		Health Net / Cognizant Confidential

Final


Schedule G-1 (Supplier Organization)		G-1-3		Health Net / Cognizant Confidential

Final


Schedule G-1 (Supplier Organization)		G-1-4		Health Net / Cognizant Confidential

Final


Schedule G-1 (Supplier Organization)		G-1-5		Health Net / Cognizant Confidential

Final


Schedule G-1 (Supplier Organization)		G-1-6		Health Net / Cognizant Confidential

Final


Schedule G-1 (Supplier Organization)		G-1-7		Health Net / Cognizant Confidential

Final


Schedule G-1 (Supplier Organization)		G-1-8		Health Net / Cognizant Confidential

Final


Schedule G-1 (Supplier Organization)		G-1-9		Health Net / Cognizant Confidential

Final


Schedule G-1 (Supplier Organization)		G-1-10		Health Net / Cognizant Confidential

Final


Schedule G-1 (Supplier Organization)		G-1-11		Health Net / Cognizant Confidential

Final

EXHIBIT G-2

MEETING FRAMEWORK


Schedule G-2		G-2		Health Net / Cognizant Confidential

Final

SCHEDULE G-2

COMMITTEE AND MEETING FRAMEWORK

Committee Name

Transition
Management

Daily Tower

Status Meeting

Service Delivery
Meeting

Performance
Meeting

Quarterly Business
Review

Technology/
Services Meeting

Strategic
Relationship
(Mission / Vision /
Innovation)
Meeting

Transition
Management
Review

Daily Operations
Review

Operations Review
Committee

Performance
Review Committee

Joint Management
& Operations
Committee

IT Management
Committee

Joint Steering
Committee
meetings & Joint
Management &
Operations
Committee

Committee Information

Description

Review transition progress and status in each of the Towers and the overall satisfaction of the Transition Plan. There will be multiple meetings required to review overall and specific Tower progress.

Review results from previous twenty-four (24) hours focusing on processing dashboards, systems availability and major processing issues including workarounds put in place.

Review service delivery performance and discuss operational issues. Review and approve operational process changes. Any procedural changes should be addressed during this meeting as well.

Review performance against contracted or stated expectations. Consider if changes are necessary to improve performance. Recommend operational changes to Service Delivery. Ongoing assessment of the effectiveness of the performance framework (i.e., measures, metrics, weightings, credits, etc.). Recommend changes in the performance framework.

Review performance against contracted or stated expectations. Consider if changes are necessary to improve performance. Ongoing assessment of the effectiveness of the performance framework (i.e., measures, metrics, weightings, credits, etc.).

Review and consideration of technology and service changes in alignment with direction from Mission / Vision / Innovation committee. Presentation and discussion of Supplier Services and Technology Product Road Map.

Update the mission and vision for strategic relationship and Services in scope. Review and approve Innovation Plan and evaluate outcomes. Approve Supplier Services and Technology Product Road Map. Identify short term specific goals for the strategic relationship, including the timeframes for achieving such goals. Assess the overall success of the relationship.

Agenda

+Review specific progress toward achieving the Transition Plan and Milestones. +Discussion / Resolution of Transition issues /Mitigation of risks

/coordination of interdependencies

+ Review daily turn over report

+ Performance Trends

+ Problems (RCAs)

+ Issues (process, actor, organizational, etc.)

+ Review monthly performance results

+ Review quarterly performance results

+ Review Services and Technology Product Road Map

+ Vendor presentations on new solutions

+ Business update

+ Goals setting, monitoring and assessment

+ Review value creation opportunities

+ Innovation Plan

+ Product Road Map

Frequency

Daily, Weekly, Monthly

Daily

Monthly or more frequently depending on the stability and maturity of the operations.

Monthly

Quarterly

Semi-Annually


Schedule G-2 (Committee and Meeting Framework)		G-2-2		Health Net / Cognizant Confidential

Final

SCHEDULE G-3

MANAGEMENT REPORTS


Schedule G-3 (Management Reports)				Health Net / Cognizant Confidential

Final

Department
Area

Report
Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

Governance

Monthly Performance Report

A monthly performance report describing Supplier’s performance of the Services in the preceding month as further described in Section 4.2(b)(i) of Schedule G (Governance).

Monthly

Active

IT Vendor Relations

PC Refresh Status Report

Report outlining the number of PCs being refreshed, broken out by laptops and desktops, Corp vs. Govt Systems, completed/pending/no refresh and lost/unlocateable

Bi Weekly

Active

Data is a combination of detailed PC data from IBM Global Finance and PC data pulled from Altiris, inside of an Access db maintained by IBM.

IBM (IO PC Refresh Coordinator)

IT Vendor Relations

Joint Operations Committee

Governance report - overview of low level tactical activities for Application Outsourcing Contract

Monthly

Active

Data pulled by SUPPLIER from Plan View, project/program plans, Remedy, financial systems

SUPPLIER

IT Vendor Relations

Joint Operations Committee

Governance report - overview of low level tactical activities for Infrastructure Outsourcing Contract

Monthly

Active

Data pulled by IBM from their CLAIM (labor tracking), project/program plans, Remedy, financial systems, and GSMRT

IBM

IT Vendor Relations

Monthly IT Contract Renewal SLA report

Scorecard outlining timeliness of renewals of contracts in the ITG Governance portfolio

Monthly

Active

Spreadsheets and SAP Contract Lifecycle Management (CLM) system

Health Net (▇▇▇▇▇ ▇▇▇▇)

IT Vendor Relations

Monthly Ebuyer Cart Analysis report

Outlines volume and quality metrics for ebuyer cart processing for IO, AO, SA, and misc software/hardware managed by ITG Governance

Monthly

Active

SAP Ebuyer system

Health Net (▇▇▇▇ ▇▇▇▇▇)


Schedule G-3 (Management Reports)		G-3-1		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only - Who
Generates Report
(Health
Net/IBM/CTS)

IT Vendor Relations

Expiring Contracts Report

Lists contracts in CLM owned by ITG Governance that have either expired or will expire in the next 3 months.

Monthly

Active

SAP CLM system

Health Net (▇▇▇▇ ▇▇▇▇ in SS&P)

IT Vendor Relations

Software Purchase Reports

Lists of historical software procurements and upcoming renewals

Monthly

Active

Compucom ordering system

Compucom

IT Vendor Relations

Blocked Report

Identifies mismatched amounts between Purchase Orders and Invoices

Weekly

Active

SAP core system

Health Net (▇▇▇▇▇ ▇▇▇▇▇▇ in AP)

IT SLM Team

Monthly Operations Report (MOR)

Displays a subset of metrics with explanation of any missed metrics for the current reporting month

Monthly

Active

Remedy, ISC Portal

Health Net SLM Team

IT SLM Team

IBM Monthly Scorecard

Displays a subset of IBM-related metrics

Monthly

Active

Remedy, ISC Portal

Health Net SLM Team

IT SLM Team

Supplier Monthly Scorecard

Displays a subset of Supplier-related metrics

Monthly

Active

Remedy

Health Net SLM Team

IT SLM Team

Health Net Quarterly Scorecard by Region (Overall)

Displays a subset of aggregated metrics for all Vendors and Health Net

Tracked Quarterly but distributed Monthly

Active

Remedy, ISC Portal

Health Net SLM Team

IT SLM Team

University of California - Web Site Availability Performance Guarantee Result ▇▇▇▇▇▇▇▇▇.▇▇▇

Displays Availability of ▇▇▇▇▇▇▇▇▇.▇▇▇ during normal business hours for the previous Quarter.

Quarterly

Active

Remedy

Health Net SLM Team


Schedule G-3 (Management Reports)		G-3-2		Health Net / Cognizant Confidential

Final

Department
Area

Report
Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only - Who
Generates Report
(Health
Net/IBM/CTS)

IT SLM Team

▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ - Web Site Availability Performance Result - New MHN EAP PG

Group

Displays Availability of ▇▇▇.▇▇▇ and ▇▇▇▇▇▇▇.▇▇▇.▇▇▇ for the previous Quarter.

Quarterly

Active

Remedy

Health Net SLM Team

IT SLM Team

Monthly Business PMR

Displays a subset of SLA’s for IBM and Supplier

Monthly

Active

Remedy, ISC Portal

Health Net SLM Team

IT SLM Team

Monthly Availability Metric Reports (Access DB)

Displays aggregated ticket detail data and summarized availability for all Vendors and Health Net

Monthly

Active

Remedy

Health Net SLM Team

IT SLM Team

General System Availability (GSA) Reports

Displays a breakout of ticket detail and individualized system availability by Vendor and Health Net

Monthly

Active

Remedy

Health Net SLM Team

IT SLM Team

Supplier Project Exception Report (weekly)

Displays the service requests for project exceptions submitted by Supplier that were approved by Health Net Mgmt

Weekly

Active

Remedy

Health Net SLM Team

IT SLM Team

Monthly Remedy Ticket Counts

Displays the count of Remedy tickets arrived monthly by Case Type and Priority

Monthly

Active

Remedy

Health Net SLM Team

IT SLM Team

Lotus Notes Mailbox Counts (monthly)

Displays the count of Lotus Notes Mailboxes, broken out by mail server

Monthly

Active

Remedy

Health Net SLM Team

IT SLM Team

Daily Morning Report Status

Displays a summary of the daily morning reports for VMS, FHP1, and HNNE

Daily

Active

Remedy

Health Net SLM Team


Schedule G-3 (Management Reports)		G-3-3		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only -Who
Generates Report
(Health
Net/IBM/CTS)

IT SLM Team

IBM

Preliminary Metric Report

Displays preliminary metric data on a weekly basis (IBM metrics only)

Weekly

Active

Remedy, ISC Portal

Health Net SLM Team

IT SLM Team

Supplier Monthly Attainment Topsheet

Displays all service levels and final attainment values for the month

Monthly

Active

Remedy

Health Net SLM Team

IT SLM Team

IBM Monthly Attainment Topsheet

Displays all service levels and final attainment values for the month

Monthly

Active

Remedy, ISC Portal

Health Net SLM Team

IT SLM Team

Resource Unit Improvement Report

Displays a list of the Resource Units with discrepancies to be discussed at the weekly meeting

Weekly

Active

Manual

IBM

IT SLM Team

Topsheet h- Centive SLA Monthly Metrics Report

Displays a list of the SLAs, Metric Data and attainments for each SLA

Monthly

Active

h-Centive

h-Centive and Health Net

ITAM

Executive Compliance Summary Potential Exposure

Displays the compliance for the given Software Product with Potential Exposure (Top 15)

Weekly

Active

Altiris

Health Net ITAM Team

ITAM

Full - Detail Compliance Summary Report

Displays the compliance for the given Software Product - Full Report Detail

Weekly

Active

Altiris

Health Net ITAM Team

ITAM

Single Trusted Source (STS)

Displays collection of Health Net IT Server Assets (CMDB)

Monthly

Active

IBM - Excel Spreadsheet (Manual Input & Update)

IBM

ITAM

Softmart - Software VAR

Displays Health Net Purchase History - Software VARs

Monthly

Active

Softmart


Schedule G-3 (Management Reports)		G-3-4		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only -Who
Generates Report
(Health
Net/IBM/CTS)

ITAM

CompuCom - Software Management Data Export

Displays Health Net Purchase History - Software VARs

Monthly

Active

CompuCom

Health Net ITAM Team

ITAM

CompuCom - Hardware Management Data Export

Displays Health Net Purchase History - Hardware VARs for Corp

Monthly

Active

CompuCom

ITAM

Ideal

Displays Health Net Purchase History - Hardware VARs for HNFS

Monthly

Active

Ideal

ITAM

TAD4D

Displays Software Discovery - Servers Only

Monthly

Active

▇▇▇▇

IBM

ITAM

TAD4Z

Displays Software Discovery - Mainframe

Quarterly

Active

▇▇▇▇

IBM

ITAM

Health Net Manual Scan BMC

Discovery (ADDM)

Displays Software Discovery - BMC

Quarterly

Active

ADDM Server: BLD- APPADDM01 & BLD-APPADDM02

IBM

ITAM

Health Net Manual Scan Commercial VMware

Displays Software Discovery - Corp VMware

Quarterly

Active

Corp VmWare Servers

IBM

ITAM

Health Net Manual Scan Federal Vmware

Displays Software Discovery - Fed Vmware

Quarterly

Active

Fed VmWare Servers

IBM

ITAM

Health Net Manual Scan Virtual IO (VIO) and HMC

Commercial

Displays Software Discovery - Virtual I/O

Server and Hardware Management Console

Quarterly

Active

IBM Virtual I/O Server(s) & IBM Hardware Management Console(s)

IBM


Schedule G-3 (Management Reports)		G-3-5		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only -Who
Generates Report
(Health
Net/IBM/CTS)

ITAM

Health Net NT Servers - Bravo Feed

Displays Software Discovery - NT ▇▇▇▇▇▇: WHSRVDB006, WHSRVDB009, WHSRVDB010

Quarterly

Active

BRAVO

IBM

ITAM

Health Net OpenVMS Discovery

Displays Software Discovery - VMS

Quarterly

Active

▇▇▇▇

IBM

ITAM

iSeries Software Scan

Displays Software Discovery - iSeries

Quarterly

Active

iSeries Servers

IBM

ITAM

DAD-Health Net Health Net Report

Displays Software License - IBM Owned and Health Net Owned/IBM Manages

EN = IBM owns license & pays ▇▇▇▇ (cust suspend their license, so IBM license is used)

IO = IBM owns & pays for license & license does NOT fall under the IBM MLA/VPA

CI = Health Net owns license, IBMGS acting as agent & pays the ▇▇▇▇

Quarterly

Active

IBM - Asset Tool

IBM

ITAM

Bravo Mass Missing SW Discrepancy Template (AS400

Nocturne)

Displays Software Discovery - Nocturne

Quarterly

Active

BRAVO

IBM

ITAM

Managed PCs with PO info (no servers)

Displays all active workstations and VM’s with Operating System, Domain & Locations

Monthly

Active

Altiris

Health Net ITAM Team

IT SLM Team

Annual Health Net Satisfaction Survey

IO SLA01 - Measures Health Net Satisfaction with Vendor

Annually

Active

IBM 3rd Party Vendor

IBM

IT SLM Team

Quarterly EU Services (Deskside)

IO SLA02 - Measures Cust Sat with Vendor Desktop services

Quarterly

Active

IBM


Schedule G-3 (Management Reports)		G-3-6		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only -Who
Generates Report
(Health
Net/IBM/CTS)

IT SLM Team

Quarterly Helpdesk Satisfaction Survey

IO SLA03 - Measures Cust Sat with Vendor Service Desk

Quarterly

Active

IBM

IT SLM Team

Application Availability

IO SLA04 - Measures Application Availability for 23 appls

Monthly

Active

Remedy

IBM

IT SLM Team

SAN

IO SLA05 - Measures SAN Availability

Monthly

Active

Remedy

IBM

IT SLM Team

NAS

IO SLA06 - Measures NAS Availability

Monthly

Active

Remedy

IBM

IT SLM Team

Network Data (Network)

IO SLA07 - Measures Network Availability

Monthly

Active

Remedy

IBM

IT SLM Team

P1 Problems -Response Time (15 Min)

IO SLA08 - Measures Response TAT for Prob Pri 1 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P1 Problems -Resolution Time (<4 Hrs)

IO SLA09 - Measures Resolution TAT for Prob Pri 1 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P2 Problems - Response Time (<2 Hrs)

IO SLA10 - Measures Response TAT for Prob Pri 2 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P2 Problems - Resolution Time (<8 Hrs)

IO SLA11 - Measures Resolution TAT for Prob Pri 2 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P1 Incidents - Response Time (<2 Hrs)

IO SLA12 - Measures Response TAT for Incid Pri 1 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P1 Incidents - Resolution Time (<1 Bus Day)

IO SLA13 - Measures Resolution TAT for Incid Pri 1 Remedy Tickets

Monthly

Active

Remedy

IBM


Schedule G-3 (Management Reports)		G-3-7		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only -Who
Generates Report
(Health
Net/IBM/CTS)

IT SLM Team

P2 Incidents - Response Time (<4 Hrs)

IO SLA14 - Measures Response TAT for Incid Pri 2 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P2 Incidents - Resolution Time(<2 Bus Days)

IO SLA15 - Measures Resolution TAT for Incid Pri 1 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

First Call Resolution

IO SLA16 - Measures number of calls that were resolved by SD

Monthly

Active

Remedy

IBM

IT SLM Team

Average Speed to Answer

IO SLA17 - Average Speed to answer calls coming in to SD

Monthly

Active

ACD

IBM

IT SLM Team

IMACS

IO SLA18 - Percentage of Incidents, Moves, Adds and Changes that were completed on time.

Monthly

Active

LN ISR, Rem SR

IBM

IT SLM Team

Average Call Abandonment Rate

IOSLA19 - Number of calls that were abandoned by the caller prior to being answered by the SD

Monthly

Active

ACD

IBM

IT SLM Team

P3 Incidents- Response Time (<1 Bus Day)

IOSLA21 - Measures Response TAT for Incid Pri 3 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P3 Incidents- Resolution Time (<3 Bus Days)

IOSLA22 - Measures Resolution TAT for Incid Pri 3 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P4 Incidents- Response Time (<2 Bus Days)

IOSLA23 - Measures Response TAT for Incid Pri 4 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P4 Incidents- Resolution Time (<5 Bus Days)

IOSLA24 - Measures Resolution TAT for Incid Pri 4 Remedy Tickets

Monthly

Active

Remedy

IBM


Schedule G-3 (Management Reports)		G-3-8		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only -Who
Generates Report
(Health
Net/IBM/CTS)

IT SLM Team

P3 Problem Response Time (<4 Hrs)

IOSLA25 - Measures Response TAT for Prob Pri 3 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P3 Problems- Resolution Time (<3Bus Days)

IOSLA26 - Measures Resolution TAT for Prob Pri 3 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P4 Problems- Response Time (<1 Bus Day)

IOSLA27 - Measures Response TAT for Prob Pri 4 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P4 Problems- Resolution Time (5 Bus Days)

IOSLA28 - Measures Resolution TAT for Prob Pri 4 Remedy Tickets

Monthly

Active

Remedy

IBM

IT SLM Team

Citrix Remote Access Server

IO SLA31 - Measures Availability of Citrix

Monthly

Active

Remedy

IBM

IT SLM Team

Voice Availability (Voice)

IO SLA32 - Measures voice Availability by tickets

Monthly

Active

Remedy

IBM

IT SLM Team

P1 Service Requests

IO SLA33 - Percentage of Pri 1 SRs completed on time

Monthly

Active

Remedy SR

IBM

IT SLM Team

P2 Service Requests

IO SLA33 - Percentage of Pri 2 SRs completed on time

Monthly

Active

Remedy SR

IBM

IT SLM Team

P3 Service Requests

IO SLA33 - Percentage of Pri 3 SRs completed on time

Monthly

Active

Remedy SR

IBM

IT SLM Team

P4 Service Requests

IO SLA33 - Percentage of Pri 4 SRs completed on time

Monthly

Active

Remedy SR

IBM

IT SLM Team

P5 Service Requests

IO SLA33 - Percentage of Pri 5 SRs completed on time

Monthly

Active

Remedy SR

IBM

IT SLM Team

Availability of DEV Servers

IO SLA38 - Measures availability of DEV Servers

Monthly

Active

Remedy

IBM


Schedule G-3 (Management Reports)		G-3-9		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only -Who
Generates Report
(Health
Net/IBM/CTS)

IT SLM Team

Availability of Non-Prod Servers

IO SLA39 - Measures availability of Non Prod Svrs (QA, TEST, Trng)

Monthly

Active

Remedy

IBM

IT SLM Team

Online Response Time

IO SLA40 - Measures online response for online applications

Monthly

Active

IBM

IT SLM Team

Speed of Messaging

IO SLA42 - Speed of messages delivered within Health Net Infrastructure

Monthly

Active

ACD

IBM

IT SLM Team

Middleware Infrastructure Avail

IIOSLA45 - Availability of Middleware Servers

Monthly

Active

Remedy

IBM

IT SLM Team

Availability of Infrastructure Services

IO SLA46 - Availability of Infrastructure Services

Monthly

Active

Remedy

IBM

IT PMO

Quarterly Project Management

IO SLA47 - Measures projects coming in at projected cost and schedule

Monthly

Active

IBM Tracking

IBM

IT SLM Team

Measurement and Reporting

IO SLA49 - Percent of internal transaction response times under two seconds for applications (FARE, Medical, ABS)

Monthly

Active

Remedy

IBM

IT SLM Team

Production Batch Application Availability

IO SLA50 - Availability of Prod Batch ready to run at batch start time.

Monthly

Active

Remedy

IBM

IT Chg Mgt

Change Backouts

IO SLA51 - Percentage of CMRs that were unsuccessful

Monthly

Active

Remedy

IBM

IT Chg Mgt

Unplanned Change Records

IO SLA52 - Percentage of total CMRs that were Unplanned

Monthly

Active

Remedy

IBM


Schedule G-3 (Management Reports)		G-3-1-10		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only -Who
Generates Report
(Health
Net/IBM/CTS)

IT Chg Mgt

Methodology Compliance Change Mgmt

IO SLA53 - Percentage of CMRs that were implemented out of compliance (not following process, w/o CMR, w/o approvals, outside approved time, etc.).

Monthly

Active

Remedy

IBM

IT Audit and Comp

Priv Access Accuracy & Delivery

IO SLA54 - Percentage of Priv Access Admin Requests provisioned on time

Monthly

Active

IBM

IT Audit and Comp

Priv Access Compliancy and Reconciliation

IO SLA55 - Percentage of Priv Access Admin removed within 72 hours.

Monthly

Active

Remedy

IBM

IT SLM Team

Access Admin BAU

IO SLA56 - Percentage of Bus As Usual Acces Admin requests fulfilled within 5 Bus Days.

Monthly

Active

LN ISR

IBM

IT PMO

Project Intake

IO Amendment 4 SLA57 - Measures the total number of days various components of the Project Intake and percentage that made it within the established TAT

Monthly

Active

IBM, Health Net Tracking, PV

IBM

IT PMO

Delivery of Project Budget

IO Amendment 4 SLA58 - Measures the costs of a project and whether in came within 10% of estimated costs.

Monthly

Active

IBM, Health Net Tracking, PV

IBM

IT PMO

Delivery of Project Schedule

IO Amendment 4 SLA59 - Tracks project schedule and measures whether it came in within 10% of estimated delivery.

Monthly

Active

IBM, Health Net Tracking, PV

IBM

IT PMO

Quality of Project Deliverables and Artifacts

IO Amendment 4 SLA60 - Measures the quality of project deliverables

Monthly

Active

IBM, Health Net Tracking, PV

IBM

IT SLM Team

Business Function Services Availability

IO Amendment 4 SLA61 - Measures availability of established Business Function Services

Monthly

Active

Remedy, Service Now

IBM


Schedule G-3 (Management Reports)		G-3-11		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System
(Data Resides)

IT Only -Who
Generates Report
(Health
Net/IBM/CTS)

IT SLM Team

Severity 1, Vital, Incident Ticket Resolution

IO Service Now SLA62 - Measures Resolution TAT for Sev Pri 1 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 1, Vital, Incident Ticket Response

IO Service Now SLA63 - Measures Response TAT for Sev Pri 1 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 2, Critical, Incident Ticket Resolution

IO Service Now SLA64 - Measures Resolution TAT for Sev Pri 2 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 2, Critical, Incident Ticket Response

IO Service Now SLA65 - Measures Response TAT for Sev Pri 2 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 3, High, Incident Ticket Resolution

IO Service Now SLA66 - Measures Resolution TAT for Sev Pri 3 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 3, High, Incident Ticket Response

IO Service Now SLA67 - Measures Response TAT for Sev Pri 3 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 4, Moderate, Incident Ticket Resolution

IO Service Now SLA68 - Measures Resolution TAT for Sev Pri 4 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 4, Moderate, Incident Ticket Response

IO Service Now SLA69 - Measures Response TAT for Sev Pri 4 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net


Schedule G-3 (Management Reports)		G-3-12		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

IT SLM Team

Severity 5, Low, Incident Ticket Resolution

IO Service Now SLA70 - Measures Resolution TAT for Sev Pri 5 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 5, Low, Incident Ticket Response

IO Service Now SLA71 - Measures Response TAT for Sev Pri 5 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Application Availability

IO Service Now SLA72 - Measures Application Availability without Client Impact (Intermittent until Amendment 4 BFS is implemented).

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Application Availability - Tier 1

AO SLA01 - Measures Application Availability for Critical Appls

Monthly

Active

Remedy

Supplier

IT SLM Team

Application Availability - MiddleWare

AO SLA02 - Measures Application Availability for Middleware Apps

Monthly

Active

Remedy

Supplier

IT SLM Team

Application Availability - Tier 2

AO SLA03 - Measures Application Availability for Non-Critical Apps

Monthly

Active

Remedy

Supplier

IT SLM Team

Application Availability - Tier 3

AO SLA04 - Measures Application Availability for New Apps undergoing base lining

Monthly

Active

Remedy

Supplier

IT SLM Team

P1 Problems- Response Time

AO SLA05 - Measures Response TAT for Prob Pri 1 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P1 Problems- Resolution Time

AO SLA06 - Measures Resolution TAT for Prob Pri 1 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P2 Problems- Response Time

AO SLA07 - Measures Response TAT for Prob Pri 2 Remedy Tickets

Monthly

Active

Remedy

Supplier


Schedule G-3 (Management Reports)		G-3-13		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

IT SLM Team

P2 Problems- Resolution Time

AO SLA08 - Measures Resolution TAT for Prob Pri 2 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P3 Problems- Response Time

AO SLA09 - Measures Response TAT for Prob Pri 3 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P3 Problems- Resolution Time

AO SLA10 - Measures Resolution TAT for Prob Pri 3 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P4 Problems- Response Time

AO SLA11 - Measures Response TAT for Prob Pri 4 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P4 Problems- Resolution Time

AO SLA12 - Measures Resolution TAT for Prob Pri 4 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P1 Incidents- Response Time

AO SLA13 - Measures Response TAT for Incid Pri 1 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P1 Incidents- Resolution Time

AO SLA14 - Measures Resolution TAT for Incid Pri 1 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P2 Incidents- Response Time

AO SLA15 - Measures Response TAT for Incid Pri 2 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P2 Incidents- Resolution Time

AO SLA16 - Measures Resolution TAT for Incid Pri 2 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P3 Incidents- Response Time

AO SLA17 - Measures Response TAT for Incid Pri 3 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P3 Incidents- Resolution Time

AO SLA18 - Measures Resolution TAT for Incid Pri 3 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P4 Incidents- Response Time

AO SLA19 - Measures Response TAT for Incid Pri 4 Remedy Tickets

Monthly

Active

Remedy

Supplier


Schedule G-3 (Management Reports)		G-3-14		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

IT SLM Team

P4 Incidents- Resolution Time

AO SLA20 - Measures Resolution TAT for Incid Pri 4 Remedy Tickets

Monthly

Active

Remedy

Supplier

IT SLM Team

P1 Problems RCA

Completion

AO SLA21 - Measures Root Cause Analysis TAT for Prob Pri 1

Monthly

Active

Remedy

Supplier

IT SLM Team

P2 Problems RCA

Completion

AO SLA22 - Measures Root Cause Analysis TAT for Prob Pri 2

Monthly

Active

Remedy

Supplier

IT SLM Team

Repeating & Nuisance items (Quarterly)

AOSLA23 - Problems and Incidents which cause the most loss to associate work that Health Net has targeted for improvement.

Quarterly

Active

Remedy

Supplier

IT SLM Team

On-Time Batch Processing Ready to Run

AO SLA24 - Critical batch jobs ready to run at start of batch window

Monthly

Active

Remedy

Supplier

IT SLM Team

P1 Service Request Completion Time

AO SLA25 - Percentage of Pri 1 SRs completed on time

Monthly

Active

Remedy

Supplier

IT SLM Team

P2 Service Request Completion Time

AO SLA26 - Percentage of Pri 2 SRs completed on time

Monthly

Active

Remedy

Supplier

IT SLM Team

P3 Service Request Completion Time

AO SLA27 - Percentage of Pri 3 SRs completed on time

Monthly

Active

Remedy

Supplier

IT SLM Team

P4 Service Request Completion Time

AO SLA28 - Percentage of Pri 4 SRs completed on time

Monthly

Active

Remedy

Supplier


Schedule G-3 (Management Reports)		G-3-15		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

IT SLM Team

P5 Service Request Completion Time

AO SLA29 - Percentage of Pri 5 SRs completed on time

Monthly

Active

Remedy

Supplier

IT SLM Team

Production backouts

AO SLA30 - Percentage of CMRs that were unsuccessful

Monthly

Active

Remedy

Supplier

IT SLM Team

Unplanned Change Records

AO SLA31 - Percentage of total CMRs that were Unplanned

Monthly

Active

Remedy

Supplier

IT SLM Team

Methodology Compliance Change Management

AO SLA32 - Percentage of CMRs that were implemented out of compliance (not following process, w/o CMR, w/o approvals, outside approved time, etc.).

Monthly

Active

Remedy

Supplier

IT SLM Team

Project Estimation Response

AO SLA33 - Provides the number of Project Estimates submitted to Health Net within 5 BD of acceptance of a Project Brief.

Monthly

Active

Supplier Tracking

Supplier

IT SLM Team

Project Time to Schedule

AO SLA34 - Provides percentage of project schedules submitted on time.

Monthly

Active

Remedy

Supplier

IT SLM Team

▇▇▇ Estimate Deviation - OOM

(Projects)

AO SLA35 - Rough Order of Magnitude deviation compared to initial Work Order.

Monthly

Active

Supplier Tracking

Supplier

IT SLM Team

▇▇▇ Estimate Deviation - ROM

(Projects)

AO SLA36 - Refined Order of Magnitude deviation compared to Requirements phase in PDLC.

Monthly

Active

Supplier Tracking

Supplier

IT SLM Team

▇▇▇ Estimate Deviation - DOM

(Projects)

AO SLA37 - Definitive Estimate deviation to Design Phase in PDLC.

Monthly

Active

Supplier Tracking

Supplier

IT SLM Team

On-Time Delivery of Projects into Production

AO SLA40 - Measures project delivery against the scheduled date.

Monthly

Active

Supplier Tracking

Supplier


Schedule G-3 (Management Reports)		G-3-16		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

IT SLM Team

Programmer Effectiveness

AO SLA48 - Measures the percentage of deliverables submitted to Health Net for UAT with no Programming Std Defects.

Monthly

Active

Supplier Tracking

Supplier

IT SLM Team

Defect Rate in Production

AO SLA49 - Compares the number of defects to the effort expended for each deliverable/release.

Monthly

Active

Supplier Tracking

Supplier

IT SLM Team

▇▇▇ Estimate Deviation Rough Order of Magnitude (ME)

AO SLA51 - Measures Deviation of Rough Order of Magnitude provided in the initial Project Brief for ME.

Monthly

Active

Supplier Tracking

Supplier

IT SLM Team

On-Time Delivery of Minor Enhancements into Production

AO SLA52 - Measures completion of ME against scheduled completion date.

Monthly

Active

Supplier Tracking

Supplier

IT SLM Team

Satisfaction Surveys (Annual)

AO SLA53 - Measures Health Net Satisfaction for Vendor Service

Annually

Active

Survey Monkey

Health Net

IT SLM Team

LMS

Compliance

AO SLA54 - Measures percentage of LMS Course compliancy for AO Supplier associates.

Monthly

Active

LMS

Supplier

IT SLM Team

QA Cost%

AO SLA55 - Measures the costs of a project and whether in came within a percentage of estimated costs.

Monthly

Active

QC, Manual Tracking

Supplier

IT SLM Team

Functional Defect Removal Effectiveness (DRE) %

AO SLA56 - Measures the effectiveness in detection and removal of functional defects during all phases of PDLC.

Monthly

Active

Supplier


Schedule G-3 (Management Reports)		G-3-17		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

IT SLM Team

QA Schedule Variance %

AO SLA57 - Tracks project schedule and measures whether it came in within a percentage of estimated delivery.

Monthly

Active

QC, Manual Tracking

Supplier

IT SLM Team

AA Privilege Access Reporting Compliance (PARC)

AO SLA58 - Percentage of Priv Access Admin Requests provisioned on time

Monthly

Active

Supplier Tracking

Supplier

IT SLM Team

AA Privilege Access Reconciliation Compliance (PARC)

AO SLA59 - Percentage of Priv Access Admin removed within 72 hours.

Monthly

Active

Remedy

Supplier

IT SLM Team

AA Business As Usual Turnaround Time

AO SLA60 - Percentage of Bus As Usual Acces Admin requests fulfilled within 5 Bus Days.

Monthly

Active

ISR

Supplier

IT SLM Team

AA User-ID Termination

AO SLA61 - Measures the TAT and full completion for ISR Account Termination requests

Monthly

Active

ISR

Supplier

IT SLM Team

Severity 1, Vital, Incident Ticket Resolution

AO Service Now SLA62 - Measures Resolution TAT for Sev Pri 1 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 1, Vital, Incident Ticket Response

AO Service Now SLA63 - Measures Response TAT for Sev Pri 1 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 2, Critical, Incident Ticket Resolution

AO Service Now SLA64 - Measures Resolution TAT for Sev Pri 2 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net


Schedule G-3 (Management Reports)		G-3-18		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

IT SLM Team

Severity 2, Critical, Incident Ticket Response

AO Service Now SLA65 - Measures Response TAT for Sev Pri 2 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 3, High, Incident Ticket Resolution

AO Service Now SLA66 - Measures Resolution TAT for Sev Pri 3 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 3, High, Incident Ticket Response

AO Service Now SLA67 - Measures Response TAT for Sev Pri 3 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 4, Moderate, Incident Ticket Resolution

AO Service Now SLA68 - Measures Resolution TAT for Sev Pri 4 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 4, Moderate, Incident Ticket Response

AO Service Now SLA69 - Measures Response TAT for Sev Pri 4 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 5, Low, Incident Ticket Resolution

AO Service Now SLA70 - Measures Resolution TAT for Sev Pri 5 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

Severity 5, Low, Incident Ticket Response

AO Service Now SLA71 - Measures Response TAT for Sev Pri 5 Service Now Tickets

Monthly

Active

Service Now

Service Now / Health Net


Schedule G-3 (Management Reports)		G-3-19		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

IT SLM Team

Application Availability

AO Service Now SLA72 - Measures Application Availability without Client Impact (Intermittent until Amendment 4 BFS is implemented).

Monthly

Active

Service Now

Service Now / Health Net

IT SLM Team

AA Emergency ID Termination

AO SLA73 - Measures TAT for ID Termination requests from OE

Monthly

Active

ISR

Supplier

IT SLM Team

AA Open Inventory

AO SLA74 - Measures AA Requests Backlog

Monthly

Active

ISR

Supplier

IT SLM Team

Communication Link Availability

SA SLA01 - Measures Availability of Supplier Network

Monthly

Active

Supplier, Remedy

Supplier

IT SLM Team

Monthly Proj Milestone and Deliverable Status Rpt

SA SLA02 - Measures TAT of Report for Project Deliverable Status

Monthly

Active

Supplier, PMO

Supplier

IT SLM Team

QA Cost

SA SLA03 - Measures the costs of a project and whether in came within a percentage of estimated costs.

Monthly

Active

QC, Manual Tracking

Supplier

IT SLM Team

Defect Removal Effectiveness Percentage

SA SLA04 - Measures the effectiveness in detection and removal of functional defects during all phases of PDLC.

Monthly

Active

Supplier

IT SLM Team

QA Sched Variance Percentage

SA SLA05 - Tracks project schedule and measures whether it came in within a percentage of estimated delivery.

Monthly

Active

QC, Manual Tracking

Supplier

IT SLM Team

Intake Transactions from Exchgs

hC SLA01 - Measures TAT for transaction delivery from Exchange

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

Transmit Exchgs Ack

hC SLA02 - Measures Exchange Transactions Acknowledgement

Monthly

Active

h-Centive

h-Centive and Health Net


Schedule G-3 (Management Reports)		G-3-20		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

IT SLM Team

Transmit Trans to Health Net (24 hr window)

hC SLA03 - Measures transactions received at Health Net within TAT window

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

Transmit Health Net Trans to exchg in 24 Hrs

hC SLA04 - Measures Health Net Transactions back to Exchange within TAT window

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

Supplier Process Trans Backlog

hC SLA05 - Number of transactions in backlog

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

File Server

hC SLA06 - Measures Server Availability

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

Database Server

hC SLA07 - Measures Server Availability

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

Business Process Server

hC SLA08 - Measures Server Availability

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

Web Server (UI)

hC SLA09 - Measures Server Availability

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

Average vs. Aggregate Total*

hC SLA10 - Overall Server Availability

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

Class 1 - (15) Minute Response Time

hC SLA11 - Measures Response TAT for Pri 1 tickets

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

Class 2 - (2) Hr Response Time

hC SLA12 - Measures Response TAT for Pri 2 tickets

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

Monthly Reporting

hC OPN01 - Defect Trends - Last Three Months (Info Only)

Monthly

Active

h-Centive

h-Centive and Health Net

IT SLM Team

SaaS Application Recovery

hC OPN02 - Re-Open Rate (Info Only)

Monthly

Active

h-Centive

h-Centive and Health Net


Schedule G-3 (Management Reports)		G-3-1-21		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

PMO

Internal Audit Manager Rpt

provides audit scores and remediation results

Weekly

Active

Health Net

PMO

IBM WO/PCR

Log

WO life cycle - TAT’s

Weekly

Active

Health Net

PMO

Supplier Aged WO

WO life cycle - TAT’s

Weekly

Active

Health Net

PMO

IBM Time Rpt

All project hours that are entered into PV

Monthly

Active

IBM

PMO

Health Net Resource Estimates for Project / Programs

Health Net PM’s to provide manual # of resources and hours needed by dept/role

Weekly

Active

Health Net

PMO

Supplier Timesheets

list of late timesheets that require Health Net PM approval

Weekly

Active

Health Net

PMO

IBM RFS

Portfolio Status Rpt

status of RFS

Weekly

Active

IBM

PMO

Bi Weekly PM Project Status Rpt

projects status rpt to project stakeholder

Bi Weekly

Active

Health Net

PMO

Project Status Report

projects status rpt to Health Net PM

Weekly

Active

IBM

PMO

Minor Enhancement - Supplier

master list of all minor enhancements / status

Weekly

Active

Health Net

PMO

Current DR PIDs

status pf RFS DR PIDs

Weekly

Active

IBM

PMO

Minor Enhancements - IBM

master list of all minor enhancements / status

Weekly

Active

Health Net


Schedule G-3 (Management Reports)		G-3-1-22		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

Web

Prv_NextGen_

<DATE>.xlsx

Monthly report of ▇▇▇▇▇▇▇▇▇.▇▇▇ Provider portal activity

Monthly

Active

Adobe Site Catalyst, TR, HNWeb, ODW

Health Net

Web

Provider_Regis tration.<DATE

>.xlsx

Monthly report of all provider registration by type

Monthly

Active

TR, HNWeb, ODW

Health Net

Web

Mbr_NextGen_

<DATE>.xlsx

Monthly report of ▇▇▇▇▇▇▇▇▇.▇▇▇ Member portal activity

Monthly

Active

HNWeb TR

SiteCatalyst ODW

ABS (EDD Group Pref File)

Health Net

Web

Member_Regis tration_<DATE

>.pdf

Monthly report of all member registration by LOB

Monthly

Active

TR, HNWeb

Health Net

Web

Employer_Web Metrics_<DAT E>.xlsx

Monthly report of ▇▇▇▇▇▇▇▇▇.▇▇▇ Employer portal activity

Monthly

Active

Adobe Site Catalyst, TR, HNWeb

Health Net

Web

Broker_WebM etrics_<DATE

>.xlsx

Monthly report of ▇▇▇▇▇▇▇▇▇.▇▇▇ Broker portal activity

Monthly

Active

Adobe Site Catalyst, TR, HNWeb,

Connecture

Health Net

Web

StaterBros_<D ATE>.pdf

Monthly activity report for employer group: Stater Bros

Monthly

Active

Adobe Site Catalyst, TR, HNWeb

Health Net

Web

CVS_<DATE>

.pdf

Monthly activity report for employer group: CVS

Monthly

Active

Adobe Site Catalyst, TR, HNWeb

Health Net

Web

UC_Web_Rep ort_<DATE>.xls

Monthly activity report for employer group: UC

Monthly / Quarterly

Active

Adobe Site Catalyst, TR, HNWeb

Health Net

Web

Raytheon_<DA TE>.pdf

Monthly activity report for employer group: Raytheon

Monthly

Active

Adobe Site Catalyst, TR, HNWeb

Health Net


Schedule G-3 (Management Reports)		G-3-23		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

Web

SCE_Web_Usage
_<Q>_<YE AR>.xls

Quarterly web usage/activity report for employer group: SCE

Quarterly

Active

Adobe Site Catalyst, TR, HNWeb

Health Net

Web

Medicare-
SNP_<DAtE>.

pdf

Monthly report of Medicare SNP registration

Monthly

Active

TR, HNWeb

Health Net

Web

Boeing_Web_
Adoption_<DATE>.pdf

Monthly activity report and electronic document distribution report for employer group: Boeing

Monthly

Active

TR, HNWeb

Health Net

Web

EDD_<DATE>

.pdf

Monthly activity report on member opt-ins for electronic document distribution

Monthly

Active

TR, HNWeb

Health Net

Web

Member_Registered
_Optin_<DATE>.xlsx

Monthly report of registered emails that opt-in for marketing communications

Monthly

Active

TR, HNWeb

Health Net

Web

AON Microsite

<NEW>

Monthly activity report for the AON ▇▇▇▇▇▇ microsite

Monthly

Active

Adobe Site Catalyst

Health Net

Web

AZ_HOSPITAL_
GROUP_WEBUSAGE.JU

N2014.xlsx

Monthly activity report on AZ Hospitals

Monthly

Active

Adobe Site Catalyst, HNWeb

Health Net

Web

CA_PrisonStaff_
ProviderSearch
_JUL2014.xlsx

Monthly Provider Search activity report for CA Prisons

Monthly

Active

Adobe Site Catalyst, HNWeb

Health Net

Web

bkr_BookOfBusiness.
<DATE>.xlsx

Monthly activity report on Broker Book of Business

Monthly

Active

Adobe Site Catalyst, HNWeb

Health Net

Web

Broker Book of Business - Broker Detail

Monthly detailed activity report on Broker Book of Business broken out by Broker

Monthly

Active

Adobe Site Catalyst, HNWeb,TR

Health Net

Web

CMS CTM Form

Monthly report on activity of CMS-CTM form

Monthly

Active

Adobe Site Catalyst

Health Net


Schedule G-3 (Management Reports)		G-3-24		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

Web

WebAuthRqst Rpt.<DATE>.xlsx

Monthly activity report on Web authorization request

Monthly

Active

HNWeb

Health Net

Web

Mobile Apps

Activity report on broker mobile apps usage

Monthly

Active

Adobe Site Catalyst, HNWeb

Health Net

Web

QI Medicare Advantage Email List

Monthly report of MA email addresses

Monthly

Active

HNWeb, TR

Health Net

Web

CCC_EMailOp tin_<DATA>.xls

Monthly report of members with email opt-in

Monthly

Active

HNWeb, TR

Health Net

Web

Duals MediConnect Enroll & Registration

Weekly list of enrolled Duals members, month to date registrations. Year-to-Date registrations produced monthly

Weekly, Monthly

Active

HNWeb, TR

Health Net

Web

QA AZ

Medicaid email list

Monthly list of AZ Medicaid email opt-ins

Monthly

Active

HNWeb, TR

Health Net

Web

IEX email list

ACA member email list by region

Monthly

Active

HNWeb, TR

Health Net

Web

QI PDF

downloads

Monthly report of al QI pdf’s that were downloaded

Monthly

Active

Adobe Site Catalyst

Health Net

Web

PMR - CA SHP

Monthly metrics provided for PMRs

Monthly

Active

Adobe Site Catalyst, TR, HNWeb, ODW

Health Net

Web

PMR -

Commercial

Monthly metrics provided for PMRs

Monthly

Active

Adobe Site Catalyst, TR, HNWeb, ODW

Health Net

Web

PMR -

Medicare

Monthly metrics provided for PMRs

Monthly

Active

Adobe Site Catalyst, TR, HNWeb, ODW

Health Net

Change Management

Infrastructure Significant Risk Changes

Provides a schedule of (high) risk changes

Weekly

Active

Manual

HNT


Schedule G-3 (Management Reports)		G-3-25		Health Net / Cognizant Confidential

Final

Department
Area

Report Title

Report Description

Frequency

Current
Report

IT Only - System

(Data Resides)

IT Only - Who
Generates Report
(Health

Net/IBM/CTS)

Change Management

CAB (Change Advisory Board) Report

Lists all upcoming changes of impact/risk. Used for Change Review Meeting

Twice-a- week (Fri/Wed)

Active

Remedy

HNT

Change Management

Change Report

Lists all scheduled changes for next 24 (Mon-Thu) or 72 (Fri) hours

Daily

Active

Remedy

HNT

Change Management

Change Management Activity Metrics

Provides change management performance against KPI’s

Monthly

Active

Remedy

HNT

Change Management

Urgent Changes

Provides a list of Urgent Changes (Unplanned and Emergency) over past 24 (Tue - Fri) or 72 (Mon) hours

Daily

Active

Remedy

HNT

Change Management

System Availability Matrix

Provides a list of services and any scheduled unavailability for the weekend

Weekly

Active

Manual

HNT

Change Management

Servers, Services, Sites, and Databases

Provides inventory and (change management) related attributes for services, servers, sites, and databases

Monthly

Active

Manual

HNT

ITG QA

QA Daily Dashboard, Issues Log, Catch-Up Plans

All projects being tested by QA or UAT provide status, deviation, defects, etc.

Daily

Active

Quality Center

Supplier

ITG QA

Readiness Tracker

All projects with approved WO or SR to provide status of pre QA artifact readiness to know if testing can start

Daily

Active

Excel

Supplier

ITG QA

Assignment Tracker

All approved projects assigned to member of the HNQA team, along with key milestones and endorsements

Daily

Active

Excel

Health Net

ITG QA

Enterprise Project Listing (EPL)

All known projects in the enterprise

Weekly

Active

PlanView

Health Net


Schedule G-3 (Management Reports)		G-3-26		Health Net / Cognizant Confidential

Application category

Commercial Application

Federal Application

Corp Application