120174 O3, ADDENDUM TWO (2) Q&A.pdf

SPB Form 26 Effective 7-19-2024

SOLICITATION ADDENDUM TWO (2) 120174 O3

QUESTIONS AND ANSWERS

Date: December 13, 2024

To: All Bidders

From: Julie Schiltz, NDCS

RE: Addendum for 120174 O3 to be opened January 22, 2025 at 2 p.m. CST

Questions and Answers

Following are the questions submitted and answers provided for the above-mentioned solicitation.

The questions and answers are to be considered as part of the solicitation. It is the responsibility of bidders to check the State Purchasing Bureau website for all addenda or amendments.

BIDDERS MUST REFER TO THE REVISED SCHEDULE OF EVENTS POSTED ON 12/09/2024.

Question Number

Section Reference

Page Number

Question State Response

1. Can you please confirm the effective date of the contract?

The contract start date will be determined during the contract award.

2. I. Procurement Procedure C. Schedule of Events

COST PROPOSAL

The RFP does not contain an effective date for the start of services per the Schedule of Events.

In the COST PROPOSAL, bidders are asked to provide administrative bids for the “Initial contract term”.

Please provide an effective date and an end date for the first contract term that is referenced in the RFP. Please also provide the dates of the Renewal 1 and Renewal 2 time periods as identified on the COST

PROPOSAL.

The incumbent administrative fee term was extended by the NDCS through September 30, 2025.

Please refer to the response in question #1.

The initial term of the contract is for four (4) years. Renewal dates will be determined based on the contract start date. Each renewal term will be two (2) years.

3. V. Project Description & Scope of Work:

A. Project Overview C. Business Requirements

In these stated locations within the RFP and Attachment A (questionnaire), the State is requiring the contractor to pay the NDCS’s medical and dental claims based on

V. Project Description & Scope of Work:

A. Project Overview, C. Business Requirements, E. Bidder Requirements, F.

Contractor Requirements, ATTACHMENT

E. Bidder Requirements F. Contractor Requirements

ATTACHMENT A

Questionnaire:

C.2 E.8

1 (Att A) 4 (Att A) the lesser of Medicare rates or bidders’ PPO contracted provider rates.

BCBSNE has provider contracts in place for our NEtwork BLUE provider network, which is utilized by the NDCS. These contracts are executed and providers are expected to be paid on the contracted NEtwork BLUE reimbursement rates in effect at the time a claim is incurred. We are prohibited from paying our contracted providers a reimbursement rate that is less than the contracted reimbursement rates under NEtwork BLUE, and it is assumed that our NEtwork BLUE contracted rates would be greater in every instance when compared to Medicare reimbursements.

Would the NDCS be open to possibly establishing a unique provider network consisting of a predefined list of providers as a subset of our NEtwork BLUE statewide providers, if those providers would agree to accept the Nebraska Medicare rates for services incurred by inmates?

A Questionnaire: C.2, E.8 are hereby amended. See posted revised documents.

Awarded bidder will pay provider claims in accordance with their contractor/provider agreement.

4. V. Project Description &

C. Business Requirements, item 7

23 The RFP states preauthorization is not applicable for emergency services or inpatient services, but that for outpatient services, NDCS will provide a “prior authorization number”.

Can the State please explain NDCS’ intent regarding preauthorization / prior authorization, and what is meant by the reference of a “prior authorization number”.

See posted revised documents.

Out-patient services: For out-patient services a consult document is given to the provider for services that are authorized.

Those are the only services that may be billed, unless subsequent approval is given by the NDCS Medical Director or designee.

Unauthorized services may be charged back to the provider.

5. V. Project Description &

C. Business Requirements, item 8

23 Requirement for in state and out-of-state services states only those services which are approved by the NDCS should be submitted for payment.

Does this mean the NDCS is the entity that approves any in-state or out-of-state services?

Does this mean the NDCS’ Medical Director will be reviewing all prior

In-state - all outpatients are determined thru an internal consulting process. Out-of-State

- Services that occur outside the State of Nebraska, these must be preapproved by the NDCS Medical Director or designee. In the event inpatient services do not appear to be necessary the utilization management nurse will work with the case management to determine medical necessity continued management.

Yes, NDCS Medical Director or designee reviews all prior authorizations. NDCS does authorizations and that the Director will pass the determinations to the contractor?

not provide the determinations to the contractor.

If the contractor has a recommendation of a mechanism that includes a reconciliation process between approved and billed services, the bidder may include in the proposal.

6. V. Project Description &

C. Bidder Requirements, item 9

25 The requirement is for the contractor to provide an outline of the utilization management of claims process and the potential to customize the process.

Does the NDCS want a post claim review just for outpatient services, meaning the claim edit would check for a preauthorization if the service requires preauthorization?

There are several questions and requirements mentioning preauthorization and utilization management throughout the RFP and Attachment A, and most of these descriptions appear to point to the NDCS’ Medical Director being the coordinator and approver of preauthorized services, but can the NDCS please confirm this?

E.9. is amended to the following: Include an outline of compliance management for claims processing in accordance with the RFP Scope of Work.

No. Bidder may propose various mechanisms.

Yes, the NDCS Medical Director or designee will provide approval.

7. V. Project Description & Scope of Work:

E. Bidder Requirements, item 8

25 The RFP states bidders are to provide an “outline of the utilization management of claims process and potential to customize”.

As the incumbent administrator, we do not apply utilization management / prior authorization on the account today since the NDCS’ Medical Director determines when a member visits a provider.

Can the State/NDCS define “utilization management” in the context of what you’re expecting of the contractor’s duties surrounding

UM/PA?

Refer to the response to question 6.

8. ATTACHMENT A

C.10.

3 This question E.10 states billing received for transplant services must be pre-approved by the NDCS Medical Director or designee, and that the patient must meet transplant criteria.

Is it the intent of the State to have transplant situations only approved by the NDCS Medical Director or designee?

Yes.

Should the NDCS utilize the contractor's prior authorization list, then transplants are required to have prior authorization. Is it the intent of the NDCS to have the contractor conduct preauthorization services, or is it the intent that NDCS will review and approve or deny services requiring preauthorization?

Refer to the response in questions # 4 and #6

9. ATTACHMENT A

E.7.

4 This question E.7 requests bidders provide a sortable file by each Specialty in the “Lincoln Physicians Directory”. Can the NDCS please explain what this reference to “Lincoln Physicians Directory” means?

E.7 is hereby amended to the following:

Provide listing of in-network providers in a sortable file by each Specialty in following 5 cities in Nebraska: Omaha metro area, Lincoln, York, Tecumseh, and McCook.

10. ATTACHMENT A

F.2.a.

5 This question F.2.a. requests that the contractor provide NDCS Accounting with an automated denial report on a monthly basis.

If NDCS is not conducting preauthorization services and the intent is for the contractor to provide preauth services, is the denial report inclusive of denied preauthorization in addition to denied claims?

The intent is not for the contractor to provide preauthorization services. Yes, all denials should be reported for NDCS auditing purposes.

11. ATTACHMENT A

K.1.

10 This question states that, prior to claims being paid, a utilization review shall be completed to include reviewing claims for appropriate services, review procedures / documentations related to a visit to a provider for appropriateness, and a review of hospital stays for appropriate length of stay. Bidders are to describe in detail the analytics capabilities and competency of providing a details, accurate and comprehensive utilization review.

Is this question K.1. stating that before any claims are paid, whether prior authorization was required or not, that the contractor conducts a post claim review for appropriateness (medical necessity) and for the length of service for an inpatient acute or post-acute level of care?

If the NDCS is not requiring prior authorization for inpatient admission, is the contractor to deny the claim if it does not meet medical necessity requirements?

Yes, for inpatient services. No prior authorization by NDCS is provided for inpatient services.

Contractor should flag the claim with concerns and contact the NDCS Medical Director or designee.

If the contractor’s UM team did not receive a prior authorization, is the NDCS saying that the contactor can review the service for medical necessity and pay the claim if the contractor determines the claim was medically necessary?

Yes, this should be paid unless otherwise noted in the RFP. If reviewed and claim looks like it is medically necessity, the contractor should pay claims if there is no Medicaid claim pending.

12. Can you please confirm if the medical plan is currently administered using the “lesser of” logic (Medicare or administrator’s contracted discount)?

How many providers, where inmates received care, do not accept Medicare reimbursement?

a. 2023

b. 2024 YTD

Questions for the current contract shall not be addressed in this RFP Q&A. The current contract may be viewed at https://statecontracts.nebraska.gov/

NDCS is unable to provide this information.

This addendum will be incorporated into the solicitation.

https://statecontracts.nebraska.gov/

Questions and Answers