15-236-SOL-00019_RFP_Amendment_001.pdf

RFP#: 15-236-SOL-00019

Medical Claims Processing

SECTION B - PRODUCTS OR SERVICES AND PRICES/COSTS

The Contractor shall provide the services described in the Statement of Work (SOW) (Section C). Except as otherwise specified in the solicitation, the Contractor shall furnish the necessary personnel, materials, services, facilities, and otherwise do all things necessary for or incident to the performance of the commercial services set forth herein.

B.1 TYPE OF CONTRACT

The Government anticipates a single Firm Fixed Price award as a result of this solicitation.

B.2 SEVERABLE SERVICES

The services acquired under this RFP are for severable services. Funds are only available for use for the line item to which they are obligated. Unused funds from one period (line item) may not rollover for use in other periods.

B.3 OTHER DIRECT COST – TRAVEL

The Contractor will be reimbursed, not to exceed the estimated travel costs per individual order, for all domestic travel as described below, incurred directly and specifically in the performance of this order. All travel conducted under this order must be in accordance with the U.S. General Services Administration (GSA) Federal Travel

Regulations (FTR), See Section (G.5) for more information.

B.4 OPTION PRICES

a. Pursuant to FAR Clause 52.217-8, Option to Extend Services and FAR Clause 52.217-9, Option to Extend the

Term of the Contract, set forth in CONTRACT CLAUSES of this contract, the Government may, by unilateral contract modification, require the Contractor to perform the Option Period(s) as defined in the Statement of Work of this contract. If the Government exercises this/these option(s), notice must be given before the expiration date of the contract. Specific information regarding the time frame for this notice is set forth in the OPTION

PROVISION of this order. If an option period is exercised the fixed price of this contract will be increased as set forth below.

B.5 PRICING TABLES

Base Year: July 01, 2015 through December 31, 2015

Tier # of Claims per Period Proposed Amount per Claim

1 <350,000

2 350,001 – 425,000

3 425,001 – 500,000

4 500,001<

Travel: $15,000 NTE (Not-to-Exceed)

Option Year 1: January 01, 2016 through December 31, 2016

Tier # of Claims per Period Proposed Amount per Claim

1 <350,000

2 350,001 – 425,000

3 425,001 – 500,000

4 500,001<

Travel: $15,000 NTE (Not-to-Exceed)

Option Year 2: January 01, 2017 through December 31, 2017

Tier # of Claims per Period Proposed Amount per Claim

1 <350,000

2 350,001 – 425,000

3 425,001 – 500,000

4 500,001<

Travel: $15,000 NTE (Not-to-Exceed)

Option Year 3: January 01, 2018 through December 31, 2018

Tier # of Claims per Period Proposed Amount per Claim

1 <350,000

2 350,001 – 425,000

3 425,001 – 500,000

4 500,001<

Travel: $15,000 NTE (Not-to-Exceed)

Option Year 4: January 01, 2019 through December 31, 2019

Tier # of Claims per Period Proposed Amount per Claim

1 <350,000

2 350,001 – 425,000

3 425,001 – 500,000

4 500,001<

Travel: $15,000 NTE (Not-to-Exceed)

SECTION C- DESCRIPTION / SPECIFICATIONS / WORK STATEMENT

1.0 GENERAL

1.1 INTRODUCTION. The purpose of this procurement is to acquire fiscal intermediary (FI) services to operate a centralized medical and dental claims processing and reimbursement system. The FI will collect, compile and organize workload and financial data, assist the Indian Health Service (IHS) in the coordination of benefits and provide statistical and financial reports to the IHS Purchased/Referred Care (PRC)1 Program, formerly known as contract health services. The FI shall calculate Medicare and other reimbursement rates in accordance with regulations and the IHS payment policy and ensure that the IHS is the payer of last resort for services provided to patients. The Contractor will participate in the solution of problems and issues which arise in the conduct of this contract. Under this contract FI services will also be made available to Tribal PRC programs operated under the

Indian Self-Determination and Education Assistance Act (ISDEAA), Public Law 93-638, as amended.

For more information on the PRC Program, visit the IHS website at http://www.ihs.gov.

1.2 BACKGROUND. The Indian Health Service (IHS) has a responsibility to provide health care services to eligible American Indian and Alaska Natives (AI/AN). Direct health care services are provided through IHS-operated and Tribally-operated hospitals, clinics and health care programs. IHS supplements its direct health care services by purchasing basic and specialty health care services from non-IHS health care providers through the

PRC program. Program funds may be used to inpatient hospitalization, purchase physician, laboratory, dental, radiology, pharmacy, and transportation services.

The PRC program is limited by Congressional appropriations and, therefore, must rely on compliance with medical and dental priorities and regulations to ensure the most effective use of PRC dollars. Regulations require

PRC to be approved in advance by authorized individuals, except in emergency cases.

The PRC program is administered through 12 IHS Area Offices that consist of approximately 69 federally-operated Service Units (SU) and 84 tribally-operated facilities. These facilities are responsible for determining the eligibility of the Indian patient and for purchasing medical services. Each IHS facility uses the Purchase Delivery

Order (PDO) for Health Services form (IHS 843-1A) (Exhibit A) to procure PRC. The PDO form is also commonly referred to as, a "treatment authorization” because it authorizes the medical and dental care provider to render the health care treatment(s) requested by the respective PRC program.

The authority for a fiscal agent contained in the Consolidated Omnibus Budget Reconciliation Act of 1985, Public

Law 99-272, Section 17003; “. . . provides authority for the Secretary of the Department of Health and Human

Services to contract with fiscal agents to perform claims payment, processing and audit functions with respect to services purchased on a contract basis by the Public Health Service ... Fiscal Agents must either be entities which could qualify as carriers for Medicare purposes, or Indian Tribes or Tribal organizations acting under the Indian

Self-Determination and Education Assistance Act (ISDEAA), Public Law 93-638 contracts. While the fiscal agents need not be Medicare carriers, they must meet the same requirements regarding efficiency and effectiveness of operations, surety bonds, and financial controls.”

1 The Appropriation Act of 2014 changed the IHS Contract Health Services (CHS) Program name to

Purchased/Referred Care (PRC) to better describe the purpose of the program for purchased care and referred care outside of IHS and does not otherwise change the program, polices, or laws applicable to CHS.

http://www.ihs.gov/

1.3 WORKLOAD. The contractor will be responsible for processing, making adjustments, reimbursements, payments and payment recoveries for approximately 466,000 medical and dental claims annually. The contractor will conduct voucher examination activities for all PRC claims to ensure payments are timely and accurate. The contractor must have the ability to receive daily transmissions from the nine Area Offices which contain all data for PRC PDO’s subject to payment by the contractor and transmit payment information directly to Unified

Financial Management System (UFMS). The contractor will also be responsible for coordinating patient benefits to ensure that IHS is the payer of last resort on all medical and dental claims. The contractor will have the capability to contact approximately 600 primary insurers, providers, and SU staff monthly to obtain alternate resource information needed to process claims. The contractor will have the ability to respond to approximately

700 written inquiry cases monthly. The contractor shall have Customer Service staff available to respond to approximately 2,500 call per month from IHS and providers between the hours of 8:00 AM to 5:00 PM Central

Standard Time (Central Standard Time is utilized to address the needs of both east and west coast IHS areas) to answer claims processing questions.

1.4 PERFORMANCE BASED REQUIREMENTS. This contract is for FI services which include a centralized medical and dental claims processing and reimbursement system for IHS in accordance with regulations, policies and standards as specified in this contract and exhibits. The Contractor shall process and make timely and accurate payments on medical and dental claims from July 1, 2015, through December 31, 2015, with the possibility of four option years.

2.0 DEFINITIONS AND ACRONYMS

2.1. Alternate Resources (Third Party Payer) - Resources other than those of the PRC program, which are available and accessible to the Indian patient such as health care providers and institutions (including facilities operated by the IHS), health payment sources or other health care programs (e.g., Medicare or Medicaid), other

Federal, State, local or private insurance for which the individual may be eligible.

2.2 Area Office - The second echelon level organizational unit in the IHS responsible for supporting the administrative, management and clinical system of health care unique to its population. There are l2 IHS Area

Offices covering the 32 Reservation States.

2.3 Billed Charges - Total charges billed by a health care provider; it shows the gross billed or retail price of services offered by the provider and does not represent the amount paid by the beneficiary or the amount collected by the provider. It is the amount which is reimbursed when the provider has no contract in place, or when the contract, rate quote or agreement is for payment at the provider’s normal billed rate.

2.4 Business Associate Agreement - An agreement that governs the use of protected health information between two parties who are exchanging information and services. The agreement specifies how the health information will be used by the business associate and identifies various safeguards that must be in place to protect the information properly. The associate is required to report any unauthorized use of the information immediately.

2.5 Clean Claim - A claim that has all the necessary correct information without any omissions or mistakes that allows it to be processed and paid promptly.

2.6 Closed Document - A document (PDO/obligation) in the IHS accounting system which indicates a final payment has been made.

2.7 Contract Health Service/Management Information System (CHS/MIS) – Computerized system by which

IHS issues purchase delivery orders, denials and records explanation of benefits data.

2.8 Contracting Officer - A person with the authority to enter into, administer, and/or terminate contracts and/or agreements and make related determinations and findings for their designated areas on behalf of the U.S.

Government.

2.9 Contracting Officer Representative (COR) - Qualified individual appointed by the Contracting Officer who is responsible for providing technical oversight and monitoring of contract administration and contractor performance.

2.10 Coordination of Benefits (COB) – The process used to determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan.

2.11 Cost Savings - A sum of money that was not expended as a result of an IHS contract, rate quote, or agreement with a provider to accept reimbursement at less than the normal billed charges.

2.12 Current Year Claim - Claims submitted to the Contractor for payment for services that occurred during the current fiscal year (October 1 – September 30).

2.13 Detail of Remittance (DOR) – Document that accompanies each payment to a provider, and displays patient name, claim, and payment calculation information or it may be sent to a provider without payment explaining why services were rejected for payment, and any applicable instructions to the provider regarding resubmission.

2.14 Diagnosis-Related Groups (DRG) - Groupings of diagnostic categories drawn from the International

Classification of Diseases and modified by the presence or absence of a surgical procedure, patient age, presence or absence of significant co-morbidities or complications, and other relevant criteria.

2.15 Document History Record (DHR) - Input record used to record transactions record in the IHS accounting system.

2.16 Electronic Funds Transfer (EFT) - An electronic method of transmitting money; a paperless system of debiting or crediting money into an account.

2.17 Error - An overpayment, underpayment or duplicate payment made on a claim or other action that prevents a claim from being paid timely and accurately.

2.18 Explanation of Benefits Report (EOBR) - A statement describing medical benefits and account activity, including explanation of why certain claims may or may not have been paid. The statement summarizes the claims and its processing history, and is utilized to monitor the status and results of authorized services.

2.19 Fiscal Intermediary (FI) - The fiscal agent/organization contracted by the IHS to validate and pay PRC claims.

2.20 Fiscal Year (FY) - The accounting year for the Federal Government beginning October 1 and ending

September 30 and is designated by the calendar in which it ends. For example FY 2015 begins October 1, 2014 and ends September 30, 2015.

2.21 ICD-9-CM – 9th revision of the International Classification of Diseases classification system used to assign codes to patient diagnosis; this is a 3 to 5 digit number.

2.22 ICD-10-CM – 10th revision of the International Classification of Diseases classification system used to assign codes to patient diagnosis; uses a 3 to 7 digit number and includes additional digits to allow more available codes.

2.23 IHS 843-1A - Universal PRC PDO form incorporating attributes of the IHS 43, 64, and 57-1As.

2.24 Interest – A fee paid by a borrower of assets to the owner as a form of compensation for the use of the assets.

It is most commonly the price paid for the use of borrowed money, or money earned by deposited funds. Interest is typically paid as a percentage of the principal.

2.25 Internal Control Number (ICN) - Unique contractor number assigned to each claim for processing and tracking purposes.

2.26 Internal Control Review – The process of providing reasonable assurance that the internal controls achieve the expected results.

2.27 Internal Controls – A process for assuring achievement of an organization's objectives in operational effectiveness and efficiency, reliable financial reporting, and compliance with laws, regulations and policies.

2.28 Inpatient Prospective Payment System (IPPS) - The Social Security Amendments of 1983 (Public Law 98-

21) established the IPPS for hospital inpatient services provided to Medicare beneficiaries. Under this system, a hospital is paid a fixed amount for each patient discharged in a particular treatment category or DRG.

2.29 Medical Priorities - Identification in ranking order of PRC services that will be funded by the PRC program.

Federal regulations permit the establishment of priorities based on relative medical need when funds are insufficient to provide the volume of PRC indicated as needed by the population residing in a PRC delivery area.

2.30 Medicare-Like Rate (MLR) – Payment methodology establishing that Medicare-participating hospitals that furnish inpatient services must accept no more than the Medicare fee schedule for all items and services authorized by IHS, Tribal, and urban Indian organization entities.

2.31 National Provider Identifier (NPI) - A unique health identifier number for individual health care providers and organizations.

2.32 Object Class Code(s) - Finance-based code used to classify types of services purchased with PRC funds.

The codes are used to record accounting transactions in the IHS accounting system.

2.33 Open Document - A document (medical purchase order/obligation) in the IHS accounting system with an unpaid obligation amount.

2.34 Open Obligation File (OOF) - Computerized file in the IHS accounting system containing all documents for which a final payment or other final action has not been made.

2.35 Patient Liability - The amount of the claim for which the patient is held responsible after the primary resource(s) have paid less any IHS disallowed charges for services not authorized or covered.

2.36 Payer of Last Resort – The individual or entity who is responsible for remaining claim costs after all other resources have paid. IHS is the payer of last resort for persons defined as eligible for PRC under regulations. See

42 CFR 136.61 for full description.

2.37 Pended Claims - Claims that must be stopped or delayed in the Contractor’s payment processing cycle because the claims did not pass all IHS and/or Contractor edits.

2.38 Percent of DRG - This indicates a discount on Medicare rates for inpatient services; e.g., if the Medicare allowance for the relevant DRG category is $1,500 and the pricing methodology is 90 percent of the DRG amount, IHS would pay $1,350.

2.39 Prior Year Claim - Claims for services that were provided in a preceding fiscal year.

2.40 Purchase Delivery Order (PDO) - An obligating document for the purchase and payment for PRC services.

2.41 Purchased Referred Care Officer (PRCO) - Area level staff who is responsible for the administration and management of the PRC program, provides guidance and technical assistance to local level federal and tribal PRC programs and conducts evaluation and reviews of the Area PRC programs within their purview.

2.42 Service Class Code(s) - PRC program-based codes used to categorize medical services purchased with PRC funds.

2.43 Service Unit (SU) - The third echelon level organizational unit in the IHS responsible for the administration and management of clinical health care services and related programs including PRC. The SU PRC program makes patient referrals and initiates the claim by determining alternate resource status and filing the IHS 43, IHS

57, or IHS 64 and 843.

2.44 Threshold - Represents the dollar limit by which payments made by the Contractor can exceed the unpaid obligations reflected in the IHS accounting system.

2.45 Unclean Claim - A claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment.

2.46 Unified Financial Management System (UFMS) – An Oracle based financial system of record that standardizes the process for all IHS financial transactions.

2.47 ACRONYMS

ACA Affordable Care Act

ADA American Dental Association

ADP Automated Data Processing

BAA Business Associate Agreement

CFO Chief Financial Officer

CHS Contract Health Services

CHS/MIS Contract Health Service Management Information System

CMO Chief Medical Officer

CO Contracting Officer

COR Contract Officer Representative

DOR Detail of Remittance

DRG Diagnosis Related Groups

EOB Explanation of Benefits

EOBR Explanation of Benefits Report

FI Fiscal Intermediary

FMO Financial Management Officer

HIPAA Health Insurance Portability and Accountability Act

IHS Indian Health Service

ICN Internal Control Number

IPPS Inpatient Prospective Payment System

MLR Medicare-Like Rate

NPI National Provider Identifier

OOF Open Obligation File

PDO Purchase/Delivery Order

PRC Purchased/Referred Care

PRCO Purchased/Referred Care Officer

SCC Service Class Code

SU Service Unit

UFMS Unified Financial Management System

3.0 SPECIFIC REQUIREMENTS

3.1 TASK I – CLAIMS PROCESSING SYSTEM

3.2 TASK II – CLAIMS PAYMENT AND RECOVERY

3.3 TASK III – REIMBURSEMENT METHODS

3.4 TASK IV – DATA/INFORMATION/REPORTING

3.5 TASK V – SUPPORT SERVICES

3.6 TASK VI – MANAGEMENT

3.7 TASK VII – TRIBALLY OPERATED PRC PROGRAMS

3.1.0 TASK I – CLAIMS PROCESSING SYSTEM (At a minimum the contract shall)

3.1.1 Provide and operate an automated system for medical and dental claims processing, adjustments, reimbursements, payment recovery, and controls to ensure accurate and timely payments in accordance with established Department of Health and Human Services (DHHS) and IHS accounting practices.

3.1.2 Conduct voucher examination activities for all PRC claims processed by the FI to ensure payments are timely and accurate.

3.1.3 Coordinate with IHS and other payers to ensure that IHS is the payer of last resort on all claims.

3.1.4 Receive, disburse, and account for funds in making IHS PRC claim payments. Claims shall be processed and paid in accordance with the terms and conditions of this contract.

3.1.5 Maintain a single mailing address for manual receipt of all claims, invoices, IHS PRC PDOs, provider refunds and other related documents.

3.1.6 Maintain sufficient internet address for receipt of electronic claims and connect appropriately for interfacing with IHS’s multiple information systems.

3.1.7 Process dental claims with SCC’s 25.2D and 25.4E for Areas specified by the COR. Dental lab services (SCC 25.2D) include prosthetic fabrication services provided by dental laboratories. Dentist services (SCC 25.4E) include all services provided by contract dentists to outpatients and inpatients. This

SCC also includes combined dental laboratory costs and dental services.

3.1.8 Be responsible for obtaining any missing EOB information needed to process medical and dental claims. Within three (3) days of processing a claim the Contractor shall coordinate with the primary payer for the coverage information and payment calculation when the information on the PDO or claims conflict.

3.1.9 Issue an EOBR and send it to the issuing facility when alternate resources have paid the claim in full and there is no IHS liability. EOBRs are sorted by PDO number by FY for each authorizing facility as specified by IHS.

3.1.10 Alternate Resources Paid Report – Collect and report the total amount of alternate resources paid on a given claim. The information will be sorted by Medicare, Medicaid and Private Insurance. Specific data elements will be determined at the time of the initial request for report. This information will be used by IHS management to determine how IHS is leveraging funds, tracking cost savings through the use of alternate resources and ensuring that IHS is the payer of last resort by alternate resource.

3.1.11 Receipt of Alternate Resource Information – Maintain a master listing of patients with alternate resources by facility. The master list shall be used to assist SUs in coordinating the use of appropriate alternate resources. After receiving SU notification of any changes in patient alternate resources status by letter or facsimile, the information will be included with all other alternate resource correspondence and updated when worked in Julian date order of receipt. The Contractor shall update the alternate resource information received on the electronic PDO when the claim is processed. The Contractor shall modify the alternate resource list for changes received via electronic transmission within three working days after receipt.

3.1.12 Perform claims control functions during processing. At a minimum the functions will include:

3.1.12.1 Implementing a system to assign and clearly identify each claim with a unique internal control number (ICN). Each claim shall be assigned the ICN within three (3) business days.

3.1.12.2 Implementing a system to track aged claims. Aging shall occur upon receipt of claim.

Reporting is required at a minimum of every thirty (30) calendar days.

3.1.13 Ensure that inpatient Medicare claims are assigned to the appropriate DRG and conduct random validation. DRG validation shall be performed after claims payment has been made, unless the Area

Office or SU requests otherwise. Results of DRG validation shall be reported to the COR. When validation results in a financial adjustment or recovery, the information shall be documented and reported to the respective PRCO.

3.1.14 The Contractor’s system shall recognize multiple remit to addresses.

3.1.15 Implement or remove a program edit within five (5) business days upon notice from the COR.

3.1.16 Have the capability to send and receive electronic data in standard transaction format as required by the HIPAA. See http://www.hhs.gov/ocr/privacy/index.html for further information.

3.1.17 Provider claims must be accompanied by the approved IHS PRC PDO form. The IHS reserves the right to waive the requirement of a hard copy PDO with each claim.

3.1.18 When the Contractor is unable to enter a claim because of incomplete data, the Contractor shall return the appropriate forms to the provider within three (3) business days for correction and shall notify the provider of the proper procedures for submitting claims.

Additional charges submitted by a provider on a previously paid and or pended claim may be processed if charges are not final. The Contractor shall notify the SU if a new PO must be issued.

3.1.19 Report all requests for additional information that remain open after 30 calendar days to the respective IHS Area PRCO.

3.1.20 Review pending claims and recycle claims after each Open Obligation File (OOF) is received from the IHS Accounting System (UFMS). Any discrepancies requiring SU action shall be referred directly to the SU PRC staff for action.

3.1.21 Pay only those claims reflected on the OOF extract received from the IHS accounting system

(UFMS).

http://www.hhs.gov/ocr/privacy/index.html

NOTE: The Tribal programs may set claim payment edits for those Tribes using thresholds. The

Contractor shall only pay claims for which adequate funds are available as reflected by comparing the claim payment amount with the estimated charge on the purchase order or are within the thresholds defined by the Tribe.

3.1.22 When the electronic signature is not utilized for rate quote and open market claims that exceed a payment amount designated by IHS, the Contractor shall verify that the Area Contracting Officer, or his/her designee with the appropriate authorizing authority, has signed the PDO.

3.1.23 Maintain and destroy all claims information and correspondence in accordance with the IHS

Records Disposition Schedule, as applicable, and as identified in 3.4.10.

3.1.24 Process claims which show a cancelled appropriation and reject claims with a final reject code that indicates the claim was returned to the IHS SU for appropriate payment action. If possible, the original

PDO and attachments will be sent to the PRCO. If the original document(s) cannot be readily located, the

Contractor may send a copy of the documents.

3.1.25 Process claims in accordance with the Prompt Payment Act, 31 U.S.C. 3901, et. seq, and its implementing policies and procedures contained in 5 CFR Part 1315. See http://fms.treas.gov/prompt/regulations.html for further information.

3.1.26 Acknowledge receipt of notification made to provider contracts or delegations of authority in a confirmation letter to the Area PRCO.

3.1.27 Make electronic funds transfer (EFT) available to providers for electronic remittance advices. The

Contractor shall work with IHS to implement EFT by modifying the bank funding processes to ensure appropriate and timely funding and payments.

3.2.0 TASK II – CLAIMS PAYMENT AND RECOVERY

3.2.1 Make payments for medical and dental claims in accordance with the IHS Contracts, applicable

Medicare-like rates and negotiated rate agreements. Any conflicts shall be referred to the COR. The

Contractor shall develop and implement internal controls as part of the claims processing system for handling provider refund checks and restitution checks to ensure proper credit is given to the originating facility. In the event of an error caused by Contractor that requires the reprocessing of a claim, Contractor shall reprocess and, as applicable, pay such claim at no additional per claim fee to the government. To the extent any error results in interest penalties owed and paid to the provider or supplier of services, the contract price established herein and paid to Contractor shall be reduced by an amount equivalent to the interest penalty paid. Adjustments in contract payments based on this section shall be made on a quarterly basis.

3.2.2 Pay the IHS patient liability amount for medical and dental claims involving alternate resources

(third-party payers) as follows:

3.2.2.1 The IHS patient liability amount is defined as the amount for which the patient is held responsible after the primary resource(s) have paid less any IHS disallowed charges for services not authorized or covered. For Medicare and Medicaid cases, payment by the Federal or state http://fms.treas.gov/prompt/regulations.html agency may constitute payment in full. If there is no IHS liability for payment, no further payment shall be made.

3.2.2.2 The contractual, regulatory, restrictions and limitations imposed by the primary resource(s) or payer(s) will apply in determining the IHS patient liability amount. The IHS patient liability amount shall not exceed the amount which would have been paid if IHS were the sole payer.

3.2.2.3 The Contractor shall not coordinate benefits if a PRC provider is being paid through PRC funds for services performed in an IHS facility, and if the IHS facility bills the primary insurer directly.

3.2.3 Provide recovery and accounting procedures for duplicate or erroneous provider payments to include:

3.2.3.1 Procedures to initiate collection procedures within five working (5) days or less of the determination that the provider received an overpayment.

3.2.3.2 A notice to the provider which includes:

The specific claim(s) on which the overpayment was made.

The amount and date of refund due.

Notification that failure to provide a refund may result in referral of the debt to the

Federal Government for collection as provided in the Debt Collection Act 1996. See http://www.fms.treas.gov/news/factsheets/dcia.html for further information.

3.2.3.3 Unique cases where an exception may warrant special consideration will be referred to the

COR for direction.

3.2.4.0 – PROCESSING, TIMELINESS AND ACCURACY

3.2.4.1. Clean Claims:

3.2.4.1.1 Process and pay all clean claims within 30 calendar days.

3.2.4.1.2 Provide detail on the claims processing timeliness to the COR.

3.2.4.1.3 A claim is considered as paid on the date the check and DOR are mailed or electronically transferred.

3.2.5.0 PENDED CLAIMS:

The Contractor shall have the ability to pend a claim. A claim may pend (be stopped or delayed in the Contractor's processing cycle) when there is something missing or wrong with either the

PDO, alternate resources, or the provider’s billing form. The Contractor shall provide a process that, at a minimum:

3.2.5.1 Reviews the claim and PDO for all inaccuracies

3.2.5.2 Requests additional information within five (5) business days to resolve discrepancies.

http://www.fms.treas.gov/news/factsheets/dcia.html

3.2.5.3 Requests information or assistance from other sources.

3.2.5.4 Resolves and processes all Contractor internal pends/holds no more than 20 days after identification of the pend reason.

3.2.5.5 Updates all necessary pricing information within 5 working days upon validation and testing of the schedules. The COR shall be notified of claims pending for more than 45 business days and the proposed plan of action to rectify the delay.

3.2.6 DENTAL CLAIMS

The IHS dental program’s procure third party administrative services to meet the following objectives, simplify the administration of the PRC program; promote consistent and equitable deployment of PRC funds among individuals, local programs, and IHS Areas; expand the scope of the dental care services through efficient and effective Third Party Administration; and assure the highest level of quality dental services to AI/ANs.

PRC funds are used to provide emergency dental care coverage, reimburse private dentists who operate in IHS facilities, provide routine care services to communities distant from IHS facilities, provide services of dental specialists when treatment exceeds the competencies of IHS staff, and pay for dental laboratory services.

3.2.6.1 The Contractor shall establish computer software program for maintaining each program as a separate client.

3.2.6.2 The Contractor shall provide a dedicated dental claims processing component to assure accurate adjudication and administration of IHS dental claims consistent with the requirements of this contract.

3.2.6.3 Schedule of Services:

Health care services are not an entitlement for AI/AN beneficiaries. In lieu of a benefits package the IHS has established medical priorities to guide the programs in the delivery of service and the expenditure of PRC funds. The dental program has developed the Schedule of Services and the referral types to suggest logical service priorities for payment. Additionally, the schedule details the limitations and exclusions which apply for each American Dental Association (ADA) procedure as appropriate. The Schedule of Services is intended as a guide to the proper use of

PRC funds in order to provide services based on and consistent with sound dental public health principles. See http://www.doh.ihs.gov/clinicmanagement/ohpg/Chapters/Chapter%205%20Table%20of%20Con tents.html, Section D, IHS Schedule of Dental Services for further details.

Under this contract the Schedule will provide the authorized services, limitations and exclusions template common to each “client.” For those programs with negotiated contracts in place, the

Contractor’s system must accommodate the specification of services and incorporate the filed fees of these contracts.

These will supplant the schedule of service elements as the template for all providers with

Government contracts. The Dental Professional Specialty Group will provide direction to the

Contractor as to what levels of dental care will be paid.

http://www.doh.ihs.gov/clinicmanagement/ohpg/Chapters/Chapter%205%20Table%20of%20Contents.html http://www.doh.ihs.gov/clinicmanagement/ohpg/Chapters/Chapter%205%20Table%20of%20Contents.html

3.2.6.4 Referrals

The IHS has developed specific referral types to assist dental programs in further delineating the authorization of PRC funds. The appropriate referral type must be entered prominently on the

IHS PDO and becomes a further modifier to the authorized services template. Referral types apply both to the contract and open market providers. The referral types and their codes are as follows:

3.2.6.4.1 Primary Care – Referral for primary care services levels I – III of the IHS

Schedule of Services is sub-divided into the following two categories:

3.2.6.4.2 Emergency Care – The provision of emergency services may be through IHS or self-referral. Authorized emergency care services are primarily contained in Level I of the IHS Schedule of Services. However, selected services in Levels II and III may apply in the resolution of the emergency situation.

3.2.6.4.3 Basic Care – Basic care services are contained within Levels II & III of the IHS

Schedule of Services.

3.2.6.4.4 Secondary Care – Referral for secondary care services e.g., Levels IV and V of the IHS Schedule of Services are sub-divided into the following two categories:

3.2.6.4.4.1 General Services – Referral for secondary care services in Levels IV and V of the IHS Schedule of Services have been made to a general dentist.

3.2.6.4.4.2 Specialist Services – Referral for secondary care services in Levels IV and V of the IHS Schedule of Services have been made to a dental specialist.

Specialty care services are discrete within the appropriate ADA classification e.g., endodontics D3000, periodontics D4000, removable prosthodontics D5000, fixed prosthodontics D6000, oral surgery D7000, and orthodontics D8000.

3.2.6.4.4.3 Exclusions – Level IX – These services will not be paid for with PRC funds.

3.2.6.5 Dental Laboratory Services – IHS staff and contract Dentists operating in IHS facilities use PRC funds to purchase dental laboratory services.

For all other dental providers the cost of the laboratory services is included in the fee charged.

3.2.6.6 Other – Selected dental procedures may be provided in a hospital setting. Services that are provided by a dentist will be billed on an IHS PDO standardized claim form. No other claim forms or non ADA procedure codes will be reimbursed.

3.3.0 TASK III – REIMBURSEMENT METHODS

3.3.1.1 The Contractor shall use the reimbursement methodologies within Section 506 of the

Medicare Modernization Act of 2003 as applicable.

3.4.0 TASK IV – DATA/INFORMATION/REPORTING

3.4.1 The contractor will provide hardware, software, and communications network technologies required to manage a PRC Automated Data Processing Claims system (ADP) business application that includes communications networks, equipment capacities, operational procedures and technology capabilities. All systems, technology, hardware and software must be ICD-10 compatible for the October 1, 2015, ICD-10 implementation date. Technologies used shall carry out key activities—such as data security, preparation, storage, and retrieval-across functional, organizational, and geographic boundaries. The Contractor shall implement and provide a system, which will provide services, equipment, and material required to support current and future operations for IHS, PRC claims processing. The following are among the services that will be required:

3.4.1.1 Mid-tier Internet architecture managed applications hosting service- The Contractor will provide, configure, and maintain all managed mid-tier hardware servers and supporting software for IHS customers to access claims activity status.

3.4.1.2 Application services- The Contractor will provide hosting of claims processing center services for applications requiring computing capabilities. The Contractor will provide all hardware, software, ongoing maintenance, support, operation, and administration for the claims processing center.

3.4.1.3 Claims processing services- The contractor will provide all the necessary hardware, Commercial Off the Self Software (COTS) software, labor, supervision, tools, materials

(including manuals and schematics), documentation, parts, equipment, transportation, and supplies necessary to process claims, maintain the data center, and support Medicare processing at the data center as required by in Section 3.3.0, Reimbursement Methods.

At a minimum, the following components shall be provided and described in the contractor’s proposal:

3.4.2 Hardware

The computing hardware utilized in performing these business functions varies and may have varying configurations. IHS is not prescribing the hardware to be used to carry out the business functions, beyond that which is needed to provide support to the functional requirements for all the work identified in this statement of work. All hardware to be used shall be documented and routinely updated as changes occur.

3.4.3 Software

Software products supporting the claims processing applications shall be described in the proposal and continually documented upon award to provide for an inventoried listing. The descriptions shall support four major service areas identified below. Documentation shall be categorized to depict the service area, general area of use within the service area, Product Name and a Description that details its functionality.

3.4.3.1 Application Development – The software shall consist of an operating system, applications software, and any executive software module necessary to implement the function requirements of this contract. The software must conform to IHS payment instructions and procedures, and perform all internal edits checks for appropriateness of service, etc. The IHS retains unlimited rights over claims information and non-software data generated by the Contractor under this

Contract.

3.4.3.2 Data Management – Data Extraction and non-relation data management applications such as Oracle that incorporates the SQL language or SQL servers and their respective software that may support client/server use.

3.4.3.3 Middleware – transaction processing ware that controls the interaction between applications and users.

3.4.3.4 Information Processing – personal computers, enterprise server (e.g. large scale, mid tier or mainframe) or enterprise server operating system (e.g. Unix AIX, Unix Solaris).

3.4.4 Procedures

Security hardware and software, together with internal and external controls and procedures, shall fully meet all IHS security requirements and privacy responsibilities. The contractor shall establish safeguards to protect against the access of unauthorized entities into the systems environment either by unauthorized software modification, online connectivity, the submission of Electronic Data Interchange (EDI) transactions or divulgence of confidential information.

3.4.5 Security

Sufficient security safeguards shall be employed to prevent unauthorized entry into the data processing facility, unauthorized access to data and data files, unauthorized software modification, divulgence of confidential processing procedures or techniques, unauthorized access to/or release of IHS patient data and claims payment information.

3.4.6 Documentation

The ADP system shall be well documented including narratives, system structure charts, data flow, diagrams, data dictionary, system edits, and file descriptions. System and module documentation shall include interconnection and inter-relation of data files. A copy of any documentation generated in the performance of this contract that does not contain limited rights data or restricted rights computer software shall be provided to the Government at contract termination along with any IHS/PRC specific modules requested by IHS.

3.4.7 Maintenance

The hardware and software shall be adequately maintained so that the Contractor is able to comply with processing standards.

3.4.8 Backup

Adequate software backup for hardware, software and data files shall be maintained on site and off site to ensure the Contractor is able to comply with the processing standards. Access to alternate hardware and software systems shall be available to ensure continued timely processing during periods when the primary system is inoperative. Key data files shall be adequately backed up to ensure recovery in the event of crashes or data destruction. Backups shall be retained for all payment data submitted to

IHS/PRC. The Contractor shall conduct a test of the backup data processing system within the first quarter of the contract and will continue to assure backup capabilities by testing the availability and capability of the backup ADP system. Testing and review of the primary ADP system configuration with the backup ADP system configuration must be done on at least an annual basis. Contractor shall provide current testing results if requested by COR. If the review of output verification concludes the existence of non-compatibility between the primary and backup ADP system, the Contractor shall notify the IHS COR immediately and within 24 hours reestablish a backup system which is compatible with IHS/PRC. Any breach in security of software, data, data files, or protected health information transmitted electronically will be reported to the COR upon confirmation of the breach.

3.4.9 The Contractor shall receive and transmit data electronically using IHS protocol. At a minimum the contractor shall:

3.4.9.1 Through compliance with the Privacy Act, and HIPAA, develop a system for ensuring security and proper handling in the receipt of claims, control of claims, and claim information in the Contractor’s possession. All claims and related information shall be date stamped with the actual day of receipt.

The Contractor, as a Business Associate (BAA), shall abide by the provisions of HIPAA and its implementing regulations. Pursuant to the provisions, the parties agree to HIPAA Business

Associate Addendum attached hereto and incorporated by reference as if fully set forth herein.

For further information see:

http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.html.

3.4.9.2 Provide an automated file system to furnish IHS required financial and statistical information and reports. Statistical data files and reports shall be produced separately for dental claims data.

3.4.9.2.1 The Contractor shall receive the IHS Medical Statistical Filters (Exhibit B) and criteria on how to classify records as outpatient or as inpatient (Exhibit C) from Office of

Information Technology and apply the updates to the applicable tables within the

Contractor’s system. The Contractor will create Export Files containing data from PRC inpatient, outpatient, and dental records layouts (Exhibit D). Export files are then transmitted via file transfer protocol (FTP) to National Patient Information Resource

System (NPIRS).

3.4.9.2.2 The database must be comprehensive and collect all data from the above mentioned information sources which pertain to the claims paid by the Contractor. The data fields to be collected and maintained are specifically identified in Exhibit D.

3.4.9.2.3 The Contractor shall maintain this database and be able to generate reports utilizing any combination of these data elements.

3.4.9.2.4 The Contractor shall, upon request of the COR, provide an electronic copy, a hard copy, or CD ROM of the data elements used in preparing standard and ad hoc report(s) requested by IHS.

3.4.9.2.5 As requested by the COR, the Contractor shall provide an electronic copy of all or part of the database.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.html

Information requested shall be transmitted within 7 calendar days of request. In the event that the 7 day timeframe cannot be met the Contractor shall contact the COR and a suitable timeframe for submission shall be negotiated.

3.4.9.2.6 The Contractor shall be responsible for assuring that all data collected meets

IHS specifications.

3.4.9.2.7 Additional specification edits may be added as IHS deems necessary. All specifications edits require prior approval by the COR before implementation. The

Contractor shall implement agreed upon changes within 15 working days after receipt.

Any major required changes to the Contractor’s computer software will be negotiated between the Contractor and the COR with approval of the Contracting Officer, in the event additional funding is requested by the Contractor to implement the change.

3.4.9.2.8 IHS will provide a listing of current Tribes, community of residence, Standard

Code book, authorizing facility codes, including all valid changes to these codes. The

Contractor shall update edit files within 5 calendar days of notification of change.

3.4.10 The Contractor shall maintain all documents on-line for the current fiscal year and two (2) prior fiscal years and off-line for six (6) years three (3) months from the date an appropriation year is cancelled.

3.4.11 The Contractor's system shall provide an audit trail that ensures all input is received and processed to completion with safeguards against "lost" data including all electronic transmissions.

3.4.12 Telecommunications with PRC

3.4.12.1 The Contractor shall accept electronic PDO information from IHS Area Offices; in addition all EOBRs shall be transmitted electronically to all Area Offices.

3.4.12.2 Each Area will electronically transmit all PRC PDO data directly to the Contractor using the following procedures:

3.4.12.2.1 The IHS Area Offices will transmit data daily. This transmission will contain all data for PRC PDOs subject to payment by the Contractor which were prepared, amended, or canceled by IHS SU. Data will include patient identification, alternate resource information and financial accounting data elements for each PDO.

3.4.12.2.2 The Contractor shall utilize the Open Obligation File (OOF), to make the necessary payments to the vendors and incorporate such payment details in the daily

Document History Record (DHR) file to the IHS financial system (UFMS).

3.4.12.3 The Contractor shall coordinate with the Area Office contact person responsible for the resolution of problems related to electronic transmissions.

3.4.12.4 Telecommunications Services – The contract will provide telecommunication services, including the following:

3.4.12.4.1 Private Line Services – hardware, software and operational services to provide data services between the IHS Data Communications Network and the contractor.

3.4.12.4.2 Private line services – cross-connect setup and provision of the point-to-point connection from the Contractor to IHS.

3.4.12.4.3 Managed public Internet Protocol (IP) services-hardware, software, and operation services necessary for the provision of managed public IP services.

3.4.12.4.4 Managed “private” network services – hardware, software, and operation services necessary for the provision of managed “private” IP services.

3.4.12.4.5 Managed “secure” network services – hardware, software, and operational services necessary for the provision of managed “secure” IP services.

3.4.13 Quality of Care Screens – The Contractor will support the Agency in the implementation of IHS

Circular 93-04, Indian Health Service Fiscal Intermediary Quality of Care Screens and Follow-up

Procedures, through screening and identifying potential quality of care issues.

3.4.14 Payment Information

3.4.14.1 The Contractor shall daily transmit provider payment data electronically to the IHS accounting system, Unified Financial Management System (UFMS), in a compatible format. The

Contractor shall issue checks to vendors against the IHS Special Bank Account and IHS will reimburse bank account through UFMS at regular intervals. After each payment cycle, the

Contractor will transmit provider payment data electronically to UFMS. The following business day, the Contractor will notify the IHS Certifying Officers via email and request the required deposit amounts to fund the Special Bank Account. Upon confirming the payment request within

UFMS, claim payments will be initiated within UFMS by each Certifying Officer to ensure prompt funding.

If UFMS is unavailable for more than one business day, including month-end processing and fiscal year-end processing, the Contractor will suspend provider payments for a similar time period, adjusted to reflect the time lag between…