15B12018R00000001_-_Solicitation_Attachments.pdf

Attachment 1

ATTACHMENT 1

15B12018R00000001

COMPUTATION OF BASIC MS-DRG PAYMENTS (OPERATING FEDERAL RATE)

CBSA CODE 30460 – LEXINGTON-FAYETTE, KY

Calculation of the Operating Federal Rate:

Step 1: Select the applicable average standardized amount for the full update

Step 2: Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area

Step 3: For hospitals in Alaska and Hawaii, multiply the nonlabor-related portion of the standardized amount by the applicable cost-of-living adjustment factor

Step 4: Add the amount from Step 2 and the nonlabor-related portion of the standardized amount (adjusted, if applicable, under Step 3)

Step 5: Multiply the final amount from Step 4 by the relative weight corresponding to the applicable MS-DRG

Index Figures: Obtained from the Centers for Medicare and Medicaid Services for discharges on/after October 1, 2017.

Table 1A (Full Update) National Adjusted Operating Standardized Amount:

Labor-related: $3,454.97 Nonlabor-related: $2,117.56

Table 4A, Wage Index for Urban Areas by CBSA (Table ): 0.8849

Table, Cost of Living Adjustment Factor: Not applicable

Table 5, MS-DRG Relative Weight (MS-DRG 76, Viral Meningitis w/o CC/MCC): 0.9615

Application for MS-DRG 076 (example):

Step 1:

Step 2:

Step 3:

Step 4:

Step 5:

$3,454.97 $3,454.97 x 0.8849 = $3,057.30 Not applicable $3,057.30 + $2,117.56 = $5,174.86 $5,174.86 x 0.9615 = $4,975.63

Payment for MS-DRG 076 under the contract would be $4,975.63 plus or minus any premium or discount established as the contract rate.

Attachment 2

ATTACHMENT 2

MEDICAL CLASSIFICATION – CARE LEVEL CRITERIA (MAY 2005)

Care Level I

Concept:

Inmates are generally healthy but may have limited medical that can be easily managed by every 6 month clinician evaluations. Needed subspecialty care is limited (not regularly required and completed in < 3 months).

Inmates with mental health conditions are stable and require chronic care appointments and/or individual psychology or health services contacts no more frequently than every 6 months. If more acute services are required, such as crisis intervention, such episodes are short-lived (i.e., less than 3 months duration, and occur no more frequently than every 2 years) and resolve without the need for hospitalization.

Age < 70 years

Care Level II

Concept:

Inmates are stable outpatients that have chronic illnesses that require at least quarterly clinician evaluations and are independent in ADLs.

Inmates with mental health conditions can be managed through chronic care clinics and/or individual psychology or health services contacts no more frequently than monthly to quarterly. If more acute services are required, such as crisis intervention, such episodes are short-lived (i.e., less than 3 months duration, and occur no more frequently than every 2 years) and resolve without the need for hospitalization.

Care Level III

Concept:

Inmates are fragile outpatients with conditions that require frequent clinical contacts (daily to monthly).

Inmates with chronic or recurrent mental illnesses or ongoing cognitive impairments which require frequent (daily to monthly) psychiatric/health services and/or psychology contacts to maintain outpatient status. Inmates may require assistance in performing some ADLs, but do not require daily nursing care.

Such assistance may include the regular services of inmate companions. Stabilization of the inmate's medical or mental health condition may periodically require hospitalization.

Care Level IV

Concept:

Inmate requires services available at MRC and may require daily nursing care.

Mental health conditions are acute or chronic and have resulted in severe impairment of functioning.

Current symptomology or treatment require 24 hour skilled nursing care or nursing assistance.

Attachment 3

ATTACHMENT 3

15B12018R00000001

PERFORMANCE-BASED OUTCOME MEASURES

Performance Element: Quality of Goods/Services

Outcome Measure Indicators:

Degree to which the care provided to the inmates was considered to be appropriate.

Extent to which the inmates received the services for which they were referred.

Degree to which services were provided that were not authorized by the Government.

Extent to which the contractor submitted invoices which were accurate, properly documented, and billed in accordance with the terms of the contract.

Extent to which the evaluation and treatment was completely documented, accurate, legible, and of the appropriate content.

Degree to which the discharge instructions provided by the attending physicians were in sufficient detail to allow subsequent care of the patients.

Degree to which the contractor’ s assigned Point of Contact was knowledgeable and available for consultation.

Performance Element: Timeliness of Deliveries/Performance

Outcome Measure Indicators:

Degree to which the medical care was provided in a timely manner.

If applicable, degree to which the scheduling of appointments was completed in a timely manner, given the urgency of the referrals.

Extent to which appointments for specialty care were generally available within 14 calendar days from date of referral to the specialty provider.

Degree to which invoices were received within 90 calendar days after an inmate’ s discharge or outpatient encounter.

When improper invoices were rejected, extent to which the revised invoices were resubmitted within 30 calendar days from the date of rejection.

Degree to which written reports by the attending physician documenting the circumstances of the inpatient treatment, outpatient procedure, or other consultation were provided to the COR within ten business days of the inpatient discharge, outpatient procedure, or other consultation.

Degree to which the contractor’ s assigned Point of Contact provided prompt assistance and coordination in the provision of the contract services.

Extent to which labs and consultations pending at time of discharge were faxed to the COR no later than ten calendar days past discharge.

Performance Element: Business Relations

Outcome Measure Indicators:

Extent to which the contractor coordinated and integrated the provision of care while the inmate was in a community-based setting.

Degree to which the attending physician or coordinator of care responded in a timely manner to requests for information from the HSA, Clinical Director, or other designated POC regarding the health status of the inmate.

Extent to which the contractor cooperated with the Government in the review of invoices, answering questions as needed and providing clarifying information.

Extent to which the contractor released inmate medical information in a timely manner, and in a manner consistent with applicable law or regulation.

Degree to which the contractor facilitated open avenues of communication between the physician, hospital/facility, and the Government regarding patient care and/or administration issues.

Extent to which the contractor was effective in interfacing with BOP Health Services staff.

Extent to which the contractor maintained positive relationships with the provider network.

Performance Element: Customer Satisfaction

Outcome Measure Indicators:

Overall level of satisfaction with the hospital/facility services provided.

Overall level of satisfaction with the physician services provided.

Overall level of satisfaction with the invoicing/billing performed by the contractor.

Overall level of satisfaction with the contractor’ s management of medical record information.

Overall level of satisfaction with the contractor’ s communication efforts.

Attachment 4

ATTACHMENT 4

LIST OF PROVIDER INFORMATION REQUIREMENTS

Single Practitioners

Full Name (Last name, first name, middle initial, and generation) Physical Address Mailing Address (if different) National Provider Identifier Number (NPI) Social Security Number Provider Specialty Contract rate applicable to each provider for each contract period

Group Practices and Suppliers

Group Name Physical Address Mailing Address (if different) National Provider Identifier Number (NPI) for the group National Provider Identifier Number (NPI) for each rendering physician in the group Employer Identification Number (EIN) Contract rate applicable to each provider for each contract period

Institutional Providers

Institution Name Physical Address Mailing Address (if different) National Provider Identifier Number (NPI) Employer Identification Number (EIN) Contract rate applicable to each provider for each contract period

Doing Business As (DBA) Providers

Group or Individual Name Physical Address Mailing Address (if different) National Provider Identifier Number (NPI) Employer Identification Number (EIN) Contract rate applicable to each provider for each contract period

Attachment 5

ATTACHMENT 5

ELECTRONIC TRADING PARTNER AGREEMENT

Agreement No.:

This Electronic Trading Partner Agreement (“Agreement”) is made as of the day of , 20___ (“Effective Date”), by and between PGBA, a subsidiary of Blue Cross Blue Shield of South Carolina (BCBSSC) , located at I-20 Alpine Road, Columbia, South Carolina 29219, and the Federal Bureau of Prisons (“Trading Partner”) located at Washington, D.C.

This Agreement provides the terms and conditions governing electronic transfers of data communications between PGBA/BCBSSC and Trading Partner and its designated contractors (collectively “Parties”) by direct digital or electronic transmission over communication lines to accomplish the Parties’ business objectives regarding the provision and acquisition of services.

This Agreement will remain in effect until terminated according to its terms.

RECITALS

WHEREAS, both Parties consider their mutual interest to be served by engaging in the electronic transfer of data communications as a means of furthering their respective business objectives;

and

WHEREAS, PGBA provides medical claims adjudication review services on behalf of persons covered under comprehensive health services contracts for the FBOP and engages in the electronic transfer of data between the FBOP and its contractors; and

WHEREAS, Trading Partner is a business entity that transacts business with PGBA on a regular basis pursuant to the terms of a Business Agreement; and

WHEREAS, each Party is or will be equipped at its own expense with the Operating System and trained personnel necessary to engage in the successful exchange of electronic data and funds;

and

WHEREAS, both Parties are entering into this Agreement to facilitate, through transmission via electronic formats consistent with or otherwise allowed by Social Security Act § 1173 and the Transaction Rules, the submission of claims for medical services provided to inmates incarcerated by the FBOP; and

WHEREAS, in the electronic transmission of data and funds, the confidentiality and security of the data exchanged are an utmost priority to both Parties; and

WHEREAS, PGBA anticipates that Trading Partner may use, in the performance of this Agreement, various third-party Business Associates in the electronic exchange of information;

Agreement No.:

NOW, THEREFORE, in consideration for the mutual promises herein, the Parties agree as follows:

I. DEFINITIONS

The following terms with initial capitals have these meanings:

1.1 ANSI means American National Standards Institute; an organization who’s Accredited Standards Committee develops and approves uniform standards for the electronic interchange of business transactions.

1.2 Business Agreement means a written agreement between PGBA and Trading Partner whereby PGBA and Trading Partner may exchange the Data included in Exhibit B.

1.3 Business Associate means a third-party organization, designated in the Trading Partner Business Associate Authorization Rider, that contracts with Trading Partner to perform services to facilitate the electronic transfer of Data on behalf of Trading Partner.

1.4 BOP means the United States Department of Justice Bureau of Prisons.

1.5 Confidential Health Information means information relating to specific Individuals, including Individually Identifiable Health Information and Health Information, that is exchanged by and between PGBA and Trading Partner or Business Associate for various business purposes, and that is protected from disclosure to unauthorized persons or entities by Social Security Act § 1171 et seq., the Standards for Privacy of Individually Identifiable Health Information, 45 C.F.R. Parts 160 and 164, the Privacy Act of 1974 (5 U.S.C. § 552A), or other applicable state and federal statutes and regulations, including statutes and regulations protecting the privacy of general medical, mental health and substance abuse records (collectively “Privacy Statutes and Regulations”).

1.6 Covered Individual means an inmate who has received services under the terms of a comprehensive health services contract.

1.7 Data means electronic information found in Attachment #1.

1.8 Data Transmission means automated transfer or exchange of Data, pursuant to the terms and conditions of this Agreement, between PGBA and Trading Partner or Business Associate by means of their respective Operating Systems, which are compatible for that purpose, and includes Electronic Data Interchange (“EDI”) and Electronic Media Claims (“EMC”) transmissions.

1.9 Electronic Data Interchange (“EDI”) means the automated exchange of business documents from application to application.

1.10 Electronic Media Claims (“EMC”) means automated methods of submitting claims for payment of medical services or supplies rendered or sold by a Provider or Supplier to an Individual.

1.11 Envelope means a control structure in a format mutually agreeable to PGBA and Trading Partner for the electronic interchange of one or more encoded Data Transmissions between PGBA and Trading Partner or Business Associate.

1.12 HHS means the United States Department of Health and Human Services.

1.13 Health Information means any information, whether oral or recorded in any form or medium that (i) is created or received by a Provider (ii) relates to the past, present, or future physical or mental health or condition of an Individual, the provision of health care to an Individual or the past, present, or future payment for the provision of health care to an Individual.

1.14 Individual means a person whose claims for services are subject to the Medical Adjudication Services contract between PGBA and the FBOP.

1.15 Individually Identifiable Health Information means any Health Information, including demographic information collected from an Individual, that is created or received by a Provider (i) identifies an Individual or (ii) creates a reasonable basis to believe the information can be used to identify the Individual.

1.16 Lost or Indecipherable Transmission means a Data Transmission that is not received or cannot be processed to completion by the receiving Party because it is garbled or incomplete, regardless of how or why the Data Transmission was rendered garbled or incomplete.

1.17 National Standard Identifier means the standard unique health identifier for each Individual, employer, health plan and Provider for use in the health care system.

(a) Employer Identifier means the Federal Employer Identification Number assigned by the Internal Revenue Service to identify the tax accounts of businesses with employees or businesses operating as partnerships or corporations or such other unique alphanumeric identifier assigned to employers pursuant to regulations implementing the Health Insurance Portability and Accountability Act of 1996.

(b) National Provider Identifier means the unique alphanumeric identifier assigned to each Provider pursuant to regulations implementing the Health Insurance Portability and Accountability Act of 1996.

(c) Additional Identifiers mean identifiers for health plans and Individuals assigned pursuant to regulations implementing the Health Insurance Portability and Accountability Act of 1996.

1.18 Operating System means the equipment, software and trained personnel necessary for a successful Data Transmission.

1.19 Proprietary Information means information used or created by Parties and their contractors in the conduct of their business activities that is not normally made available to the public, the disclosure of which will or may impair Parties competitive position or otherwise prejudice Parties ongoing business.

1.20 Provider means a hospital or professional practitioner duly certified or licensed to provide health care services to Covered Individuals, and includes, without limitation, extended care facilities, skilled nursing facilities, rehabilitation facilities, home health agencies, hospices, physicians, dentists, clinical social workers, ambulance services, and hospitals or professional practitioners specifically certified or approved by HHS to provide reimbursable health care services to individuals.

1.21 Security Access Codes mean alphanumeric codes that PGBA assigns to Trading Partner to allow Trading Partner access to PGBA’s Operating System for the purpose of successfully executing Data Transmissions or otherwise carrying out this Agreement.

1.22 Source Documents mean documents containing Data that are or may be required as part of a Data Transmission concerning a claim for payment of charges for medical services that a Provider furnishes or medical supplies that a Supplier sells to a Covered Individual.

Source Documents are subject to the security standards of Article V of this Agreement.

Examples of Data contained within a Source Document include, without limitation, Individual’s name and identification number, claim number, diagnosis codes for the services rendered, dates of service, service procedure descriptions, applicable charges for the services rendered, the Provider’s or Supplier’s name and/or National Standard Identifier, and signature.

1.23 Supplier means a person or organization engaged in the business of selling or leasing durable medical equipment or supplies to Covered Individuals.

1.24 Trade Data Log means the complete, written summary of Data and Data Transmissions exchanged between the Parties over the period of time this Agreement is in effect and includes, without limitation, sender and receiver information, and transmission date, time and general nature.

1.25 Transaction Rules means the Standards for Electronic Transactions, 45 C.F.R. Parts 160 and 162, as may be amended or modified from time to time.

II. TERM AND TERMINATION

2.1 Term of Agreement. This Agreement will remain in effect for an initial period of One year (1) year(s) from the Effective Date, and will automatically renew for successive periods of One year (1) year(s) unless terminated pursuant to Section 2.2 or Section 2.3.

2.2 Voluntary Termination. Either Party may terminate this Agreement on Sixty_ (60) day(s) prior written notice to the other Party.

2.3 Termination for Cause. Either Party may terminate this Agreement upon Sixty_ (60) day(s) prior written notice to the other Party upon the default by the other Party of any material obligation of this Agreement, provided that the written notice sets forth the default with reasonable specificity and the default is incurable or, being capable of cure, has not been cured within the Sixty_ (60) day period after receipt of the written notice.

III. OBLIGATIONS OF THE PARTIES

3.1 Mutual Obligations. The mutual obligations of PGBA and Trading Partner include the following:

(a) EDI Data Transmission Accuracy. The Parties will take reasonable care to ensure that Data Transmissions are timely, complete, accurate and secure. Each Party will take reasonable precautions in accordance with Article V of this Agreement to prevent unauthorized access to the other Party’s Operating System, Data Transmissions or the contents of an Envelope transmitted to or from either Party.

(b) Retransmission of Lost or Indecipherable Transmissions. A Party will retransmit the original transmission within Five_ (5) business day(s) of its discovery that a Data Transmission is a Lost or Indecipherable Transmission.

(c) Equipment Cost. Each Party will obtain and maintain, at its own expense, its own Operating System necessary for timely, complete, accurate and secure Data Transmission pursuant to this Agreement. Each Party will pay its own costs related to Data Transmission under this Agreement, including, without limitation, charges for the Party’s own Operating System equipment, software and services, maintaining an electronic mailbox, connection time, terminals, connections, telephones, modems and applicable minimum use charges. Each Party will be responsible for its own expenses incurred for translating, formatting and sending or receiving communications over the electronic network to any electronic mailbox of the other Party.

(d) Backup Files. Each Party will maintain adequate backup files, electronic tapes or other sufficient means to recreate a Data Transmission for a time that is in accordance with the Federal Acquisition Regulations. Such backup files, tapes or other sufficient means will be subject to the terms of Article V of this Agreement to the same extent as the original Data Transmission.

(e) Transmission Format. All standard transactions, as defined by Social Security Act § 1173(a) and the Transaction Rules, conducted between PGBA and Trading Partner or Business Associate, will only use code sets, data elements and formats specified by the Transaction Rules.

All other Data Transmissions conducted between PGBA and Trading Partner or Business Associate will use the code sets, data elements and formats mutually agreed upon by the Parties.

(f) Testing. Prior to the initial Data Transmission, each Party will test and cooperate with the other Party in testing each Party’s Operating System to ensure the accuracy, timeliness, completeness and confidentiality of each Data Transmission.

(g) Data and Data Transmission Security. PGBA and Trading Partner will employ security measures necessary to protect Data and Data Transmissions between them, including authentication, encryption, password use, or other security measures in compliance with Social Security Act § 1173(d) and any HHS implementing regulations or guidelines and as set forth in Article V of this Agreement. Unless PGBA and Trading Partner agree otherwise, the recipient of Data or Data Transmission will use at least the same level of protection for any subsequent transmission as was used for the original transmission.

(h) National Standard Identifiers. PGBA and Trading Partner will use National Standard Identifiers in all Data and Data Transmissions conducted between the Parties.

3.2 Parties Obligations. Parties will:

(a) Not copy, reverse engineer, disclose, publish, distribute, alter or use Data, Data Transmission or Envelope for any purpose other than for which the other has been specifically authorized under the terms of this Agreement.

(b) Not obtain access by any means to Data, Data Transmission, Envelope, or the others Operating System for any purpose other than as the other party has specifically granted access under this Agreement. In the event that either party receives Data or Data Transmissions not intended for the other, the receiving Party will immediately notify the other and make arrangements to retransmit or otherwise return the Data or Data Transmission. After such retransmission or return, the Party will immediately delete the Data and Data Transmission from its Operating System.

(c) Protect and maintain the confidentiality of any proprietary codes or unique identifiers issued to either Party.

(d) Limit disclosure of codes and unique identifiers to authorized personnel on a need-to-know basis.

(e) Make available to each other, via electronic means, Data and Data Transmissions for which this Agreement grants access or authorization, or as provided by law.

(f) Provide each other with at least Ninety (90) days prior written notice of any change or addition to the code sets, data elements or formats for Data Transmissions set forth in Section 3.1(e) and Exhibit B of this Agreement.

(g) Provide each other with information that will allow the Trading Partner access to PGBA’s Operating System. PGBA reserves the right to change Security Access Codes at any time and in such manner as PGBA, in its sole discretion, deems necessary.

IV. BUSINESS ASSOCIATES

4.1 Business Associate Assistance. Parties will request that Business Associates acknowledge the mutual obligations of the Parties set forth in Section 3.1 and Parties obligations set forth in Section 3.2, even though Business Associates are not a signatory to this Agreement.

4.2 Responsibility for Business Associates. Parties are liable for any act, failure, or omission of Business Associate with which Parties contract to receive, transmit, store or process Data or Data Transmissions or perform related activities, as though the act, failure or omission were that of the Party.

4.3 Notices Regarding Business Associates. Trading Partner will, prior to commencement of Business Associate’s services in connection with this Agreement, submit a complete, executed Business Associate Authorization Rider (“Business Associate Rider”) designating each Business Associate authorized to send or receive Data or Data Transmissions to or from either party on the Parties behalf. Either Party will notify the other at least Sixty (60) days prior to the date of any material change to the information contained in the Business Associate Rider. The Business Associate Rider will be effective and incorporated into this Agreement on the date it is received by the other Party. Either Parties designation of any Business Associate for purposes of performing services in connection with this Agreement is subject to the other Parties approval.

Either Party will not unreasonably withhold approval of the others designated Business Associates.

V. CONFIDENTIALITY AND SECURITY

5.1 Data Security. The Parties will maintain adequate security procedures to prevent unauthorized access to Data, Data Transmissions, Security Access Codes, Envelope, backup files, Source Documents or the Parties Operating Systems. The Party will immediately notify the other of any unauthorized attempt to obtain access to or otherwise tamper with Data, Data Transmissions, Security Access Codes, Envelope, backup files, Source Documents or Operating Systems.

(a) Confidential Health Information. Parties will comply with all applicable Privacy Statutes and Regulations, guidelines and health care industry customs concerning treatment of Confidential Health Information.

(b) Proprietary Information. Parties will treat the others Proprietary Information obtained or learned in connection with this Agreement as confidential and will not use the others Proprietary Information for its own commercial benefit or any other purpose not authorized in this Agreement. Each Party will safeguard the others Proprietary Information against unauthorized disclosure and use.

(c) Notice of Unauthorized Disclosures and Uses. Parties will promptly notify the other of any unlawful or unauthorized use or disclosure of Confidential Health Information or the others Proprietary Information that comes to the attention of a

Party and will cooperate with the other in the event that any litigation arises concerning the unlawful or unauthorized disclosure or use of Confidential Health Information or Proprietary Information.

5.2 Operating Systems Security. Each Party will develop, implement and maintain measures necessary to ensure the security of each Party’s own Operating System and each Party’s records relating to its Operating System. Each Party will document and keep current its security measures. Each Party’s security measures will include, at a minimum, the requirements and implementation features set forth in Social Security Act § 1173(d) and all applicable HHS implementing regulations.

VI. RECORDS RETENTION AND AUDIT

6.1 Records Retention. Parties will maintain complete, accurate and unaltered copies of all Source Documents from all Data Transmissions it receives from each other for not less than the time specified by the Federal Acquisition Regulations from the date that the Party receives them. All retained records will be subject to the same security measures as Data and Data Transmissions.

6.2 Trade Data Log. PGBA and Trading Partner will each establish and maintain a Trade Data Log to record all Data Transmissions between the Parties during the term of this Agreement. Each Party will take necessary and reasonable steps to ensure that its Trade Data Log constitutes a complete, accurate, and unaltered record of each Data Transmission between the Parties. Each Party will retain Data Transmission records for not less than Twelve_ (12) month(s) following the date of a Data Transmission. Each Party will maintain its Trade Data Log on computer media or other suitable means that permit timely retrieval and presentation in readable form.

6.3 Right to Audit. Either Party will have the right to audit relevant the others business records, Trade Data Log, Operating System in either’s sole discretion or as deemed necessary to ensure compliance with this Agreement.

6.4 Government Requests for Information. Either Party will notify the other immediately upon receipt of any request from a government authority for information or documents relating to this Agreement, except to the extent such notification is prohibited by law.

VII. REPRESENTATIONS AND WARRANTIES

7.1 Government Programs. Parties represents and warrants that:

(a) Neither the United States government, any state or local government, nor any prime contractor, subcontractor or other person has notified either party, either orally or in writing, that either has breached or violated any law, certification, representation, clause, provision or requirement pertaining to or involving any government contract or government subcontract that has resulted or may result in either being charged with a criminal offense;

(b) No termination for convenience, termination for default, cure notice or show cause notice is currently in effect or threatened against either Party by the United States government or any state or local government;

(c) Neither Party nor any of its directors, officers, employees or agents are or have been under criminal investigation or indictment by any government entity;

(d) Neither Party has been debarred or suspended from participation in the award of contracts with any government entity (excluding for this purpose ineligibility to bid on certain contracts due to generally applicable bidding requirements);

(e) There exists no fact or circumstance that would warrant the institution of suspension or debarment proceedings or the finding of nonresponsibility or ineligibility on the part of either Party or any director, officer or employee of either Party; and

(f) No payment has been made by either Party or by any person on behalf of either Party in connection with any government contract or government subcontract in violation of or requiring disclosure pursuant to the Foreign Corrupt Practices Act, as amended (15 U.S.C. §§ 78dd-1, 78dd-2).

7.2 Legal Compliance. Parties will use reasonable efforts to comply, and to cause it’s directors, officers, employees and Business Associates to comply, in all material respects with all requirements of all laws pertaining to government contracts or government subcontracts, the violation of which may result in Parties or its directors, officers or employees, or other persons being charged with a criminal offense. For purposes of this Section 7.2, “laws” mean all applicable statutes, laws, rules, regulations, permits, decrees, injunctions, judgments, orders, rulings, determinations, writs and awards.

7.3 Warranties Regarding Business Associates. Parties warrant that Business Associates will be requested to make no changes in the Data content of Data Transmissions or the contents of an Envelope. Parties further warrant that Parties will advise Business Associates of this Agreement.

7.4 Notice of Violations. Parties will notify the other in writing within Twenty (20) business days of obtaining knowledge of any criminal investigation, indictment, information or charge by any governmental entity (or communications indicating that the same may be contemplated) related to the other Party or any of the Parties directors, officers, employees, vendors, agents or Business Associates.

7.5 Right to Terminate. If, during the term of this Agreement, either Party, any of its related business entities or any of its officers, directors, managing employees or Business Associates is:

(a) charged with a criminal offense relating to one or more government contracts or government subcontracts or to federal health care programs (as defined in Social Security Act § 1128B(f));

(b) listed by a federal agency as debarred, proposed for debarment, or suspended; or

(c) otherwise excluded from federal program participation, including exclusion from participation in a federal health care program (as defined in the Social Security Act § 1128B(f));

The other Party will have the right to terminate this Agreement by written notice to the other.

VIII. INDEMNIFICATION

8.1 Indemnification. Parties will indemnify, defend and hold the other harmless from any and all claims, actions, damages, liabilities, costs, or expenses, including, without limitation, reasonable attorneys’ fees, arising out of any act or omission of the other, Business Associates, or their respective employees, subcontractors or other persons in the performance of this Agreement. Parties will have the option at its sole discretion to employ attorneys to defend any such claim, action or proceeding arising out of these acts or omissions, the costs and expenses of which will be the others responsibility. Parties will provide the other with timely notice of the existence of such action. Parties will provide information, documents and other cooperation as reasonably necessary to assist the other in establishing its defenses to such action.

8.2 Breach of Warranties. Parties will indemnify and hold the other harmless from and against any and all liability resulting from:

(a) any misrepresentation in representations and warranties in Article VII of this Agreement;

(b) failure to notify the other as required in Section 7.4 of this Agreement; or

(c) actual exclusion during the term of this Agreement from any federal health care program (as defined in the Social Security Act § 1128B(f)).

8.3 Participation in Actions. Parties reserve the right, at its option and expense, to participate in the defense of any suit or action brought against the other or Business Associates arising out of any act or omission in connection with this Agreement.

8.4 Dispute Assistance. Each Party will reasonably cooperate in providing necessary assistance to the other Party when the other Party is actively involved in a dispute with a third party concerning Data Transmissions that either are or reasonably could be the source of litigation with that third party.

8.5 Limitation of Liability. Except claims or causes of action related to Parties actual or alleged breach of Article V of this Agreement or fraud by the other, neither Party will be liable for any special, incidental, indirect, exemplary or consequential damages resulting from any claim or cause of action arising out of any delay, omission or error in any Data Transmission or the other Party’s performance or failure to perform in accordance with the terms of this Agreement, including, without limitation, loss of use, revenues, profits or savings, even if a Party has been advised in advance of the possibility of such damages.

IX. MISCELLANEOUS

9.1 Notices. Any notice pertaining to this Agreement will be in writing. Notice will be deemed given when personally delivered to the Party’s authorized representative listed below, or sent by means of a reputable overnight courier or by certified mail, postage prepaid, return receipt requested. A notice sent by overnight courier or by certified mail will be deemed given on the date of receipt or refusal of receipt. All notices will be addressed to the appropriate Party as follows:

To: PGBA.

Government Programs Electronic Data Interchange Department, FC-DEC PO Box 202007

Florence SC 29502-2007

Attn:

Title:

To: Federal Bureau of Prisons (Trading Partner)

(Address)

(City, State, Zip Code)

Attn:

Title:

9.2 Amendments. This Agreement may not be changed or modified except by an instrument in writing signed by each Party’s authorized representative.

9.3 Choice of Law. This Agreement and the Parties’ rights and obligations hereunder are governed by and will be construed under federal law.

9.4 Dispute Resolution. Disputes will be resolved in accordance with federal law.

9.5 Assignment of Rights and Delegation of Duties. This Agreement is binding upon and inures to the benefit of the Parties and their respective successors and assigns. Parties retain the right to assign or delegate any of its rights or obligations hereunder to any of its wholly owned subsidiaries, affiliates or successor companies. Otherwise, neither Party may assign its rights or delegate its obligations under this Agreement without the prior written consent of the other Party, which consent will not be unreasonably withheld or delayed.

9.6 Force Majeure. Each Party will be excused from performance for any period of time during this Agreement that it is prevented from performing any obligation or service, in whole or in part, as a result of causes beyond its reasonable control and without its fault or negligence. Such acts include, without limitation, acts of God, strikes, lockouts, riots, acts of war, epidemics, governmental regulations imposed after the fact, fire, communication line failures, power failures, earthquakes, floods or other natural disasters. Delays in performance because of the occurrence of such events will automatically extend due dates for a period equal to the duration of such events. Such automatic extension will have no effect on the exercise of either Party’s right of voluntary termination of this Agreement under Section 2.2 of this Agreement.

9.7 No Waiver. Failure or delay on the part of either Party to exercise any right, power, privilege or remedy in this Agreement will not constitute a waiver. No provision of this Agreement may be waived by either Party except in a writing signed by an authorized representative of the Party making the waiver.

9.8 No Agency. Nothing in this Agreement will place either Party in a relationship whereby either (i) is the principal or agent of the other for any purpose or (ii) has the authority to bind the other in any way.

9.9 Severability. The provisions of this Agreement are severable. If any provision of this Agreement is held or declared to be illegal, invalid or unenforceable, the remainder of the Agreement will continue in full force and effect as though the illegal, invalid or unenforceable provision had not been contained in the Agreement.

9.10 Entire Agreement. This Agreement, together with its Exhibits, any applicable Business Associate Rider, EFT Rider and other Riders and Amendments, constitutes the entire understanding between PGBA and Trading Partner with respect to the subject matter of this Agreement and supersedes and cancels all previous written or oral understandings, agreements, negotiations, commitments, and any other writing and communication by or between the Parties. In the event of any inconsistency between any provision of this Agreement and any provision of a Rider to this Agreement, the provision of this Agreement controls.

9.11 Automatic Amendment for Regulatory Compliance. This Agreement will automatically amend to comply with any final regulation or amendment to a final regulation adopted by HHS concerning the subject matter of this Agreement upon the effective date of the final regulation or amendment.

9.12 Survival. The provisions of Sections 3.1(d) and 3.2; Article V; Sections 6.1 and 6.2; and Article VIII will survive termination of this Agreement.

SIGNATURES

The Parties will be bound by all the terms, provisions and conditions of this Agreement upon execution of the Agreement by each Party’s authorized representative.

Agreed to

TRADING PARTNER

Agreed to

PGBA

By: By:

Name: Name:

Title: Title:

Authorized Signature: __________________ Authorized Signature:__________________

Address: PO Box 202007

City, State, Zip: Florence SC 29507-2007

Date: Date:

Contact: Contact:

Title: Title:

Telephone: ( ) Telephone: ( )

Exhibit A – Page 1

EXHIBIT A

TRADING PARTNER INFORMATION

Trading Partner Information

Name:

Address:

Contact:

Telephone: ( ) Tax ID:

Vendor Information

Name:

Address:

Contact:

Telephone: ( ) Tax ID:

Exhibit B – Page 1

EXHIBIT B

EDI STANDARDS

I. Standard Formats for Data Transmissions. PGBA, Trading Partner and Business Associate will send and receive Data Transmissions involving the standard transactions established by the Transaction Rules in compliance with the Transaction Rules as follows:

(a) Health Care Claim or Equivalent Encounter Information:

(1) Professional or Institutional health care claim—ASC X12N 837, Version 5010.

II. EDI Communication Protocols. PGBA and Trading Partner or Business Associate will send and receive Data Transmissions in accordance with the EDI communication protocols set forth in accordance with a mutually agreeable format.

III. EDI Acknowledgement transactions. Parties will receive response files consisting of one record for each claim submitted to the other or in accordance with a mutually agreeable format.

IV. Security Standards. Parties and Business Associates will each develop, implement and maintain appropriate security measures for its own Operating System. These security measures will be in compliance with Social Security Act § 1173(d) and any HHS implementing regulation or guideline for electronically maintained or electronically transmitted Confidential Health Information.

If final electronic data security regulations issued by HHS implementing the Health Insurance Portability and Accountability Act of 1996 require a Chain of Trust Partner Agreement with terms and conditions not included in the Agreement, including the Exhibits and Riders to the Agreement, sufficient to comply with such final electronic data security regulations, then the Parties will amend or add a rider to the Agreement to bring the Agreement into compliance with the requirement for such a Chain of Trust Partner Agreement. If the Parties are unable or unwilling to make such an amendment or add such a rider to the Agreement within 30 days prior to the compliance date for such final electronic data security regulations, either may terminate the Agreement effective no later than such compliance date.

V. Automatic Amendment for Regulatory Compliance. This Exhibit B will automatically amend to comply with any final regulation or amendment to a final regulation adopted by HHS concerning the subject matter of this Exhibit B upon the effective date of the final regulation or amendment.

Attachment 6

ATTACHMENT 6

15B12018R00000001

INFORMATIONAL REQUIREMENTS FOR MEDICAL CLAIMS

1. Medical claims shall be transmitted in accordance with regulatory and industry standards for the submission of ANSI 837 transactions. The contractor shall be responsible for maintaining its information system(s) so that it remains compliant with such regulatory and industry standards. Any system changes that are required by the BOP’s medical claims adjudicator that are not the result of a regulatory or industry-wide change shall be negotiated on a case-by-case basis.

2. Each medical claim, whether submitted electronically or in hard copy , shall identify the inmate by his/her individual BOP inmate register number and shall reflect the patient’s relationship to insured as self. The inmate number shall be keyed with five digits, a hyphen, and three digits in the following format: 12345-678. In an electronically transmitted medical claim, this information shall be keyed at 2100BA NM109 for both facility and professional medical claims. In a UB-04 hardcopy medical claim submission, the BOP inmate register number shall be included in the Cert. - SSN - HIC. - ID NO. field, block 60. In a professional hardcopy medical claim submission, the BOP inmate register number shall be included in the Insured’s I.D. Number field, block 1a.

3. Each medical claim, whether submitted electronically or in hard copy, shall identify the invoice number under which the individual medical claim is being invoiced. In an electronically transmitted medical claim, the invoice number shall be referenced in the Patient Account Number field submitted in the 2300 loop, CLM01 segment. In a UB-04 hardcopy medical claim submission, the invoice number shall be included in the Patient Control Number field, block 3a. In a professional hardcopy medical claim submission, the invoice number shall be included in the Patient Account Number Field, block 26. The invoice number shall be limited to 13 characters. Positions 1-3 will be the institution’s alpha facility code, positions 4-5 will be alpha/numeric and mutually agreed upon by the institution and contractor, and positions 6-13 will be alpha/numeric and sequential. Not all positions, 6-13, must be used. No special characters will be allowed.

4. Medical claims for professional services provided under category 2e1 and 2e2 Outpatient Institution Services – Other Physicians, shall be filed with Place of Service Code 09.

5. Paper medical claims submitted to the medical claims adjudicator shall be mailed or otherwise delivered to the following address:

Mailing:

PGBA/FBOP Medical Adjudication PO Box 870777

Surfside Beach, SC 29587-8777

Physical:

PGBA/FBOP Medical Adjudication 8733 Hwy. 17-ByPass South Surfside Beach, SC 29575

Attachment 7

ATTACHMENT 7

15B12018R000000001

TECHNICAL PROPOSAL SUMMARY SHEETS BY HOSPITAL NETWORK

COMPREHENSIVE MEDICAL SERVICES – USP McCreary

Each offeror shall complete this two-page attachment for each hospital network proposed, without altering the format or the information sought by the form. The completed attachment supersedes any information described in the technical proposal. In the event of any conflicts between the completed attachment and the technical proposal, the information provided in this attachment shall take precedence.

Offeror:

Hospital provider (name, address):

Type of facility (e.g., acute, tertiary, ambulatory surgery):

Accreditation type/date:

Proximity of hospital to USP (in miles):

Number/type of beds:

Any exclusions on hospital services offered? (if so, describe):

Emergency Room trauma level:

Based on proximity and/or capability, is this hospital the primary Emergency Room provider for USP inmates, as recognized by the local emergency medical service responder?

Summarize enhancements available at this hospital:

Describe how this hospital network would be utilized within the offeror’s overall provider network (e.g., primary provider, secondary provider, etc.):

Physician Specialties in this hospital network

Offered? # of Physicians

Physician Specialties in this hospital network

Offered? # of Physicians

Anesthesiology Other:

Cardiology/Surgery Other:

Dermatology Other:

Emergency Room Other:

ENT/Surgery Other:

Endocrinology Other:

Family Medicine Other:

Gastroenterology Other:

General Surgery Other:

Gynecology (if female) Other:

Hematology Other:

Infectious Disease Other:

Internal Medicine Other:

Nephrology Other:

Neurology Other:

Obstetrics (if female) Other:

Oncology Other:

Ophthalmology Other:

Optometry Other:

Orthopedics/Surgery Other:

Pathology Other:

Psychiatry Other:

Pulmonology Other:

Radiology Other:

Urology Other:

Proximity of physician offices to the USP :

Minimum __________ miles Maximum __________ miles

On-site Clinics at the USP Offered?

Privileges at this hospital?

Privileges at another hospital in the offeror’s network?

Will the provider also perform services within an inpatient, outpatient, or office setting? Please indicate.

Dermatologist ENT Specialist General Surgeon Neurologist Optometrist Orthopedic Surgeon Psychiatrist Urologist

Attachment 8

ATTACHMENT 8

15B12018R00000001

PAST PERFORMANCE QUESTIONNAIRE FOR

BUREAU OF PRISONS MEDICAL SERVICES CONTRACT

REFERENCE IDENTIFICATION

Name of Reference/Activity (include point of contact)

Address

Phone

Fax

Date Questionnaire

CONTRACT IDENTIFICATION

Contractor Name for whom questionnaire is completed Contract Number

Contract Type

Period of Performance

Estimated Value of Contract, including all options

Description of Services Number of BOP locations serviced by this contract

EVALUATION

Below are listed specific questions relating to the following four categories of contractor performance: quality of goods/services, timeliness of deliveries/performance, business relations, and customer satisfaction. Please rate the contractor for each question based on the guidelines provided for each element. There is a comment section provided below each question. Please provide comments for any responses receiving a rating of fair, poor, or unsatisfactory.

QUALITY OF GOODS/SERVICES

Rating Guideline + - Plus The contractor has demonstrated an exceptional performance level that justifies adding a point to the score. It is expected that this rating will be used in those rare circumstances when contractor performance clearly exceeds the performance levels described as excellent.

Excellent There are no quality problems.

Good Nonconformances do not impact achievement of contract requirements.

Fair Nonconformances require minor agency resources to ensure achievement of contract requirements.

Poor Nonconformances require major agency resources to ensure achievement of contract requirements.

Unsatisfactory Nonconformances are compromising the achievement of contract requirements, despite use of agency resources.

Based upon a review of the medical record documentation, to what degree was the care provided to the inmates considered to be appropriate?

[ ] Excellent [ ] Good [ ] Fair [ ] Poor [ ] Unsatisfactory [ ] N/A

Comment: ________________________________________________________________

To what extent did the inmates receive the services for which they were referred?

[ ] Excellent [ ] Good [ ] Fair [ ] Poor [ ] Unsatisfactory [ ] N/A

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