5. PWS 03.19.2024.pdf

Performance Work Statement (PWS) RRMB – Healthcare Delivery Services

Title: Healthcare Delivery Services for Adults in Custody in the Community

Requiring Activity Name: Federal Bureau of Prisons Health Services Division For the Residential Reentry and Management Branch

1.0 SCOPE

The Bureau of Prisons (BOP) requires a nationwide healthcare delivery system designed to provide a comprehensive model of medical care to both male and female federal adults in custody (AIC) housed in Residential Re-entry Centers (RRC) and on Home Confinement (HC) to include those being monitored by the Federal Location Monitoring program under the United States Probation Office. These incarcerated individuals are housed at various locations across the United States. These individuals require all levels of healthcare you would normally find within the community. Services shall be on an as needed basis in a manner which conforms to community standards and all local, state, and federal laws and regulations applicable to the delivery of health care to members of the general public. Healthcare requirements are provided in Attachment 001. This list is comprehensive and includes a diversity of medical and ancillary services covering a wide spectrum from inpatient and outpatient facility and physician services that may be routine, specialty or urgent/emergent, but may not be all-inclusive. The Contractor shall discuss their plan for offering a diversity of services Any services a contractor is unable to provide or unable to provide in an area, shall be identified.

This contract will be for the Residential Re-entry Management Branch (RRMB).

However, it will be administered and monitored by the Health Services Division (HSD) with collaboration of the RRMB, Field Acquisition Office (FAO) and the Residential Re-entry Contracting Section (RRCS). Together each section will ensure this diverse contract is meeting the needs of this unique population in the most cost-efficient manner.

The BOP is looking for an organization that understands the private sector market; has experience in negotiating with organizations or providers that can deliver and maintain a large network of physicians, hospitals and ancillary services that meet or exceed the requirements as outlined in this PWS. The community provider capacities secured under this contract are intended to be responsive to the required healthcare needs of this unique population. Contractors shall manage and recruit resources to ensure sufficient Provider network and support services. They shall establish cost control measures, manage provider network, process referrals including pre-certification of defined services as determined by the government, scheduling of appointments, coordination of admissions and discharges, clinical information transfer, clinical quality improvement activities and processing of accurate claims and invoices. The AICs will have access to healthcare services when requested and approved in accordance with the contract. Urgent/emergent medical care will be addressed within this PWS.

1.0.1 Attachments/Links

• Attachment 001 – Healthcare Services List

• Attachment 002 – Medical Care Levels

• Attachment 003 – BOP Claims Data

• Attachment 004 – IT Requirements

• RRC Facilities -https://www.bop.gov/about/facilities/residential_reentry_management_centers.jsp

• BOP Clinical Practice Guidelines - BOP: Health Management Resources

• BOP National Drug Formulary - 2022_winter_formulary_part_1.pdf (bop.gov).

1.0.2 Explanation of Terms

Adult in Custody (AIC) – An individual or prisoner confined under the auspices and the authority of the BOP (see 28 Code of Federal Regulations (C.F.R.) § 500.1(c)). May also be referred to as a resident, patient, individual, offender or inmate.

Ancillary Services - All ancillary services approved in accordance with the contract shall be provided by the Contractor, or subcontractor, as an adjunct to the medical services provided. These services include, but are not limited to, the following:

pharmacy, laboratory, radiology, rehabilitation, dental, optometry, and autopsy.

Average Wholesale Price (AWP)- The average wholesale price of a prescription drug published and updated by Medi-Span. The AWP price will be based on the actual 11-digit NDC of the package size dispensed on the date dispensed. Supplier will use the NDC of the original packaging manufacturer rather than a repackaged NDC.

Brand Drugs- a prescription drug that is protected by a patent, supplied by one company and marketed under the manufacturer’s brand name or a multi-source brand product which was once a Brand product. Drugs with a Medi-Span code of “M”, “N”, and “O” will be considered brands.

Bureau of Prisons (BOP) - The BOP is an agency of the federal government within the Department of Justice (DOJ), the contractor shall enter into the resulting contract

Contracting Officer (CO) – BOP employee with the authority to enter into, administer and/or terminate contracts on behalf of the United States Government.

Contracting Officer’s Representative (COR) – A BOP employee designated and authorized in writing by the contracting officer to perform specific technical or administrative functions. The designated COR is the point-of-contact and liaison between the Health Services Division (HSD), Residential Reentry Management Branch (RRMB) and the contractor. The primary function of the COR is to regulate, evaluate, and inspect contract work as it progresses, recommend final acceptance of completed work, and to provide the CO with information and recommendations on any problems arising in the day-to-day administration of the contract.

Contractor – The firm, individual, or entity, following award selection, with which the BOP enters into this contract; ensures performance of services described in this Healthcare Delivery Performance Work Statement.

Federal Acquisition Regulation (FAR) – The FAR is the principle set of rules regarding Government procurement in the United States and is codified at Chapter 1 of Title 48 of the Code of Federal Regulations, 48 CFR 1.

https://www.bop.gov/about/facilities/residential_reentry_management_centers.jsp https://www.bop.gov/resources/health_care_mngmt.jsp https://www.bop.gov/resources/pdfs/2022_winter_formulary_part_1.pdf

Fiscal Year (FY)– One-year period beginning on October 1 and ending on September 30.

Generic Drugs- Any drug that is not a Brand. A drug with a Medi-Span code of “Y” on the date dispensed will be considered a generic.

Health Services Division (HSD) – Central Office Division within the BOP responsible for the healthcare of offenders. HSD employees involved in this contract shall include Management Analysts, Health Systems Specialists (HSS) and other employees assigned to assist with oversight and management of transitional healthcare of inmates in the community.

Health Systems Specialist (HSS) – BOP personnel responsible for pre-certifications and approvals of medical appointments, procedures and pharmaceutical requests within the BOPs IT systems.

Home Confinement (HC) –Also known as home detention, is a custody option whereby inmates serve a portion of their sentence at home while being monitored. This is the least restrictive designation for residential re-entry. HC inmates are typically placed on home confinement within 200 miles of a residential re-entry center (RRC). Both HC and RRC inmates may be using the services of this contract.

Healthcare Services – Sometimes referred to as medical services or care. Includes any medical treatment, including ancillary services delivered to a patient. This will include, but is not limited to services listed in Attachment 001.These do not include services which are considered for an “offender’s convenience.”

Intergovernmental Agreement (IGA) – Contractual agreement between a local/state government agency and the BOP to temporarily house AICs.

Mental Health Services – For purposes of this PWS, these services are defined as inpatient evaluation/treatment only.

Managed Care Administrator – The Contractor’s designated representative, regardless of local title, who has ultimate responsibility for the overall performance of the contractual services described herein.

Multi-source Brand Drug- A drug product manufactured by more than one company or source; commonly used to describe a brand drug for which generic equivalents are available.

Network – The collective group of facilities, providers and suppliers the offeror uses to provide healthcare services to RRMB offenders under this contract.

Out of Network – Refers to any facility, provider or supplier that has not previously negotiated a rate with the contractor under this negotiated procurement.

Provider – Refers to the licensed medical professional providing care on behalf of the Contractor for the Healthcare Delivery contract.

Residential Reentry Center (RRC) - Also known as halfway houses. The BOP contracts with RRCs to provide assistance to offenders who are nearing release. RRCs provide a safe, structured, supervised environment, as well as employment counseling, job placement, financial management assistance, and other programs and services.

RRCs help offenders gradually rebuild their ties to the community and supervise offenders' activities during this community reintegration phase of the BOP's reentry.

Residential Reentry Management Branch (RRMB) - RRMB employees members develop and administer contracts for community-based programs and serve as the BOP's local liaison with the Federal courts, the U.S. Marshals Service, State and local corrections, and a variety of community groups. The BOP's community-based programs are collectively administered by employees of the Residential Reentry Management Branch (RRMB) in Central Office, Washington, DC, three RRM Sector Management Teams (SMTs), and the 24 RRM field offices throughout the United States. The field offices are responsible for all residential reentry activities within their assigned judicial districts. The BOP contracts with residential reentry centers (RRCs) to provide assistance to offenders who are nearing release.

United States Department of Justice (DOJ) – The United States Department of Justice (DOJ) was established by statute in June 1870, with the Attorney General as its head. It is the agency responsible for law enforcement. The BOP is a component agency within the DOJ.

1.0.3 Background

The BOP was established in 1930 to provide more progressive and humane care for Federal AIC’s, to professionalize the prison service, and to ensure consistent and centralized administration. Today, the BOP is responsible for the custody and care of approximately 14,000 Federal AICs in the community. The Federal prison system is a nationwide system of prisons and detention facilities for the incarceration of AICs who have been sentenced to imprisonment for Federal crimes and the detention of individuals awaiting trial in Federal court. It is the mission of the BOP to protect society by confining these individuals in the controlled environments of prisons and community-based facilities that are safe, humane, cost-efficient, and appropriately secure, and that provide work and other self-improvement opportunities to assist them in becoming law-abiding citizens.

The BOP houses the majority of its AICs in correctional facilities owned and operated by the BOP. However, a portion are housed outside of BOP facilities in Residential Reentry Centers, state correctional facilities (termed long-term boarders), jails/short-term detention centers, contract juvenile detention facilities, and private residences through home confinement authority. These individuals are managed by the Residential Reentry Management Branch and throughout this document are referred to as AICs in the community. Some AICs in the community who are placed on home confinement may also be supervised by the United States Probation Office under the Federal Location Monitoring (FLM) program. It is vital that these individuals receive the same health care and treatment opportunities as those housed in a RRC. RRMB is also responsible for AICs located in state and local facilities. These state and local facilities provide in-house medical care, however in cases where these individuals need outside medical care, these services will be approved and provided by outside (community) medical care.

It is the BOP’s goal that all eligible HC AICs will be enrolled in Medicare/Medicaid programs. In the case of Home Confinement AICs who have private insurance, or whom are eligible and approved for Medicare/Medicaid, the Contractor shall be a secondary payor for healthcare services approved under this contract, unless otherwise determined by the BOP. In addition, the Contractor shall be a secondary payor for healthcare services approved under this contract but covered by private insurance for RRC AICs, unless otherwise determined by the BOP.

Contractors shall refer to the following link for locations of the RRCs where AICs in the community are housed.

https://www.bop.gov/about/facilities/residential_reentry_management_centers.jsp The total number of all AICs in the community are captured in the BOP’s weekly population report under the heading “other type of facilities”, available at www.bop.gov under Population Statistics.

As an agency under the Executive Branch of the United States Government, the BOP receives an annual appropriation of funds on a fiscal year basis to accomplish its assigned mission. The public trust demands that this annual appropriation be prudently managed. Thus, dollars spent to maintain the health of the AIC population must reflect the agency’s best efforts to obtain cost-effective healthcare consistent with community standards.

In meeting the healthcare needs of a growing AIC population, the BOP provides essential medical care services to these individuals. For AICs in the community, such care must be obtained through referrals to community-based providers. These individuals may be housed and placed in various facilities and locations throughout the United States. The majority of AICs in the community are housed in private contract facilities in which the BOP remains responsible for not only the healthcare needs of these individuals within the facility but also responsible for all AICs placed on home confinement. AICs placed on home confinement are ordinarily within a 200-mile radius of the RRC. These locations are separated by sectors.

In order to meet the healthcare needs of this population as it changes, the Contractor shall be responsible for establishing network facilities and providers upon notification from the HSD that a new RRC facility has been established. In these new cases, the Contractor shall have 30 days upon notification to integrate new providers into their network.

1.0.4 Medical Care Levels

AICs in the community will be classified in one of the BOP’s defined medical care levels.

Medical care levels are administrative classifications which are based on a four-level scale. Care Level I represents the healthiest while Care Level IV represents individuals with serious health issues. Criteria for categorizing a AIC in the care level categories are included in Attachment 002. The RRMB AIC population ranges in care level. The contractor will be responsible to provide medical services within all care levels.

Classification and designation of AICs is the sole responsibility of the BOP and may change at any time without consideration to the contractor.

https://www.bop.gov/about/facilities/residential_reentry_management_centers.jsp http://www.bop.gov/

Medical care may be classified as routine, urgent or emergent. Care shall be received based on the type of care needed and approved in accordance with the contract.

Attachment 003 is a report of the most common medical claims and pharmaceuticals billed to the BOP for AICs in the community. This report provides offerors historical data for the types of medical care required.

1.0.5 Organizational Conflict of Interest

The objective of this solicitation is to satisfy the BOP’s requirement for the provision of healthcare to AICs in the community. Potential organizational conflict of interest may arise if the awardee is an entity which also holds or participates in a separate contract/agreement with the BOP as a medical claim’s adjudicator. A possible conflict of interest may exist if the awardee has dual responsibilities for the submission of medical claims for services rendered under the resulting contract and for the adjudication of those medical claims under a separate contract/agreement with the BOP.

Offers received from any firm which holds or participates in a separate contract/agreement for BOP medical claims adjudication services must address any potential organizational conflict of interest that may arise and must provide a detailed explanation of how such conflicts will be avoided. Offers received from any firm which holds or participates in a separate contract/agreement for BOP medical claims adjudication services which fail to adequately address/resolve potential conflicts of interest will be rejected without further consideration. This limitation on the eligibility of offerors has been authorized by Federal Acquisition Regulation (FAR) 9.506.

1.0.6 Objectives

OBJECTIVE #1: Manage resources and maintain open avenues of communication, facilitating the exchange of information between the contract provider, contract RRC facility, and the Government regarding the contract services to ensure medical care is carried out seamlessly.

OBJECTIVE #2: Maintain an appropriately sized network of Providers of diverse services as needed, as listed in Attachment 001, which conform to community standards and all local, state and Federal laws and regulations applicable to the delivery of health care to members of the general public to those AICs in the community located across the United States (including Hawaii and Puerto Rico).

OBJECTIVE #3: Develop and implement a managed care approach which provides each RRMB AIC with sufficient identification to facilitate the authorization and delivery of health care services within the contractor’s network of care providers. This approach shall promote continuity of care for offenders transitioning from community custody to full release from custody.

OBJECTIVE #4: Manage Providers and claims processing to ensure only approved services are submitted and invoices are priced accurately and submitted timely in accordance with the contract.

OBJECTIVE #5: Manage medical record information in a manner which promotes continuity of care while observing restrictions on the release of information and timely transfer of clinical information.

OBJECTIVE #6: Provide an approved contract management process with monthly reports to capture statistical data to ensure the contract is operating in an efficient and effective manner which supports the mission.

OBJECTIVE #7: Provide method for pharmaceutical management (e.g. Pharmacy Benefit Manager (PBM)) to ensure AICs obtain routine and urgent pharmaceuticals at competitive pricing in the community. Method should include sufficient identification of the AIC and the payor responsibility.

OBJECTIVE #8: Provide billing procedures for exceptions to normal approving, scheduling and billing requirements for AICs in the community including medical care for AICs housed under Intergovernmental Agreements with state and local facilities.

2.0 SUMMARY OF REQUIREMENTS

2.0.1 OBJECTIVE #1: Manage resources and maintain open avenues of communication, facilitating the exchange of information between the contract provider, contract RRC facility, and the Government regarding the contract services to ensure medical care is carried out seamlessly.

The Contractor shall provide sufficient management to ensure that the work specified in this contract is performed efficiently, accurately, on time, and in compliance with the requirements of this document. There shall be an open line of communication between the Contractor and BOP to ensure only services approved in accordance with the contract are rendered.

Administrative Management and Communication The Contractor shall provide a communication plan addressing the requested information. A successful contract is dependent upon excellent communication, so be detailed in your plan (e.g. scheduler(s), medical technical employees, contracting employees, finance employees, management, etc). The Point of Contact (POC(s)) shall have sufficient clinical knowledge to facilitate discussions and authority to provide problem resolution quickly. This contract shall provide a 24-hours a day 7 days a week (24/7) call line which shall be staffed with medical personnel at a level no lower than a Registered Nurse (RN). This nurse line shall be used for non-scheduled care that is urgent/emergent in nature and can also be used for triage of medical concerns which may include referral to urgent/emergent care. The number of POCs will be determined by the Contractor who shall ensure the workforce is sufficient to allow for streamlined communication and daily problem solving.

Status Meetings During the initial stages of this contract, the Contractor shall be required to meet with BOP technical, contracting, and management employees to discuss the Contractor’s progress and implementation schedules. At a minimum, the Contractor shall make available the Managed Care Administrator and any other relevant employees. These meetings may be conducted by either conference call or face-to-face discussions and will not be unreasonable as to time or frequency.

It is anticipated that the frequency of the Status Meetings will decrease to monthly meetings once the Contractor’s performance is established. The COR shall be responsible for coordinating times and method/location for all meetings.

The Communication Plan shall include at a minimum the following:

• Proposed schedule of meetings from kick-off to close-out and delivery method (e.g. Kick-off meeting within 30 days of award/in person; monthly progress meetings/virtual, etc).

• Response times for routine and urgent inquires.

• Identify the Managed Care Administrator

• Point(s) of Contact (POC) - who will be responsible for facilitating the Contractor’s delivery of health services under this contract and the number of POC’s with corresponding responsibilities shall be identified in the plan.

• Hierarchy of contacts including roles and authority with an escalation process for resolving concerns.

• These lists shall be updated by the Contractor and provided to the COR as needed.

Implementation/Transition-Out Strategy and Risk Management Plans To ensure continuity of services at the outset and close-out of this contract, the Contractor shall develop and provide an implementation strategy plan, as well as a transition-out plan with a schedule. These plans shall address all objectives within the PWS to ensure continuity of services. Transition-out activities require collaboration with a team comprised of the BOP and/or successor Contractor personnel. The term transition-out is related to activities taking place during and after the last option period, in which the Contractor is transferring duties and responsibilities to another Contractor.

Residual services are provided by the Contractor for a period of time after the Contractor’s network no longer provides care, but the Contractor continues to process claims/invoices and perform other administrative duties for services that occurred during the performance period. All parties involved in transition-out services must ensure minimal disruption of services to AICs receiving care and providers delivering care.

In addition, the Contractor must create and adhere to a Risk Management Plan which must consist of risk and issue management processes for implementation and transition-out. The Contractor shall report risks and issues to the BOP and must describe measures to either minimize or eliminate the potential impact on the BOP. The Contractor shall update the BOP during scheduled meetings or as often as necessary on these issues.

Provider Network and Referral/Scheduling Management The Contractor shall detail the approach for creating and maintaining an adequate network of providers as well as perform referral/scheduling management in accordance with the requirements of the contract. Contractor shall ensure they have established sufficient communication avenues with their providers to ensure understanding of contract requirements. No AIC may be transferred to another medical facility without prior approval by authorized BOP, with the exception of emergency cases which will require follow-up approval. A contract provider may discuss with the AIC only the diagnosis and possible treatment options directly related to the approved referral. The Contractor shall ensure their providers do not guarantee future treatment. All consultant recommendations shall be approved in accordance with the contract. The Contractor shall not perform any treatment/procedures unrelated to the reason for the consultation without receiving prior authorization in accordance with the contract, except in emergency/urgent situations that would result in a negative clinical outcome.

Record Management and Transfer of Info Management The Contractor shall provide sufficient and on-going education to their Providers to establish guidelines and processes to streamline the transfer of information while observing restriction on release of information. In addition, the Contractor shall ensure records are easily accessible to the government upon request in accordance with the contract.

Claims and Invoicing Management The Contractor shall employ a sufficient claims and invoicing management system to ensure bills represent necessary services approved at the best possible rate allowed under the contract. They shall provide sufficient and on-going education to their Providers and their facilities, so they clearly understand the contract requirements involving medical services for AICs and invoicing requirements.

2.0.2 OBJECTIVE #2: Maintain an appropriately sized network of Providers of diverse services, as needed, as listed in Attachment 001, which conform to community standards and all local, state and Federal laws and regulations applicable to the delivery of health care to members of the general public to those AICs in the community located across the United States (including Hawaii and Puerto Rico).

Network Access The Contractor shall provide a comprehensive, credentialed network of primary physicians, specialists and facilities including walk-in clinics, urgent and emergent care, covering all areas for each RRC within a 30-mile radius of the RRC location(s). Any services for RRC AIC’s required outside of this radius requires COR approval.

Healthcare services shall be on an as-needed basis in a manner which adheres to community standards of quality and cost-effective healthcare.

The offeror’s technical proposal shall discuss in detail the diversity of services being offered and shall identify any services they are unable to provide in an area. The contractor shall ensure their provider network is sufficient that AICs can receive services within the required timeframes. Offerors are encouraged to offer alternative delivery methods to ensure they are providing a diversity of medical services in each area.

Failure to maintain an adequate network of providers with a diversity of services and failure to process referrals timely will be considered a performance issue.

Any provider on the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) exclusionary list shall be prohibited from network participation.

See: http://oil/hhs.gov/exclusions/index.asp for further details.

The Contractor shall pro-actively monitor network adequacy on an ongoing basis to ensure that the network is sufficient at all times to meet appointment time frame standards. The Contractor shall notify and communicate with the COR in writing issues with network and scheduling and their plan including the time frame to remedy the issue.

http://oil/hhs.gov/exclusions/index.asp

Out-of-Network Providers The Contractor should provide an adequate network of providers and facilities to meet the needs of the RRC and Home Confinement population. However, situations may arise when medical services are required from out-of-network providers or facilities. In these situations, the Contractor shall provide the appropriate documentation to support the out-of-network charges and shall invoice in accordance with the Schedule of Items.

Documentation requirements will be discussed during the kick-off meeting.

Network Provider Education The Contractor shall provide education to network providers to ensure that network providers and their facility employees are fully aware of the special provisions applicable to providing healthcare services to AICs in the community under this medical contract.

Education shall include the referral and authorization process and timely submission of claims to the Contractor. The BOP should not receive claims and invoices directly from Providers for services under this contract. All claims and invoices shall be sent to the Contractor for repricing under the contract. Any dispute will be between the Contractor and their Provider(s). The Contractor is responsible for performance of services under this contract.

Contractor Process and Referrals The Contractor shall provide a referral management infrastructure and processes to support referral of authorized care 24 hours a day, 7 days a week. This system shall meet all federal government information technology guidelines outlined in this PWS and Attachment 004 and must be approved in accordance with Federal Acquisition Regulation (FAR) prior to implementation. This system shall interface with the RRMB referral management system which is currently referred to as R3M. The Contractor shall make available its system to manage workflow, process referrals, store data, and generate reports. The Contractor shall coordinate all referral functions among the RRC, RRMB, HSD and the network provider.

All referrals for medical care shall be submitted by the RRC and approved through R3M which will interface with the Contractor’s approved system, unless otherwise approved by the government. The BOP shall be responsible for approving referrals based upon this contract and the BOP’s Clinical Practice Guidelines and Drug Formulary. The Clinical Practice Guidelines and Drug Formulary are available at BOP: Health Management Resources and 2022_winter_formulary_part_1.pdf (bop.gov).

The anticipated process for the contractor to develop capabilities with R3M are outlined below. Due to changes in technology, these capabilities are subject to change.

• Create SSL webservice on their side to receive data from R3M SSL webservice API.

• Write code to integrate data send from R3M into their system.

• Test their SSL webservice to receive data from R3M.

• Test code to integrate R3M precert data into their system.

• Write code to integrate JSON data into their system.

• Test sending encrypted email from BOP to their email system.

• Test code to integrate JSON data into their system.

https://www.bop.gov/resources/pdfs/2022_winter_formulary_part_1.pdf

Referral and approval procedures are outlined below:

Routine/Specialist Referral Approval:

• Upon identification of a routine medical need or referral to a Specialist, the RRC will request a referral in R3M to BOP. All BOP approved healthcare services will be sent to the Contractor through the interface of systems, unless otherwise approved by the BOP.

Urgent/Emergent Approval – Time allows for approval through the 24/7 Nurse Line:

There may be times when there is an urgent/emergent need where time doesn’t allow processing through routine referral means but where a call to the 24/7 Nurse Line is acceptable to obtain direction to the appropriate level of care. In these cases the following procedures shall apply:

• The resident will have access to the 24/7 hour Nurse phone line who will direct the resident to the appropriate level of care within close proximity appropriate for the urgency or emergency. In-network facilities should be used when time allows commensurate with community standards for care.

• Upon referral the contractor shall notify the RRC if the nurse referred the AIC to seek medical care. This information shall include the AIC information, date, medical request and location of medical provider recommended so a follow-up request for services can be submitted.

Urgent/Emergent Approval – Time Doesn’t Allow for Prior Referral and Approval:

There may be times when urgent/emergent care is required and time does not allow for processing through routine referral means or use of the 24/7 Nurse Line. In these cases, the following procedures may apply:

• The Contractor is required to provide BOP access to the list of urgent/emergent in-network facilities for each RRC area. This should be updated as often as necessary or upon request from the COR. This list will be used by the RRC Managers to direct AICs for medical care when time does not allow for a proper referral to be made through R3M. In the case of an emergency, the ambulance will take the AIC to the nearest appropriate medical care.

• In these situations, it is the BOP’s goal that RRC’s shall submit these urgent/emergent referrals within one working day of the emergency visit.

• The Contractor shall follow-up with these providers to ensure proper notification of payor responsibility and billing requirements.

Scheduling and Appointment Time Frames

• Once approved and the most appropriate provider has been selected, the Contractor shall schedule an appointment on behalf of the patient within the required time frames outlined below:

o AICs must be scheduled for an appointment by the Contractor within 10- 14 days for routine care with the appointment being scheduled commensurate with the community standard.

o AICs must be scheduled for an appointment by the Contractor within 30 days for specialty care with the appointment being scheduled commensurate with the community standard.

o AICs must be able to schedule an appointment for a routine diagnostic within 10 - 14 days, unless clinically indicated, with the appointment being scheduled commensurate with the community standard.

• Once confirmed, the Contractor shall communicate the appointment date/time to the AIC through the RRC. The Contractor shall also provide any clinical instruction for the appointment to the individual through the RRC and ensure any preliminary information needed from the AIC is communicated back to the network provider. This correspondence shall clearly state that “No other services shall be permitted without prior authorization, unless an urgent/emergent event has occurred. In this case the BOP should be notified immediately.” If clinical information needed by the network provider is not provided with the authorization, the Contractor shall follow-up with the authorizing RRMB official to obtain the information and forward it to the network provider.

The Contractor shall notify and communicate with the COR in writing issues with network and scheduling and their plan including time frame to remedy the issue.

Network Facility Accreditation The Contractor shall ensure that the following facility accreditation requirements are met to ensure that the quality of care provided by the Contractor’s network is of at least the same quality of care within the community.

All facilities proposed by the Offeror shall maintain accreditation from a nationally recognized healthcare accrediting organization. It is the BOP’s preference to obtain the services of facilities that are accredited by the Joint Commission, if applicable. If requested by the Contracting Officer, the Contractor shall submit documents validating this accreditation or certification as part of its proposal.

Throughout the performance period, the Contractor shall immediately report any changes in a facility’s or provider’s accreditation status to the Contracting Officer’s Representative (COR) and the Contracting Officer (CO) if status changes to Provisional Accreditation, Conditional Accreditation, Preliminary Denial of Accreditation, or Denial of Accreditation.

Network Provider and Credentialing

The Contractor must always be composed of a comprehensive network of licensed healthcare providers unless licensure is not applicable to such providers to deliver the services. If requested by the Contracting Officer, the Contractor shall document primary source verification of the credentials for each provider including current license from the appropriate State Board of Medical Examiners, education from professional schools or universities, evidence of completion of internships and/or residence, DEA registrations, National Practitioner Data Bank (NPDB) information and peer review completion.

2.0.3 OBJECTIVE #3: Develop and implement a managed care approach which provides each RRMB AIC with sufficient identification to facilitate the authorization and delivery of health care services within the contractor’s network of care providers. This approach shall promote continuity of care for offenders transitioning from community custody to full release from custody.

Partnerships with community-based medical providers offer a powerful approach to improving the AIC health while supporting re-entry into the community. By connecting these individuals with local medical and pharmaceutical providers within their geographical release destination, these partnerships can provide continuity of care for individuals after completion of their sentence.

This partnership may necessitate using a managed care approach. In proposing a managed care approach, the contractor will act as a liaison between the AICs medical and pharmaceutical provider. Therefore, the technical proposal must outline a system where the community-based medical providers will have the ability to identify the patient as a RRMB AIC for the provision of medical and pharmaceutical care while in the care and custody of the BOP. Also, the procedures proposed should allow the AIC, medical and pharmaceutical provider to foster a relationship for continued medical care after release from BOP custody.

Contractor shall provide a method of sufficient identification necessary in order to facilitate the authorization and delivery of health care within the contractor’s network of care providers while under BOP custody. Plan shall include sufficient information to identify the AIC as the patient and the contract awardee as the vendor. All disputes with the health care provider shall be between the contract awardee and the healthcare provider. The Government’s relationship shall be with the awardee of the contract. The contractor shall develop a release plan for the AIC to ensure an ability to foster a relationship for continuity of medical and pharmaceutical care for the individual and transfer payor responsibility upon release from custody.

2.0.4 OBJECTIVE #4: Manage Providers and claims processing to ensure only approved services are submitted and invoices are priced accurately and submitted timely in accordance with the contract.

Claims and Invoice Submittal

Overview. Upon completion of a treatment encounter, the Contractor shall prepare and submit proper invoices for services rendered under this contract. For the purpose of this contract, a specific definition for what documentation constitutes an invoice is provided below. A proper invoice shall include the information specified in FAR clause 52.212-4, Contract Terms and Conditions - Commercial Products and Commercial Services, paragraph (g). Services shall be invoiced in accordance with the terms and conditions of the contract, including the payment rate structures specified in the contract.

Invoice/Medical Claims Adjudication. The Contractor shall be responsible for processing of claims and payments to providers. Only invoices submitted from the awarded Contractor to the BOP will be accepted for reimbursement.

There are two categories of invoices that may be submitted under this contract.

1) Invoices for healthcare services (including pharmaceuticals) scheduled by the Contractor and completed for AICs in the community and 2) Invoices with payor only responsibility. In both cases the invoices shall include documentation of medical services approved and billed in accordance with the contract. The Payor only responsibility is discussed further in Objective #9.

The Contractor shall utilize an existing automated claims processing system to process and adjudicate claims. The Contractor shall provide their proposed claims adjudication system process which shall validate referral and prior authorization and any other data needed to properly adjudicate claims. The Contractor shall develop rules to apply the correct fee schedule based upon information provided on the referral from the RRC.

The contractor shall ensure that correct payment schedules are used to pay providers.

The contractor shall deny claims that are not authorized in accordance with the contract and notify the BOP. These claims shall be clearly identified.

The adjudication process of invoice/medical claims shall ensure, at a minimum, the services billed by the provider were properly authorized in accordance with the contract and ordered by the RRMB; are appropriately coded in compliance with Medicare coding policies (where applicable); billed in accordance with the contract; have all applicable documentation to support the charges; and do not represent duplicate billings for payments already made. If the services were authorized, the contractor will submit an invoice in accordance with the contract rates and terms/conditions.

If an authorization for the services rendered is not found, the claim will be pended for further review. These will be handled on a case-by-case basis and should be the exception. If no pre-authorization was granted, the Contractor shall provide a list of claims with documentation and sufficient written justification of proposed resolution to the BOP. If authorization is not granted, the Contractor shall deny the claim and inform the provider that the care was not authorized and therefore is not reimbursable. If a pre-authorization is matched to the claim or post-authorization is given based on information provided, the government will pay the Contractor according to the terms of the contract.

In addition, the Contractor is advised the BOP may utilize the services of a third-party medical claims adjudicator to review medical claims submitted by the contractor under this contract. When requested by BOP, the contractor shall comply with all reasonable requests for additional invoice/medical claim/medical record documentation. All invoice payments shall be made by the BOP and any disagreements regarding the paid amount of any invoice shall be resolved directly with the BOP.

At the outset of establishing a Third-Party Claims Adjudication contract, the BOP will schedule a meeting to discuss information requirements for medical claims along with other pertinent details.

Invoice Submittal. Invoices shall be electronically submitted weekly or as otherwise determined by the BOP using an encrypted email service or other BOP approved secure method of transferring information. The Contractor shall provide claims and invoices in a uniform and systematic manner. The format provided shall be a PDF version and an unlocked Microsoft Excel spreadsheet for easy sorting and filtering capability. Each medical claim included on an invoice shall reference, at a minimum, the following information unless otherwise indicated by the government: Document Number of obligation, sector, RRC or IGA facility, AICs name and register number, date of service, approval number/date, provider of service and NPI number, line item or category reference from contract, description of service, billed code, billed amount by provider, contract rate and invoiced amount. The contractor shall invoice the lesser amount.

Medical claims detailed in the invoice shall be listed first in descending order by the Document number, second in alphabetic order by the AICs last name, and third by ascending date of service (i.e., earliest to latest) when more than one medical claim is present for the same individual within the same invoice. Invoices shall be billed by Sector unless otherwise indicated by the government.

The Contractor shall not submit a medical claim for processing that the contractor knows, or has reason to believe contains inaccurate, incomplete, or misleading information. Additionally, the Contractor shall only submit Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) provided by medical service providers. Medical claims which contain inaccurate, incomplete or misleading information shall be held by the Contractor and not submitted until such time as all lines are deemed to be accurate and complete. At that time, the Contractor may proceed with submitting the medical claim for processing and invoicing the institution for all services represented by that medical claim.

If applicable, following written notification to the Contractor by the Contracting Officer that a third-party medical claims adjudication service will be utilized by the BOP, the Contractor shall electronically transmit claims to the BOP's medical claims adjudicator via American National Standards Institute (ANSI) 837 format that also conforms to Medicare and Health Insurance Portability and Accountability Act of 1996 (HIPAA) electronic billing standards.

Provider Information.

National Provider Identifier (NPI) Numbers - The Contractor shall utilize only providers who have a current National Provider Identifier (NPI) number.

Technical Data for Submission of Medical Claims. The Contractor shall properly adjudicate all medical claims. If applicable, prior to the submission of an invoice to the BOP, the Contractor shall electronically transmit the information found on each individual invoiced medical claim via ANSI 837 format only, to the BOP's medical claims adjudicator. Any claims submitted to the medical claims adjudicator’s claims clearinghouse with missing or invalid provider information will be automatically rejected in a 277CA Claims Acknowledgement message noting the missing or invalid provider information received.

After the Contractor's electronic transmission to the BOP's medical claims adjudicator, the Contractor shall promptly submit an electronic copy of the invoice to the BOP. The Contractor will also post the ANSI 837 file in an FTP site set up and maintained by the BOP's medical claims adjudicator.

Procedures for Filing Corrected Medical Claims A corrected claim is a replacement of a previously submitted claim with claim line level denials or issues.

Facility Services: If it becomes necessary to file a corrected medical claim for facility services, the Contractor shall electronically transmit the information found on each individual corrected medical claim via ANSI 837i format only, to the BOP’s medical claims adjudicator. Facility Provider corrected claims should include a value of '7' (Replacement of Prior Claim) in Loop 2300, Segment CLM05‐3.

Physician/Professional Services: If it becomes necessary to file a corrected medical claim for professional services, the Contractor shall electronically transmit the information found on each individual corrected medical claim via ANSI 837p format only, to the BOP’s medical claims adjudicator. Professional Service Provider corrected claims should include a value of '7' (Replacement of Prior Claim) in Loop 2300, Segment

CLM05‐3.

After the Contractor's submission to the BOP's medical claims adjudicator, the Contractor shall promptly submit an electronic copy of the invoice or credit memo, as applicable, to the BOP. Invoices for corrected medical claims shall be clearly marked as such and shall be separate from routine invoices. Invoices or credit memos for corrected medical claims shall detail information pertaining to the original medical claim submission (including any amount(s) previously paid and the associated invoice numbers) and shall bill only for the corrected medical claim submission or reflect the credit amount due for the corrected medical claim submission.

Payment by the BOP.

Upon receipt of a claim from a provider, the Contractor will process the claim verifying that the care was authorized in accordance with the contract. The BOP will pay all invoices directly to the Contractor. If the invoiced amount of a medical claim exceeds the adjudicated amount of that medical claim, the BOP may take an administrative deduction from the invoice. The BOP will provide written notification to the Contractor when an administrative deduction is taken from an invoice payment.

If the Contractor is in disagreement with the paid amount of a medical claim, the contractor will provide written notification to the BOP of the disagreement along with the reasons why the Contractor believes the medical claim was paid incorrectly. If there is a Third-Party Medical Claims Adjudicator, the BOP will interface between the Contractor and the medical claims adjudicator, to bring resolution to any disagreements. In the absence of an adjudicator, the BOP will resolve any disagreements with the contractor. If it is determined that a medical claim was paid incorrectly by the BOP, interest on the underpayment will be paid, when required, by the Prompt Payment Act.

Timeliness of Medical Claims The Contractor is responsible for ensuring they negotiate adequate time frames with their Providers for submission of claims in order to meet the government’s invoicing requirements. The contractor will submit invoices to the BOP within 120 calendar days from date of approval in R3M or from date of service, whichever is later.