IHS_PRC_Appeals_Contract_SOW.docx

Purchased/Referred Care Medical Review of Purchased/Referred Care (PRC) Appeals

Introduction/Background:

Purchased/Referred Care Program The Purchased/Referred Care (PRC) Program, in the IHS Office of Resources, Access, and Partnerships (ORAP) is integral to providing comprehensive health care services to American Indians and Alaska Natives (AI/AN). The Indian Health Service (IHS) health system delivers care through direct care services provided in IHS, Tribal, and urban (I/T/U) health facilities (e.g., hospitals, clinics) and through PRC services provided by non-IHS providers. The general purpose of PRC is for IHS and Tribal facilities to purchase services from private health care providers in situations where: 1) no IHS or Tribal direct care facility exists; 2) the existing direct care element is incapable of providing required emergency and/or specialty care; 3) utilization in the direct care element exceeds existing staffing; and 4) supplementation of alternate resources (e.g., Medicare, Medicaid, or private insurance) is required to provide comprehensive health care to eligible AI/AN).

Medical Priorities When funds are not sufficient to purchase the volume of PRC services needed by the eligible population residing in the PRC service delivery area, IHS PRC regulations require I/T/U PRC programs to use a medical priority system to fund the most urgent referrals first. Medical priority (MP) levels of care are defined as follows:

MP Level I: Emergent or Acutely Urgent Care Services are defined as threats to life, limb and senses MP Level II: Preventive Care Services are routine prenatal care, diagnostic procedures MP Level III: Specialty Services are considered ambulatory care which include inpatient and outpatient care services MP Level IV: Chronic Tertiary and Extended Care Services are defined as requiring rehabilitation services, skilled nursing facility care MP Level V: Excluded Services are services and procedures that are considered purely cosmetic in nature, i.e., plastic surgery

Objective/Purpose:

Appeals and Medical Reviews The PRC Program administers a time limited, three-tier reconsideration and appeal process for any person to whom PRC is denied. A patient or provider, acting on the patient’s behalf, may first seek reconsideration or an appeal from the Service Unit level. If denied, they may seek a second appeal to the Area level and if necessary a final appeal to the IHS Director at the Headquarters level.

The ORAP Director is responsible for processing all appeals that will be sent to the IHS Director. Those appeals that are denied based on medical priority are referred to the Director of the Office and Clinical and Preventive Services for medical review to determine appropriateness of care and classification within the medical priority levels. The Board Certified physician reviewer makes a recommendation to uphold or overturn the PRC denial based on the medical review.

The purpose of this contract is to secure one or more Board Certified physician reviewers to complete the third level medical reviews and make recommendations for the consideration by the IHS Director.

Definitions and Applicable Documents:

Appeal processes are defined in the Indian Health Manual, Part 2, Chapter 3, Contract Health Services, Section 11 CHS Payment Denial and Appeals https://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_pc_p2c3#2-3.11 and Section 12 Appeals https://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_pc_p2c3#2-3.12

Description/Scope of Work (SOW):

Appeal Files Each PRC appeal file includes the initial PRC denial and subsequent appeal and denial letters from the first and second tiers of consideration, medical records for the episode of care, and Area medical reviews. Appeal files will be provided by ORAP to the contractor for medical review and recommendation to uphold or overturn a PRC denial.

Format Medical reviews will conform to the following format and include a handwritten signature of reviewing physician:

I. Patient Background Appeal Information II. Second Level Medical Priority Determination III. Third Level Assessment, Medical Priority Determination and Recommendation to Overturn or Uphold the PRC Denial

Deliverables and Schedule:

The PRC files will be sent by ORAP staff directly to the contractor. The expected turnaround time for a medical review is 14 days. The contractor is expected to review up to 200 appeal files during the base year and at least 100 and up to 200 appeal files per year in option periods 1-4.

Appeal files will be delivered by Secure Data Transfer. Final medical reviews will be returned to the IHS by express overnight mail. All shipping costs after contractor receives the complete appeal files are the responsibility of the contractor.

Tasks Date

Meet with ORAP program staff and OCPS COR to develop work plan Month 1

Receive IHS PRC Appeal Files and patient medical records Month 1 – 12

Review patient medical records to determine medical priority Month 1 – 12

Prepare medical reviews in accordance with IHS guidelines Month 1 – 12

Return files and medical reviews to ORAP in required format Month 1 – 12

Performance Standards and Quality Measurement:

IHS ORAP and OCPS will perform periodic quality reviews to ensure the review process and the written reports meets quality review standards. Random selection of third level review reports will be done by OCPS.

Commission Furnished Property (Facilities, Equipment, or Services):

Contractor will supply all property necessary to review medical records and write report.

Contractor Tasks/Responsibilities/Capabilities:

Contractor must have a Board Certified Licensed Physician review the medical records, determine the Medical Priority Level for the medical services requested, recommend whether to uphold or overturn the denial and write the report.

Deliverable Reporting and Communication:

If additional medical records are needed in order to complete the review, contractor will contact the ORAP program staff. ORAP program staff and OCPS COR will communicate as needed to address any issues related to the processes outlined in this SOW. Contractor will return all medical records with final report.

Security Requirements:

The Contractor shall have a secure area to work on the medical reviews as they contained Protected Health Information. Contractor will perform reviews at a site of their choice not provided by the government.

Location of Work and Travel:

No travel is required for this SOW.

Special Considerations/Requirements:

None