Rate_Quotation_Option.pdf

DEPARTMENT OF HEALTH & HUMAN SERVICES

Public Health Service Albuquerque Area Indian Health Service 4101 Indian School Rd NE, Ste 225

Albuquerque, New Mexico 87110

February 1, 2017

Dear Contractor:

Attached is Request for Rate Quotation (RQ) package which is an option to and is associated with Solicitation# 17-242-SOL-00018, for Professional Physician and Other Ambulatory Health Care Services for the Albuquerque Area Indian Health Service. This option is for providers who do not frequently see our patients and/or do not wish to enter into a formal contract and are not willing to accept the Medicare Like Rate (MLR) as proposed in the IHS Final Rule- March 21, 2016-Federal Register (Attachment D-1). All reasonable offers will be considered. This is an open and continuous RQ for a period of 12-months through February 2, 2018.

Mail completed Rate Quotations to:

Albuquerque Area Indian Health Service Attn: Patricia Trujillo Division of Contracts & Grants 4101 Indian School Road NE, Suite 225 Albuquerque, New Mexico 87110

This document can also be found at the federal government point of entry (GPE) website FEDBIZOPPS at www.fbo.gov.This RQ does not commit the government to pay any costs for the preparation and submission of a proposal.

Additionally, the Contracting Officer is the only individual who can legally commit the Government to expenditure of public funds in connection with this proposed acquisition.

Should you have any questions or need guidance completing the forms, please contact Patricia Trujillo at 505/256-6754.

Sincerely, /s/

Dawn Sekayumptewa Supervisory Contract Specialist Division of Contracts & Grants, AAIHS

Enclosures cc: RFP 17-242-SOL-00018

RATE QUOTATION FOR PROFESSIONAL HEALTH CARE SERVICES

Provider Name:

(Legal Ent i ty Name)

To Be Completed by the Indian Health Service (IHS)

Issuing Office: Albuquerque Area Indian Health Service, Division of Contracts & Grants

Rate Quotation Number:

Date of Quotation (Pg 3 Para. 6):

Duration of Rate Quotation:

Applicable Service Unit(s): Acoma-Canoncito-Laguna Service Unit Santa Fe Service Unit (for ranking purposes only) Albuquerque Indian Health Center Southern Colorado Ute Service Unit Jicarilla Service Unit Taos-Picuris Service Unit Mescalero Service Unit Zuni Service Unit

1. Professional Health Care Service Specialty

Please indicate your specialty by checking the applicable box(es).

[ ] Allergy [ ] Obstetrics/Gynecology [ ] Urology [ ] Anesthesia [ ] Ophthalmology [ ] Other: (specify below) [ ] Audiology [ ] Optometry [ ] Cardiac Surgery [ ] Oral Surgery [ ] Cardiology [ ] Orthopedics [ ] Critical Care [ ] Otolaryngology [ ] Dermatology [ ] Pathology [ ] Emergency Medicine [ ] Pediatrics [ ] Endocrinology [ ] Pediatric Cardiology [ ] Family Practice [ ] Pediatric Pulmonary Medicine [ ] Gastroenterology [ ] Perinatology [ ] General Practice [ ] Physical Medicine and Rehabilitation [ ] General Surgery [ ] Physiotherapy [ ] Geriatric Medicine [ ] Plastic and Reconstructive Surgery [ ] Hand Surgery [ ] Podiatry [ ] Hematology/Oncology [ ] Proctology [ ] Infectious Disease [ ] Psychiatry [ ] Internal Medicine [ ] Psychology [ ] Maxillofacial Surgery [ ] Pulmonary Medicine [ ] Medical Laboratory [ ] Radiation Oncology [ ] Nephrology [ ] Radiology, Diagnostic (includes CAT & MRI) [ ] Neurology [ ] Retinal Specialist [ ] Neurosurgery [ ] Rheumatology [ ] Nuclear Medicine [ ] Thoracic Surgery

2. Rate Quotation Information

The Provider should be aware of the following IHS policies and procedures in determining a rate:

� The Indian Health Service (IHS) has an established policy to contract for health care services for Purchase Referred Care (PRC) formerly known as Contract Health Care (PRC) eligible American Indians and Alaskan Natives (AI/AN) only with those health care providers who agree to accept, as payment in full, reimbursement at rates no higher than the prevailing Medicare Care Fee Schedule, including co-insurance and deductibles for allowable charges. By Federal Register/Vol. 81, No.

54/Monday, March 21, 2016/Rules and Regulations; the Secretary of HHS issued a final rule to implement a methodology and payment rates for the Indian Health Service (IHS) Purchased/Referred Care (PRC). These final regulations became effective on May 20, 2016. Medicare Like Rate (MLR), IHS Final Rule- March 21, 2016-Federal Register (Attachment D-1). You are encouraged to quote your most competitive rate with the knowledge that cost will be considered in selecting providers in conjunction with quality of care, geographic proximity, and other relevant considerations, which is most favorable to the IHS patients and the Government.

� Patients receiving services under this contract may only speak a native language and/or reside on a Native American Reservation. The Contractor’s staff shall be sensitive to the unique cultural factors of the people they treat, which may include use of an interpreter as necessary in communication of services being rendered. Unique cultural factors that may contribute to the patient’s treatment include: use of their language communications; village and tribal customs; use of traditional healers;

isolation; housing conditions and lack of resources.

� IHS will utilize a standard purchase-delivery order form (IHS-843-1A) to issue orders for health care services against rate quotations. “Attachment D-4” illustrates this form and lists all of the applicable provisions and clauses.

� As directed by the IHS, the IHS Fiscal Intermediary (FI) will reimburse claims based on the CMS Medicare Physician Fee Schedule applicable to the dates of service on the claims.

� Claims for professional services must be submitted on a CMS 1500 claim form using Medicare guidelines and must indicate the full billed charges for the services rendered. The IHS FI will calculate the amount of payment based on the lesser of the billed charge or the appropriate Medicare Rate Fee Schedule and any percentages (below or above) as indicated in Paragraph 3. Rate Quotation.

� Procedures and/or diagnoses must be coded in accordance with the most current International Classification of Diseases, Tenth Edition (ICD-10-CM) or American Medical Association's Current Procedural Terminology, 9th Edition (CPT-

9) and approved supplements, e.g., the Healthcare Common Procedure Coding System (HCPCS) as appropriate.

� Providers may not bill IHS patients for charges determined to be non-allowable by the IHS FI or the patient's Alternate Resource Payor.

� Unless cited in Paragraph 3 Rate Quotation, Medicare Fee Schedules will be automatically adjusted upon receipt of the regulatory changes by the IHS FI handling payment. Providers must notify the Albuquerque Area IHS Division of Contracts & Grants in writing, of any changes in Medicare participation status.

3. Rate Quotation

The IHS is requiring that rate quotations be expressed as a percentage of the Medicare Fee Schedule. This percentage may be lower than or above the Medicare Fee Schedule. In the infrequent event a Medicare fee does not exist for a service or the service is not covered by Medicare Part B, reasonable allowable fees will be established by the FI.

Please indicate the rate of reimbursement you will accept for furnishing professional health care services to IHS patients.

MEDICARE FEE SCHEDULE less_______% OR plus_______% No-Show Fee: $________

4. Duration of Rate Quotation

The rate quoted in paragraph 3, page 2, shall remain in effect for a period of five (5) years (the duration period is found on page 1). Upon completion of each year, the IHS will require the provider furnish updated representations and certifications. IHS reserves the right to require the provider verify the accuracy of the rate quote and other information.

5. Contact

Provide a name and phone number of an individual in your organization that we may contact in the event there are any questions regarding the information provided in this Rate Quotation document.

Name:

(type or print legibly)

Title:

Telephone Number (include area code): ( ) Fax Number: ( )

6. Official Authorized to Sign for Provider

I hereby certify that for purposes of application of the false statements provisions of the Program Fraud Civil Remedies Act of 1986 (45 CFR 79), that to the best of my knowledge, all the statements are true, accurate, and do not omit any material fact, which would render the statement false, fictitious, or fraudulent as a result of the omission.

Signature: Date:

Name and Title (type or print legibly)

7. Professional Provider Information

Instructions: Complete the information requested in Section A and B (pages 4-6). If an item is not applicable, mark "N/A" (do not leave any blanks). Type or print legibly.

ATTENTION - if you are a Group Practice and bill for each affiliated provider under separate TIN/EINS then, individual rate quotations must be established with each provider. You may photocopy this rate quotation document for additional copies or contact the Division of Contracts & Grants at 505/256-6754.

SECTION A

COMPLETE ONLY ONCE

Information, which applies to the practice as a whole (whether responding as an individual provider or group practice).

1. Provider Name:

(Legal Entity Name)

2. Provider Office Address

Street:

City: State: Zip Code:

3. Telephone No. (include area code): ( ) Fax No. : ( )

4. Mailing Address (if different from office street address)

Street:

City: State: Zip Code:

5. Tax Identification Number (TIN):

a) Data Universal Numbering System (DUNS) Number:

b) Registered in SAM.gov? [ ] YES [ ] NO [ ] In Process

6. Entity Identification Number (EIN) if available:

7. Name of Provider's Medicare Carrier:

8. If services are provided in one of the listed categories, please indicate whether the facility is Medicare certified.

Rural Health Center [ ] YES [ ] NO [ ] N/A Free-Standing Ambulatory Surgical Center [ ] YES [ ] NO [ ] N/A Free-Standing Dialysis Center [ ] YES [ ] NO [ ] N/A

9. Business Size. Definition: Federal Acquisition Regulation (FAR) Part 13.003 requires that certain procurements costing $2,500 - $100,000 be reserved for small business concerns, and FAR Subparts 19.001 and 19.102 define a small business in the health care industry as one which is (1) independently owned and operated, (2) does not dominate its field of operations, and (3) has annual receipts (including affiliates) which do not exceed $5.0 million.

Based on this definition, are you a small or large business?

[ ] Small Business [ ] Large Business

10. Socioeconomic Classification. Federal Agencies are required to maintain information and report on their use of small disadvantaged businesses and woman-owned small businesses for procurements costing $25,000 or less (FAR 53.302-347 and 53.301-281).

Please indicate which of the following characterizes your business.

[ ] Small Disadvantaged Business. Small business concern which is at least 51 percent unconditionally owned by Native Americans, Black Americans, Hispanic Americans, Subcontinent-Asian Americans, Asian-Pacific Americans, and/or Indian Tribes, and whose management and daily business operations are controlled by one or more such individuals/tribes. (The more specific definitions contained in FAR Subpart 19.001 are available from IHS).

[ ] Woman-Owned Business. Business concern, which is at least 51 percent owned by one or more women who are United States citizens and who also control and operate the business (FAR 19.001).

[ ] Not Applicable.

Information Applicable to Group Practices Only

11. List GROUP Medicare number(s) (do not list each participating provider's Medicare number; see Section B):

12. List GROUP Medicaid number(s) (do not list each participating provider's Medicaid number; see Section B):

13. Do all provider's within the group practice bill under one (1) Tax Identification Number/Entity Identification Number

(TIN/EIN)?

[ ] YES [ ] NO - please refer to page 3, paragraph 7.

14. How many providers are in the group practice?

15. Are all providers within the group practice participating under this rate quotation?

[ ] YES

[ ] NO - Please contact the Division of Conttracts & Grants at 505/256-6754 prior to submitting rate quotation.

SECTION B

Information specific to each provider whether practicing as an individual or is group affiliated. Photocopies of Section B may be made so information on each affiliated provider can be completed.

1. Provider Name:

2. Provider's Social Security Number:

3. Medical Specialty(s):

4.

Medicare Participating Provider?

[ ] YES

[ ] NO

5. Provider's Medicare Number(s) (list all):

6. National Provider ID (NPI):

7. Do you Accept AHCCCS/Medicaid Patients? [ ] YES [ ] NO

8. Provider's AHCCCS/Medicaid Number:

9. Admitting/Staff Privileges: Please list the hospitals for which you have admitting and/or staff privileges.

Hospital Name City State

10. Provider Certification - All providers (individual or group affiliated) responding to the rate quotation must complete and sign the form entitled "Certification" found on pages 7 & 8. Verification of the information provided in the certification may be made by the IHS by contacting the National Practitioner Data Bank, Federation of State Medical Boards and/or those agencies responsible for licensing and board certification. Photocopies of page 7 & 8 may be made as necessary.

CERTIFICATION

Provider Name:

� I graduated from the located in (name of educational institution) (city/state) in the year of and was awarded a degree/certificate in .

(nursing, medicine, etc.)

� Did you graduate from a foreign university? [ ] NO [ ] YES - indicate the exam you passed and the date:

[ ] FLEX or [ ] ECFMG exam on .

(date)

� Are you a United States Citizen? [ ] YES [ ] NO

� My license to practice ] has [ ] has not been terminated, suspended or revoked in any State, the District of Columbia, or Puerto Rico, or a Territory of the U.S.

� I currently hold an active medical license(s) in the following State(s):

State License No. Issue Date

� I have an inactive medical license(s) in the following State(s):

State License No. Issue Date Reason License Lapsed or is Inactive

� Please indicate which of the following applies to you:

[ ] I am Board certified in the specialty(s) of:

[ ] I am Board eligible in the specialty(s) of

[ ] I am not Board certified nor eligible.

� I have current medical malpractice insurance in the amount of per occurrence $ in the aggregate $ . Expiration Date: .

� Medical malpractice insurance carrier:

Certification (continued)

I, [ ] have [ ] have never been suspended from participating in Medicare, Medicaid, or another Federal, State, or local medical programs.

I hereby certify, that for purposes of application of the false statements provisions of the Program Fraud Civil Remedies Act of 1986 (45 CFR 79), that to the best of my knowledge, each of the above statements are true, accurate, and does not omit any material fact which would render the statement false, fictitious, or fraudulent as a result of the omission.

Original Signature of Provider Date

Printed or Typed Name

Rvsd01/31/17 (AAIHS:PT/DS)

Rate Quotation Agreement Checklist

Solicitation#: 17-242-SOL-00018

Professional Physician and Other Ambulatory Health Care Services

The following checklist is to assist you in ensuring that the acceptable minimum documents are submitted with your rate quotation and signed by an official authorized to bind your organization.

Document Requirement Number of Copies

1. Rate Quotation For Professional Health Care Services 1 Copy with Original (Pages 1 -8) Signature Complete all applicable sections and sign

2. Appendix D-2: Business Associate Agreement 1 Copy Complete Fillable items in I and IIA.

3. Copies of Certifications, Licenses, Medical Malpractice Insurance 1 Copy and Specialty Training for each provider (if applicable).

Note: Please retain a copy of the RQ Agreement package for your reference.