26-002 - Claims Payment and Communication _ Enterprise Print and Fullfillment AutomationRFP - FINAL.pdf

REQUEST FOR PROPOSALS FOR

Claims Payment and Communication Services (Part1) and

Enterprise Print and Fulfillment Automation (Part2)

RFP 26-002

PROJECT DESCRIPTION

CalOptima is seeking proposals for Claims Payment and Communication Services, which include secure printing, processing, and mailing of payments, checks, and related documents, along with optional digital delivery and payment processing capabilities. The scope also includes Enterprise Print and Fulfillment Automation to provide both routine and ad-hoc print and fulfillment services. The services will include printing, managing, storing, packaging, addressing, and distributing materials to be handled by the United States Postal Service or other carriers, as well as producing PDF conversions of select Variable Data Printing (VDP) components and delivering these to CalOptima for archiving. Vendors may submit proposals for one or both service areas.

https://www.caloptima.org/

SCHEDULE

RFP

Expected number of contracts to be awarded Up to 3

Pre-proposal meeting date and time NA

Is pre-proposal meeting mandatory? ☐ Yes ☒ No

Pre-proposal meeting link/location NA

Deadline for Questions, Comments & Contract Exceptions

9/8/2025 @4PM Pacific Standard Time

Proposal Due Date and Time 11/3/2025 @2PM Pacific Standard Time

Interviews/Presentations 1/5/2026 – 1/16/2026

Vendor Selection (Tentative) 1/20/2026

CONTRACT

Expected Duration of Initial Agreement 5 years

Options to Extend Provide pricing for 3 one- year options & 5 one-year options

Pricing method Please see attached pricing forms

DESIGNATED POINT OF CONTACT

Name Lisa Ha

Email Lisaha@caloptima.org

While this proposal is ongoing, communication with CalOptima staff regarding it is prohibited except through the Designated Point of Contact.

Submit questions and proposals via Bidnet Direct.

If taking exception to any terms, use the Requested Changes and Modifications Form and submit via e-mail to the Designated Point of Contact.

https://www.bidnetdirect.com/california/caloptimahealth

RFP 26-002 i 8/13/25

TABLE OF CONTENTS

SECTION 1 - CALOPTIMA Health

SECTION 2 - INSTRUCTIONS TO PROPOSERS

2.1 Questions, Comments & Contract Exceptions

2.2 Revisions to the Solicitation

2.3 Communication

2.4 Pre-proposal conference and site visits (If Applicable)

2.5 Modification or Withdrawal of Proposal

2.6 Joint Proposals

2.7 Prohibited Prior Work

2.8 Conflicts of interest

2.9 No Commitment

2.10 Pricing

2.11 Estimated Quantities

2.12 Proposal Submission

2.13 Ownership and Disclosure of Proposals and Materials

2.14 Electronic Signature and Consent

SECTION 3 - PROPOSAL EVALUATION AND CONTRACT AWARD

3.1 Determination of Responsiveness

3.2 Proposal Evaluations

3.3 Determination of Responsibility

3.4 Contract Award

3.5 Post Award Requirements

SECTION 4 - PROPOSAL CONTENTS AND FORMAT

4.1 Experience and Organizational Capability

4.2 Proposed Services

4.3 References

4.4 Supplemental Services (optional)

4.5 Supplementary Documents

4.6 Price

4.7 Required Forms (Attached)

SECTION 5 - PROTESTS

5.1 Protest Eligibility

5.2 Protest Deadlines

5.3 Protest Contents

RFP 26-002 ii 8/13/25

SECTION 6 - PROPOSER CERTIFICATIONS

6.1 BACKGROUND SUMMARY

6.2 KEY TERMS

6.3 SECTION 1 – PROVIDER CLAIMS PAYMENT AND COMMUNICATION SERVICES SOW

(PART 1)

6.4 SECTION 2 – ENTERPRISE PRINT AND FULFILLMENT AUTOMATION SOW (PART2)

6.5 Pricing

ATTACHMENT 1 - AUTHORIZED SIGNATURES

ATTACHMENT 2 - PRICE PROPOSAL

ATTACHMENT 3 - SECURITY QUESTIONNAIRE

ATTACHMENT 4 - REQUESTED CHANGES AND MODIFICATIONS

ATTACHMENT 5 - CALOPTIMA LEVINE ACT DISCLOSURE STATEMENT

ATTACHMENT 6 - STANDARD CONTRACT

RFP 26-002 3 8/13/25

SECTION 1 - CALOPTIMA HEALTH

CalOptima Health is a public agency created by the Orange County Board of Supervisors to offer health insurance programs for low-income children, adults, seniors and people with disabilities.

It is Orange County’s single largest health insurer, providing coverage through three major programs - MediCal, California’s Medicaid Program for low-income children, adults, seniors, and people with disabilities; OneCare, which is a Medicare Advantage special needs plan for seniors and people with disabilities who qualify for both Medicare and MediCal; and PACE, Program of All-Inclusive Care for the Elderly, providing health and social services to frail older adults, so they can remain living in their communities.

SECTION 2 - INSTRUCTIONS TO PROPOSERS

2.1 Questions, Comments & Contract Exceptions

2.1.1 Submit all questions via BidNet Direct, by the Deadline for Questions and Comments. Responses will be posted on BidNet Direct as questions arrive.

CalOptima may not be able to acknowledge questions and comments received after the deadline.

2.1.2 If taking exceptions or suggesting revisions to the attached contract, instead of submitting those through BidNet Direct, use the attached Requested Changes and Modifications form and email it the Designated Point of Contact by the Deadline for Questions, Comments & Contract Exceptions. Identify specific sections and paragraph numbers to which exceptions are taken, as well as the rationale for the change. If requesting changes to language, identify specific words or phrases to be changed and provide new requested language.

CalOptima will consider contract exception requests and if suggested modifications are accepted, the solicitation will be revised, and an addendum will be posted with the revised terms. However, if sufficient proposals are received with few or no suggested modifications, CalOptima may accept the proposals with few requests and reject those with more.

2.1.3 Failure to make exceptions prior to the deadline for questions and comments, or as otherwise directed, will be deemed a waiver of any objection.

2.1.4 CalOptima may determine non-responsive any proposals that are conditional or that include material exceptions to the specifications or terms.

2.1.5 Requests for complete replacement of the contract, or for replacement of the federal provisions, will not be granted and will render a proposal non-responsive.

2.1.6 If a “REQUESTED CHANGES AND MODIFICATIONS” form is not submitted during the Question, Comments and Contract Exceptions deadline, the terms submitted in the Sample Contract will be in force.

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2.2 Revisions to the Solicitation

CalOptima may cancel, revise, or reissue this solicitation, in whole or in part, for any reason. Revisions will be posted as addenda on BidNet Direct. No other revision of this solicitation will be valid. Proposers are responsible for ensuring that they have received all addenda prior to submitting proposals.

2.3 Communication

2.3.1 Other than the Designated Point of Contact, no proposer or person acting on behalf of a prospective proposer may communicate with or discuss the details of the procurement process or any proposal with any officer, agent, or employee of CalOptima other than the Designated Point of Contact. CalOptima may deem unresponsive a proposal from any proposer or persons acting on behalf of a proposer who violates this prohibition. This prohibition does not include mere administrative matters (e.g. due dates, etc.).

2.3.2 Outside of evaluation committee meetings, members of an evaluation committee and associated subject matter experts may not communicate about matters involving deliberations or the details of an ongoing solicitation with co-workers, supervisors, directors, individuals in other departments, or other CalOptima staff that is not directly involved in evaluating proposals.

2.4 Pre-proposal conference and site visits (If Applicable)

2.4.1 If a pre-proposal conference is scheduled, and if American with Disabilities Act (ADA) accommodations are required, submit a request for accommodations to the Designated Point of Contact.

2.4.2 Answers to questions will be posted as addenda on BidNet Direct.

2.4.3 If the pre-proposal meeting is mandatory, proposers who did not attend the pre-proposal meeting may be disqualified.

2.5 Modification or Withdrawal of Proposal

Proposals may be withdrawn, modified, or replaced at any time prior to the Due Date and Time. After the Due Date and Time, proposals may not be modified unless requested by CalOptima.

2.6 Joint Proposals

If submitting a joint proposal, one entity will be fully responsible for performance under any resulting contract and other participants must be subcontractors. In addition, all entities in the joint proposal will be required to undergo the same background checks before CalOptima executes a Contract.

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2.7 Prohibited Prior Work

2.7.1 No person or entity may submit a proposal in response to this RFP if that person or entity has:

A. Been a single entity that drafted or directly assisted CalOptima in establishing specifications and requirements for this procurement, or

B. Has had access and exposure to information pertinent to this procurement that is not available to other proposers and that would provide an unfair competitive advantage.

2.7.2 Proposers that received assistance from any such person or entity will be disqualified.

2.7.3 This exclusion does not apply:

A. To general and non-specific advice or information offered to or requested by CalOptima to aid in developing the solicitation, as long as the participation was limited to conceptual, preliminary, or initial plans or specifications and all potential proposers have access to the same information, including the conceptual, preliminary or initial plans.

B. To comments made at a pre-proposal conference or to comments made subsequent to publication of the solicitation or if multiple sources were consulted for assistance prior to release of the solicitation.

2.8 Conflicts of interest

Proposers and subcontractors or subconsultants are eligible for contracts with CalOptima only if they are not currently, and will not, during the performance of the required services, participate in any other similar work involving a third-party with interests currently in conflict or likely to be in conflict with CalOptima’s interests.

2.9 No Commitment

This RFP does not commit CalOptima to make an award, nor will CalOptima pay any costs incurred by proposers in the preparation and submission of proposals, or costs incurred in making necessary studies for the preparation of proposals.

2.10 Pricing

If a pricing sheet is provided, submit prices using the pricing sheet or as otherwise directed. Failure to submit prices as directed may result in the proposal being found non-responsive.

2.11 Estimated Quantities

If the solicitation results in an indefinite quantity or requirements contract, the actual amount of goods or services requested may be less than the maximum value of the

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contract and there is no guarantee, either expressed or implied, as to the actual quantity of goods and services that will be authorized under the Contract.

2.12 Proposal Submission

2.12.1 Allow time for all documents to upload to BidNet Direct. Failure to complete an upload may result in rejection of a proposal.

2.12.2 Complete all documents electronically. Other than signatures, hand-written responses, whether or not submitted electronically, may be rejected.

2.12.3 If directed to submit information as one or more PDF, Excel, or other electronic files, include the solicitation name and number in all filenames.

2.12.4 No proposals or modifications submitted by email or facsimile will be considered. Proposals not submitted by the Due Date and Time via BidNet Direct may be rejected.

2.12.5 Proposals must be signed by a legally authorized representative of the entity submitting the proposal.

2.13 Ownership and Disclosure of Proposals and Materials

2.13.1 All open proposals, including documents and materials submitted with proposals, become the property of CalOptima.

2.13.2 CalOptima is subject to California Public Records Act (California Government Code, Section 6250 et. seq.). With selected exceptions, the contents of any submissions will be treated as open records and will be open to inspection by interested parties after a contract is executed or CalOptima rejects all proposals.

2.13.3 If submitting confidential or proprietary information as part of a proposal, clearly delineate any limits on the use or distribution of that material in writing.

Documents protected by law from public disclosure will not be disclosed if clearly marked with the word "Confidential" on each applicable page, with each confidential provision clearly identified. A mere list of confidential pages will not suffice to meet this requirement. Requests to treat the entire proposal as confidential will be rejected and will result in no part of the proposal being treated as confidential.

2.13.4 Trade secrets may be marked as confidential only to the extent they meet the requirements of the California Uniform Trade Secrets Act (CUTSA). Only information claimed to be a trade secret at the time of submittal to CalOptima and marked as confidential will be treated as a trade secret.

2.14 Electronic Signature and Consent

Submission of any materials in response to this RFP constitutes:

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2.14.1 Consent to CalOptima’s release of such materials without notice to the person or entity submitting the materials; and

2.14.2 Complete waiver of all claims against CalOptima and its officers, agents, and employees that CalOptima has violated a proposer's right to privacy, disclosed trade secrets, or caused damage by allowing the proposal or materials to be inspected; and

2.14.3 Agreement to hold CalOptima harmless for release of such information; and

2.14.4 Acknowledgement that CalOptima will not assert any privileges that may exist on behalf of the person or entity submitting the materials.

SECTION 3 - PROPOSAL EVALUATION AND CONTRACT AWARD

3.1 Determination of Responsiveness

3.1.1 Each proposal will be reviewed to determine whether it conforms to the instructions set forth in this solicitation. CalOptima, in its sole discretion, may waive minor irregularities in submissions if it determines that there will be no advantage provided to the proposer, and no other proposer would suffer a disadvantage.

3.1.2 Failure to conform to any revisions in instructions or specifications may render a proposal non-responsive.

3.1.3 If a proposal is found non-responsive, CalOptima will notify the proposer, and the proposer will no longer be included in any activities or correspondence regarding the solicitation.

3.2 Proposal Evaluations

3.2.1 CalOptima will establish a committee to evaluate responsive proposals.

Evaluations will be based on the criteria specified in the RFP as well as information gathered from background checks, oral presentations, and CalOptima’s knowledge of the proposer.

3.2.2 After reviewing all responsive proposals, the evaluation committee may request clarifications and may recommend one or more top-ranked proposers for final negotiation of contract terms. Alternatively, CalOptima may invite top-scoring proposers for oral presentations, after which proposers may be allowed to amend their proposals and submit best and final offers. After final evaluations of proposals, presentations, and best and final offers, the evaluation committee may recommend one or more top-ranked proposers for final negotiation of contract terms.

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3.3 Determination of Responsibility

Prior to awarding a contract, CalOptima will make a determination of a proposer's responsibility based on initial information submitted in the proposal, information submitted upon request by CalOptima, information resulting from CalOptima’s inquiry of proposer's references and investigations into the proposer’s background, and CalOptima’s own knowledge of the proposer. CalOptima will take into consideration matters such as the proposer’s integrity, compliance with public policy, record of past performance, and financial and technical resources. Proposers determined to be non-responsible and who cannot be made to be responsible within timelines set by CalOptima will not be considered further.

3.4 Contract Award

3.4.1 Award, if made, will be to the responsive, responsible firm that the evaluation committee concludes offering the best value to CalOptima for the services and goods described in this solicitation, or if applicable, for a specific portion of the services and goods described. Failure to award a contract to lowest cost proposer will not constitute a valid cause of action against CalOptima.

3.4.2 Debriefings, if requested, will only be provided after contract award.

3.5 Post Award Requirements

If selected for award, the selected consultant or contractor may be required to provide various forms and disclosures before a contract can be executed. Examples of requested forms and disclosures may include:

3.5.1 Forms

A. Insurance certificates as outlined in the contract or PO if not already provided;

B. W9 signed within the previous 6 months.

3.5.2 Disclosures

A. All pending litigation and tax liens;

B. Any criminal charges where the company and/or officers, and/or owners of over 10% of the company are defendants regarding the charges;

C. Audited financial statements for the past three fiscal years, if requested;

D. Samples, drawings, illustrations, and related items.

3.5.3 Staff agreements

If the work requires access to documents and materials that are confidential or unavailable to the general public, CalOptima may require execution of a non-disclosure or similar agreement prior to providing access to such materials. The

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selected proposer will be required to collect, store, and maintain such signed agreements for all staff that will have access to such materials.

SECTION 4 - PROPOSAL CONTENTS AND FORMAT

Proposals should demonstrate the experience, capacity, training, knowledge, and skills necessary to successfully perform the work described in this solicitation. The information may include: the financial capacity of the firm, the staff size, staff licenses and experience, competing demands on the resources of the firm and the individuals, and any other information that would enable CalOptima to make a fair assessment of a proposer’s suitability.

Submit proposals in the following order. Number all pages.

4.1 Experience and Organizational Capability

4.1.1 Experience

Provide a summary of experience providing similar services, demonstrating the experience and capacity necessary to successfully perform the services required by this RFP. Include examples, descriptions of work completed, and outcomes, if known.

4.1.2 Organizational Capacity

Provide evidence of adequate human, organizational, technical, and professional resources and abilities to meet the needs of this solicitation. Include an organizational chart for the organization responding to this solicitation and describe the organization’s expertise and capability to complete the proposed work.

4.1.3 Key Personnel

If certain individuals are essential to the proposed work, they will be considered Key Personnel. Include their resumes, a description of their past work related to proposed services, and proposed role on the project team for the duration of the engagement. If CalOptima accepts the proposal, Key Personnel may not be replaced without CalOptima’s approval and no substitutes may be made unless CalOptima accepts the substitute as substantially equivalent.

4.2 Proposed Services

4.2.1 Describe the services to be provided and a work plan for delivering the services.

As applicable, include a detailed breakdown and description of the specific steps that will be followed to perform the services required by this RFP. Proposers may elect to include in this section any innovative methods or concepts that might be beneficial to CalOptima if the requirements established in this RFP are met.

Include a proposed schedule for the completion of the services and the deliverables, including the start and end dates and intermediate delivery dates.

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4.2.2 List the types of documents, materials, and resources required from CalOptima for completion of the services described in the RFP.

4.3 References

Identify three public agencies in California for which your organization completed deployments. These agencies must be part of the CalPERS retirement system and also have a 9/80 workweek available to their employees. Include the name, title, email address, and telephone number of the person at the client organization who is most knowledgeable about the work. Ensure that the information is current and accurate because if references cannot be contacted, the proposal may be rejected. If contractually prohibited from disclosing a client, include sufficient detail regarding the work and the size of the organization to provide a demonstrated record of success in similar engagements.

4.4 Supplemental Services (optional)

List any related and recommended products or services not specified in this RFP that may be offered and that CalOptima might consider.

4.5 Supplementary Documents

As applicable, provide additional documents and materials in the following order:

4.5.1 Minimum Qualifications, using CalOptima forms if provided

4.5.2 Financial Documents, if requested.

4.5.3 Samples, drawings, illustrations and related items.

4.5.4 If this is a solicitation for Information Technology related goods and services, and third-party items are included, provide the third-party software specifications, warranties, and sales terms.

4.6 Price

4.6.1 Include a price proposal for the services to be provided and the total price for all services, inclusive of time in hours for the completion of each task and items which are normally referred to as reimbursable expenses, i.e., travel, meals, and lodging. Reimbursement will not be made for out of pocket or reimbursable expenses, which must be included in the total price. This total price will be used in determining scores for evaluation purposes.

4.6.2 If including any optional services or products, price and label such services or products as optional, and include those in an addendum. These optional services or products will not be used to evaluate the proposal or price.

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4.6.3 If providing a combination of software and services, indicate whether software is proprietary or from a third-party. If software requires a separate purchase or agreement by CalOptima, if known, provide the price of the software for the duration of the contract; if unknown, provide an estimated price.

4.7 Required Forms (Attached)

4.7.1 Authorized Signatures

4.7.2 Price Proposal Form

4.7.3 Levine Act documentation

4.7.4 Audit and Legal Questionnaire

SECTION 5 - PROTESTS

Protests that do not comply with the protest procedures outlined below will be rejected.

5.1 Protest Eligibility

5.1.1 Protests or objections may be filed regarding the procurement process, solicitation or addenda content, or contract award.

5.1.2 CalOptima will review only protests submitted by actual or prospective proposers and bidders. Protests by actual or prospective subcontractors will be rejected.

5.2 Protest Deadlines

File protests with any supplemental materials by 5 p.m. PST, as appropriate, on the deadlines set forth below. Failure to file by the relevant deadline constitutes a waiver of any protest on those grounds. Supplemental protest materials filed after the relevant deadline will not be considered unless CalOptima determines that there are extenuating circumstances.

5.2.1 If relating to the content of the solicitation or an addendum, file within five business days after the date CalOptima releases the solicitation or addendum.

5.2.2 If relating to contract award, file within five business days following CalOptima’s announcement of the proposer selected, which announcement may be made by a public posting or by direct notice to proposers.

5.2.3 The date of filing is the date CalOptima receives the protest, unless received after 5 p.m. PST or on a CalOptima non-business day, in which case the date of filing will be the next business day.

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5.3 Protest Contents

5.3.1 Submit protests in writing to the Designated Point of Contact. Include all of the following:

A. Detailed grounds for the protest, supported with technical data, documentary evidence, names of witnesses, and other pertinent information related to the subject being protested; and

B. The law, rule, regulation, or policy upon which the protest is based, alleging a clear violation of a specific law, rule, regulation, or policy; and

C. If applicable, identification of any proprietary or confidential material, which must be indicated by stating on the front page of the protest document that proprietary material is included and identifying the alleged proprietary information wherever it appears within the protest documents.

5.3.2 Protest documents will not be withheld from any interested party outside of CalOptima unless withholding the information is required by law or regulation.

Identifying either the entire contents or the majority of contents of a protest as proprietary or confidential will result in no part of the protest being treated as proprietary or confidential by CalOptima.

SECTION 6 - PROPOSER CERTIFICATIONS

By submitting a proposal, each proposer certifies that:

• Its submission is not the result of collusion or any other activity that would tend to directly or indirectly influence the selection process; and

• It is able or will be able to comply with all requirements of this solicitation at the time of contract award; and

• All required licenses, certificates and permits are or will be valid at the time of contract award and will be kept valid for the duration of the contract; and

• Neither proposer, its employees, nor any affiliated firm providing goods and services contemplated by this solicitation has prepared the plans, specifications, or requirements for this solicitation, or has any other actual or potential conflict of interest;

• It is unaware of any financial or economic interest of any public officer or employee of CalOptima relating to this solicitation; and

• It is not presently debarred or declared ineligible for award of a contract by any federal agency or from participating in any federal healthcare programs.

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SCOPE OF WORK

6.1 BACKGROUND SUMMARY

CalOptima Health, a county-organized health system, is the largest health insurer in Orange County, offering health insurance plans for over 900,000 members, predominantly low-income children, adults, seniors and people with disabilities.

Insurance coverage is primarily offered through three programs: Medi-Cal, which is California’s Version of Medicaid, OneCare (Medicare Advantage) and PACE (Program of All-Inclusive Care for the Elderly).

CalOptima contracts with many health care providers, including doctors, specialists, pharmacies, hospitals, health networks, medical groups and other health care organizations, all of which provide services to CalOptima members and submit claims for payment to CalOptima.

CalOptima is issuing this RFP to cover two distinct service areas:

• Claims Payment and Communication Services (Part 1)

• Enterprise Print and Fulfillment Automation (Part 2)

Firms may submit proposals in response to Part 1, Part 2, or both. Each part addresses a distinct service area and will be evaluated separately. CalOptima may give additional consideration to proposals that address multiple service areas, and to proposals that demonstrate added value through operation efficiencies, cost savings, or integrated service delivery. Prior to commencement of services under any contract, an awarded contractor will be subject to an audit for compliance with federal and state flow-down requirements.

Currently, CalOptima uses a secure FTP site for print materials. This technology may change during the term of any resulting contract. All references to FTP in this RFP or any resulting contract will be interpreted to include any successor technology at no additional cost to CalOptima.

6.2 KEY TERMS

BCP: Business Continuity Plan

CASS: Coding Accuracy Support System

CMS: Centers for Medicare & Medicaid Services

DHCS: California Department of Health Care Services

DHHS: Department of Health and Human Services

DPV: Delivery Point Validation

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EFT: Electronic Funds Transfer

EOB: Explanation of Benefits

ERA: Electronic Remittance Advice, an electronic document insurance payers use to communicate payment information and claim adjudication details to healthcare providers

FTP: File Transfer Protocol

HIPPA: Health Insurance Portability and Accountability Act

KPI: Key Performance Indicator

MICR: Magnetic Ink Character Recognition - a technology that helps verify the authenticity and clearing of paper-based documents, such as checks.

NCOA: National Change of Address - a database maintained by the United States Postal Service (USPS) that contains the change-of-address records

PGP: Pretty Good Privacy

PHI: Protected Health Information

PII: Personally Identifiable Information

PRA: Provider Remittance Advice

RA: Remittance Advice

SLA: Service Level Agreement

USPS: United States Postal Service

VDP: Variable Data Printing - a form of digital printing in which information from a database or external file enables various elements such as text, graphics, and images to be changed from one printed piece to the next without hindering the printing process.

6.3 SECTION 1 – PROVIDER CLAIMS PAYMENT AND COMMUNICATION SERVICES SOW

(PART 1)

6.3.1 OVERVIEW

CalOptima is seeking proposals from contractors with experience providing high-volume claims payments and communications to healthcare providers, CalOptima members, and other stakeholders in both electronic and paper formats. Work will include the secure printing, processing, and mailing of payments, checks, and related documents, as well as optional digital delivery and payment processing services.

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Our goals are to leverage the infrastructure of one or more contractors for cost-effective, scalable operations that will improve operational efficiency, reduce internal staff burdens, and enhance the customer experience through accurate, timely, and secure delivery of printed and electronic payment-related documents.

The ideal proposal would offer a system that:

• Outsources provider claims payment and communication services

• Ensures compliance with regulatory and data security requirements

• Integrates with CalOptima’s existing claims adjudication and accounting systems

• Improves delivery timeliness and customer satisfaction through measurable KPIs (e.g., 99% on-time document delivery)

CalOptima will transmit PGP-encrypted print files containing claims communication data, review and approval templates, file formats, and operational configurations; will handle internal sign-off of high-dollar checks when applicable; and will provide contacts for system integration, data mapping, and project management. Delivery of a complete system, or any component, will not be considered complete until CalOptima has provided written final acceptance of the complete system or component.

The successful proposer will have experience in high-volume healthcare payment processing and the ability to handle 4+ million remittance records annually as well as a secure infrastructure for PHI, PII, and financial data management.

6.3.2 Processing and Mailing Services

The selected contractor will be responsible for processing and mailing payments, which will include the following tasks:

A. Decrypting, parsing, and importing data into the contractor’s payment system;

B. Accepting secure data files (e.g., EOB, checks, remittances);

C. Delivering payment claims for services rendered to the health-care providers who submitted the claims;

D. Merging and formatting documents using approved CalOptima templates and business rules;

E. Processing and delivering documents electronically or via print to providers and members. Documents may include:

i Electronic Fund Transfers, Electronic Payment Cards (eCards), or checks with MICR encoding;

ii Explanations of Benefits;

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iii Provider Remittance Advice in standard 835 ERA and CalOptima’s proprietary layout;

iv Notices of Payment Adjustment or Denials

F. Identifying and parsing out payments in excess of a certain threshold for secondary level review and/or signature that includes mailing paper checks back to the business.

6.3.3 Document distribution and oversight controls

The proposed system must be able to do the following:

A. Generate positive pay and other banking files

B. Prepare and distribute documents and checks electronically and/or by mail via USPS (First-Class or Certified Mail, with tracking and return-to-sender options as needed);

C. Ensure delivery within two business days of file receipts from CalOptima;

D. Provide print and mailed date response files in layout defined by CalOptima for each check file completed;

E. Provide audit controls for special handling, high-dollar payments;

F. Automate copy arrangements and distribution of check copies including audit parameters;

G. Detect fraudulent payments and perform sanction monitoring;

H. Manage mailing year-end 1099s and supplement CalOptima’s 1099 data where needed;

I. Summarize and distribute payment data appropriately;

J. Provide document storage and retention as required;

K. Regenerate Remittance Advice documents for a specified data range;

L. Securely store PHI, PII, and bank or credit information;

M. Securely handle checks and check stock with fraud prevention controls;

N. Put checks and EOBS into envelopes using secure dual-window envelopes or customized formats.

6.3.4 System Integration

The system will be required to

A. Ensure compatibility with CalOptima’s claims adjudication proprietary output files;

B. Map payment data to CalOptima’s Remittance Advice templates;

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C. Collaborate with U.S. Bank, (CalOptima’s current bank) on system configuration.

6.3.5 Testing & Go-Live

A. Conduct full end-to-end prior to go-live;

B. Support agreed-upon integration and implementation timelines.

6.3.6 Operations & Delivery

A. Provide a portal for CalOptima to:

i Approve, prioritize, and manage outgoing files and batch runs;

ii Configure and schedule special runs and ad hoc file processing;

iii View delivery status, run logs, exception alerts, and address validation results;

iv Access reports, audit logs, and archived documents on demand.

B. Return printed materials to CalOptima as requested or necessary.

i Checks $25,000.00 and over ii Checks to providers named in the Federal Government’s Terrorist Watch List

6.3.7 Reporting & Support

A. Generate detailed data and process reports for each payment run;

B. Provide end-user training and reference guides;

C. Offer live, ongoing customer support;

D. Manage year-end 1099 reporting and distribution.

6.3.8 Disaster Recovery & Business Continuity Plan

A. Maintain storage and backup of all critical data, including encrypted print files, remittance advice, payment reports and audit logs.

B. Provide a documented business continuity plan, outlining how essential services would continue during and after a major disruption

6.3.9 Current Average Volume

The following statistics are based on historical data and are provided for information only; actual numbers may vary.

• Two standard claims financial processes per week

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• Three to five special ad hoc claims financial processes per month

• For the prior 6 months:

o Printed checks: 510,727 o Bank ACH files: 172,684 o 835 AHC payments: 3,267,028

• Total RA (including non-payment): 4,427,100

• (Average page count: 17 – range 1 to 100+ pages per proprietary RA)

6.3.10 Implementation Project Management

Project management tasks will include the following at a minimum:

A. Producing a detailed Project Work Breakdown Structure (WBS) Plan

B. Managing the project plan

C. Organizing and attending weekly project meetings

D. Logging, tracking, and resolving risks, issues, actions, and decisions

6.3.11 Comprehensive Test Strategy and Plan

The proposed system must be able to pass CalOptima IT security vulnerability tests and may be required to demonstrate a disaster recovery event prior to final deployment.

Required tasks and deliverables will include at a minimum:

A. Test Strategy

B. Test Use Cases and Scripts

C. Test Execution

D. Defect Management and Resolution

6.3.12 Deliverables

• Receipt and Mail File Confirmation report

• Weekly and monthly transaction summary reports

• Quarterly audit and compliance reports

• SLA performance reports (e.g., turnaround time, error rates)

• Integration and implementation documentations

• 1099 processing outputs and summary files

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• Web portal access, training materials and reference documentation

• Disaster Recovery Plan

• Weekly status reports

• Monthly Executive Status Reports

6.3.13 Evaluation Criteria

Proposals will be evaluated on the following criteria.

• Experience of proposer and team members with public health management organizations, specifically in California, with electronic payment methods and provider adoption of electronic payments,

• Proposed approach, including technology and equipment, automation, tracking features, data security and privacy protocols, disaster recovery methodology, electronic payment delivery options, ability to deploy quickly

• Proposal clarity, breadth of coverage

• Price

6.4 SECTION 2 – ENTERPRISE PRINT AND FULFILLMENT AUTOMATION SOW (PART2)

6.4.1 Overview

CalOptima is seeking proposals for providing routine and ad-hoc print and fulfillment services. The services will include printing, managing, storing, packaging, addressing, and distributing materials to be handled by the United States Postal Service or other carriers, as well as producing PDF conversions of select Variable Data Printing (VDP) components and delivering these to CalOptima for archiving. Work will include preparing and filling mailers that include several pieces, as well as inventory management of stored CalOptima materials. The contractor must be a certified USPS Full Service Provider able to provide an attestation of such certification at CalOptima’s request.

Currently, CalOptima produces different types of material and mails multiple pieces that vary in complexity and that must be delivered within specific time frames that will include set-up and delivery. Services may be ordered in any quantities at any time. Prior to executing a contract, CalOptima will review disaster recovery procedures and processes to ensure uninterrupted service.

6.4.2 Required Services

Services will include all of the following:

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A. Print, sort, and distribute documents by language and program;

B. Manage quality, printing costs, mail costs, and inventories needed to process CalOptima’s requirements in a timely manner;

C. Comply with rules of regulatory environment in which CalOptima operates, with the ability to manage and safeguard PHI and destroy material containing PHI as CalOptima may instruct;

D. Maintain a quality control system and the ability to stay current on industry regulations and standards;

E. Produce materials in several fonts, including Times New Roman, Arial, Noto Sans, Noto Serif, Gulim, and Batang’

F. Provide printed material with text in CalOptima’s eight “threshold” languages of English, Spanish, Vietnamese, Farsi, Korean, Arabic, Russian and Chinese. During the course of the contract, other languages may be added at no additional charge to CalOptima’

G. Expedite proofs when needed;

H. Provide overtime and weekend printing, fulfillment and direct mail requests as needed for “rush” projects;

I. Provide secured bins and shredders for documents containing PII and other protected and confidential information and shred printing errors and overruns at no additional cost to CalOptima;

J. Provide appropriate kitting and storage of materials;

K. Provide all required inserting, cutting, sealing, perforations, folding and labeling (pressure) materials such as brochures, letters, flyers, posters, newsletters, booklets, postcards, gift cards and promotional items.

6.4.3 Project Orders

A. Projects will be assigned as needed. Not all projects are foreseeable and many projects may occur unexpectedly but require quick turnaround. For every project order issued by CalOptima, the contractor will be expected to i Provide proofs within 48 hours of receiving an order and within 24 hours for orders designated as “rush” by CalOptima, ii Provide a timeline for each project, stating when art files and data are required from CalOptima to meet the required delivery or drop date;

iii Provide a quote and lead time Within 48 hours of CalOptima approving proofs;

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iv Pick up or provide additional material needed for fulfillment and mailing services; and v Print, mail and deliver materials as requested.

B. Notify CalOptima’s Vendor Management immediately if a project requires additional costs for any of the services. Any additional costs must be approved by CalOptima in writing prior to the commencement of any work associated with the additional costs.

C. Price quotes must include all direct and indirect costs, project specifications, accounting services, administrative fees, print overruns, packaging and freight (Destination Freight Prepaid).

D. Notify CalOptima of any reason for the delay to provide a bid within the required turnaround time.

E. Prior to acceptance of “Rush” orders, provide various shipping options and their respective prices.

6.4.4 Print Requirements

A. Provide print-on-demand, high volume duplicating, offset printing and/or web press services, and photocopying (various sizes, quantities, weights, media, image types, duplexing and finishes). All of the following will be required:

i Black and white digital print and photocopying ii Full color digital and photocopying iii Spot color printing iv 4 color process printing v Black and white Variable Data Print vi Full-color Variable Data Print vii Print from electronic files via digital interface viii Binding and finishing services, including specialized finishing (saddle stitch, perfect bind, coil, foam core mounting, laminating, etc.)

ix Graphic design services, including minor text changes and preparation of die line x Camera matching xi Large Format Printing

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B. CalOptima will provide artwork as camera-ready or in electronic format (e.g., InDesign, PDF, etc.) print ready. It will be the contractor’s responsibility to ensure that press specifications are communicated and that artwork received is in a camera ready or PDF print ready to the contractor’s specifications.

C. Copies must be of quality equal to the original camera-ready copy.

D. All new projects require a PDF, contact or paper proof.

E. Provide print proofs for all new static and reprint art files provided by CalOptima within 24 hours or within the agreed upon time.

F. Submit proofs by email or CalOptima’s secure FTP site, as directed. If requested, submit hard copy proofs.

G. A proof must be approved in writing by a CalOptima authorized personnel prior to the actual production of any job.

H. On occasion, CalOptima may perform an on-site press check.

I. CalOptima will not accept or be responsible for payment of over or under runs. All spoilage must be factored into the price quote.

J. Deliver three samples of each version printed materials to CalOptima following the completion of each project.

6.4.5 Variable Data Printing (VDP)

A. Materials may contain both static and VDP components. VDP components include ID cards, selection forms and letters. Data fields on VDP components may include member name, ID number and birth date.

Some VDP components are produced using existing static shells, such as ID cards and selection forms. Other VDP components are produced entirely, such as letters. VDP components are simplex and duplex, are printed on a variety of paper sizes and are produced in all CalOptima threshold languages.

B. VDP components may be transactional and may change at any time. The contractor will:

i Process data files to determine whether VDP components are required, gather artwork and/or static shells (when necessary) to create VDP components.

ii Produce simplex and duplex VDP components.

iii Produce VDP components in all required paper sizes.

iv Produce VDP components in all CalOptima threshold languages, including current and future languages.

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v At CalOptima’s request, securely destroy VDP components within 24 hours from the date of the request.

C. VDP components may contain multiple records per component. For example, one packet may contain four Health Information forms and four member ID cards printed on one ID card shell. Contractor will identify members in the same family (Family Link IDs) and generate packets based on predetermined set-up specified by CalOptima.

6.4.6 Fulfillment and Direct Mail

CalOptima has a variety of mailing configurations, which may include folding and inserting one letter into an envelope, inserting multiple pieces, match mail, and segregation based on criteria, such as primary language or program. The contractor must have extensive, updated knowledge of the USPS mailing regulations for any piece that CalOptima designs for mailing, and must be able to process bulk quantities of certified mail. All files are to be transmitted to CalOptima via FTP or secure email, as directed by CalOptima.

A. Contractor will prepare and process CalOptima’s mailing using bulk mail methods to receive a reduce postage rate.

B. Data files must be processed using a USPS certification program to determine valid addresses and accuracy. The contractor may not change or modify a mailing address without CalOptima’s approval.

C. Coding Accuracy Support System and Delivery Point Validation:

i Contractor will conduct CASS certification and DPV processing and must verify the accuracy and validate the addresses for all mailing lists submitted by CalOptima.

ii Deliver to CalOptima a report detailing all invalid entries or rejects found on each original list provided by CalOptima.

D. CalOptima’s data files are processed through NCOA monthly. CalOptima can provide a copy of the BCC Data Services Processing Certificate issued by BCC Software, LLC.

i Data files may not be processed through NCOA unless requested by CalOptima.

ii At the request of CalOptima, provide NCOA processing and update CalOptima data lists with the most current addresses. Deliver to CalOptima the NCOA results with each member’s Content Identifier Number (CIN) included on each original list provided by CalOptima.

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E. Providing the correct placement of the return address, indicia, bar code, etc. to ensure that CalOptima receives the most competitive postal rates and adheres to the USPS mailing regulations.

F. Allow CalOptima the use of contractor’s U.S. Postal indicia at no additional cost to, and maintain a postage escrow account.

G. Data Files must be sent via secured email or may be posted to CalOptima’s secure FTP site. Contractor may retrieve and process data files in text (tab-delimited, text (fixed width) and Microsoft Excel formats.

H. If requested by CalOptima, determine the outcome of each record, create a validation file and post validation files to CalOptima’s secure FTP site or submit by email, as directed.

I. A mailing proof (i.e. fan out, live) must be approved by CalOptima authorized personnel prior to the actual fulfillment of a job and/or mail drop at the USPS.

J. At no cost to CalOptima, provide copies of mailing documents in a PDF file upon request. Testing of PDF files may be requested prior to final submission.

K. Provide a copy of the USPS 3602, 3602-R, 3600-FCM receipt, metered reports/receipts, if applicable and/or any other form of mailing confirmation following the completion of direct mail.

6.4.7 Material and Inventory (If applicable)

A. Projects may require multiple drops and may require inventory of items.

These may include static material, books or promotional items. Provide costs associated with the following:

i Storage of material produced and supplied by CalOptima or a 3rd party contractor.

ii A minimum of one yearly physical inventory of any CalOptima material.

iii Providing CalOptima with online access to CalOptima’s “real time” inventory report.

B. All unused product must be returned to CalOptima, or if applicable, returned to stock within 48 hours after job completion, at no cost to CalOptima. CalOptima materials may be destroyed only after receiving written authorization to do so by CalOptima.

C. Upon request from CalOptima, provide a usage report for individual static inventory items including version control. Re-order points may be updated at any time.

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D. Upon request from CalOptima, provide a usage report for individual packets mailed by language.

6.4.8 Daily Packet Fulfillment

A. CalOptima’s daily packet programs include programming, data processing, VDP, PDF, fulfillment services, inventory management, bulk mail services, tracking and reporting of the stages of the fulfillment and mailing process, and producing PDFs for archiving.

B. During the course of a contract, CalOptima may add or remove or make changes to packet mailings.

C. Orders will be provided by an executed CalOptima Purchase Order (PO), Term Purchase Order (TPO), a release issued against a Blanket Purchase Order (BPO), or, an email by CalOptima’s Vendor Management department. In all cases, only Purchase Orders issued by CalOptima’s Vendor Management department are valid.

D. No verbal modifications to print, fulfilment, direct mail or delivery specifications will be valid. Valid modifications must be in the form of written notice by CalOptima’s Vendor Management department.

E. CalOptima is required by Federal and State regulators to mail packets within certain time frames. Contractor must meet the following Service Level Agreements regarding the various parts of CalOptima’s daily packet program.

6.4.9 Member Communications Packets

A. All member packets defined by CalOptima as CMS and DHCS-regulated programs must be processed and delivered to USPS within 1 business day from the time CalOptima posts the file to the FTP site.

B. SLA requirements are based on the following mailing quantities for the Medi-Cal line of business. Time for SLA will begin from the time CalOptima posts the file to the FTP site.

i Up to 20,000 mailing…