40DHHS-S3392-VOC Scope of Work.docx

40DHHS-S3392 SCOPE OF WORK

A. PROJECT PURPOSE

1. Project Purpose. In accordance with NRS 217.010, the State is authorized to provide assistance with medical expenses and related expenses to individuals who are victims of violent crime within the State of Nevada. The Division of Child and Family Services (DCFS) seeks a vendor to provide services for the review and processing of claims.

2. Project Timeline. The selected vendor may be asked to begin work either October 14, 2025, May 1, 2026, or July 1, 2026 depending on responses.

B. PROJECT REQUIREMENTS

1. Records Management Software System for DCFS and Vendor Staff Use. Provide electronic records management of victims' files. Use includes but may not be limited to create/view victim client files, maintain provider information, organize documents, review claims, update claim statuses, send communications, record notes, manage payment information, search, apply multiple levels of approval for transactions, and run robust dynamic/ad hoc and template data reports. DCFS staff should be able to assign system access, access levels, and terminate user access.

2. Application Receipt and Review. Receive victims’ applications and backup documentation from victims and providers, allowing for a variety of submission formats to accommodate victims’ situations. Review applications for eligibility, allowability, and completion. Establish victim client file. Notification to DCFS staff of new applications.

3. Claims Review and Bill Negotiation. Provide claims and medical billing review for allowability, errors, fraud, waste, and abuse. Contact providers to request additional documentation as needed. Answer provider questions. Negotiate with insurance companies and providers.

a. Examples of allowable costs include medical/hospital, dental, vision, physical therapy, counseling, chiropractic, ambulance, bio-hazard cleanup, funeral expenses, relocation allowance, and lost wages

b. Review must include checks for:

1. Allowable costs

2. Adherence to fee schedule

3. Miscoding

4. Unnecessary treatment

5. Excessive treatment

6. Bundling/unbundling/re-bundling

7. Allowable treatment

8. Duplicate payments

9. Drugs/supplies allowances (based on National Drug Code fee schedule)

c. An Explanation of Benefits statement must be produced to demonstrate allowable charges and any reductions taken.

4. Payment Processing. Process and issue payments.

a. Provide the means for authorized users to process payments to individuals/providers through a variety of methods (paper, electronic payment transfer, etc.).

b. Prevent payments from exceeding authorized levels established by the State. As levels may change throughout a fiscal year due to program funding, the system must also be able to dynamically accept changes in payment levels for processing future claims as well as being able to project the effect of such changes on the current claims inventory. For example, tier 3 payments shall be held pending funding availability.

c. Payment batches must be able to be segregated for processing by tier and payment type to enable prioritization.

d. Monitor and prevent duplicate payments. Correct as needed.

e. Allow for two levels of DCFS approval on each payment. The system must allow authorized users to suspend or make exception payments on a case-by-case basis and provide a means to document the reasons for exception.

f. At all times during the payment process, users must be able to view all supporting documents and claim information.

g. The system must provide DCFS staff with the ability to schedule payments based on available funding. Scheduling must be allowed based on bill type and/or service dates. The system must also permit the Program to reduce payments by selected percentages based on bill type and/or service dates.

h. The system must track and provide reporting on all subrogation payments received. A Breen Formula calculator must be built into the system that allows users to determine appropriate subrogation payment amounts. Calculated results should be stored in the system to provide documentation for review by Administrators.

i. Vendor must maintain a Treasury Management account at a bank selected by the State Treasurer’s Office for the purposes of payment issuance. Reconcile account monthly and provide detailed reporting to the Administrative Services Division. Reports must include payments cleared, payments outstanding and payments voided.

j. Process stop payments as required.

k. Check printing and mailing services are required. All payments approved by the Program are to be mailed each week. Positive pay files must be uploaded to the bank Treasury Management System each week

5. Communications. Send standard and customized communications to victims and providers. Communications must be recorded in the victims’ electronic records. Example communications subjects include claim approvals/denials, subrogation, closure, document requests, claim status, etc.

6. Reporting. Provide DCFS staff with regular reports both through the software system and analyses. Reports may be requested by the State at any time and the awarded vendor shall provide such reports within five (5) working days.

a. Analysis reporting topics may include:

1. Cost analyses of funding saved through negotiations

2. Costs of time invested in negotiations to determine return on investment and effectiveness

3. Statistical reporting demonstrating adherence to management performance standards

4. Management reporting demonstrating compliance with program policies

5. Financial reporting on all aspects of payment processing

b. Software system reporting should Provide DCFS staff with the ability to

1. Run template and ad hoc reports for the data contained in the software system

2. Run data backups for the entire system

3. Customize reports and report templates as federal and state reporting requirements change

4. Example reports include information such as the number of claims processed for each type of crime within a fiscal year or calendar year, applications and payment totals on victim demographics, crime type, tier payment priority, and county which the crime occurred as well as the total dollars paid by category

7. Personnel Services and Liaison with DCFS. A full-time position should be assigned to work directly with DCFS staff and do the following:

a. Day-to-day review of claims processing and payments

b. Flag all exceptions to program policies

c. Calculation of funds available for payment processing

d. Creation of quarterly and annual reports

e. Interface with State and Federal Auditors

f. Attend periodic DCFS operational meetings

g. Respond to questions, concerns, and requests for program system changes

h. Assist DCFS staff with the design and implementation of electronic and paper forms

C. TRANSITIONAL SERVICES

1. Conversion. Lead and complete a successful conversion of existing program data and implementation of chosen vendor system within 90 days of acceptance of contract.

2. Training. Provide training to DCFS staff members online or at the individual office locations (Reno, Carson City and Las Vegas). All travel, training and support costs are to be included in the proposal and are limited to reimbursement in accordance with GSA rates.

D. OPTIONAL SERVICES

1. Optional Services. The State is seeking best value in this solicitation. Vendors may propose services and features above and beyond the scope of this RFP to enhance the end product. Creativity is encouraged. The following describe optional services the State desires. Vendors may respond to these services and/or propose other services.

2. Apps. Apps compatible with smart phones for victim, DCFS staff, and/or provider access to portals

3. Provider Panel or Related Option

a. Managed Care Organization(s) affiliated with the vendor, which will help maximize savings potential. The Provider Panel may consist of multi-specialty physicians and hospitals that can provide quality care at very competitive prices. This allows the option of processing medical bills locally in Nevada or on-site at the agency.

b. Provide at a minimum a monthly report accounting for savings realized for the Managed Care component. Review of savings will occur without prior notification to the awarded vendor.

c. Obtain and maintain W-9’s for all vendors/providers. Manage and maintain all vendor entries into the software system. Produce and mail all required year-end tax forms as required by IRS regulations. Responsible for electronic filing of tax information. Responsible for compliance with all IRS reporting regulations, including research and corrections on B-Notices.

E. RESPONDING TO THIS RFP

a. Response Requirements. Provide information regarding approach to meeting the project requirements, including visual examples that will allow the State to best understand what is being offered

b. Identify what items, if any, in this RFP are not included in the Vendor proposal

c. If subcontractors are anticipated to be used for any of the tasks, indicate what tasks and the percentage of time subcontractor(s) are expected to spend on those tasks

d. Responses should not exceed 25 pages (not including visual examples)

e. Implementation timelines must be clearly outlined in vendor’s response

f. Proposals should include information regarding architecture, security, and implementation of software systems

g. Proposals must include a description of the billing personnel to be used for this project. Billing personnel must be knowledgeable in medical terminology (e.g. ICD-9, CPT, RVS codes), and have extensive billing expertise in workers’ compensation. Data processing/information technology professionals must be able to adapt the existing bill audit process (hardware and software) to meet State requirements. Proposals shall include evidence of the above qualifications for billing personnel, and data processing/information technology professionals respectively.

2. Presentation. Following proposal scoring, higher scoring vendors will be invited to present to the evaluation committee.

d. Presentations should be 30 minutes or less with 30 minutes reserved for introductions and Q&A for a total meeting time of 60 minutes.

e. The State will provide an Internet connection, laptop, and display screen if vendors elect to present with these tools.

f. Ideal presentations will provide the State with a clear understanding of what the vendor intends to provide, with a focus on

1) The step-by-step process from application to payment

2) The software system’s look, feel, functionality, and features the vendor is capable of providing.

40DHHS-S3392 Page 1 of 1 Scope of Work