41NHA-S3818 SOWs Final 06.08.26.docx

SCOPE OF WORK

1. General Program and Enterprise Requirements

2. Third Party Liability (TPL)

3. Managed Care TPL Data Exchange and Evaluation

4. Managed Care Secondary Recovery

5. Recovery Audit Contracting (RAC)

6. Medicaid Estate Recovery (MER)

7. Subrogation and Casualty Reduction

8. Cost Avoidance

9. Health Insurance Premium Payment (HIPP)

1. SCOPE OF WORK – GENERAL PROGRAM AND ENTERPRISE REQUIREMENTS

General program and enterprise requirements apply to all Scopes of Work within this Request for Proposal (RFP), as listed above.

General Requirements

Vendor shall be required to adapt to changes to the programs after implementation. Vendor shall be responsible for making necessary changes that are in line with NVHA, state and federal policy, and legal mandates that affect programs under NVHA, i.e., changes to documentation requirements, the supply of additional supporting documentation if needed, adjustments to program activity that may arise due to the State Plan changes.

Any changes shall be completed within 30 calendar days.

Vendor shall report to NVHA the process for managing complaints regarding Vendor action, inaction, or software issues. Vendor shall describe in detail how they shall present complaints from third parties, i.e., recipients, providers, other agencies and/or persons to NVHA staff.

This process shall be outlined and delivered to NVHA within 30 calendar days of contract implementation.

Vendor shall provide NVHA with requested reports needed to ensure funding, including but not limited to the facts and figures for federally mandated reporting, Centers for Medicare and Medicaid Services (CMS) reporting, etc.

Vendor shall provide NVHA with any special reporting requests. Due to time-sensitivity, these reports shall be submitted to NVHA within 10 calendar days following the date of request.

Vendor shall have the ability to interface with the Nevada interChange Medicaid Management Information System (MMIS), as well as maintain the required computing system requirements to complete necessary tasks within the system.

Vendor shall have the ability to accept files from other sources and connections to the Federal Data Services Hub (FDSH).

Vendor shall maintain a comprehensive database of insurers and insureds for the Nevada Medicaid population. This shall include information on recipients such as recipient identification numbers, names, potential TPL coverage, date of birth, and additional relevant data.

Vendor shall maintain a receivables system and access to NVHA’s state banking lockbox. NVHA shall work with the awarded Vendor to ensure access. Access to data from this lockbox shall be maintained by specified Vendor staff at all points during the contract period.

For any reports contained in this RFP that do not have an attachment specifying an expected layout, Vendor shall be responsible for collaborating with NVHA to develop the report layout within 30 days of contract implementation.

NVHA reserves the right to direct Vendor to amend or update any Report in accordance with the best interests of the State and at no cost to NVHA. Amendments or updates may be required prior to or after implementation.

Vendor shall determine which file transfers (inbound and outbound) shall be necessary in order to complete the requirements found in this RFP. This evaluation shall be completed within 60 days of contract implementation.

Vendor shall provide NVHA workflows for each area in the RFP within 30 days prior to the start of the contract.

Vendor shall provide NVHA with a Standard Operating Procedure Manual for each area in the RFP within 30 days prior to the start of the contract for review and approval and annually thereafter, on the contract date.

Fiscal Requirements

Vendor shall maintain an accounting system and employ accounting procedures and practices that conform to generally accepted accounting principles and standards. All charges applicable to the resulting contract shall be readily ascertainable from such records. Vendor shall be required to submit monthly and annual performance reports as outlined in the Deliverables Schedule to NVHA or within 30 days of an Ad Hoc report request by NVHA. See RFP Section 2.6 – Potential TPL Ad Hoc Report Requests for list of potential TPL Ad Hoc report requests.

NVHA shall establish the lockbox and maintain ownership of that lockbox. NVHA shall give the necessary access needed for Vendor to complete functions found within the scopes of work.

Vendor shall deposit checks received as a result of this contract into an established State of Nevada account within 24 hours of the receipt of funds.

Vendor shall submit a digital itemized report of deposits accompanied by copies of deposit slips, check copies, and bank receipts to NVHA on a daily basis.

Vendor shall ensure that the bank forwards all deposit records to Vendor. Vendor shall retain these deposit records, check copies, and supply digital copies to NVHA staff upon request.

Vendor shall use lockboxes designated by NVHA for receipt of payments from payors. Vendor shall instruct payors to send funds to appropriately designated lockboxes dependent on the program the collection is for. Vendor shall use the following lockbox protocols:

Vendor shall utilize NVHA designated address on all billings submitted to health care payors and specify that funds are to be made payable to NVHA.

Vendor shall ensure that NVHA is furnished with a bank statement for the lock box upon NVHA request, which shows all the activity in the lock box account during that month. This statement shall identify all check transfers, deposits and interest accrual.

Vendor shall ensure that the bank sends remittance correspondence to Vendor for posting to its accounts receivable (A/R) system. Where possible, this information shall be received in electronic format, ensuring that no keying errors occur in the process of posting to the A/R system. Vendor shall maintain stringent controls over its A/R system claim adjudication process.

Vendor shall notify and require that providers, TPL and other paying parties send corresponding Explanation of Benefits (EOB) and payment data to Vendor at the time payment is submitted to the lockbox.

Vendor shall electronically transfer gross recoveries directly to an account designated by NVHA on a basis as required by NVHA.

It is the responsibility of Vendor to maintain and otherwise back up corresponding claims data in support of this requirement. All recoveries shall be accompanied by the corresponding claims associated with the collection to substantiate rightful ownership of the monies to NVHA.

Vendor shall disposition claims (i.e. apply money to a billing or a claim in MMIS) when funds are received, and post EOB denials or receipt of recovery, to the appropriate accounts receivable, within 10 business days of receiving the necessary claim data.

Completed dispositioning of the claims using claim data in MMIS system shall be completed within 30 days of receipt of the collection (i.e., check, money order, wire) by Vendor. Vendor shall disposition or refund any payments by the end of the current fiscal year.

Fees associated with these collection activities shall be based on recoveries actually dispositioned in MMIS. Payment from NVHA is only owed once a check has been fully dispositioned in the system by Vendor.

Monies received that do not have identified claim details, or that are not proven to be owed to NVHA by the 30-day threshold, shall be refunded to the payor at no cost to NVHA.

Refunds shall be completed within 30 calendar days from the date of deposit. If Vendor is unable to complete a refund within the 30-day timeframe, the refund shall be forwarded by the 35th day to NVHA Recoveries team to post. Vendor shall be responsible for tracking the refund compliance. Refunds shall be approved by NVHA before being sent.

Vendor shall be responsible for maintaining auditable records regarding the issued refunds.

Vendor shall utilize an automated A/R system to provide accurate information regarding claims status for a claim billed to a third-party health care payor and provide financial and management reporting. The A/R system shall maintain individual, claim specific records on each claim billed by Vendor, thus ensuring that, for every claim submitted to a third party, Vendor can certify that either payment or a denial of payment has been received.

After Vendor bills claims, it shall monitor adjudication through the claims tracking portion of its automated A/R system. To ensure maximum recovery and the proper and complete disposition of each claim, it shall follow up on unprocessed claims to obtain the adjudication status of all billed claims. Rejected claims shall be analyzed, corrected, and resubmitted until it is deemed that all claims have been correctly paid or processed.

Vendor shall allow sufficient access of its A/R system to NVHA to ensure that it can research the status or history of request for payment from a third-party payor.

The A/R system shall provide key project statistics to complete monthly project status workload reports and Ad Hoc reports requested by NVHA.

The A/R system shall produce managerial reports used by Vendor to ensure quality control of all output.

The A/R system shall provide a comprehensive audit trail for all transactions associated with claims billed by Vendor. All activity on each claim shall be recorded, and all updates to the claim shall be shown, together with the identifying code of the employee who updated the record.

Vendor shall provide a reconcilable accounting of all transactions, processes and reports.

Vendor Accounting Requirements

Payments related to the Contract shall not be made payable to Vendor.

Vendor shall not accept as payment any tender other than check, cashier’s check, treasurer’s check, wire, ACH, or money order.

Any acceptance of installment payments shall be approved in advance by NVHA.

Vendor shall be responsible for depositing and ensuring the deposit of all funds in relation to the Contract.

Vendor shall deposit funds only into State approved accounts within 24 hours of receipt.

Vendor shall restrictively endorse all payments upon receipt as appropriate.

Vendor shall make every effort to determine if a payment pertains to any scope of work resulting from this contract and deposit appropriately.

Vendor shall notify NVHA of any payment that does not appear to be related to the contract and proceed as instructed by NVHA.

Payments not yet deposited shall be stored in a secure location by Vendor.

Payments not deposited by the end of the business day shall be logged by Vendor. This log shall be submitted to NVHA for review as appropriate at the end of each business day, by 5:00 PM (PST).

NVHA reserves the right to direct Vendor to amend or update its payment hold log in accordance with the best interests of the State and at no cost to NVHA. Amendments or updates may be required prior to or after implementation.

Vendor shall generate and submit to NVHA all required data files and forms necessary to post payment amounts to MMIS if needed.

If there is no deposit for a particular business day, Vendor shall notify NVHA via e- mail.

As identified above, Vendor shall submit a digital itemized report of deposits accompanied by copies of deposit slips, check copies, and bank receipts to NVHA on a daily basis. This itemized report shall include the following information at a minimum:

Scope of work activity resulting in payment (i.e. Subrogation, RAC, TPL, Secondary Recovery, etc.)

Date check received Deposit date Deposit number Check date Check number Check amount Payor Case number (if applicable) Other information as required by NVHA

The daily accounting report shall be submitted to NVHA for review and approval no later than 5:00 P.M. PST as appropriate each business day.

NVHA reserves the right to direct Vendor to amend or update its daily accounting report in accordance with the best interests of the State and at no cost to NVHA. Amendments or updates may be required prior to or after implementation.

Vendor shall submit to NVHA a monthly report of all accounting activities that includes recovery totals for each applicable scope of work.

The monthly accounting report shall include the following information at a minimum:

Scope of work activity that resulted in payment Date check received Deposit date Deposit number Check date Check number Check amount Payor Case number (if applicable) and/or Claim IDs Medicaid recipient last name

Medicaid recipient first name Medicaid recipient number Explanation of payment (e.g., full, partial, provider refund, carrier payment, etc.)

Date of notification to third party that an amount was owed Last claim paid date, if applicable Associated daughter/mother claim if applicable Other information as required by NVHA

The monthly accounting report shall be submitted to NVHA for review and approval no later than 5:00 P.M. PST on the first business day following month end for the given data.

NVHA reserves the right to direct Vendor to amend or update its monthly accounting report in accordance with the best interests of the State and at no cost to NVHA. Amendments or updates may be required prior to or after implementation.

Standard Requirements

Vendor shall comply with the following. Refer to RFP Attachment – Vendor Recovery and Recoup Checklist pertaining to this Section 1.4 Standard Requirements. Vendor shall review and complete each section and submit response with Vendor proposal.

Vendor shall conduct all required components resulting from this RFP in accordance with NVHA timeframes and established Federal and State standards.

Vendor shall pay for all expenses incurred as a result of the performance of services under contract resulting from this RFP. NVHA shall not be charged for any expenses Vendor incurs.

Vendor shall agree that NVHA will not be charged for any additional costs incurred by Vendor, outside of the negotiated contract, for implementation costs for any RFP component.

Vendor shall agree that NVHA is not be responsible for providing administrative, technical, legal or clerical assistance to Vendor except as otherwise provided herein.

Vendor shall cooperate fully with other vendors, consultants, or other parties that are approved by NVHA.

Vendor shall follow through and log all NVHA referrals and assignments in an appropriate, professional, and timely manner.

Vendor shall perform all services and maintain systems supporting this Contract exclusively within the United States. Vendor shall not permit any portion of the services or supporting systems to be maintained outside the United States unless expressly approved in advance and in writing by NVHA.

Vendor shall disclose the locations of hosted environments, operational support functions, subcontractor services, and workforce locations supporting this Contract upon request by NVHA.

Enterprise Security and Compliance

Vendor shall maintain and operate all systems, infrastructure, applications, and services supporting this Contract in accordance with applicable Federal and State laws, regulations, and NVHA security requirements, including HIPAA and applicable Nevada privacy and security statutes.

Vendor shall implement and maintain administrative, technical, and physical safeguards aligned to nationally recognized standards, including NIST SP 800-53 or equivalent industry frameworks appropriate to the services provided under this Contract.

Vendor security controls shall include, at a minimum:

Role-based access controls and least privilege access principles Multi-factor authentication for privileged and remote access Logging, monitoring, and audit trail capabilities Secure configuration and vulnerability management processes Network and system protections designed to prevent unauthorized access Workforce security and annual security/privacy awareness training

Vendor shall maintain systems and infrastructure sufficient to support all operational, reporting, audit, and data exchange requirements associated with this Contract and shall ensure such systems remain scalable, supportable, and secure throughout the contract term.

Vendor shall provide the following documentation prior to implementation or access to NVHA data and shall update such documentation at least annually, or upon significant system, operational, or security-related changes:

Security System Plan (SSP) Risk Management Plan and associated risk assessment and risk treatment methodologies Incident Response Plan (IRP) Business Continuity and Disaster Recovery documentation (BC/DR) Workforce security and privacy training documentation Change management documentation and procedures Vulnerability management documentation and procedures Independent security assessment reports, such as SOC 2 Type II or HITRUST assessments, where applicable Additional security, compliance, operational, or technical documentation reasonably requested by NVHA related to systems, subcontractors, hosted environments, operational support functions, or services supporting this contract.

Vendor shall notify NVHA within 24 hours of discovery of any confirmed or suspected:

Security incident Unauthorized disclosure of protected or confidential information Significant operational failure Material compliance issue Vendor error that may impact contractual services, data integrity, system operations, reporting, or security obligations.

Vendor shall fully cooperate with NVHA regarding investigation, mitigation, remediation, corrective actions, and reporting activities associated with such event.

Vendor shall ensure all subcontractors, hosted environments, and third-party services supporting this Contract are subject to equivalent security and privacy requirements.

All systems containing NVHA data shall maintain appropriate safeguards to protect the confidentiality, integrity, and availability of information entrusted to Vendor under this Contract.

Vendor shall submit to NVHA’s Privacy Officer, a monthly report, by the 10th of each month of all incidents whereby PHI may have been released inappropriately.

Enterprise Data Governance and Data Quality Requirements

Vendor shall comply with NVHA enterprise data governance, data quality, and information management requirements for all systems, interfaces, reporting, and deliverables associated with this Contract.

Vendor shall implement and maintain data management practices designed to ensure the accuracy, completeness, consistency, integrity, availability, and timeliness of all data processed, stored, transmitted, or reported under this Contract.

Vendor shall ensure data quality management practices align with applicable Federal and State information quality requirements and support the accuracy, integrity, reliability, and usability of data used for operational, financial, reporting, audit, and program integrity purposes.

Vendor responsibilities shall include, at a minimum:

Enforcement of NVHA-approved data governance policies and standards;

Data quality monitoring and correction processes Maintenance of data dictionaries, metadata, interface specifications, and related technical documentation Identification, tracking, and remediation of incomplete, inaccurate, duplicate, or corrupt data Auditability and traceability of data modifications and system transactions Collaborate with NVHA regarding data quality improvement initiatives and reporting requirements.

Vendor shall maintain systems and processes capable of supporting secure data exchange, standardized reporting, and interoperability with NVHA systems, MMIS, and other approved entities.

Vendor proposed solutions shall include sufficient data validation, quality assurance, reconciliation, and review capabilities to prevent the introduction of inaccurate or incomplete information into NVHA systems.

Vendor shall provide NVHA access to data, technical documentation, audit trails, and supporting records necessary for oversight, reporting, compliance review, auditing, or operational support purposes.

Data Ownership, Access, and Exchange Requirements

Vendor shall support the collection, exchange, storage, access, retention, and transmission of all information necessary to perform services under this Contract in accordance with applicable Enterprise Requirements.

Vendor shall acknowledge all data created, received, maintained, processed, transmitted, stored, or otherwise managed under this Contract, including but not limited to recipient information, case management information, operational records, and program data, shall remain the property of the State of Nevada. Vendor shall have no ownership or proprietary rights to such data and shall provide authorized NVHA personnel with appropriate access to systems, records, databases, audit trails, and supporting information necessary for operational oversight, auditing, compliance review, reporting, reconciliation, transition activities, investigations, or other authorized governmental purposes.

Vendor shall use NVHA information solely for purposes authorized under this Contract and shall not disclose, share, sell, mine, commercially exploit, or otherwise use data outside the scope of authorized contractual activities.

Vendor shall not publish, disclose, distribute, commercialize, benchmark, or otherwise use NVHA information, statistics, or data for purposes outside the scope of authorized contractual activities without prior written approval from NVHA.

Vendor shall not permit any offshore performance of work involving protected health information (PHI), confidential information, recipient data, case management information, operational records, personally identifiable information, tax information, security information, logs, metadata, or other sensitive Nevada Medicaid information without prior written approval from NVHA.

Vendor shall prohibit offshore access to protected information by contractors, subcontractors, affiliates, workforce members, employees, consultants, call center personnel, technical support personnel, system administrators, developers, analysts, service providers, or other third parties unless expressly authorized in advance and in writing by NVHA.

Vendor shall perform services and maintain systems supporting this Contract within the United States unless expressively approved in advance and in writing by NVHA.

Vendor shall disclose the locations of hosted environments, operational support functions, subcontractor services, and workforce locations supporting this Contract upon request by NVHA.

Vendor shall remain fully responsible for ensuring all subcontractors, downstream service providers, hosted environments, and operational support functions comply with all contractual privacy, security, confidentiality, and data protection obligations.

Vendor shall provide NVHA with timely access to data, records, reports, audit trails, and supporting documentation necessary for operational oversight, auditing, compliance review, reporting, reconciliation, transition activities, or other authorized governmental purposes.

Vendor shall maintain appropriate retention, archival, retrieval, and destruction processes consistent with applicable Federal and State requirements and NVHA policies.

Vendor shall support standardized and interoperable electronic data exchange with NVHA, MMIS, Managed Care Organizations (MCOs), contractors, and other approved entities as required for performance of contractual obligations.

Vendor shall return or securely destroy NVHA data in accordance with NVHA instructions and applicable legal and regulatory requirements upon contract termination or request by NVHA.

Technical and System Operational Requirements

Vendor shall provide and maintain systems, applications, infrastructure, interfaces, and operational support necessary to perform all services required under this Contract.

Vendor systems shall:

Support interoperability and data exchange with NVHA, MMIS, MCOs, and other approved entities Support scalable operations, projected workload increases, and future program expansion Maintain sufficient availability, reliability, and performance to support operational and reporting requirements Support auditability, reporting, reconciliation, and transaction traceability Support configurable workflows, reporting, and operational processing functions necessary to meet program requirements.

Vendor shall maintain appropriate technical documentation, interface specifications, file layouts, operational procedures, and system support processes necessary to support ongoing operations and integration activities.

Vendor shall maintain security, risk management, and workforce training practices consistent with applicable Enterprise Security Requirements and associated deliverables.

Vendor shall notify NVHA in advance of significant system changes, interface modifications, hosting changes, or other material operational changes that may impact services, integrations, reporting, or security posture.

Vendor shall notify NVHA within 24 hours of discovery of:

Actual or projected operational backlogs Service delivery failures Processing delays Staffing shortages System outages

Other conditions that may materially impact contractual performance, operational timelines, reporting obligations, or service levels.

Vendor shall provide NVHA with:

Nature and scope of the issue;

Affected operational areas;

Estimated impact;

Corrective action plan;

Estimated resolution timeline.

Vendor shall cooperate with NVHA regarding mitigation, remediation, operational prioritization, and ongoing status reporting until resolution.

Vendor shall ensure all hosted environments, cloud services, subcontractor-supported systems, and technical components supporting this Contract remain compliant with applicable Enterprise Requirements defined elsewhere in this RFP.

Planning and Administration Requirements

Vendor shall ensure that adequate planning and project management are dedicated to the contract resulting from this RFP as follows:

Appoint a Project Manager to support the State Project Management Office in coordinating the activities of all individuals and organizations involved in the project by requiring Vendor to select and identify the Project Manager when responding to this RFP.

Have the Project Manager assist in providing on-going direction and oversight to the State project staff and report progress and problems to the stakeholders. The Project Manager shall coordinate all organizations involved in the project and ensure resource requirements are identified and addressed.

Document all key assumptions that could impact scope, timelines, resources, or decision-making to ensure clarity for all stakeholders in an effort to reduce potential risk during implementation.

Work with the State to provide a detailed project plan with fixed deadlines to include, but not be limited to:

Project schedule including tasks, activities, activity duration, resource assignment, sequencing and dependencies Project work plan for each deliverable, including a work breakdown structure Completion date of each task Project milestones Entrance and exit criteria for specific project milestones Project organization including a resource plan defining roles and responsibilities for Vendor, subcontractors (if applicable) and State.

Vendor shall facilitate, attend, and participate in all project-related meetings requested by the State at a location to be determined by the State.

Attendance may be in person or via teleconferencing, as mutually agreed to by the project team. These meetings shall follow an agenda mutually developed by Vendor and the State. Vendor shall prepare materials or briefings for these meetings as requested by the State. Minutes shall be taken and distributed by Vendor staff within five working days after the meeting. Minutes may be distributed via email.

The agenda may include, but not be limited to:

Review and approval of previous meeting minutes Contractor project status State project status Contract status and issues, including resolutions Quality Assurance status Decision, risk, and issues reporting Mitigation planning New action items Outstanding action items, including resolutions Setting of next meeting date Other business

Vendor shall provide written project status reports delivered to State project management monthly, within five working days following the first day of each month. The format shall be approved by the State prior to issuance of the first monthly project status report. The status reports shall include, but not be limited to the following:

Overall completion status of the project in terms of the State approved project work plan and deliverable schedule;

Status of Earned Value Management Measures including Schedule Performance Index, Cost Performance Index, or other appropriate measures;

Accomplishments during the period, including State staff/stakeholders interviewed, meetings held, Joint Application Development sessions and conclusions/decisions determined;

Problems encountered and proposed/actual resolutions;

What shall be accomplished during the next reporting period;

Status of Risks and Issues that need to be addressed, including contractual;

Quality Assurance status;

Updated MS Project timeline showing percentage completed, tasks assigned, completed and remaining;

Identification of schedule slippage and strategy for resolution;

Contractor staff assigned and their location/schedule;

State resources required for activities during the next time period;

Resource allocation percentages including planned versus actual by project milestone. Include any known Resource Constraints.

Vendor shall develop and submit to the State for approval within 30 business days of the contract effective date, a comprehensive communication plan describing the approach used for handling communications with both internal and external audiences. Effective communication is critical to the development of productive relationships with concerned stakeholders. The communication plan shall include but not be limited to a plan for generation, documentation, storage, transmission and disposal of all project information.

Vendor shall develop and submit to the State for approval within 30 business days of the contract effective date, a risk management plan to ensure that risks and issues are identified, planned for, analyzed, communicated and acted upon effectively.

Vendor shall develop and submit to the State for approval within 30 business days of the contract effective date, a quality assurance plan including, but not limited to, the methodology for maintaining quality of the code, workmanship, test plan including testing strategy, training plan (if applicable) project schedules and subcontractor(s) activities.

Vendor shall develop and submit to the State for approval within 30 business days of the contract effective date, a Change Management Plan and Control Procedures and present it to the State for acceptance. This plan shall be used by Vendor and the State in the design, specification, construction, implementation and support of the system.

Vendor shall collaborate with the State to develop an approach to a Lessons Learned Document to be submitted to the State for approval at the completion of the project.

The State shall perform a Post Implementation Evaluation Review (PIER) approximately six months after full implementation and State acceptance of all deliverables. Vendor's Project Manager shall be required to participate on site for a period of not to exceed three days.

Privacy and Regulatory Compliance Requirements

Vendor shall comply with all applicable Federal and State privacy, confidentiality, information protection laws, regulations, and requirements related to information accessed, created, received, maintained, transmitted, or processed under this Contract, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA) and applicable Nevada statutes and regulations.

Vendor shall use NVHA information solely for purposes authorized under this Contract and shall limit access to information based upon authorized business need and least privilege principles.

Vendor shall ensure workforce members and subcontractors with access to protected, confidential, or sensitive information receive appropriate privacy, confidentiality, and security training consistent with applicable legal, regulatory, and contractual requirements.

Vendor shall cooperate with NVHA regarding privacy inquiries, audits, investigations, compliance reviews, and other oversight activities associated with this Contract.

Where applicable, Vendor shall execute and comply with required privacy, confidentiality, and data-sharing agreements, including Business Associate Agreements (BAAs), prior to accessing protected information.

Vendor shall prohibit use of NVHA information for product development, artificial intelligence model training, data aggregation, benchmarking, marketing, or other secondary purposes unless expressly authorized in writing by NVHA.

Encryption Requirements

Vendor shall protect all protected, confidential, sensitive, or regulated information transmitted, processed, or stored under this Contract using industry-standard encryption and data protection practices consistent with applicable laws, regulations, State policies, and Enterprise Security Requirements.

Vendor shall align encryption methodologies and associated key management practices with current industry standards and applicable NVHA requirements.

Vendor shall ensure electronic transmission methods used for exchanging protected information with NVHA are appropriately secured and approved for such use.

Data Conversion and Transition Requirements

Vendor shall support all data conversion, migration, transition, and implementation activities necessary to ensure continuity of operations under the Contract.

If required by NVHA, Vendor shall facilitate the transfer, conversion, validation, and accessibility of historical case data, operational records, and associated system information necessary to continue program operations.

Vendor shall support conversion and accessibility of no less than ten (10) years of historical case data within the implemented solution unless otherwise approved by NVHA.

Converted data and associated case management functionality shall be operational and accessible by the mutually agreed upon implementation date established in the approved implementation and transition plan.

Vendor shall cooperate with NVHA, incumbent vendors, Fiscal Agents, MMIS operations, and other approved entities necessary to support successful transition and implementation activities.

Penalties Requirements

All penalties and fees assessed to Vendor on behalf of NVHA shall be seen as a reduction in payment on Vendor’s invoice.

In circumstances where Vendor is not invoicing or an invoice is not available to reduce, Vendor shall submit a check to NVHA for payment of any outstanding penalties and charges by the 10th of any month following the month in which a penalty or charge has been assessed.

Failure to provide a functioning operational solution containing the required converted data by the approved implementation date may result in a penalty of $5,000 per day until the deficiency is resolved, unless otherwise approved by NVHA in writing.

Improper Pricing Requirements

Vendor shall ensure that all prices proposed for all projects are accurate and consistent with the terms of the contract.

For all projects completed under this contract, if Vendor submits an invoice containing incorrect pricing in favor of Vendor, Vendor shall submit a new, corrected invoice within five calendar days from the original due date with a 35% reduction in cost for each incorrectly priced item.

If Vendor continues to provide incorrect invoicing, NVHA has the option to cancel their contract in its entirety without penalty.

Vendor shall not be allowed to aggregate fees into contract after award has been made. Failure to comply may be grounds for cancellation.

If Vendor makes unrequested and/or unapproved changes to file formatting, this shall result in $25.00 penalty per file.

Performance Requirements

Vendor may be subjected to a 25% hold back on each invoice based on the viability, correctness, and timeliness of data as indicated below:

Holdback funds for viability and correctness below shall be released upon Vendor submission of corrections and upon acceptance of those corrections by NVHA.

Viability – data shall be delivered in a format as described in each scope of work Correctness – data shall be free of errors and provide accurate information.

Timeliness – data shall be delivered per requirements within each scope of work. For any item with a timeline not identified within the scope of work, data shall be supplied within 10 working days of initial request. Failure to provide data within the specific timeframe shall result in a 10% holdback being forfeited.

Scheduled deliverables not received timely shall be subjected to a $500.00 per day penalty.

Deliverables

Vendor shall be responsible for providing the following deliverables detailed below, including documentation supporting the collection of funds and summary documents needed for reporting and accounting.

1.1.1 If issues are found within the submitted documentation, such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours.

1.1.2 Vendor shall work with NVHA to determine file layouts for all deliverables.

1.1.3 NVHA reserves the right to direct Vendor to amend or update all Reports in accordance with the best interest of the state and at no cost to NVHA.

1.1.4 Invoices are required to have all corresponding documents submitted in excel or CSV format.

Program and Enterprise Requirements Deliverables Schedule – Planning and Administration

1. Vendor shall perform due diligence and furnish any supplementary deliverables needed to ensure successful implementation of the solution/system.

2. SCOPE OF WORK – THIRD PARTY LIABILITY (TPL)

Federal law sets forth State obligations in 42 CFR 433.135 – 154 to identify and pursue recovery from any individual, entity, or public or private program that is or may be liable to pay all or part of the medical assistance provided on behalf of a recipient. The Medicaid and Children’s Health Insurance Program (CHIP), by law, is intended to be the payer of last resort. All other available resources shall be exhausted before the Medicaid and CHIP programs pay for the care of an individual eligible for Medicaid and/or CHIP.

Program Evaluation

This scope of work has several important components in addition to the identification and collection of TPL related payments. These additional components include required assessment meetings to evaluate the program and increase program efficiency. As such, Vendor shall be expected to:

Vendor shall attend quarterly assessment meetings with the State to evaluate the effectiveness and deficiencies of the work plan in regard to this scope of work and formulate any revisions and amendments to the plan as necessary to ensure the accomplishment of the activities outlined in this scope.

Vendor shall develop a plan that describes the review standards to be used, desk and field review approaches, peer or professional review approaches, capacity of reviews typically handled by Vendor during a specific time frame, and templates of typical review reports. The work plan shall include operating procedures related to case tracking, reporting, and record retention.

Vendor shall ensure the plan addresses Vendor’s commitment to complete all reviews that may be ongoing and extend past the contract’s expiration and/or termination date.

Vendor shall use accepted and valid accounting, analytical, statistical, or peer-review methods, or combinations thereof to make the determination of improper payment. Therefore, the plan shall describe Vendor’s principal methodologies to be considered in making determinations of magnitude of improper payment. The plan shall also include specifics to address Vendor’s ability and approaches to provide expert witness support at the State’s administrative hearing and/or in court.

Vendor shall deliver routine recommendations and justifications of methodology for selection of claims and recipients to be reviewed for TPL.

Vendor shall deliver a routine tracking instrument to track and report volume, category, reason, potential exposure of improper payment, status, finding, recoupment and disposition of new, open and closed reviews, and review documents monthly, quarterly, and annually. The tracking instrument shall include the backlog of cases. The State shall have access to this tracking system.

Vendor shall deliver communications of review findings and reports both to other health care coverage (OHC) and the State and provide recommendations on resolutions of review disputes.

Data Matching Expectations

Vendor shall conduct payment reviews and evaluate Medicaid enrollees to determine the presence of a TPL. Vendor shall be expected to use recipient information gained from state systems in tandem with data retrieved from additional originations and entities to correctly match recipients with their OHC(s), including Medicare. Vendor shall use previously established and vetted data matching practices.

Vendor shall provide a Veterans Affairs benefits verification program. Vendor shall provide the cost avoidance that includes the identification of qualifying service members or Veterans who may meet the requirements for benefits through the Nevada Department of Veterans Services TPL Vendor shall conduct Medicaid enrollee reverifications monthly.

Review the Nevada resource file monthly and identify active policies (excluding Medicare policies) that have not been verified within the previous 12 months. Vendor shall then reverify the coverage information for such policies. If the policy is still active with no changes to the policy information, no change shall be made. If there is an update to the policy coverage information, Vendor shall submit an updated policy as part of its monthly delivery of the deliverable files to NVHA. If the policy was terminated, Vendor shall submit a termination record as part the monthly deliverable file to NVHA.

If Vendor is unable to obtain updated or terminated policy information due to incorrect/insufficient policy information available when verifying with the carrier as part of the reverification process, then Vendor shall terminate the policy by using the last cost avoided date.

NVHA shall reimburse per member verified and not by policy verified once in a 12-month period. All reverifications shall be noted in MMIS.

The State shall have all rights to use, disclose, or duplicate, for any purpose whatsoever, all data mining criteria, algorithm, computer routines, reports, and analyses developed, derived, documented, or furnished by Vendor as the result this contract.

To assist in the identification of TPL and confirm that recipient and their OHC(s) has been correctly identified, at a minimum, Vendor shall deliver or participate in the following activities:

Vendor shall initiate a comprehensive review process for claims submitted to health insurance carriers and Medicare to identify unpaid, non-adjudicated, denied and other groups of claims that appear most likely to be resolved and paid as a result of targeted follow up.

Vendor shall be expected to maintain and input data into an internal eligibility file based on data from insurance carriers and other available means. This data shall be uploaded by Vendor into MMIS unless another upload process is designated by NVHA.

Vendor shall conduct eligibility data matches utilizing Medicaid enrollment data and comparing that data to the comprehensive eligibility file.

Vendor shall identify Medicaid clients who also have coverage from another source as identified through data matches conducted with its comprehensive data eligibility file.

Vendor shall employ multiple approaches to verifying health care coverage and obtaining policy-specific information from payors to ensure additional coverage is identified in the course of the data match process.