6300 RFP for TPA Amendment 1 Final.pdf

RFP: S-29100-00011086 – Third Party Administrator and Provider Network Services for Off-Site Healthcare Amendment #1

RFP NO: S-29100-00011086 – THIRD PARTY

ADMINISTRATOR AND PROVIDER NETWORK FOR OFF-SITE

HEALTHCARE – AMENDMENT #1

SECTION 1: PURPOSE

The purpose of this Amendment #1 is to provide clarification as to what the Oregon Department of Corrections (DOC) is requiring in the RFP, to remove a form that is no longer in use, and to correct some incorrect references.

SECTION 2: MODIFICATIONS

The RFP and related Attachments are amended as follows (with new language indicated by bold underlined font and deleted language indicated by strikethrough font):

2.1 The RFP Cover page is hereby amended as follows:

Opening Date and Time: October 9, 2024 October 25, 2024, at 2:00 PM

2.2 Page 3, List of Attachments, is hereby amended as follows:

LIST OF ATTACHMENTS

ATTACHMENT A: SAMPLE CONTRACT

ATTACHMENT B: DISCLOSURE EXEMPTION AFFIDAVIT

ATTACHMENT C: PROPOSER INFORMATION AND CERTIFICATION SHEET

ATTACHMENT D: RESERVED

ATTACHMENT E: COST PROPOSAL FORM

ATTACHMENT F: COBID CERTIFICATION / OUTREACH PLAN

ATTACHMENT G: RESPONSIBILITY INQUIRY

ATTACHMENT H: TOTAL EXTERNAL COST COMPARISON

ATTACHMENT I: EXTERNAL COST DISTRIBUTION BY LOCATION AND MONTH

ATTACHMENT J: DOC HEALTH REFERRAL OUTSIDE AGENCY RESERVED

ATTACHMENT K: TECHNOLOGY REQUIREMENTS

ATTACHMENT L: GENERAL INFORMATION QUESTIONNAIRE

ATTACHMENT M: NOTICE OF INTENT TO PARTICIPATE

2.3. RFP Section 1.1, second paragraph only, is hereby amended as follows:

It is ODOC’s expectation that a Contract will be executed with the apparent successful Proposer no later than January 1, 2025, and that claims administration services will begin no later than March 1, 2024 2025. The current cost of Services, including cost of

RFP: S-29100-00011086 – Third Party Administrator and Provider Network Services for Off-Site Healthcare

AIC healthcare and contractor administration fees, is approximately $2,500,000 per month.

2.4. RFP Section 1.2, Schedule, is hereby amended as follows:

The table below represents a tentative schedule of events. All times are listed in Pacific Time. All dates listed are subject to change. N/A denotes that event is not applicable to this RFP.

Event Date Time

Pre-Proposal Conference August 23, 2024 10:00 AM

Questions / Requests for Clarification Due August 30, 2024 2:00 PM

Answers to Questions / Requests for Clarification Issued (2pprox..)

September 6, 2024

RFP Protest Period Ends

7 calendar days prior to RFP Opening

Opening (Proposal Due) See RFP cover page

Opening of Proposal October 9, 2024 October 25, 2024

2:00 PM

Presentations, Demonstrations, or Interviews TBD

Issuance of Notice of Intent to Award (approx..)

October 30, 2024 November 15, Award Protest Period Ends 7 calendar days after Notice of Intent to Award

2.5. RFP Section 2.3.2, Project Overview and Background, On-Site Healthcare Services, 4th paragraph only, is hereby amended as follows:

All pre-authorizations and treatment plans will be established and authorized by ODOC.

There is a Therapeutic Levels of Care (TLC) Committee for ODOC Institutions located on the east side of the State and a similar committee for those located on the west side.

Both committees meet twice each month and review a total of 30 to 40 On-site and Off-site cases per meeting. Both TLC Committees include physicians and a care coordinator LPN or RN who review the chronic On-site and Off-site cases. ODOC resources also include approximately 630 Health Services staff comprised of pharmacists, radiology technicians, physicians, nurses, and other healthcare professionals. Once Off-site care

RFP: S-29100-00011086 – Third Party Administrator and Provider Network Services for Off-Site Healthcare has been approved, an Oregon Department of Corrections Health Referral Outside Agency form (Attachment J) is completed.

2.6. RFP Section 2.4, Scope of Work, is hereby amended as follows:

2.4 Scope of Work

The successful Proposer will be responsible for paying all outside medical and dental providers including, but not limited to: specialists, surgeons, clinics, labs, imaging centers, and hospitals. The successful Proposer will also manage a limited amount of On- Site goods and services as described in Section 2.3.2, Project Overview and Background, On-site Healthcare Services, third paragraph. This responsibility will include tracking of AIC care, obtaining discounts on PPO and non-PPO services, looking for early hospital release opportunities, and providing innovative solutions to help save on global expenses including medical care, transport costs and security detail. Since AICs need transportation and security for all Off-site services, concurrent review and discharge planning should consider ODOC Institution availability. Claims need to be managed from beginning to end. This management involves eligibility determinations (including Medicaid eligibility as further described in Exhibit 1, Sample Contract, Attachment 2, Section B.1 Attachment A, Exhibit A, Section B.1), claims payment, partnering with ODOC on utilization management and enforcing ODOC healthcare decisions.

2.7. RFP Section 2.4.3 Billing Procedures and Reserves is hereby amended as follows:

2.4.3 Billing Procedures and Reserves

Please refer to Attachment A, Exhibit 2 Attachment A, Exhibit A, Section B.1, the Statement of Work.

2.8. RFP Section 2.4.5, Institution Pre-authorization / Concurrent Review / Utilization / Discharge Planning, last paragraph only, is hereby amended as follows:

A “Health Referral Outside Agency Form” (Attachment J) is completed each time an AIC requires Off-site services. The successful Proposer will receive copies of all ODOC Health Referral Forms which shall become part of the successful Proposer’s electronic claims file. Each approved Off-site case involving concurrent review or discharge planning will require special coordination between the ODOC Care Coordinator and the successful Proposer about the approved treatment. The successful Proposer will add this

RFP: S-29100-00011086 – Third Party Administrator and Provider Network Services for Off-Site Healthcare information to the electronic case file. The successful Proposer will have access to the ODOC attending physician when additional information is needed.

2.9. RFP Section 4.11, Point and Score Calculations, is hereby amended as follows:

4.11 Point and Score Calculations

Points are the total possible for each section as listed in the table below.

Price points are calculated as stated in Section 4.10.3, Price Evaluation.

2.10. Attachment A, Exhibit A, Section A.40 is hereby amended as follows:

40) “Provider Manual” shall refer to a manual containing written information that is necessary for Network Providers to meet Service expectations for this Contract.

RESERVED

2.11. Attachment A, Exhibit A, Section D.1.d is hereby amended as follows:

d) Training of Network Provider and DOC staff in the use of the Provider Manual, Provider Directory, including the managed care program and its components.

2.12. Attachment A, Exhibit A, Section D.3.c is hereby amended as follows:

c. Training and educating high-volume Network Providers and their supporting staff as necessary on the use of the Provider Manual and the Provider Directory.

Contractor shall:

i) Ensure that Network Providers receive necessary training prior to treating any

AIC, unless otherwise approved in writing by DOC.

ii) Provide updated training and Provider site visits as needed or as requested by

DOC.

2.13. Attachment A, Exhibit A, Section D.3.d is hereby amended as follows:

d) Training and educating DOC staff as requested by DOC on the use of the

Provider Manual, Provider Directory, and the managed care program and its components. During the initial roll out it, is expected that this training shall

TOTAL POINTS POSSIBLE : 624 740

POINTS POSSIBLE 524 640

4.10.2.1 Technology Requirements and Proposer Capabilities, Attachment K

4.10.2.2 General Information Questionnaire, Attachment L 424 540

4.10.3 PRICE POINTS POSSIBLE 100

RFP: S-29100-00011086 – Third Party Administrator and Provider Network Services for Off-Site Healthcare be done weekly until DOC is comfortable with the Contractor’s implementation. Contractor shall:

i) Provide initial training sessions on-site virtually at each of the following

Designated DOC Institutions:

• Santiam Correctional Facility/Oregon State Correctional Institution

(one combined session)

• Oregon State Penitentiary

• Columbia River Correctional Institution

• Coffee Creek Correctional Facility

• Deer Ridge Correctional Institution

• Eastern Oregon Correctional Institution

• Powder River Correctional Facility

• Snake River Correctional Institution

• Two Rivers Correctional Institution

• Warner Creek Correctional Facility

• All newly opened or reopened DOC Institutions

ii) Providing new DOC staff with similar training upon request by DOC and as needed. New staff training is not required to be on site shall be conducted virtually.

iii) Providing update training and Provider site virtual visits if necessary as determined by Contractor or by DOC.

2.14. Attachment A, Exhibit A, Section F.2.b is hereby amended as follows:

b) Contractor will provide virtual training at least quarterly, or as requested by DOC, to DOC staff and DOC-Contracted providers on the use of the criteria. Contractor shall periodically review and update the criteria and shall, with the exception of internal or proprietary quantitative thresholds for Utilization Management, and Contractor shall make criteria readily available upon request to both In-Network and Out-of-Network Providers.

2.15. Attachment A, Exhibit A, Section I.4 is hereby amended as follows:

4) MIS reports shall represent the topics which meet the data analysis requirements specified by DOC. These reports include, but are not limited to, Admits Detail for the month with 12 months of historical data; Biennium Claims Paid with 12 months of historical data; Total Claims paid for the month with 12 months of

RFP: S-29100-00011086 – Third Party Administrator and Provider Network Services for Off-Site Healthcare historical data; Clinical Reports based on disease states, inpatient trends, and outpatient trends; Clinical Classification (paid amount by clinical classifications); Emergency Ambulance (both air and ground) costs; ER

Frequent flyers; ER Trends; Financial Report; High Dollar Claimants; IBNR

Data; Non-Contracted providers; Outpatient Authorizations; and report of self injuries. The scope and nature of the individual reports can be changed or deleted by written mutual consent of the parties.

a) DOC shall identify standard Management Information System

Reports which Contractor shall produce and forward to DOC on a monthly basis (“Standard Reports”). Examples include but are not limited to: OHA

Claims, Standard Reports are due on or before the 20th calendar day of the month following the month reported. If the 20th calendar day is a Saturday, Sunday or holiday, the due date shall be the last business day before the

20th.

b) If Contractor anticipates the Standard Reports will not be delivered by the due date, Contractor shall provide DOC’s Contract Administrator written notice, including why the reports are delayed, when the reports will be delivered, and any actions to be taken to prevent late reporting in the future. When reports are not received or time frames are delayed more than

15 days, DOC may seek remedial action. Refinements, additions, or deletions to these reports by Contractor shall be at no cost to DOC.

Contractor shall provide DOC MIS reports electronically and in hard copy as requested by DOC.

c) Ad hoc reports, as requested. DOC may require Contractor to prepare and submit to DOC “one time” specialized reports on short time frames in order to meet DOC informational requirements. Report content and delivery requirements will be provided to Contractor in writing by DOC. Contractor shall provide reports electronically and in hard copy as requested by DOC. Contractor shall provide reports at no cost to DOC unless otherwise approved in advance in writing by the DOC Contract Administrator.

2.16. Attachment A, Exhibit A, Section L.1 is hereby amended as follows:

L. FINANCIAL STANDARDS AND REPORTING

1) Contractor shall maintain a formal accounting system for all funds related to this

Contract which complies with Cost Accounting Standards Board (CASB) Generally

Accepted Accounting Principles (GAAP) requirements, including internal audits to ensure proper monitoring in the areas of finance, financial accounting, internal controls, special checks, and history maintenance transactions for possible fraud and abuse, including but not limited to:

RFP: S-29100-00011086 – Third Party Administrator and Provider Network Services for Off-Site Healthcare

a) A log of all returned funds to ensure timely processing of credits to DOC and to facilitate the analysis of returned checks to determine any developing reasons or trends for the return of the checks.

b) Appropriate controls to ensure the separation of functions of Claims adjudication and accounting, including receipts and control of returned funds.

c) Adjustments to Claims that will result in funds being returned to DOC shall be accomplished through adjustment of future Claims submitted by providers, except at end of the Fiscal Year, adjustments will be returned to DOC.

d) Appropriate documentation of all adjustments and the reasons for those adjustments. In addition, Contractor will ensure timely update of the AIC’s history.

e) Contractor’s ADP system shall not issue a check for less than $1.00.

2.17. Attachment A, Exhibit G – Part 4 only is deleted in its entirety.

2.18. Attachment E, Part II – Optional “Alternative” Cost Proposal, is hereby amended as follows:

Provide a brief description below describing Proposer’s Alternate Cost Proposal

(if any) which Proposer may wish to submit for future consideration.

Alternative Cost Proposals are optional and will not be evaluated or assigned points as part of the initial RFP evaluation process. Alternate Cost Proposals may, however, be discussed if Proposer is invited for an interview. Optional Cost

Proposals submitted, if any, must include estimated total monthly cost to DOC based on an AIC population of 14,500 approximately 10,048, and detail as to how the estimate cost was calculated.

2.19. Attachment K, Section K.1, last paragraph only, is hereby amended as follows:

Please review Section IX of the Sample Contract Attachment A, Exhibit A, Section I for additional management information system information and requirements.

2.20. Attachment K, Section K.2.2, second paragraph only, is hereby amended as follows:

DOC is in need of requires the Contractor to provide an “Outside Appointment Predictor” (OAP). The two primary functions of the OAP are as an authorization system for Medical Services of AICs and to audit claim payments to Medical Providers. The OAP is a data entry system where future Medical Service is provided to an AIC. The information is logged and scheduled by DOC personnel. Reports are then generated to verify that the service was performed and/or authorized. Therefore, the ECP system should have the capabilities of scheduling appointments and treatments of AICs. The

RFP: S-29100-00011086 – Third Party Administrator and Provider Network Services for Off-Site Healthcare goal, but not a requirement, is that the Contractors’ ECP system will accommodate an Outside Appointment Predictor system.

2.21. Attachment L, Section L.1.4 ,is hereby amended as follows:

L.1.4 Number of years Proposer, as a company, has been in the business of supplying services of the nature described in the Scope of Work, RFP Section 3 2.4, and the Sample Contract - Statement of Work, including how many State of Oregon contracts and employees you serve?

2.22. Attachment L, Section L.1.10.b, is hereby amended as follows:

b) A brief description of responsibilities and qualifications for all Key Personnel, including liaison, network Account Manager and other proposed contractor staffing in Oregon (reference Attachment 2, Section V.C of the Sample Contract Attachment A, Exhibit A, Section E). Provide information that clearly demonstrates professional competence to perform the Work.

2.23. Attachment L, Section L.3.11, is hereby amended as follows:

L.3.11 Have you ever had to pay on a performance guarantee? If yes, provide details.

Please identify proposed Performance Guarantees in Section D.7 L.7.

2.24. Attachment L, Section L.3.14, is hereby amended as follows:

L.3.14 Describe how Proposer will ensure that data and information retained on the Electronic Claims Payment (ECP) system is secure from unauthorized use and mismanagement. Reference Technology Requirements Attachment F, Section F.1 Attachment K. Section K1.

2.25. Attachment L, Section L.3.18, is hereby amended as follows:

L.3.18 Medicaid Claims. Describe how Proposer would process Medical claims and how Proposer would meet Medicaid claim requirements described in Section II.A Attachment A, Exhibit A, Section B.1, “Medicaid Benefits”, of the Sample Contract.

Include how Proposer would meet all State and Federal required Medicaid-specific reporting requirements.

2.26. Attachment L, Section L.4.5, is hereby amended as follows:

L.4.5 Provide Proposer’s PPO Network growth goal projections for adding future providers. Describe how Proposer intends to meet the Performance Guarantees contained in Section X.B of the Sample Contract Attachment A, Exhibit A, Section J.2.

2.27. Attachment L, Section L.4.13, is hereby amended as follows:

RFP: S-29100-00011086 – Third Party Administrator and Provider Network Services for Off-Site Healthcare

L.4.13 Describe Proposer’s credentialing process for network and non-network providers and how it will meet requirements described in Section VII of the Sample

Contract Attachment A, Exhibit A, Section G.

2.28. Attachment L, Section L.5, Case Management ,is hereby amended as follows:

L.5 Case Management (100 points maximum)

Describe how your proposed case management program will meet requirements as described in Section 2.4.5 of this RFP and Section VI of the Sample Contract Attachment A, Exhibit A, Section F.

2.29. Attachment L, Section L.6, is hereby amended as follows:

L.6 Implementation and Transition Plan (50 maximum points)

If you are awarded the contract, provide an overview of how Proposer can meet or exceed all of the requirements identified in RFP Section 3 Section 2.4 and the Sample Contract (Exhibit 1) Statement of Work Attachment A, Exhibit A. Identify specific activities you will accomplish, and data/information needed from DOC prior to beginning claims administration services. Provide a description of how transition from current TPA contractor would be accomplished, including but not limited to meeting requirements described in Sections VIII.B.21 and X.C.3 of the Sample Contract Attachment A, Exhibit A, Sections H.2.s and J.3.C.

2.30. Attachment L, Section L.7, is hereby amended as follows:

L.7 Performance Measures and Guarantees (50 maximum points)

Section X.B of the Sample Contract Attachment A, Exhibit A, Section J.2 identifies performance measures and guarantees currently in effect. Please describe performance guarantees and measures Proposer offers to provide.

SECTION 3: PROTEST

Protests to this Amendment #1 must be submitted in the manner required in RFP sections

4.4.2 and 4.4.3 .