RFQ_75D301-22-Q-74251_QA1_12_23_2021.pdf

RFP# 75D301-22-Q-74251 g (WTCHP) Third Party Administrator (TPA) Support Q&A 1 - 12/23/2021

Question Number

RFQ

Reference

(if applicable) Question CDC Response

1 F.3 Proposal Evaluation and Phases Please confirm there will be a separate chance to ask questions about Phase II requirements after Down Select Notification.

No. Offerors are advised that no additional question and answer periods are anticipated for this solicitation.

F.4 Technical and Pricing Proposal Instructions Phase I Tasks/Volumes 1.a. Fundamental Capability Checklist

Are the additional comments limited to 100 words for each of the 9 questions or 100 words across the 9 questions? No more than 100 words for each question. See the amended solicitation at Section F.4.1.a.

4.3.3.2 Secure Self-Service Portal and

4.7.1 Secure Self-Service Portal

No text is provided under this heading. Are all requirements now under 4.7.1? Yes. See the amended solicitation. The heading for 4.3.3.2 is removed.

F.4 Technical and Pricing Proposal Instructions Phase II Proposal Components Technical Approach Oral Presentation

Will the Oral Presentation be conducted as a video conferencing event? Yes.

5 4.2.2.1 Change Control Process Should this be 4.2.1.1 in order to align under Section 4.2.1, Implementation of Contract Management Plan? Yes. See the amended solicitation. Change Control Process updated to Section 4.2.1.1.

F.4Technical and Pricing Proposal Instructions Phase I Tasks/Volumes 1b. Understanding of the Requirement and Overview of Risk Awareness and Risk Management Approach

ii. Provider Network Management

Item ii., Provider Network Management Approach, asks for the approach to managing the existing provider network, but also cites sections e4.5 (Medical Benefits Administration?) and e4.6 (Claims Processing?). Does the government expect us to address PWS elements 4.5 and 4.6 as part of Provider Network Management or are these to be separate sections?

The two sections are critically linked, and should be addressed in conjunction in each offeror's proposal.

F.4 Technical and Pricing Proposal Instructions Phase II Proposal Components Past Performance Questionnaires

Will the government accept a CPARS report in lieu of a Past/Present Performance Questionnaire submitted by the customer?

No. However, the Government is aware that completion and receipt of past performance questionnaires (PPQs) is not under the direct control of any offeror. In all cases, the Government reserves the right to gather and use recent and/or relevant past performance data from other sources including the Contractor Performance Assessment Reporting System (CPARS) and other Government databases.

B.3 Skills and Experience Requirements for Key Personnel;

4.7 Data and Business Information Management; and

D-2.22 CDCA_H009 Key Personnel

Section 4.7 indicates that "The Data and Analytics lead for the project shall be designated as 'Key Personnel'." Section B.3 and D-

2.22 do not include this position. Please confirm that the Data and Analytics Lead is required to be Key Personnel. Yes. See the amended solicitation at Sections B.3 and D-2.21.

9 Attachment E (Summary Volume Data)

For consistency in pricing assumptions, please provide a historic volume of paper claims received by the incumbent and/or a forecast of paper claims expected during this TPA Period of Performance?

YTD in 2021, we have received 32,884 paper claims (2740.3 average/month). This is less than 8% of our total claims received during the same time period. We expect similar (if not lower) numbers of paper claims during the TPA contract period of performance.

10 Attachment E (Summary Volume Data)

For consistency in pricing assumptions, please provide a high-level forecast of outgoing print and postage volumes for this TPA period of performance?

Based on data from the last three years, we expect approximately 4500 letters and 54 remits sent out per month, costing approximately $2350 and $48 per month, respectively. We expect similar volumes of outgoing mail during the TPA contract period of performance.

11 Attachment E (Summary Volume Data)

Please provide an hourly call volume distribution defined as the average number of daily calls per each hour of operation (i.e. 8am - 8:59am; 9am - 9:59 am) using data from the past 12 months?

YTD in 2021, we have received 246 calls a day on average. The hourly distribution per each hour of operation can be found below as a percentage of the daily calls:

08:00-08:59: 9.90% 09:00-09:59: 14.11% 10:00-10:59: 14.84% 11:00-11:59: 13.52% 12:00-12:59: 12.54% 13:00-13:59: 12.71% 14:00-14:59: 12.35% 15:00-16:00:10.02%

12 4.6.7 Fraud, Waste, & Abuse Prevention and Detection Does the scope of FWA Prevention and Detection include pharmacy claims and/or claims for the NPN members?

The Contractor will need to focus on FWA for the claims they are adjudicating (CCE claims), but will also collaborate with the Program on overall FWA prevention efforts.

F.4 Phase I Tasks/Volumes 1b. Understanding of the Requirement and Overview of Risk Awareness and Risk Management Approach iii.a iii.a. requests "The Offeror shall describe in-detail the structure and capabilities of the Offeror's data system to support Program reporting. This description shall include high-level technical and data architecture descriptions, a list of standard reports, a data dictionary, and back-up and recovery procedures and capabilities that shall be provided to the Program". Please confirm that the request is for a high-level description of all listed items rather than comprehensive documentation. Confirmed.

B.3 - Skills and Experience Requirements for Key Personnel Section 4.7 – Data and Business Information Management.

According to this section, we must have a Data and Analytics Lead for the project designated as Key Personnel; however, his position is not listed in B.3.

Can the Government clarify that this position is not a Key Position?

See the Government's response to Question #8.

Technical Approach Oral Presentation In addition to key personnel, may offerors plan to bring in additional contributors to demonstrate the completeness of the solution? Yes, so long as the additional personnel are essential to the offeror's technical approach.

Pricing Proposal For the CLINs x002 and x003 that are listed as severable line items, will the Government consider minimum guaranteed quantities of PMPM units? Yes. See the amended solicitation at Section B.2.

G.2 CDC100_0005 Evaluation of the Data Management Plan (DMP) (Nov 2018) The Data Management Plan submitted as a part of the offeror’s proposal will be evaluated during the pre- award process for quality and completeness and will potentially require later revision as the DMP will be updated during the contract period of performance.

Please confirm if the data management plan needs to be submitted during Phase II? Please confirm if this plan can be submitted as an appendix that does not count against page count?

The Data Management Plan (DMP) shall be submitted during Phase II as an administrative submission, and is considered an appendix that does not count against stated page limitations.

18 Attachment AE

How will the HHS subcontracting plan be evaluated for basis of award? Or will this plan be reviewed upon execution to confirm small business percentages allocated towards the program totals?

Proposed HHS Subcontracting plans will be evaluated to determine whether each offeror has presented a feasible solution and the extent to which it meets the stated subcontracting goals. Plans will be evaluated on an individual basis.

Subcontracts - Small Business Subcontracting Plan Will the government confirm that an offeror may utilize its own individual subcontracting plan in response to this proposal, to ensure that all requirements within FAR clause 52.219-9(d) are included, in lieu of the template? Offerors are instructed to use the provided template.

Subcontracts - Small Business Subcontracting Plan Will the government please confirm that an offeror may provide an addendum to “Attachment AE_HHS Subcontracting Plan Template” to ensure full response to the required information, and to ensure that all requirements at 52.219-9(d) are included within our subcontracting plan? Yes, offerors may provide an addendum to the provided template.

Subcontracts - Small Business Subcontracting Plan “Attachment AE_HHS Subcontracting Plan Template” is not fully compliant with current FAR 52.219-9(d) requirements. For example, “6. Reporting and Cooperation: (FAR 52.219-9(d)(10)” includes the requirements at 52.219-9(d)(10) (i) through (iv), but does not include (v) through (vii). Will the government please confirm that an offeror may include these requirements within an addendum to the Subcontracting Plan? See the Government's response to Question #20.

Attachment AD vs RFP On Page 104 of the RFP - there is a list of what is required for Phase I and Phase II. The Pricing Proposal is listed as part of Phase II, yet Attachment AD Instruction indicated that this should be part of the Phase I submission.

Can the Government clarify when it is expecting to see the Pricing Proposal and all of its components?

The Pricing Proposal, inclusive of a completed Attachment AD, shall be submitted during Phase II. Refer to the amended Attachment AD.

75D301-22-Q-74251_WTCHP_TPA_Solicitation.pdf, Page 108, Pricing Proposal Can government specify which is the consolidated cost spreadsheet that captures the entire contract cost

No template is provided for the required Pricing Proposal Spreadsheet. Offerors shall submit a Pricing Proposal Spreadsheet in Microsoft Excel format that is comprised of the elements listed on Page 108 of the solicitation.

75D301-22-Q-74251_WTCHP_TPA_Solicitation.pdf, Page 10 Page 109, requests a "Pricing proposal spreadsheet" with following pricing elements

a. Direct Labor

b. Materials and Services

c. Subcontracted Items (if applicable)

d. Travel

e. ODC

d. Indirect Cost and doesn’t provide instructions whether to break down the pricing by each of the contract year or should be summed up across the contract period

Offerors shall provide a Pricing Proposal Spreadsheet including the delineated pricing elements that is organized according to the Contract Line Item Numbers (CLINs) listed in Section B. Pricing should also be broken down by CLIN and contract year and summed up across the contract period.

Attachment AD_PMPMPricing_template

Should the vendors assume the cost that need to be specified is for labor cost associated with business operations only? Where should material cost and ODC cost such as software or hardware should be listed during operations?

Note that the PMPM pricing template is applicable only to PMPM CLINs. Necessary travel and ODCs required to perform PMPM services should be rolled into the applicable PMPM CLIN per contract period. Travel and Other Direct Costs relating to business operations, outreach, printed materials, software, hardware, and other similar pricing elements may be proposed using the applicable Travel and Other Direct Costs CLIN per contract period.

Offerors shall be specific as to what elements are included in PMPM CLINs versus ODCs.

Attachment AD_PMPMPricing_template Does PMPM cost applicable for the base period since its a transition-in period, implementation centric with no business operations performance.

No. Refer to Section B. No PMPM lines are included for the Base Period, and shall not be proposed by offerors.

5D301-22-Q-74251_WTCHP_TPA_Solicitation.pdf Page 7, the option year 4 doesn’t include "Contract Management:"

as a service line item whereas rest of the base year through option year 3 includes "Contract Management" line item

Correct. There is no "Contract Management" CLIN for Option Year 4. However, see the amended solicitation, which adds new CLIN 4001 for Transition-Out services, updates the numbering for the remaining Option Year 4 CLINs, and updates Section B. 1 to include new CLIN 4001.

Will Phase 2 oral demonstration be virtual or in person? If in person, what location?

Will offerors be expected to give a live product demo or should offerors plan for static slides only?

Virtual. Oral Presentations will not be limited to the presentation of static slides if offerors choose to provide demos. Live demos are not required. Offerors shall make their own determination on how to present during their oral proposals.

Page 107, 1.c Draft Contract Management Plan Can the government describe the scope of the "repositories" identified in the Draft Contract Management Plan?

Currently this descriptor includes the provider data repository (Section 4.4.3) and records repository (Section 4.7.6). However, offerors should be prepared to maintain and manage additional repositories containing WTC Health Program data throughout the life of the contract.

30 Section B - Continuation of SF 1449

In Section B - Continuation of SF 1449 (p.3 of 117 in the RFP) the Government has provided a table of CLINs. Is it the Government's intention for the Contractors to fill out the table in response of this solicitation?

Yes. In addition to providing the required pricing proposal information during Phase II, each offeror shall complete Standard Form 1449 together with Section B - Continuation of

SF1449.

31 Section B - Continuation of SF 1449

In Section B (p.3 of 117 in the RFP) the Government has provided separate CLINs for Travel, ODCs, PMPM (Member Services) and PMPM (Provider Network Management, Benefit Administration, Claims Processing, Data and Business Information Management).

Is it the Government's intention to have the necessary Travel and ODCs required to perform the PMPM service included as part of the PMPM (Member Services) and PMPM (Provider Network Management, Benefit Administration, Claims Processing, Data and Business Information Management) price? See the Government's response to Question# 25.

CDC PMPM Pricing Template (Attachment AD) - Proposed PMPM Tab and Section B - Continuation of SF1449

In the Base Period Section B - Continuation of SF1449 has CLINs for Transition In (CLIN 0001), Travel (CLIN 0002) and ODCs (CLIN 0003) but does not have a CLIN for PMPM based services (CLINs x003 and x004 in Option Periods). However, Attachment AD Proposed PMPM worksheet requires a rate for the base period.

Is it the Government's intention for the bidders to provide Base Period Pricing for the Member Services PMPM and Provider Network Management, Benefit Administration, Claims Processing, Data and Information Management PMPM? If so, what is the basis for the pricing in the Base Period? See the Government's response to Question #26.

CDC PMPM Pricing Template (Attachment AD) - Proposed PMPM Tab and Section B - Continuation of SF1449

The Proposal Submission Phase I deliverables provided in Table F.3-1: Proposal Evaluation Phases do not call out any pricing deliverables in Phase I. However, the instructions tab in the Attachment AD Pricing Template calls for its delivery Phases I & II. Please confirm that submission of the Attachment AD Pricing Template is only required in Phase II. See the Government's response to Question# 22.

34 Section B - Continuation of SF 1449

It appears the in the RFP provided Section B there is a missing CLIN in the last contract period of performance (05/01/2025 – 04/30/2026) for Contract Management. Please confirm that this is correct and provide an updated Section B. See the Government's response to Question# 27.

CDC PMPM Pricing Template (Attachment AD) - Proposed PMPM Tab and Section B - Continuation of SF1449

The definition of the PMPM Member, the billing unit for CLINs x003 and x004 is defined on page 8, B.2 PMPM Units as "Active Members are those who have at least 1 paid Medical claim within the last 18 months", however, the estimated annual volume for these separate PMPM CLINs have different annual volumes (e.g., CLIN 1002 = 684,000 vs CLIN 1003 = 540,000). Please clarify how billing units with the same definition would have different billing volumes or provide an additional definition if these PMPM rates would have a different billing volume.

The apparent discrepancy between the Member Services PMPM and the Provider Network Management, Benefit Administration, Claims Processing, Data and Business Information Management (Benefits and Claims) PMPM is due to the difference in active members served under each CLIN. Member Services activities must be performed for all active WTC Health Program members, while the Benefits and Claims activities are only for WTC Health Program members in the New York Metropolitan Area (does not include NPN members).

CDC PMPM Pricing Template (Attachment AD) - Proposed PMPM Tab and Section B - Continuation of SF1449

CLIN x003 is the combination of 4 PWS sections that provide services for Claims and Providers. Claims and Provider have different volume metrics that would drive cost.

Can the government provide historical or estimated quantities of Authorization Volumes, Credentialing Volumes and Enrollment Volumes for Claims and Providers?

Offerors may refer to new AttachmentP_AdditionalSummaryVolumeData in the amended Bidders Library.

Section B - Continuation of SF1449, Section G - Evaluation Factors for Award How will the Total Evaluated Price be calculated?

The total evaluated price for each proposal includes the sum of all proposed line items together with the full 6-month extension required by FAR 52.217-8.

38 Section 4.5.4 Utilization Management Program

To achieve an accreditation award, UM accreditation requires a minimum of 6 mos of UM activity to meet the accreditation file review. The accreditation process would take up to one year after start of health care delivery to achieve accreditation. Would the government allow accreditation at 18 mos after SCHD?

The government will allow accreditation within 18 months after SCHD. See the amended solicitation at Section 4.5.4.

39 Section 4.5.4 Utilization Management Program

Is it the government's intent to get a separate population health accreditation in addition to UM? If so, the population health program will require at least one year of historical information and other information in addition to a historical analysis, program development and program implementation to meet accreditation requirements. A separate program would require 2 years to develop and implement program.

The population health accreditation is not required but is allowable. 2 years of development and implementation is acceptable.

40 Section 4.4.1-Provider Network Adoption Report Is there a pre-set format for the listed reports? And if so can we obtain a copy? No, the Contractor may propose their methodology.

41 Section 4.4.1 Provider Network Management Plan Is there a pre-set format for the listed reports? And if so can we obtain a copy? No, the Contractor may propose their methodology.

Section 4.4.1 Indicates Provider demographic info can be found in attachment E for the network providers.

There is a list of providers, zip codes and claims utilization but not a list of network providers with their full demographics ( address, TIN, etc.…) will we be receiving that information?

A full list of demographics for network providers will be provided to the awardee after award.

Section 4.5.4.3 Retrospective UM - Medical Necessity Review

Does WTC already have a retrospective review process in place? If so, will WTC share the criteria or process?

The Program doesn’t currently have a formal process for retrospective review for medical necessity, aside from claims reviews. The Utilization Management (UM) program was not part of similar historical contracts.

Section 4.5.4.1Prospective UM - Population Health and Predictive Analytics

Do prospective UM activities include the expectation of prior authorization of all inpatient, outpatient, and other health care services; does this review include both benefits and medical necessity review?

Prospective UM activities require benefits and medical necessity review and expectation of prior authorization for all inpatient, outpatient, and other health care services.

45 Section 4.5.3 Prior Authorization Does WTC have a defined list of basic services that do not require prior authorization?

Yes. This information is part of WTCHP's codebook, which will be provided to the awardee following award.

Section 4.6.2.1 Paper Claims What is the current percentage of claims that are paper vs online claims, and what is the volume of paper claims received per year?

Since paper requires more processing time, this information will allow for a more accurate price estimate.

See the Government's response to Question# 9.

Section 4.3.1.1 Enrollment Application Processing How long does it take to process an application (paper or online) in the CARE Portal? Initial enrollment processing (data entry) times can vary depending on the legibility of the submitted documentation, and take approximately 5 minutes for online applications and 10 for paper applications. However, the preliminary evaluation (required for both online and paper applications) can take an additional 10-20 minutes depending on the legibility, quality, and complexity of submitted supporting documentation.

Section 4.3.1.1 Enrollment Application Processing What volume of enrollment applications received are considered insufficient?

Based on data from 2021, an average of 40-55% of applications received are considered insufficient at the time of receipt and go into a suspend status.

Section 4.3.1.1 Enrollment Application Processing What are the Follow Up Activities and how long do they take per member?

Enrollment follow-up activities are activities conducted to obtain information and/or written documentation that is necessary for the Program to render an enrollment decision.

This includes sending letters, making phone calls, and/or communicating with the applicant via other means. It also includes receiving and reviewing newly-submitted documents, receiving phone calls escalated from the Call Center, and receiving phone calls made directly to the processor. Activities required (and the time associated with each activity) can vary widely based on the quality of the application and the needs, understanding level, and responsiveness of the applicant.

Utilization Management

How many certifications are received and approved and how long do each take to complete?

Certification processing (data entry) times take approximately 10 minutes to complete per certification request. Over the last 3 years, approximately 70% of certification requests received were approved each month. Offerors may refer to new AttachmentP_AdditionalSummaryVolumeData in the amended Bidders Library for additional context.

Utilization Management What is the acceptable maximum percentage for auto-adjudication

(professional vs. institutional) There is no acceptable maximum.

Utilization Management

What is the expected volume and scope of audits?

Neither an expected volume nor scope of audits can be accurately communicated at this time.

General Please confirm the Contractor is expected to load claims history. If so, please provide the claims history file format and file structure (i.e. locations and benefit plans). Yes. This information will be provided to the awardee following award.

General Are members allowed to access the NPN when traveling, or if they spend a few months in a warmer location like Florida each year?

Per the WTC Health Program transfer policy, members can only transfer once a year (unless there are extenuating circumstances). Generally, members who split their time in multiple locations have to choose a single Clinical Centers of Excellence (CCE) or Nationwide Provider Network (NPN) to receive their care.

Section B - Continuation of SF 1449 Option Year 4 (Transition Out) Items

Contract Management activities are not listed in Section B for Option Year 4. Is it the Program's intent that there will be no Contract Management activities required during Option Year 4?

See the Government's response to Question# 27.

Section 4.3.1.1 – Enrollment Application Processing The RFP states, "The Contractor shall support streamlined enrollment processing through the CARE Portal and facilitate accurate tracking, communication, and information exchange across stakeholders Current enrollment process flows can be found in the Bidder’s Library (Attachment F)." Please advise if the Contractor would receive one or multiple batch files from the CARE Portal on a daily basis.

The Contractor will receive two files from the CARE Portal on a daily basis, one for enrollment and one for certifications.

Section 4.3.2.2 – Member Engagement and Communications Please provide the average annual volume of documents requiring translation for the past 3 years. Total volume of documents requiring translation over the past 3 years as of December 21, 2021:

2019: 71 2020: 51 2021: 63 No outgoing documents have been translated by the current HPS Contractor. Outgoing letters are generally auto-generated from templates provided by the Program that are already translated into Spanish, Polish, and Chinese. The awardee is expected to translate any manual one-off outgoing letters into the target language, as appropriate.

Section 4.3.3.1.3 – Call Center Performance Reporting Please provide the average handle (talk) time per call, separated by Member and Provider calls.

We were not able to separate the information by member and provider calls, but provided the average handle and talk time YTD in 2021 in new AttachmentP_AdditionalSummaryVolumeData in the amended Bidders Library.

Section 4.3.3.1.3 – Call Center Performance Reporting Please provide the average time Customer Service Representatives spend on call follow up, total handle time, separated by Member and Provider calls.

See the Government's response to Question# 58. In reference to "call follow up," assuming this means calls escalated from the Call Center, we do not currently track time spent by those individuals.

Section 4.3.3.1.3 – Call Center Performance Reporting Please provide the current list of escalation reasons. This information will be provided to the awardee following award. Generally, calls are escalated when the call scripts do not or cannot address a caller's needs. For example, if someone calls on behalf of a member and states they are a designated representative (but are not listed as such in the system of record), the call center representative will escalate to the HIPAA Team.

Section 4.3.3.1.3 – Call Center Performance Reporting How does the Program measure Resolution Rate? Is it based on one call resolution or over a specific period of time? Is it based on the status of the case or the ability to resolve the question/inquiry? For example, a member calls to inquire about enrollment. Is the call resolved after providing a status update or after the enrollment status is finalized?

The resolution rate is based on the ability to resolve the question or inquiry. In the example provided, the call is considered resolved after the enrollment status update is provided.

Section 4.4.1.1 – Provider Enrollment and Data When a new provider joins the network, who is authorized to sign off on the agreement? Is this WTCHP? Are electronic signatures acceptable? If not, how are wet signatures handled?

The vendor is authorized to sign provider agreements on behalf of the Program, but the network is considered to belong to the WTC Health Program. The Program is open to either electronic or ink signatures.

Section 4.4.1.1 – Provider Enrollment and Data Please provide the number of providers in the WTCHP. Please provide additional information regarding provider credentialing/recredentialing requirements.

As of 12/14/2021, the WTC Health Program has 55,956 rendering and group providers on its provider list.

Section 4.4.1 – Provider Network and Adoption Are there National vendor agreements (vision, dental, DME) to consider that affect NYMA network? Will those contracts convert or will they need to be recontracted?

Yes, there are a few vendors that are located outside of the New York Metropolitan Area that serve Clinical Centers of Excellence (CCE) members. Contracts will not be transferred and providers will need to be re-contracted.

Section 4.4.1 – Provider Network and Adoption Please provide the credentialing information and files along with upcoming recredentialing needs. Please confirm the transition plan for credentialing expectations.

The Contractor's strategy for recredentialing providers shall be addressed in its Transition- In Plan.

Section 4.5.3 – Prior Authorization This section states, "Once the Transition-In Plan is finalized in coordination with the Program, the Contractor shall implement the prior authorization approach." Does the finalization of the Transition-In Plan coincide with the Start of Health Care Delivery

(SHCD)?

The Transition-In Plan is initially addressed in the technical approach, and will be further developed by the awardee during the transition-in period to ensure that the prior authorization approach meets Program requirements. The transition-in report (documenting how the contract transition was actually implemented) is not due until 10 business days of

SHCD.

Section 4.6.1 – Claims System Capabilities This section requires accepting electronic claims in EDI 837 formats. We note that WTCHP already has payer ID number(s).

Does the Program transition the existing payer ID numbers or is it anticipated that new payer IDs will be created? The payer ID belongs to the WTCHP. It is not anticipated that new payer IDs will be created.

Section 4.6.1.1 – Claims Payments This section requires weekly claim level adjustments on any recovery efforts performed by the Program and designated contractors. Can you provide the average annual number of adjustments from 2010-2021 to coincide with the provided claims volume?

2017 - 38446 2018 - 33748 2019 - 28431 2020 - 38085

2021 (YTD) - 21864

Section 4.6.2 – Business Rules This section states, "Claim Forms: The Contractor shall reject any claims submitted on unapproved claim forms. When an unapproved claim form is submitted, the Contractor shall always deny the claim and notify the claimant that the Program only accepts approved claim forms that are received within the timely filing deadline. Acceptable forms include those in Section 4.6, current claim forms CMS 1500, UB04, and ADA (dental claims).

Updates shall be made to align with industry practice." Please confirm the Contractor will only process medically necessary dental services outlined in Section 4.2 Dental Services of the WTC Administrative Manual be covered. If so, please confirm the medically necessary dental claims are included in the workload provided in Attachment E - Tab 9 Claims Processing Summary. If the dental claims are not included, please provide that workload volume.

Yes. The Contractor will only process medically necessary dental services. We processed a total of 32 dental claims in 2019, and 53 dental claims in 2020.

Section 4.6.7 – Fraud, Waste, & Abuse Prevention and Detection

This section states, "The Plan shall comply with the WTC Health Program FWA SOP that defines timelines and reporting requirements." The FWA SOP was not included in the Bidder's Library. Will the Program provide this document prior to the Phase I or Phase II submission dates?

The SOP will be provided to the awardee along with other materials following award. The timelines and reporting requirements may be found in Section 4.6.7 of the solicitation.

Section 4.7 – Data and Business Information Management This section states, "The Data and Analytics lead for the project shall be designated as “Key Personnel.” The Data and Analytics Lead shall be responsible for maintaining and overseeing completion of data user agreements, and management of security documentation/agreements. The Contractor shall specify a lead role that shall be key for data engineering and governance, a lead for analytics, a security officer, and a lead for testing to oversee implementation of changes/updates. The Contractor shall recommend business engineering and analytics staff for Program consideration." The Data Analytics Lead and the required qualifications for the position are not listed in Section B.3. Please confirm the Data Analytics Lead is a key personnel position. If so, please provide the required qualifications for this position.

See the Government's response to Question# 8.

Section 4.7.2.4 – Dashboard Reporting; Table 3: Required Dashboards (updated Monthly)

Under the Criteria Elements column of Table 3 for Summary Level View - Member Demographic Information, the Program lists "appointments" as an element to provide for Utilization. Please provide clarification of what is meant by "appointments" (designated representative appointments, medical appointments, etc.). Medical appointments.

Section 4.7.5 – Data Integrity and Governance This section states, "The Contractor shall serve as custodian of the Program data provided by partner contractors and the Program."

Does this include the member, claims, and provider data from the

NPN?

The referenced program data includes member and claim adjudication records for NPN members. However, it will not include NPN provider data.

F.3 Proposal and Evaluation Phases, Table F.3-1: Proposal Evaluation Phases, Phase II, 3. Technical Approach Oral Presentation: d. Staffing Plan & Key Personnel

This section states, "Proposed Key Personnel shall be introduced and participate significantly in presentations. It is the Offeror’s responsibility to ensure their proposed Key Personnel can attend the scheduled Oral Presentation. Emergent or exigent circumstances for the absence of Key Personnel may be allowable at the Government’s discretion." Please clarify whether the Oral Presentation will be in-person or virtual.

See the Government's response to Question# 4.

F.4 Technical and Pricing Proposal Instructions, Phase I, 1.b.

Understanding of the Requirement and Overview of Risk Awareness and Risk Management Approach

This section has a 10-page limit but requires response to numerous topics. Can more pages be allowed for this section?

No.

F.4 Technical and Pricing Proposal Instructions, Phase I, 1.b.

Understanding of the Requirement and Overview of Risk Awareness and Risk Management Approach, iii. Data and Business Information Management Approach

The Data and Business Information Management Approach is included in the 10-page Understanding of the Requirement and overview of Risk Awareness and Risk Management Approach response. The Data section requires a data dictionary and list of current standard reports. Our current data dictionary is more than 1,000 pages. Can these items be moved to Phase II? Alternatively, can more pages be allowed?

See the amended solicitation. The Data Dictionary is removed as a proposal requirement.

F.4 Technical and Pricing Proposal Instructions, Phase I Tasks/Volumes, 2. Prior Demonstrated Experience

This section states, "Offerors proposing subcontractors may submit one (1) subcontractor reference. Any subcontractor performance references shall accurately identify the entity who performed the work and must also be within the last three (3) years." Please clarify if the Offeror can only submit 1 subcontractor reference in total or one subcontractor reference per subcontractor. Of the three (3) total relevant references provided as part of an offeror's proposal, one (1) reference may be submitted that describes a proposed subcontractor's relevant experience.

F.4 Technical and Pricing Proposal Instructions, Phase I Tasks/Volumes, 2. Prior Demonstrated Experience

This section states, "Offerors shall provide a narrative for each of three (3) relevant references to demonstrate its capabilities and expertise with similar agencies, programs, and/or populations within the last three (3) years. Offerors proposing subcontractors may submit one (1) subcontractor reference. Any subcontractor performance references shall accurately identify the entity who performed the work and must also be within the last three (3) years." Please clarify if the subcontractor reference(s) are in addition to the three (3) relevant references or must they be part of the three references?

Part of the three (3) relevant references.

F.4 Technical and Pricing Proposal Instructions, Phase II, Past Performance Questionnaires

This section states, "Offerors shall use Attachment AC: Past /Present Performance Questionnaire to request performance feedback relevant to this requirement." Please confirm whether all bidders, even those with past/present performance already in the Contractor Performance Assessment and Reporting System (CPARS), must complete and submit the Past/Present Performance Questionnaires. Confirmed.

F.4 Technical and Pricing Proposal Instructions, Phase II, Key Personnel Resumes

This section states, "Resumes shall clearly, yet concisely, demonstrate how the individual meets or exceeds the required qualifications listed at Section B.2 of the solicitation." Please confirm this references B.3 instead of B.2. Confirmed. See the amended solicitation.

F.4 Technical and Pricing Proposal Instructions, Phase II, Pricing Proposal, 2.f.

Please confirm that the offeror may submit a single statement that no organizational conflicts of interest exist. Confirmed.

F.4 Technical and Pricing Proposal Instructions, Phase II, Pricing Proposal, 2.f.

If a single OCI statement is not acceptable, can the government provide a template for offerors' use? See the Government's response to Question 81.

Attachment E_SummaryVolumeData Please provide the anticipated number of change requests implemented per CLIN.

WTCHP doesn't currently track change requests by CLIN, and we don't anticipate a significant number of change requests. Change requests do not happen on a regularly scheduled cadence, and are generally ad hoc in nature.

Attachment E_SummaryVolumeData, Provider Data - Summary

Please provide the historical volume of providers that have enrolled for the last 5 years.

Please provide the historical volume for the number of providers that have credentialed for the last 5 years.

How many contracts/credentialing packets are currently open?

Is there currently a backlog? If so, please provide that volume. Offerors may refer to new AttachmentP_AdditionalSummaryVolumeData in the amended

Bidders Library. There are currently 303 providers going through the provider enrollment and credentialing process.

Attachment H TransferProcessFlow - Tab 2. HPS Transfer Report

The HPS Transfer Process Flow states, "Run Daily Transfer Report in MicroStrategy." Does the Program require the TPA to use the MicroStrategy software?

No. The process flows were included as context for the enrollment, certification, and transfer process flows. The contractor does not need to use MicroStrategy; however, the contractor does need to have the ability to generate transfer reports (reports that include member demographic and certification information to facilitate the transfer process)

Attachment J_MemberCommunicationResponsibilities Attachment J outlines member communication responsibilities.

Can the government provide this same information for provider communication responsibilities?

No. Provider communication responsivities are at the discretion of the contractor to ensure that providers are aware of all relevant changes to Program policy, and do not have as specific requirements as member communication.

Section B - Continuation of SF 1449 CLINs X0002 and X0003 for each option year

Section B.2 explains that the PMPM units represents the current Active Members who have at least one (1) paid medical claim in the past 18 months and the government's estimated increase in Active Members per contract period. The quantities listed for PMPM Member Services and PMPM Provider Network Management, Benefit Administration, Claims Processing, Data and Business Information Management, however, do not match. Please clarify what each of these quantities represent.

See the Government's response for Question# 35. The unit is based on a per member per month (PMPM) model. For example, CLIN1002 was calculated by the Government's estimate of 57,000 active members x 12 months in the PoP, which is 684,000 PMPM units.

Section H-Bidders' Library, #F-Enrollment Process Flow, #G- Certification Process Flow, #H-Transfer Process Flow, #F- Enrollment Process Flow

Does the government wish to retain the current process flow? If not, what areas would the government like to see changed or improved? Does the government wish offerors to propose alternative process flows based on industry best practices?

We welcome offerors to propose alternative process flows based on industry best practices.

However, some changes may take longer to implement than others (such as changes to CARE Portal functionality).

89 Section H-Bidders' Library, #F-Enrollment Process Flow

Is the BSOC Mail House (at HPS) located and operated by the incumbent TPA or is a portion of this process located and operated by the Program? Can you please clarify?

BSOC is entirely located and operated by the incumbent TPA. Each offeror shall propose how they will manage mail center operations. Offerors should also refer to the amended solicitation at Section 4.3.2.2, and to the volume data for mail center operations provided within new AttachmentP_AdditionalSummaryVolumeData in the amended Bidders Library.

90 Section H-Bidder's Library, #E-Summary Volume Data What was the average call handle time specific to HPS in 2021 for each Contact Type or overall if unavailable by Contact Type? See new AttachmentP_AdditionalSummaryVolumeData in the amended Bidders Library.

91 Section H-Bidder's Library, #E-Summary Volume Data What percentage of enrollment applications received in 2021 were received via paper and what percentage was received online?

Approximately 65% of enrollment applications received in 2021 were received online, while the remaining 35% were paper.

92 Section H-Bidder's Library, #E-Summary Volume Data

What percentage of paper enrollment applications received in 2021 were received via US mail and what percentage was received via fax?

Of all the "paper" documents received by the mail center (including enrollment applications), approximately 62% were received by fax, while the other 38% were received via US mail.

93 Section H-Bidder's Library, #E-Summary Volume Data

What percentage of initial enrollment applications received in 2021 required outreach to the Member (e.g. due to insufficient information)? See the Government's responses to Question #s 48 and 49.

94 Section H-Bidder's Library, #E-Summary Volume Data

What is the number of utilization management reviews conducted in 2021 by review type (concurrent, retrospective) or overall if unavailable by review type.

We have done fewer than 20 reviews in 2021 for concurrent, inpatient hospitalizations as we are currently in the pilot phase. The retrospective UM program has not begun. We expect the numbers to go up significantly once the full utilization management program is implemented in coordination with the new vendor.

95 Section H-Bidder's Library, #E-Summary Volume Data Please provide claim type data to separate volumes for facility vs.

professional and ebill vs. paper? YTD in 2021, we have received 32,884 paper claims and 396,438 electronic claims.

96 Section B - SF1449 Would the government consider making the Contract Management CLIN FFP? No.

B.3 & D-2.22 CDCA_H009 Key Personnel, Section 4.2.5, Section 4.7

Sections B.3 and D-2.22 indicate four key personnel: Transition Lead, Program Manager, Medical Director, and QA/QC Specialist.

However, within the Section 4.2.5 the RFP requires a Quality Monitoring and Improvement Lead as key and Section 4.7 requires a Data and Analytics Lead as key. Please clarify and confirm the key personnel requirement for this contract. See the Government's response to Question# 8.

It is understood that on January 2, 2011, the President Barack Obama signed Public Law No. 111-347, the James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act). The final bill allocated $4.2 billion towards the program. How much of the allocated program funds have been spent vs what remains available?

On December 18, 2015, the Program was reauthorized as part of the James Zadroga 9/11 Health and Compensation Reauthorization Act. This act includes authorization (and appropriate funding) for the Program through 2090.

It is understood that as of June 30, 2021, the Program had 112,042 members enrolled, including 81,460 responders and 30,582 survivors. Table Item Option Year 1 thru 4 Items: 1002, 1003, 2002, 2003, 3002, 3003, 4001, 4002 state numbers above and beyond what is written in Section 1 "Background". Can you detail/comment how the respective Quantity / Unit numbers Section B "Continuation of SF 1449" correlate to the numbers represented in Section 1?

The unit numbers in x002 and x003 are based on per member per month. See the Government's responses to Question #s 35 and 87.

Table Item Option Year 1 thru 4 Items: 1002 & 1003, 2002 &2003, 3002 & 3003, 4001 & 4002; what is the difference between individual members identified i.e., line 1002 vs line 1003? See the Government's response to Question # 35.

Why is the CDC's NIOSH, soliciting proposals for the World Trade Center (WTC) Health Program Third Party Administrator (TPA) "the Program" support service?

The WTC Health Program is an Operating Division under NIOSH. The WTC Health Program is soliciting proposals for a third party administrator to provide contract management, member services, network management, medical benefits management, claims adjudication, and data and IT services on behalf of the Program.

What is the expected annual number of new enrollments of individuals into this program?

The Program expects approximately 8,400 new active members each year--5,400 NYMA members, and 3,000 members outside of the NYMA.

Does the program pay medical providers/insurance carriers on behalf of individuals, or does the program reimburse individuals for expenses they have already incurred and paid out of pocket? If a mix of both please provide an estimated split.

The Program pays medical providers/insurance carriers when claims are submitted to the Program. The Program cannot directly reimburse members for expenses they have already incurred and paid out of pocket. However, the TPA vendor must have a mechanism to reimburse members in situations where the vendor provider network charges co-pays and balance bills a member, and the member pays that bill.

If funds are to be paid to program members as reimbursement for expenses incurred and paid out of pocket by program members, is it acceptable to pay these reimbursements via prepaid/preloaded debit card?

Checks are the preferred form of reimbursement for member out-of-pocket expenses.

However, the Program is open to alternative recommendations for reimbursement with the awarded vendor.

What is the estimated total amount of reimbursements paid to program members annually?

Ideally, the total amount should be $0, as having reimbursements paid to members would imply that the network is not being managed appropriately. Members should never receive a bill or pay anything out of pocket for covered services.

What role does the TPA contractor play in reviewing medical claims and determining which expenses are covered by the program?

The TPA contractor is responsible for adjudicating medical claims for New York Metropolitan Area members (non-NPN members) and ensuring that the proper edits are applied in accordance with Program policy.

Is the TPA contractor expected to approve and deny claims from individuals?

No, the TPA contractor only adjudicates medical claims submitted by healthcare providers.

Program members would not be submitting any claims to the TPA contractor.

Describe the “clinical reviews” requirements of the TPA contractor.

The TPA contractor is required to use their clinical expertise to assess appropriateness of clinical services, medical necessity, and compliance with Program policy.

What percent of claims are received by the TPA contractor directly from medical providers or insurance carriers with specific covered expenses already identified?

Approximately 100%. Providers should only submit claims to the TPA Contractor that are covered by the Program.

The Scope of Work states: “The Contractor will not be responsible for underwriting cost of care or developing and coding new information technology systems." This implies the TPA contractor is not expected to build new technology, which seems at odds with Section B "Continuation of SF 1449" pricing schedule and the overall RFP that carves out over a year to develop the system to manage the program. Please reconcile.

The TPA contractor is expected to leverage existing technology and customize it, rather than building it from scratch. The year-long transition period is intended to include all transition activities (customize, test, and implement solutions related to member services, provider network management, medical benefit administration, claims processing, data and business information management), not to develop a system to manage the Program.

What is the expected number of beneficiaries that will receive a death benefit from a program member on an annual basis?

The WTC Health Program does not provide death benefits; the WTC Health Program provides limited health care coverage for conditions determined to be related to 9/11 exposure. If you are referring to beneficiaries of the 9/11 Victim Compensation Fund, that is a separate federal program.

What is the role of the TPA contractor in determining beneficiary eligibility and amounts of death benefits? See the Government's response to Question# 111.

What is the expect amount of death benefits to be paid to beneficiaries annually? What is the minimum, average and maximum death benefits allowed by the program? See the Government's response to Question# 111.

Are death benefits to beneficiaries of program members allowed to be paid out via pre-paid debit card? See the Government's response to Question# 111.

Please explain your current funding process and banking arrangements.

Claims payments are made through the Centers for Medicare & Medicaid Services…