ATT110_TPA_QuestionsandAnswers (revised 05.20.25).xlsx

Q&A published 05.20.25 (Amd 9) RFP No. 75D301-25-R-73216 World Trade Center Health Program Third-Party Administrator ATT110, Questions and Answers

1) performing verification of current EPN provider information and eligibility to be within Program network. Though the criteria is slightly different than what is listed in TGD 032, the Program is considering this verification sufficient and will not require re-credentialing as part of transition-in (as noted in response to Q3 of ATT118).

2) updating provider agreements of current EPN providers' signed Provider Terms & Conditions, with such agreements transferred to the TPA upon award. This will likely reduce the number of providers that require re-affiliation upon TPA award.

3) moving NPN claims adjudication from the NPN contract to the HPS contract. This will likely result in a simpler transition-in, with historical claims data coming from a single source (HPS) instead of two sources (HPS and NPN).

386 N/A N/A How should offerors take such updates (as noted in response to Q385) into account for proposal purposes? 1) As noted in response to Q3 of ATT118, offerors shall assume that the current EPN provider verification process will result in all current EPN providers being credentialed between October 2024 and November 2025, meaning that any current EPN providers who are being re-affiliated will not need to be credentialed again / have credentials verified until October 2026 and beyond. In other words, offerors shall propose assuming no requirement for re-credentialing current EPN providers during transition-in.

2) As noted in response to Q3 of ATT118, offerors shall assume all future EPN providers need to agree to the updated Program Terms and Conditions after award of the TPA. In other words, this current project should have no impact on the offeror's proposal.

3) Offerors shall assume that claims data will be coming from two sources (HPS and NPN), as described in the pre-proposal conference briefing. In other words, this current project should have no impact on the offeror's proposal.

*300, 342, and 343 *Clarification: See Amendment 9 to the RFP. Providers are to be reimbursed for medical claims via EFT. The TPA Contractor is responsible for obtaining and maintaining complete and accurate EFT information for all network providers. Provider reimbursement through alternative means (e.g., paper check) can be made only on a limited-case basis with Program approval and subject to applicable laws, policies, and procedures, including limits imposed by Exec. Order No. 14247, 90 Fed. Reg. 14001 (March 25, 2025, Modernizing Payments To and From America’s Bank Account.

Q&A published 5.09.25 (Amd 8) RFP No. 75D301-25-R-73216 World Trade Center Health Program Third-Party Administrator ATT110, Questions and Answers

Volumes of failures is generally dependent on the accuracy of the data. The Government would expect resolution/reconciliation of such files to be initiated as soon as possible, no later than 2 business days of the TPA receiving the notification of failure from the payment contractor. The TPA Contractor is expected to make best efforts to complete follow-up actions within 10 business days; however, the Government recognizes that the TPA Contractor is dependent on the responsiveness of the provider for completion. See Amendment 8 to the RFP.

Column E describes the Program's paper claim volume by provider source. For the period of January through June 2024, there's a total of 486 paper claims.

Internal&ExternalComms tab Cell AA30 provides the average of 5,312 claims received in inbound Program mail from January to July 2024.

Question: Are these 5,312 mailed claims, presumably paper claims, represented in the existing data on the ClaimsProcessing&Payment tab? If not, how are they handled? Table 1 on the Claims Processing and Payment tab has been updated to clarify the different paper claim volumes received. Table 1A (new) provides an overview of the claims received by the HPS clearinghouse, while Table 1B (previously provided, but without sufficient context) provides an overview of claims received by the HPS vendor for adjudication. Both tables are included so that offerors can see the total number of paper claims submitted by providers through the various submission pathways. Note that claims received by the clearinghouse (paper and electronic) that are authorized by the CCEs are ultimately sent to the HPS vendor for adjudication and are therefore captured in Table 1B (Column O); claims undergoing the CCE authorization process "pend" at the clearinghouse. Under the TPA contract, all medical necessity review will be performed by the TPA vendor, and there will no longer be a CCE authorization process.

The incoming mail categorized as "claims" includes paper claims as well as other claims-related documentation (e.g., claims appeals). Those paper claims received by this process are captured in the new Table 1A, as such claims are routed to the clearinghouse.

304 116 4.7.1 The PWS states, "The TPA Contractor’s member profile system shall be able to address situations where a single individual may have multiple member profiles concurrently and/or sequentially."

However, ATT008 states only that the TPA must send the member a Welcome letter and that providers are to be sent a Welcome Packet. Please clarify if the TPA is to send a new member a letter or a packet. If a packet is to be sent, how will the TPA acquire the membership card to mail to the new member? Attachment ATT008 references the Welcome Letter that is provided by the Program via the CARE Portal; however, it notes that "the TPA may need to include a mechanism for the member to select CCE preference (currently, a postcard) and/or an ID Card." The TPA may also choose to include additional documentation beyond what is generated in CARE (e.g., instructions to log into the self-service portal). The TPA is responsible for producing and sending the membership card.

Please see Amendment 8 to the RFP. Language has been updated in Section 4.2.5 to align terminology between ATT008 and the PWS, while still indicating that the ultimate mailing will include more than just a welcome letter.

(2) ATT118_TPA_FAQ.pdf,

(3) ATT016_TPA_WTCHPPProvider Terms and Conditions (v2 revised 4.14.25).docx,

Please confirm whether or not the providers will be considered directly contracted with the Program or the contractors and/or a commercial or federal provider network provided by the contractor?

Please define "own" and clarify who will have the contractual relationship with the providers of the NPN.

Please describe how the provider executing the "provider terms and conditions form" effects the governments understanding and position in regards to the government's usage of provider information for providers who do not submit claims. As noted in response to Q2 in Attachment ATT118, FAQ about the TPA and provider network, provider agreements are exclusively between the TPA Contractor and the providers (or their authorized signatories). The TPA Contractor will enter direct contractual relationships with EPN providers. For the NPN, the TPA may either recruit individual providers and/or rent a leased network; provided, authorized signatories on behalf of individual providers or provider groups shall execute a provider agreement (Attachment ATT116) directly with the TPA. The Program is not a party to either the EPN or NPN providers’ contracts with the TPA. NPN and EPN providers are not considered to be directly contracted with the Program.

Use of a commercial or federal provider network provided by the TPA Contractor is allowable; however, such a network can only be considered in-network for the WTC Health Program network if all providers within said network have agreed to all Program enrollment and credentialing requirements, including the Program Terms and Conditions in Attachment ATT016.

The EPN was developed by the Government, and the Government retains ownership of all associated information related to this network, including provider demographic data, services/specialties, and financial information. Additionally, the Government may, through its contract with the TPA Contractor, require the TPA Contractor to transfer its rights and obligations under the signed Program Terms and Conditions in Attachment ATT016 for the EPN to a successor TPA. This is what the Government means by “owning” the EPN. By contrast, the Government does not own the NPN, or have an intent to own the NPN, in the same way, and the Government may not direct the TPA Contractor to transfer its rights and obligations under the signed Program Terms and Conditions with NPN providers to a successor TPA.

The Government will have access to information on all NPN providers, including those who do and do not submit claims. For example, the Government requires the TPA Contractor to furnish a provider directory that captures provider information for all providers authorized to provide services to one or more Program members. The TPA Contractor is also required to furnish copies of executed provider agreements to the Program upon the Program’s request. These requirements are necessary for the TPA Contractor to effectively and efficiently perform as the TPA Contractor.

However, the TPA Contractor is not required to deliver to the Government a comprehensive list of all NPN providers (i.e., both providers who have submitted claims and provider who have not submitted claims). The Government recognizes that the NPN provider network composition may be considered proprietary either by the TPA Contractor or by the entity through which the TPA Contractor rents a provider network, if applicable. Accordingly, the Government does not intend to release to others, reproduce, distribute, or publish the full list of NPN providers, or direct the TPA Contractor to do so, in a manner that is outside the scope of the tasks in the TPA Contract. In short, the Program will not “take” the TPA Contractor’s complete NPN provider network for its own use independent of the TPA Contract nor furnish it to another entity, like a successor contractor.

NPN data on submitted claims, and data on the NPN providers who have submitted claims, is, however, considered Program data that the Program may use and release to others, to the extent such sharing of claims data and data on the NPN providers who have submitted claims is, as determined by the Program, necessary to fulfill a Program function, like the transition of the TPA Contract to a successor contractor, where the sharing of NPN providers who have submitted a claim is necessary to facilitate recruitment of active NPN providers to promote continuity of care for WTCHP members.

333 AMD07, page 110; Q&A Published 1/16/25 PWS 4.5.2 How are providers who provide peer to peer reviews for UM reimbursed and at what rate? Also, will the Government confirm the estimate annual volumes of these types of reviews? There is no established reimbursement rate for peer to peer, and applicable rates would be subject to negotiations between the TPA Contractor and, if utilized, a subcontracted medical provider performing the peer to peer review for the TPA Contractor. UM, including peer to peer, is a cost of doing business to be included in CLIN X006 and will not be a separately invoiced service. Please see Amendment 8 to the RFP.

Estimated annual volumes are not available as the Program does not currently require a peer to peer review process.

The timeline to review and stakeholders involved to respond to such requests will be dependent on the content and extent of the request, though the Program intends to complete reviews timely to facilitate the enrollment process. The TPA Contractor will not be held responsible for delays to negotiation that are due to Program review of provider-proposed revisions to the Provider Terms & Conditions. The Access to Care metric (02.04) in ATT003, QASP, has been updated to clarify this exclusion to the calculation methodology.

Please be reminded that the TPA and the provider may negotiate additional terms beyond what is provided in the Program Terms & Conditions, so long as such terms do not conflict with the Program's terms. In such cases, Program involvement is not required.

339 ATT016_TPA_WTCHPProvider TermsandConditions (v2 revised 04.14.25) Reimbursement Rate for Claims If the provider is reimbursed below fee schedule under an existing network agreement between the provider and the TPA, will the TPA or network be reimbursed the difference between provider reimbursement and fee schedule or a % of savings? Can the difference between the fee schedule allowance and the network agreement amount be treated as revenue by the TPA? The Program reimburses medical claims via direct-to-provider payment pursuant to the established fee schedule with funds set aside for that purpose. Due to Program constraints, there is no flexibility to that arrangement and no ability to implement spread pricing with partial payment to the TPA.

340 ATT016_TPA_WTCHPProvider TermsandConditions (v2 revised 04.14.25) Recitals If the TPA contractor leverages one or multiple "PPO" networks for the WTCHP NPN network, then providers will typically identify their affiliation with the network brand vs. individual payers, third party administrators, or plans.

Will the government consider revisions to ATT016_TPA_WTCHPProvider TermsandConditions to reference the provider/network overarching agreement to mitigate confusion and disruption in getting agreements executed quickly during on-boarding/transition and continual network development? As noted in response to Q1 in Attachment ATT118, FAQ about the TPA and provider network, references to the network brand is allowable if all providers within the leased network are considered in-network under the TPA contract, as defined as providers (or their authorized representative(s)) who have agreed to all Program enrollment and credentialing requirements, including the Program Terms and Conditions.

Please be reminded that the TPA and the provider may agree to additional terms beyond what is provided in the Program Terms & Conditions, so long as such terms do not conflict with the Program's terms.

341 AMD07, page 105 Section 4.4.3 The government stated in the Q&A that not all existing NPN providers have EFT information on file. Please provide the following:

1. Total number of NPN providers who have EFT information on file

2. Total number of NPN providers who do not have EFT information file for which the TPA will be expected to obtain EFT information in accordance with adequacy standards and timeliness requirements outlined in 4.4.3 Of the current NPN providers who are located outside the NY metropolitan area and have had a claim approved since 8/1/22, approximately 6,100 providers do not have EFT information on file.

The Government cannot provide a response to #2. Though the Government requires the TPA to prioritize recruitment of any providers currently rendering services to NPA members (Section 4.2.2), there is no guarantee that all providers will be interested. Furthermore, depending on which (if any) providers decline joining the TPA NPN and where they are located, there may or may not be a resulting network gap that will need to be filled.

Where forms meet criteria, the DR's information needs to be added to the CARE Portal and linked to the member's record. Where forms do not meet criteria, the TPA is responsible for documenting the reason criteria is not met and doing a single outreach attempt to the member. As noted in ATT101, Summary Volume Data, the level of effort for processing a Designated Representative appointment is approximately the same as it is for processing a HIPAA Authorization form, with some additional data capture (up to 10 fields).