Amendment 0002 - 75H70422R00006 - 6-28.pdf

(x)

75H70422R00006 x x copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted ; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE

RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR

OFFER. If by virtue of this amendment you desire to change an offer already submitted , such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

x

Rockville MD 20857 5600 Fishers Lane, Mailstop 09E70 Division of Acquisition Policy Indian Health Service

05/23/20220002

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

12. ACCOUNTING AND APPROPRIATION DATA (If required) is not extended.is extended, Items 8 and 15, and returning

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended , by one of the following methods: (a) By completing

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

FACILITY CODE CODE

10B. DATED (SEE ITEM 13)

10A. MODIFICATION OF CONTRACT/ORDER NO.

9B. DATED (SEE ITEM 11)

9A. AMENDMENT OF SOLICITATION NO.

CODE

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code)

7. ADMINISTERED BY (If other than Item 6)CODE 6. ISSUED BY

PAGE OF PAGES

4. REQUISITION/PURCHASE REQ. NO.3. EFFECTIVE DATE2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO. (If applicable)

1. CONTRACT ID CODE

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

05/23/2022

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority) appropriation data, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

E. IMPORTANT: Contractor is not is required to sign this document and return __________________ copies to the issuing office.

ORDER NO. IN ITEM 10A.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

This administrative amendment provides updated RFP details to incorporate the answers the

IHS provided via Amendment 0001 on June 13, 2022.

Period of Performance: 08/01/2022 to 07/31/2023

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)15A. NAME AND TITLE OF SIGNER (Type or print)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA 15B. CONTRACTOR/OFFEROR 16C. DATE SIGNED

(Signature of person authorized to sign) (Signature of Contracting Officer)

PAUL B. PREMOE

STANDARD FORM 30 (REV. 11/2016)

Prescribed by GSA FAR (48 CFR) 53.243

Previous edition unusable

Except as provided herein, all terms and conditions of the document referenced in Item 9 A or 10A, as heretofore changed, remains unchanged and in full force and effect .

75H70422R00006 Amendment-00002 Page 2 of 85

Indian Health Service

Request for Proposal

For

Purchased Referred Care (PRC)

Fiscal Intermediary (FI)

Support Services

(RFP) 75H70422R00006

Amendment – 000002

You are invited to submit a proposal in accordance with the requirements of the following Solicitation.

Proposals must be received by the Government no later than the local time on the Due Date stated in the table below.

Issue Date: 06/28/2022

Due Date & Time:

06/17/2022

2:00 p.m., EST

Point of Contact:

Darryl Smith

Darryl.Smith@ihs.gov mailto:Darryl.Smith@ihs.gov

75H70422R00006 Amendment-00002 Page 3 of 85

B.1. CONSIDERATION

The Contractor shall provide the commercial services described in Section C, Description/ Specifications/Performance Work Statement (PWS). Except as otherwise specified in the contract, the Contractor shall furnish the necessary personnel, equipment, materials, services, and otherwise do all things necessary for the performance of the work set forth herein.

B.2. CONTRACT PRICING

The Indian Health Service (IHS) is planning to issue a Time-and-materials contract vehicle as a result of this solicitation. The requirement is being solicited as full and open competition. You are invited to submit a written proposal utilizing the below Schedule of Prices for the services specified in Section C, under Request for Proposal (RFP) 75H70422R00006.

Schedule of Prices

Base Period

Tier # of Claims per Period

Proposed Amount per

Claim

1 200,000 > $

2 200,000 - 299,999 $

3 300,000 – 399,999 $

4 400,000 – 499,999 $

5 500,000 – 599,999 $

6 600,000 < $

Travel Not-To-Exceed (NTE) Amount $25,000

Base Period NTE Amount $20,000,000.00

Option Period 1

Tier # of Claims per Period

Proposed Amount per

Claim

1 200,000 > $

2 200,000 - 299,999 $

3 300,000 – 399,999 $

4 400,000 – 499,999 $

5 500,000 – 599,999 $

6 600,000 < $

Travel Not-To-Exceed (NTE) Amount $25,000

Base Period NTE Amount $20,000,000.00

Option Period 2

Tier # of Claims per Period

Proposed Amount per

Claim

1 200,000 > $

2 200,000 - 299,999 $

SECTION B – PRODUCTS OR SERVICES AND PRICES/COSTS

75H70422R00006 Amendment-00002 Page 4 of 85

3 300,000 – 399,999 $

4 400,000 – 499,999 $

5 500,000 – 599,999 $

6 600,000 < $

Travel Not-To-Exceed (NTE) Amount $25,000

Base Period NTE Amount $20,000,000.00

Option Period 3

Tier # of Claims per Period

Proposed Amount per

Claim

1 200,000 > $

2 200,000 - 299,999 $

3 300,000 – 399,999 $

4 400,000 – 499,999 $

5 500,000 – 599,999 $

6 600,000 < $

Option Period 4

Tier # of Claims per Period

Proposed Amount per

Claim

1 200,000 > $

2 200,000 - 299,999 $

3 300,000 – 399,999 $

4 400,000 – 499,999 $

5 500,000 – 599,999 $

6 600,000 < $

B.3. TRAVEL LINE ITEMS

Travel Line items shall be treated as part of the effort for the purposes of this contract and shall be handled in the following manner. The Contractor will notify the Contracting Officer’s

Representative (COR) of the requirement at least 30 business days prior to the scheduled travel.

Upon COR’s approval, the Contractor shall prepare a proposal reflecting the actual cost of the items and submit it to the COR within 5 business days. The pricing for the proposal shall be based on the commercial catalog pricing and receipts of the all items over $300 shall be included with the invoice.

The Contractor shall be reimbursed for travel costs in accordance with FAR 31.205-46.

Local. The cost of local travel, meal, and/or incidental expenses cost will not be reimbursed for

Contractor performance when involving local travels.

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Non-local. In the event that non-local travel is required, the Government will reimburse the cost via appropriate contract line item.

75H70422R00006 Amendment-00002 Page 6 of 85

SECTION C- DESCRIPTION / SPECIFICATIONS / PERFORMANCE WORK

STATEMENT

1.0 General

1.1 Introduction. The purpose of this procurement is to acquire fiscal intermediary (FI) services to operate a centralized medical and dental claims processing and reimbursement system. The FI will collect, compile and organize workload and financial data, assist the Indian Health Service

(IHS) in the coordination of benefits and provide statistical and financial reports to the IHS

Purchased/Referred Care (PRC) Program. The FI shall calculate reimbursement rates in accordance with regulations and the IHS payment policy and ensure that the IHS is the payer of last resort for services provided to patients. The Contractor will participate in the solution of problems and issues that arise in the conduct of this contract. Under this contract, FI services will also be made available to Tribal PRC programs operated under the Indian Self- Determination and Education Assistance Act (ISDEAA), Public Law 93-638, as amended.

For more information on the PRC Program, visit the IHS website at http://www.ihs.gov/prc.

1.2 Background. The IHS has a responsibility to provide health care services to eligible

American Indian and Alaska Natives (AI/AN). Direct health care services are provided through

IHS-operated and Tribally-operated hospitals, clinics and health care programs. IHS supplements its direct health care services by purchasing basic and specialty health care services from non-IHS health care providers through the PRC program. For example, PRC program funds may be used to purchase inpatient hospitalization, physician, laboratory, dental, radiology, and transportation services.

The authority to contract for a fiscal agent is contained in the Consolidated Omnibus Budget

Reconciliation Act of 1985, Public Law 99-272, Section 17003 that “. . . provides authority for the Secretary of the Department of Health and Human Services to contract with fiscal agents to perform claims payment, processing and audit functions with respect to services purchased on a contract basis by the Public Health Service ... Fiscal Agents must either be entities which could qualify as carriers for Medicare purposes, or Indian Tribes or Tribal organizations acting under the Indian Self-Determination and Education Assistance Act (ISDEAA), Public Law 93-638 contracts. While the fiscal agents need not be Medicare carriers, they must meet the same requirements regarding efficiency and effectiveness of operations, surety bonds, and financial controls.”

The PRC program is administered through 12 IHS Area Offices that consist of approximately

170 IHS and tribally-managed service units. These facilities are responsible for determining the eligibility of the patient and for purchasing medical services. Each IHS facility uses the

Purchase Delivery Order (PDO) for Health Services form (IHS 843-1A) (Exhibit A) to procure

PRC. The PDO form is also commonly referred to as, a "treatment authorization” because it authorizes the medical and dental care provider to render the health care treatment(s) requested by the respective PRC program.

The PRC program is limited by Congressional appropriations and must rely on compliance with medical and dental priorities and regulations to ensure the most effective use of PRC dollars.

75H70422R00006 Amendment-00002 Page 7 of 85

Regulations require PRC to be approved in advance by authorized individuals, except in emergency cases.

1.3 Workload. The contractor will be responsible for processing, making adjustments, reimbursements, payments and payment recoveries for approximately 466,000 medical and dental claims annually. The contractor will conduct voucher examination activities for all PRC claims to ensure payments are timely and accurate. The contractor must have the ability to receive daily transmissions from the IHS Area Offices that contain all data for PRC PDO’s subject to payment by the contractor and transmit payment information directly to Unified

Financial Management System (UFMS). The contractor will also be responsible for coordinating patient benefits to ensure that IHS is the payer of last resort on all medical and dental claims. The contractor will have the capability to contact approximately 600 primary insurers, providers, and SU staff monthly to obtain alternate resource information needed to process claims. The contractor will have the ability to respond to approximately 200 written inquiry cases monthly. The contractor shall have Customer Service staff available to respond to approximately 6,000 call per month from IHS and providers between the hours of 8:00 AM to

5:00 PM Central Standard Time to answer claims processing questions.

1.4 Performance Based Requirements. This contract is for FI services which includes a centralized medical and dental claims processing and reimbursement system for IHS in accordance with regulations, policies and standards as specified in this contract and exhibits.

2.0 Definitions and Acronyms

2.1. Alternate Resources (Third Party Payer) – Health care resources other than those of the PRC program which are accessible and available to the Indian patient such as health care providers and institutions (including facilities operated by the IHS), health payment sources or other health care programs (e.g., Medicare or Medicaid), other Federal, State, local or private insurance for which the individual may be eligible.

2.2 Area Office – The second organizational level in the IHS responsible for supporting the administrative, management and clinical system of health care unique to its regional population.

There are l2 IHS Area Offices covering the 37 States.

2.3 Billed Charges – Total charges billed by a health care provider; it shows the gross billed or retail price of services offered by the provider and does not represent the amount paid by the beneficiary or the amount collected by the provider. It is the amount that is or may be reimbursed to the provider when the provider has no existing contract in place, or when the contract or rate quote agreement indicates payment at the provider’s normal customary billed rate.

2.4 Business Associate Agreement – An agreement that governs the use of protected health information between two parties who are exchanging information and services. The agreement specifies how the health information will be used by the business associate and identifies various safeguards that must be in place to protect the information properly. The associate is required to report any unauthorized use of the information immediately.

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2.5 Claim – A bill for services that a health care provider submits for payment.

2.6 Clean Claim – A claim that has all the necessary correct information without any omissions or mistakes that allows it to be processed and paid promptly.

2.7 Closed Document - A document (PDO/obligation) in the IHS accounting system that indicates a final payment has been made.

2.8 Contract Health Service/Management Information System (CHS/MIS) – Computerized system by which IHS issues purchase delivery orders, denials and records explanation of benefits data.

2.9 Contracting Officer – A person with the authority to enter into, administer, and/or terminate contracts and/or agreements and make related determinations and findings for their designated areas on behalf of the U.S. Government.

2.10 Contracting Officer Representative (COR) – Qualified individual appointed by the

Contracting Officer who is responsible for providing technical oversight and monitoring of contract administration and contractor performance.

2.11 Coordination of Benefits (COB) – The process used to determine which insurance plan has the primary payment responsibility and the extent to which the other plans will contribute when an individual is covered by more than one plan.

2.12 Cost Savings – A sum of money that was not expended as a result of an IHS contract, rate quote, or agreement with a provider to accept reimbursement at less than the normal billed charges.

2.13 Current Year Claim - Claims submitted to the Contractor for payment for services that occurred during the current fiscal year (October 1 – September 30).

2.14 Detail of Remittance (DOR) – Document that accompanies each payment to a provider, and displays patient name, claim, and payment calculation information or it may be sent to a provider without payment explaining why services were rejected for payment, and any applicable instructions to the provider regarding resubmission.

2.15 Diagnosis-Related Groups (DRG) – Groupings of diagnostic categories drawn from the

International Classification of Diseases and modified by the presence or absence of a surgical procedure, patient age, presence or absence of significant co-morbidities or complications, and other relevant criteria.

2.16 Document History Record (DHR) – Input record used to record transactions record in the

IHS accounting system.

2.17 Electronic Funds Transfer (EFT) – An electronic method of transmitting money; a paperless system of debiting or crediting money into an account.

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2.18 Error – An overpayment, underpayment or duplicate payment made on a claim or other action that prevents a claim from being paid timely and accurately.

2.19 Explanation of Benefits Report (EOBR) – A statement describing medical benefits and account activity, including explanation of why certain claims may or may not have been paid.

The statement summarizes the claims and its processing history, and is utilized to monitor the status and results of authorized services.

2.20 Fiscal Intermediary (FI) – The fiscal agent/organization contracted by the IHS to validate and pay PRC claims.

2.21 Fiscal Year (FY) – The accounting year for the Federal Government beginning October 1 and ending September 30 and is designated by the calendar in which it ends. For example

FY 2019 begins October 1, 2018 and ends September 30, 2019.

2.22 ICD-10-CM – 10th revision of the International Classification of Diseases classification system used to assign codes to patient diagnosis; uses a 3 to 7 digit number and includes additional digits to allow more available codes.

2.23 IHS 843-1A – Universal PRC PDO form incorporating attributes of the IHS 43, 64, and 57-

1As.

2.24 Interest – A fee paid by a borrower of assets to the owner as a form of compensation for the use of the assets. It is most commonly the price paid for the use of borrowed money, or money earned by deposited funds. Interest is typically paid as a percentage of the principal.

2.25 Internal Control Number (ICN) – Unique contractor number assigned to each claim for processing and tracking purposes.

2.26 Internal Control Review – The process of providing reasonable assurance that the internal controls achieve the expected results.

2.27 Internal Controls – A process for assuring achievement of an organization's objectives in operational effectiveness and efficiency, reliable financial reporting, and compliance with laws, regulations and policies.

2.28 Inpatient Prospective Payment System (IPPS) – The Social Security Amendments of

1983 (Public Law 98-21) established the IPPS for hospital inpatient services provided to

Medicare beneficiaries. Under this system, a hospital is paid a fixed amount for each patient discharged in a particular treatment category or DRG.

2.29 Medical Priorities – Identification in ranking order of health care services that may be funded by the PRC program. Federal regulations permit IHS to establish priorities of care based on relative medical need when PRC funds are insufficient to provide the volume of PRC indicated as needed by the population residing in a PRC delivery area.

2.30 Medicare-Like Rate (MLR) – Payment methodology establishing that Medicare-participating hospitals that furnish inpatient services must accept no more than reimbursement

75H70422R00006 Amendment-00002 Page 10 of 85 amount based on PPS reasonable cost (non-PPS hospitals) for all items and services authorized by IHS, Tribal, and urban Indian organizations.

2.31 National Provider Identifier (NPI) – A unique health identifier number for individual health care providers and organizations.

2.32 Object Class Code(s) – Finance-based code used to classify types of services purchased with PRC funds. The codes are used to record accounting transactions in the IHS accounting system.

2.33 Open Obligation File (OOF) – Computerized file in the IHS accounting system containing all documents for which a final payment or other final action has not been made.

2.34 Patient Liability – The amount of the claim for which the patient is held responsible after the primary resource(s) have paid less any IHS disallowed charges for services not authorized or covered.

2.35 Payer of Last Resort – The individual or entity who is responsible for remaining claim costs after all other available resources have paid. IHS is the payer of last resort for persons defined as eligible for PRC under regulations. See 42 CFR 136.61 for full description.

2.36 Pended Claims – Claims that must be stopped or delayed in the Contractor’s payment processing cycle because the claims did not pass all IHS and/or Contractor edits.

2.37 Percent of DRG – This indicates a discount on Medicare rates for inpatient services; e.g., if the Medicare allowance for the relevant DRG category is $1,500 and the pricing methodology is

90 percent of the DRG amount, IHS would pay $1,350.

2.38 Prior Year Claim – Claims for services that were provided in a preceding fiscal year.

2.39 Purchase Delivery Order (PDO) – An obligating document, IHS 843-1A, for the purchase and payment for PRC services.

2.40 Purchased/Referred Care Officer (PRCO) – Area Office level staff who is responsible for the administration and management of the PRC program, provides guidance and technical assistance to local level federal and tribal PRC programs and conducts evaluation and reviews of the Area PRC programs within their purview.

2.41 Purchased/Referred Care Rates – Payment methodology establishing Medicare payment methodologies to all physician and other health care professional services and non-hospital-based services.

2.42 Service Class Code(s) – PRC program-based codes used to categorize medical services purchased with PRC funds.

2.43 Service Unit (SU) – The third organizational level in the IHS responsible for the administration and management of clinical health care services and related programs including

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PRC. The SU PRC program approves the payment of patient referrals and initiates the purchase delivery order.

2.44 Threshold – Represents the dollar limit by which payments made by the Contractor on behalf of Tribal programs can exceed the estimated charges.

2.45 Unified Financial Management System (UFMS) – An Oracle based financial system of record that standardizes the process for all IHS financial transactions.

2.46 Acronyms

ACA Affordable Care Act

ADA American Dental Association

ADP Automated Data Processing BAA Business Associate Agreement

CFO Chief Financial Officer

CHS/MIS Contract Health Service Management Information System

CMO Chief Medical Officer

CO Contracting Officer

COR Contract Officer Representative

DOR Detail of Remittance

DRG Diagnosis Related Groups

EOB Explanation of Benefits

EOBR Explanation of Benefits Report

FI Fiscal Intermediary FMO Financial Management Officer

HIPAA Health Insurance Portability and Accountability Act

IHS Indian Health Service

ICN Internal Control Number

IPPS Inpatient Prospective Payment System

MLR Medicare-Like Rate

NPI National Provider Identifier

OOF Open Obligation File

PDO Purchase/Delivery Order

PRC Purchased/Referred Care PRCO Purchased/Referred Care Officer

SCC Service Class Code

SU Service Unit

UFMS Unified Financial Management System

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3.0 Specific Requirements

3.1 Task I – Claims Processing System

3.2 Task II – Claims Payment and Recovery

3.3 Task III – Reimbursement Methods

3.4 Task IV – Data/Information/Reporting

3.5 Task V – Support Services

3.6 Task VI – Management

3.7 Task VII – Tribally Operated PRC Programs

3.1.0 Task I – Claims Processing System (At a minimum the contractor shall)

3.1.1 Provide and operate an automated system for medical and dental claims processing, adjustments, reimbursements, payment recovery, and controls to ensure accurate and timely payments in accordance with established Department of Health and Human Services (DHHS) and IHS accounting practices.

3.1.2 Conduct voucher examination activities for all PRC claims processed by the FI to ensure payments are timely and accurate.

3.1.3 Coordinate with IHS and other payers to ensure that IHS is the payer of last resort on all claims, unless an exception is approved by IHS, such as tribal self-insurance and waiving an EOB.

3.1.4 Receive, disburse, and account for funds in making IHS PRC claim payments.

Claims shall be processed and paid in accordance with the terms and conditions of this contract.

3.1.5 Maintain a single mailing address for manual receipt of all claims, invoices, IHS

PRC PDOs, provider refunds and other related documents.

3.1.6 Maintain sufficient internet site for receipt of electronic claims and to connect appropriately for interfacing with IHS’s multiple information systems.

3.1.7 Process dental claims with Service Class Codes (SCC) 25.2D and 25.4E for Areas specified by the COR. Dental lab services (SCC 25.2D) include prosthetic fabrication services provided by dental laboratories. Dentist services (SCC 25.4E) include all services provided by contract dentists to outpatients and inpatients. This SCC also includes combined dental laboratory costs and dental services.

3.1.8 Be responsible for obtaining any missing Explanation of Benefits (EOB) information needed to process medical and dental claims. Within three (3) days of processing a claim the Contractor shall coordinate with the Service Unit for coverage information and payment calculation when the information on the PDO or claims conflict.

3.1.9 Issue an Explanation of Benefits Report (EOBR) and send it electronically to the issuing facility when alternate resources have paid the claim in full and there is no IHS

75H70422R00006 Amendment-00002 Page 13 of 85 liability. EOBRs are sorted by PDO number by Fiscal Year (FY) for each authorizing facility as specified by IHS.

3.1.10 Alternate Resources Paid Report – Collect and report the total amount of alternate resources paid on a given claim. The information will be sorted by Medicare, Medicaid and Private Insurance. Specific data elements will be determined at the time of the initial request for report. This information will be used by IHS management to determine how

IHS is leveraging funds, tracking cost savings through the use of alternate resources and ensuring that IHS is the payer of last resort.

3.1.11 Receipt of Alternate Resource Information – Maintain a master listing of patients with alternate resources by facility. The master list shall be used to assist SUs in coordinating the use of appropriate alternate resources. After receiving SU notification of any changes in patient alternate resources status by letter or facsimile, the information will be included with all other alternate resource correspondence and updated when worked in Julian date order of receipt. The Contractor shall update the alternate resource information received on the electronic PDO when the claim is processed. The Contractor shall modify the alternate resource list for updates within three working days after receipt.

3.1.12 Perform claims control functions during processing. At a minimum the functions will include:

3.1.12.1 Implementing a system to assign and clearly identify each claim with a unique internal control number (ICN). Each claim shall be assigned the ICN within three (3) business days.

3.1.12.2 Implementing a system to track aged claims. Aging shall occur upon receipt of claim. Reporting is required at a minimum of every thirty (30) calendar days.

3.1.13 Ensure that inpatient Medicare claims are assigned to the appropriate DRG and conduct random validation. DRG validation shall be performed after claims payment has been made, unless the Area Office or SU requests otherwise. Results of DRG validation shall be reported to the COR. When validation results in a financial adjustment or recovery, the information shall be documented and reported to the respective

Purchased/Referred Care Officer (PRCO).

3.1.14 The Contractor’s system shall recognize multiple remit to addresses.

3.1.15 Implement or remove a program edit within five (5) business days upon notice from the COR.

3.1.16 Have the capability to send and receive electronic data in standard transaction format as required by the Health Insurance Portability and Accountability Act (HIPAA).

See http://www.hhs.gov/ocr/privacy/index.html for further information.

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3.1.17 Provider claims must be accompanied by the approved IHS PRC PDO form. The

IHS reserves the right to waive the requirement of a hard copy PDO with each claim.

3.1.18 When the Contractor is unable to enter a claim because of incomplete data, the

Contractor shall return the appropriate forms to the provider within three (3) business days for correction and shall notify the provider of the proper procedures for submitting claims.

Additional charges submitted by a provider on a previously paid and or pended claim may be processed if charges are not final. The Contractor shall notify the SU if a new PO must be issued.

3.1.19 Report all requests for additional information that remain open after 30 calendar days to the respective IHS Area PRCO.

3.1.20 Review pending claims and recycle claims after each Open Obligation File (OOF) is received from the IHS Accounting System (UFMS). Any discrepancies requiring SU action shall be referred directly to the SU PRC staff for action.

3.1.21 Pay only those claims reflected on the OOF extract received from the IHS accounting system (UFMS).

NOTE: The Tribal programs may set claim payment edits for those Tribes using thresholds. The Contractor shall only pay claims for which adequate funds are available as reflected by comparing the claim payment amount with the estimated charge on the purchase order or are within the thresholds defined by the Tribe.

3.1.22 When the electronic signature is not utilized for rate quote and open market claims that exceed a payment amount designated by IHS, the Contractor shall verify that the

Area Contracting Officer, or his/her designee with the appropriate authorizing authority, has signed the PDO.

3.1.23 Maintain and destroy all claims information and correspondence in accordance with the IHS Records Disposition Schedule, as applicable, and as identified in 3.4.10.

3.1.24 Reject claims older than the current fiscal year plus the five prior fiscal years with a final reject code that indicates the claim was returned to the IHS SU for appropriate payment action. If possible, the original PDO and attachments will be sent to the PRCO.

If the original document(s) cannot be readily located, the Contractor may send a copy of the documents.

3.1.25 Process claims in accordance with the Prompt Payment Act, 31 U.S.C. 3901, et.

seq., and its implementing policies and procedures contained in 5 CFR Part 1315. See http://fms.treas.gov/prompt/regulations.html for further information.

3.1.26 Acknowledge receipt of notification made to provider contracts or delegations of authority in a confirmation letter to the Area PRCO.

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3.1.27 Make electronic funds transfer (EFT) available to providers for electronic remittance advices. The Contractor shall work with IHS to implement EFT by modifying the bank funding processes to ensure appropriate and timely funding and payments.

3.2.0 Task II – Claims Payment and Recovery

3.2.1 Make payments for medical and dental claims in accordance with IHS Contracts, applicable Medicare-like rates, Purchased/Referred Care Rates and negotiated rate agreements. Any conflicts shall be referred to the COR. The Contractor shall develop and implement internal controls as part of the claims processing system for handling provider refund checks and restitution checks to ensure proper credit is given to the originating facility. In the event of an error caused by the Contractor that requires the reprocessing of a claim, Contractor shall reprocess such claim and, as applicable, pay such claim at no additional per claim fee to the government. To the extent any Contractor-caused error results in interest penalties owed and paid to the provider or supplier of services, the contract price established herein and paid to Contractor shall be reduced by an amount equivalent to the interest penalty paid. If a new PDO is required to reprocess the claim, the Contractor will be responsible for the portion of interested owed up to the time a new PDO is requested.

3.2.2 Pay the IHS patient liability amount for medical and dental claims involving alternate resources (third-party payers) as follows:

3.2.2.1 The IHS patient liability amount is defined as the amount for which the patient is held responsible after the primary resource(s) have paid less any IHS disallowed charges for services not authorized or covered. For Medicare and

Medicaid cases, payment by the Federal or state agency may constitute payment in full. If there is no IHS liability for payment, no further payment shall be made.

3.2.2.2 The contractual and regulatory restrictions and limitations imposed by the primary resource(s) or payer(s) will apply in determining the IHS patient liability amount. The IHS patient liability amount shall not exceed the amount which would have been paid if IHS were the sole payer.

3.2.2.3 The Contractor shall not coordinate benefits if a PRC provider is being paid through PRC funds for services performed in an IHS facility, and if the IHS facility bills the primary insurer directly.

3.2.2.4 For services subject to the PRC Rates regulation, the contractor shall review the patient liability and pay the lessor of the allowed amount or the patient liability, unless otherwise specified in a contracted rate. This shall not apply to

Tribal programs that have not opted-in to the PRC rates.

3.2.3 Provide recovery and accounting procedures for duplicate or erroneous provider payments to include:

3.2.3.1 Procedures to initiate collection procedures within five working (5) days or less of the determination that the provider received an overpayment.

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3.2.3.2 A notification to the provider which includes:

The specific claim(s) on which the overpayment was made.

The amount and date of refund due.

Notification that failure to provide a refund may result in referral of the debt to the Federal Government for collection as provided in the Debt Collection Improvement Act 1996. See https://www.fiscal.treasury.gov/dms/about/about-dcia.html for further information.

3.2.3.3 Unique cases where an exception may warrant special consideration will be referred to the COR for direction.

3.2.4.0 PROCESSING, TIMELINESS AND ACCURACY

3.2.4.1. Clean Claims:

3.2.4.1.1 Process and pay all clean claims within 30 calendar days of receipt.

3.2.4.1.2 Provide detail on the claims processing timeliness to the COR.

3.2.4.1.3 A claim is considered as paid on the date the check and DOR are mailed or electronically transferred.

3.2.5.0 PENDED CLAIMS:

The Contractor shall have the ability to pend a claim. A claim may pend (be stopped or delayed in the Contractor's processing cycle) when there is something missing or wrong with either the PDO, alternate resources, or the provider’s billing form. The Contractor shall provide a process that, at a minimum:

3.2.5.1 Reviews the claim and PDO for all inaccuracies

3.2.5.2 Requests additional information within five (5) business days to resolve discrepancies.

3.2.5.3 Requests information or assistance from other sources.

3.2.5.4 Resolves and processes all Contractor internal pends/holds no more than

20 days after identification of the pend reason.

3.2.5.5 Updates all necessary pricing information within 5 working days upon validation and testing of the schedules. The COR shall be notified of claims pending for more than 45 business days and the proposed plan of action to rectify the delay.

3.2.6.0 DENTAL CLAIMS

https://www.fiscal.treasury.gov/dms/about/about-dcia.html

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The IHS dental program’s procure third party administrative services to meet the following objectives, simplify the administration of the PRC program; promote consistent and equitable deployment of PRC funds among individuals, local programs, and IHS Areas; expand the scope of the dental care services through efficient and effective Third Party Administration; and assure the highest level of quality dental services to AI/ANs.

PRC funds are used to provide emergency dental care coverage, reimburse private dentists who operate in IHS facilities, provide routine care services to communities distant from IHS facilities, provide services of dental specialists when treatment exceeds the competencies of IHS staff, and pay for dental laboratory services.

3.2.6.1 The Contractor shall establish a computer software program for maintaining each program as a separate client.

3.2.6.2 The Contractor shall provide a dedicated dental claims processing component to assure accurate adjudication and administration of IHS dental claims consistent with the requirements of this contract.

3.2.6.3 Schedule of Services:

Health care services are not an entitlement for AI/AN beneficiaries. In lieu of a benefits package the IHS has established medical priorities to guide the programs in the delivery of service and the expenditure of PRC funds. The dental program has developed the Schedule of Services and the referral types to suggest logical service priorities for payment. Additionally, the schedule details the limitations and exclusions which apply for each American Dental Association (ADA) procedure as appropriate. The Schedule of Services is intended as a guide to the proper use of PRC funds in order to provide services based on and consistent with sound dental public health principles. See https://www.ihs.gov/doh/clinicmanagement/ohpg/Chapters/Chapter%205%20Tab le%20of%20Contents.html, Section D, IHS Schedule of Dental Services for further details.

Under this contract the Schedule will provide the authorized services, limitations and exclusions template common to each “client.” For those programs with negotiated contracts in place, the Contractor’s system must accommodate the specification of services and incorporate the filed fees of these contracts.

These will supplant the schedule of service elements as the template for all providers with Government contracts. The Dental Professional Specialty Group will provide direction to the Contractor as to what levels of dental care will be paid.

3.2.6.4 Referrals

https://www.ihs.gov/doh/clinicmanagement/ohpg/Chapters/Chapter%205%20Table%20of%20Contents.html https://www.ihs.gov/doh/clinicmanagement/ohpg/Chapters/Chapter%205%20Table%20of%20Contents.html

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The IHS has developed specific referral types to assist dental programs in further delineating the authorization of PRC funds. The appropriate referral type must be entered prominently on the IHS PDO and becomes a further modifier to the authorized services template. Referral types apply both to the contract and open market providers. The referral types and their codes are as follows:

3.2.6.4.1 Primary Care – Referral for primary care services levels I – III of the IHS Schedule of Services is sub-divided into the following two categories:

3.2.6.4.1.1 Emergency Care – The provision of emergency services may be through IHS or self-referral. Authorized emergency care services are primarily contained in Level I of the IHS Schedule of

Services. However, selected services in Levels II and III may apply in the resolution of the emergency situation.

3.2.6.4.1.2 Basic Care – Basic care services are contained within

Levels II & III of the IHS Schedule of Services.

3.2.6.4.2 Secondary Care – Referral for secondary care services e.g., Levels IV and V of the IHS Schedule of Services are sub-divided into the following two categories:

3.2.6.4.2.1 General Services – Referral for secondary care services in Levels IV and V of the IHS Schedule of Services have been made to a general dentist.

3.2.6.4.2.2 Specialist Services – Referral for secondary care services in Levels IV and V of the IHS Schedule of Services have been made to a dental specialist. Specialty care services are discrete within the appropriate ADA classification e.g., endodontics D3000, periodontics D4000, removable prosthodontics D5000, fixed prosthodontics D6000, oral surgery

D7000, and orthodontics D8000.

3.2.6.4.2.3 Exclusions – Level IX – These services will not be paid for with PRC funds.

3.2.6.4.3 Dental Laboratory Services – IHS staff and contract Dentists operating in IHS facilities use PRC funds to purchase dental laboratory services.

For all other dental providers the cost of the laboratory services is included in the fee charged.

3.2.6.4.4 Other – Selected dental procedures may be provided in a hospital setting. Services that are provided by a dentist will be billed on an IHS

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PDO standardized claim form. No other claim forms or non ADA procedure codes will be reimbursed.

3.3.0 Task III – Reimbursement Methods

3.3.1 The Contractor shall use the reimbursement methodologies within 42 CFR 136

Subpart D and Subpart I as applicable.

3.3.2 In one unique case, the FI will calculate the reimbursement rate for the

Congressional University of New Mexico Hospital. The rate is a per diem rate based on the hospital cost report excluding several line items.

3.4.0 Task IV – Data/Information/Reporting

3.4.1 The contractor will provide hardware, software, and communications network technologies required to manage a PRC Automated Data Processing Claims system

(ADP) business application that includes communications networks, equipment capacities, operational procedures and technology capabilities. All systems, technology, hardware and software must be ICD-10 compatible. Technologies used shall carry out key activities – such as data security, preparation, storage, and retrieval-across functional, organizational, and geographic boundaries. The Contractor shall implement and provide a system, which will provide services, equipment, and material required to support current and future operations for IHS PRC claims processing. The following are among the services that will be required:

3.4.1.1 Mid-tier Internet architecture managed applications hosting service – The

Contractor will provide, configure, and maintain all managed mid-tier hardware servers and supporting software for IHS customers to access claims activity status.

3.4.1.2 Application services – The Contractor will provide hosting of claims processing center services for applications requiring computing capabilities. The

Contractor will provide all hardware, software, ongoing maintenance, support, operation, and administration for the claims processing center.

3.4.1.3 Claims processing services – The contractor will provide all the necessary hardware, Commercial Off the Shelf (COTS) Software, labor, supervision, tools, materials (including manuals and schematics), documentation, parts, equipment, transportation, and supplies necessary to process claims, maintain the data center, and support Medicare processing at the data center as required by in Section 3.3.0, Reimbursement Methods.

At a minimum, the following components shall be provided and described in the contractor’s proposal:

3.4.2 Hardware

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The computing hardware utilized in performing these business functions varies and may have varying configurations. IHS is not prescribing the hardware to be used to carry out the business functions beyond that which is needed to provide support to the functional requirements for all the work identified in this performance work statement (PWS). All hardware to be used shall be documented and routinely updated as changes occur.

3.4.3 Software

Software products supporting the claims processing applications shall be described in the proposal and continually documented upon award to provide for an inventoried listing.

The descriptions shall support four major service areas identified below. Documentation shall be categorized to depict the service area, general area of use within the service area, Product Name and a Description that details its functionality.

3.4.3.1 Application Development – The software shall consist of an operating system, applications software, and any executive software module necessary to implement the function requirements of this contract. The software must conform to IHS payment instructions and procedures, and perform all internal edits checks for appropriateness of service, etc. The IHS retains unlimited rights over claims information and non-software data generated by the Contractor under this

Contract.

3.4.3.2 Data Management – Data Extraction and non-relation data management applications such as Oracle that incorporates the SQL language or SQL servers and their respective software that may support client/server use.

3.4.3.3 Middleware – Transaction processing ware that controls the interaction between applications and users.

3.4.3.4 Information Processing – Personal computers, enterprise server (e.g. large scale, mid-tier or mainframe) or enterprise server operating system (e.g. Unix

AIX, Unix Solaris).

3.4.4 Procedures

Security hardware and software, together with internal and external controls and procedures, shall fully meet all IHS security requirements and privacy responsibilities.

The contractor shall establish safeguards to protect against the access of unauthorized entities into the systems environment either by unauthorized software modification, online connectivity, the submission of Electronic Data Interchange (EDI) transactions or divulgence of confidential information.

3.4.5 Security

Sufficient security safeguards shall be employed to prevent unauthorized entry into the data processing facility, unauthorized access to data and data files, unauthorized software modification, divulgence of confidential processing procedures or techniques, unauthorized access to/or release of IHS patient data and claims payment information.

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3.4.6 Documentation

The ADP system shall be well documented including narratives, system structure charts, data flow, diagrams, data dictionary, system edits, and file descriptions. System and module documentation shall include interconnection and inter-relation of data files.

3.4.7 Maintenance

The hardware and software shall be adequately maintained so that the Contractor is able to comply with processing standards.

3.4.8 Backup

Adequate software backup for hardware, software and data files shall be maintained on site and off site to ensure the Contractor is able to comply with the processing standards.

Access to alternate hardware and software systems shall be available to ensure continued timely processing during periods when the primary system is inoperative. Key data files shall be adequately backed up to ensure recovery in the event of crashes or data destruction. Backups shall be retained for all payment data submitted to IHS/PRC. The

Contractor shall begin the process of conducting a test of the backup data processing system within the first quarter of the contract and will continue to assure backup capabilities by testing the availability and capability of the backup ADP system. Testing and review of the primary ADP system configuration with the backup ADP system configuration must be done on at least an annual basis. Contractor shall provide current testing results if requested by COR. If the review of output verification concludes the existence of non-compatibility between the primary and backup ADP system, the

Contractor shall notify the IHS COR immediately and within 24 hours reestablish a backup system which is compatible with IHS/PRC. Any breach in security of software, data, data files, or protected health information transmitted electronically will be reported to the COR upon confirmation of the breach.

3.4.9 The Contractor shall receive and transmit data electronically using IHS protocol.

At a minimum the contractor shall:

3.4.9.1 Through compliance with the Privacy Act, and HIPAA, develop a system for ensuring secure and proper handling in the receipt of claims, control of claims, and claim information in the Contractor’s possession. All claims and related information shall be date stamped with the actual day of receipt.

The Contractor, as a Business Associate (BAA), shall abide by the provisions of

HIPAA and its implementing regulations. Pursuant to the provisions, the parties agree to the HIPAA Business Associate Addendum attached hereto and incorporated by reference as if fully set forth herein.

For further information see:

http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov

.html.

http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.html http://www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.html

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3.4.9.2 Provide an automated file system to furnish IHS required financial and statistical information and reports. Statistical data files and reports shall be produced separately for dental claims data.

3.4.9.2.1 The Contractor shall receive the IHS Medical Statistical Filters and criteria on how to classify records as outpatient or as inpatient from

Office of Information Technology and apply the updates to the applicable tables within the Contractor’s system. The Contractor will create Export

Files containing data from PRC inpatient, outpatient, and dental records layouts (Exhibit B_NPIRS Export File Template). Export files are then transmitted via file transfer protocol (FTP) to National Patient Information

Resource System (NPIRS).

3.4.9.2.2 The database must be comprehensive and collect all data from the above mentioned information sources which pertain to the claims paid by the Contractor. The data fields to be collected and maintained are specifically identified in Exhibit B.

3.4.9.2.3 The Contractor shall maintain this database and be able to generate reports utilizing any combination of the data elements.

3.4.9.2.4 The Contractor shall, upon request of the COR, provide an electronic copy or hard copy of the data elements used in preparing standard and ad hoc report(s) requested by IHS.

3.4.9.2.5 As requested by the COR, the Contractor shall provide an electronic copy of all or part of the database.

Information requested shall be transmitted within 14 calendar days of request.