SOW - CLEARINGHOUSE SERVICES.pdf

ASU Clearinghouse Secure Data Transport Services

1. PURPOSE:

To provide clearinghouse secure data transport services to and from the Medicare Administrative Contractor and Commercial Insurance Payers using Centers for Medicaid and Medicare Services approved commercially available Internet-based connection services to the following Albuquerque Area Indian Health Service facility:

Albuquerque Service Unit 801 Vassar Dr. NE Albuquerque, NM 87106

Acquisition will be for one base year and four one-year options for renewal.

2. DESCRIPTION OF SERVICES/SUPPLIES

The contractor shall be in accordance with all Federal, State, Local, Tribal and IHS regulations and shall be made with minimal divergence from the schedule established and with minimum disturbance and maximum protection of government personnel, property and general public.

BACKGROUND INFORMATION:

Centers for Medicaid and Medicare Services announced that Novitas Solutions, Inc., LLC (Novitas) was awarded the contract for the combined administration of Part A and Part B Medicare fee-for-service claims.

The Novitas MAC (Medicare Administrative Contractor) responsibilities will include Part A Fiscal Intermediary (FI) and Part B carrier for Colorado, New Mexico, Oklahoma, and Texas; the National carrier and FI for Indian Health Service; and the National carrier and FI for the Veterans Affairs Medicare Equivalent Remittance Advice Project. Hence, Novitas Solutions, Inc. is the only FI provider that adjudicates claims for Medicare services for all of the Indian Health Service agency, and as well as all tribal facilities that are enrolled in the Medicare program. To facilitate the implementation, Novitas migrated all electronic claims submitters from their legacy front-end system to the EDI gateway, GPNet for Medicare Part A claims and the Professional Provider Telecommunications Network (PPTN) for Medicare Part B claims. Both of these systems, the GPNet and PPTN require a Network Service Vendor in order to transmit the data files.

SPECIFICATIONS FOR THE NETWORK SERVER VENDOR:

ESTABLISH ENTRY POINT:

• The contractor shall provide the entry point into the Novitas Solutions, Inc. processing system.

SECURE DATA EXCHANGE SERVICE:

• The contractor shall provide a secure data transport service between ASU that is recognized by CMS as an authorized Internet- based commercially available connection.

These services will include the following:

1. Billing a.) Extract, create, utilize Electronic Health Record (EHR) for validation of specific Provider evaluation, diagnosis, and management of a patient presentation in order to link billable diagnostic and procedural codes;

and validate Insurance eligibility in order to approve billable patient encounters for the Outpatient Facility at Albuquerque Indian Health Center (AIHC); Santa Ana Health Center (SAHC); and Zia Health Clinic (ZHC).

The Resource and Patient Management System (RPMS) is utilized, with each staff member creating a transaction that is electronically captured as "cashiering sessions" are closed at the end of the day, when a reconciliation is performed and exported to the Unified Financial Management System.

b.) An additional process occurs when file is recreated of all claims approved through RPMS by the Biller and sent though a Clearinghouse which is the electronic data interchange (EDI) that is received electronically for varied Insurers, also informs the client of any claim file errors, which is rejected and reported to the Client. In this process the file is then authenticated, corrected, which is then released to the Payers for processing. The payers will process the claims which are reimbursed to the Service Unit.

c.) All Payers such as Medicare, Medicaid, Private Insurance (many) and VA are to be submitted through the proposed electronic data interchange (EDI), Inc.

2. Qualifications a.) The revenue cycle must be augmented with a streamlined and reliable service to receive claims being transmitted electronically with real-time claim acceptance, and a complex error message translated in clear messaging in order to support the higher claims success rate and reconciliation that ensures the reliability of reimbursement at an increased rate and decreased denials and rejections.

b.) The capabilities must have easy access to the hundreds of payers for real-time and batch eligibility and connectivity and availability 24/7.

3. Electronic Claims Transmission and Reporting a.) The claims received in the Clearinghouse will verify a "clean claim" by a scrubbing engine which has Local and National Coverage Determination, Payer Rules and Correct Coding Initiatives (CCI). Errors are identified with suggested corrections and returned to the Client.

Claims for all Payers have to be verified for eligibility transaction to ensure coverage exist before claims are sent to the Payer.

b.) Claims Management must have the capability of identifying denied claims and must have the capability to perform payer appeals for reimbursement.

c.) Claims acceptance and reimbursement must be successful.

d.) Technical support and service training and implementation must be available without any impacts to the Agency's revenue cycle.

The service shall comply with the following constraints:

• The service shall not require ASU to install contractor software within the AAIHS environment.

• The service shall enable ASU/Novita’s data exchanges utilizing an ASU/ contractor VPN and secure File

Transfer Protocol (FTP) as approved by the Indian Health Service (IHS) Office of Information Technology.

• The service shall support EDI transactions and interactive telnet sessions.

• The service shall support multiple users and access shall be workstation independent.

• The service shall not entail development of HIPAA (Health Insurance Portability and Accountability Act) transaction set translation or mapping processes, non-CMS or non-IHS generated data or messages, or data reformatting;

• The service shall conform to the information agreements to be established via an Interconnection Security Agreement and Memorandum of Understanding between the Indian Health Service and the contractor.

• The service shall also conform to a business associate agreement to be established between the ASU and the contractor.

MAINTENANCE AND SUPPORT:

The contractor shall support end-to-end communication testing, implementation and daily operations of the data transfers from the contractor to ASU which shall include, at a minimum:

• The contractor shall provide routine technical support to implement corrections to service occurring as a result of errors, flaws or other failures within their service.

• The contractor shall notify a designated ASU point of contact (Contracting Officer's Representative (COR)) of any scheduled maintenance that shall result in downtime at least two (2) days prior to the maintenance period.

• The contractor shall notify a designated ASU point of contact of any issues at their facility that results in a disruption of data exchange capabilities. This notification shall occur as soon as possible after the disruption has been identified.

• The contractor shall provide customer support for reporting, documenting, tracking and resolving of service problems, which shall be available via telephone and email to ASU technical staff during the period 8:00 a.m. through 5:00 p.m. Mountain Standard Time.

INTERNET BASED CONNECTION SERVICE:

• Conformity and standardization – ASU would have similar access to Medicare and hundreds of payers.

• Unlimited DDE and PPTN online Medicare claims status/corrections, etc., through an enhanced web portal.

• Automated batch 837/835 file transfers to and from Medicare through the Enterprise Server on location at the Albuquerque Area.

• Automated batch 276/277 claims corrections capability via the Enterprise Server on location at the

Albuquerque Service Unit, Business Office.

• All payer eligibility workflow tool with single and batching inquiries 270/271.

• Single sign-on for Medicare and COMPLETE

• Unlimited support, no annual membership fees

• Medicare Eligibility (HETS)

• Medicaid Eligibility

• Commercial Eligibility

• Veteran’s Administration (VA) Eligibility

• Transaction History

• Multiple/Simultaneous Inquiries

• Batch

• Revalidation

• Dashboard

• Included in CHOICE All Payer Eligibility

• Medicare Eligibility (HETS)

• Medicaid Eligibility

• Commercial Eligibility

• Transaction History

• All-Payer Claims can take electronic claims from RPMS and Alerts billing staff to errors so they can fix claim errors in minutes rather than days or weeks.

• Submit all claims at once in batch instead of submitting them separately one at a time.

• Reduce human error and the need to manually re-key transaction data over and over at each payer’s website.

• Provide a single location to manage all electronic claims, including VA claims.

• Help avoid prolonged wait-times being on hold with Medicare and other payers inquiring about claim errors.

• Provide knowledgeable support personnel.

• Reduce payment cycles leading to more accurate revenue forecasts.

• Reduce or eliminate need for paper forms, envelopes and stamps.

• Greatly simplifies and speeds up claims processing.

UPGRADE AND/OR ENHANCEMENTS–

Any future upgrades, enhancements including new releases and new versions to the items noted in the specifications shall be addressed and modified, at the discretion of the Contracting Officer, in accordance with Federal Acquisition Regulations.

3. DELIVERY LOCATION

A Clearinghouse Secure Data Transport Services Agreement shall be provided to the following Albuquerque Area Indian Health Service Facility:

Albuquerque Indian Health Center 801 Vassar Dr. NE Albuquerque, NM 87106

1. PERIOD OF PERFORMANCE

The items required under this contract shall commence NLT 10 days after award:

Start End Base 12/01/24 11/30/25

Option Year #1 12/01/25 11/30/26 Option Year #2 12/01/26 11/30/27 Option Year #3 12/01/27 11/30/28 Option Year #4 12/01/28 11/30/29

2. COMPENSATION

Clearinghouse secure data transport services to and from the Medicare Administrative Contractor and Commercial Insurance Payers using Centers for Medicaid and Medicare Services approved commercially available Internet-based connection services agreement for the specified Albuquerque Service Unit in the following format:

Estimated Usage (per month) Medicare Claims Commercial Claims Eligibility Lookups Monthly Annual

Base 500 3000 60 3500 42000 Option Year #1 500 3000 60 3500 42000 Option Year #2 500 3000 60 3500 42000 Option Year #3 500 3000 60 3500 42000 Option Year #4 500 3000 60 3500 42000

DDE/FISS Connects Needed: 2

The Contractor shall be compensated at the agreed contract amount based on monthly invoices submitted and only for services in direct performance of this contract. The Contract does not allow for annual or sick leave or other fringe benefits. Per mandate by the U. S. Department of Treasury and effective July 1996, payments by Electronic Funds Transfer System will be made to the Contractor's designated financial institute.

The Contractor's pricing/cost includes all mandatory Federal, State and Local taxes. It is the sole responsibility of the Contractor to collect and pay for all New Mexico State Gross Receipt Taxes for business/work performed in the State of New Mexico, regardless of county the business/service/work was performed. A firm fixed-price purchase order will be awarded for a base year, with four, one-year options for renewal. Total contract award shall not exceed five years. Option renewals will be on the basis of satisfactory services provided and contingent upon availability of funds for the appropriate fiscal year.