A.02 PERFORMANCE WORK STATEMENT -TPC.doc

PERFORMANCE WORK STATEMENT

SERVICES

Third Party Collection (TPC) Services Regional Health Contracting Office-Atlantic

1. 0. INTRODUCTION.

1.0.1. The Contractor shall provide Third Party Collection Services support for all Military Treatment Facilities supported by the Regional Health Contracting Office-Atlantic. The services will be of a nature and scope described in the paragraphs below. Department of Defense (DOD) policy requires that all Military Treatment Facilities (MTFs) collect payment for medical services rendered to authorized DOD beneficiaries who have other health insurance (OHI) coverage. Under the Third Party Collection Program (TPCP), the Contractor shall augment current MTF staff in such actions which ensure that; MTFs receive Third Party Collection payments for services provided to non-Active Duty DOD beneficiaries who have OHI coverage, and who receive medical treatments from Medical Treatment Facilities (MTFs) named herein, from those patients’ OHIs for those the costs of health care provided in any Government facility of the uniformed services from those third party payer/insurance company(s) who are obligated to pay the United States Government. The contractor shall, in conjunction with MTF staff, perform such steps from OHI discovery through collection to posting from third party payers in this Third Party Collection Program (TPCP). The Government will retain overall responsibility for the Third Party Collection program. Functions performed by government employees will continue to be performed with the in-house staff. Contractor augmentation at each MTF will be specified in the applicable task order.

1.0.1.1.

The quality of care provided by the contractor employees shall be of a quality meeting or exceeding currently recognized national standards as established by the Joint Commission (JC). Contractor employees shall give the highest regard to patient dignity and observe the precepts of the American Hospital Association’s Bill of Rights for Patients. The Contractor employees shall abide by the Medical Treatment Facility (MTF) rules, regulations and by laws, including Medical Staff By laws, as well as applicable Army regulations governing such things as medical records.

1.1. GENERAL.

1.1.1. This contract is a non-personal services contract and is not intended to create an employer-employee relationship between the Government and the individual contract public health service providers. The contract does not create an employer-employee relationship between the Government and any corporation, partnership, business association or other party or legal entity with which the contractor may be associated.

1.1.2. Confidentiality / HIPAA. The Contractor shall abide by AR 40-3 and AR 40-66 concerning the nature of limited privileged communication between patient and health care provider for security and personnel reliability programs. The Contractor shall abide by AR 40-66 concerning the confidentiality of patient records, as embodied in federal statutes including the Privacy Act of 1974 and the Drug and Alcohol Act, Public Law 92-129 and HIPAA. The Contractor shall not release any medical or personal information.

1.1.3. Removal of Contractors. At any time during the performance of this contract, the Contracting Officer or COR may direct the contractor to immediately remove any Contractor whose actions or impaired state raises reasonable suspicion that clear and present danger of physical harm exists to other Contractors or government personnel. This provision will be used in emergency situations only and not for the purpose of bringing performance issues or other non-urgent concerns to the attention of the contractor.

1.1.3.1. If the need for a removal occurs, the COR will contact the contractor's point of contact and direct the contractor to remove that individual from the military facility and to not use that individual to perform any public health services required under this contract until the issue has been resolved by the Contracting Officer. The contractor shall formally meet with the COR to discuss further action in accordance with the local Quality Assurance and Inspection (QA&I) Plan and AR 40-68. A review of the basis for removal will be made by the Contracting Officer within 3 working days after the COR directed the removal.

1.1.3.2. If, after any investigation deemed necessary by the Contracting Officer and discussions with the contractor's representative, the Contracting Officer concludes that the Contractor’s impairment requires permanent removal from performance under the contract, the Contracting Officer will notify the contractor that permanent removal is required. In the event of disagreements between the government and the contractor's representative concerning matters of impaired Contractors, the decision of the Contracting Officer will be final. During the period of time between the removal and the final decision of the Contracting Officer, the contractor shall provide a backup/replacement Contractor in accordance with the terms and conditions of this contract

1.1.4. Conflict of Interest.

1.1.4.1. Contractor shall not be an employee of the United States Government if the employment would create a conflict of interest. The Contractor who is an employee of the Department of Defense, either military or civilian, shall not be employed unless such person seeks and receives approval in accordance with DoD 5500.7-R and MEDCOM Reg 600-3.

2.0 SCOPE OF WORK.

2.0.1 Contractor shall, in conjunction with and under the direction of the MTF staff, provide a regional solution that transitions the current individual MTF outpatient and inpatient billing operations into a decentralized regional concept of business/billing revenue cycle activities for the Region Health Command – Atlantic (RHC-A). Industry best business practices shall be incorporated to ensure MTF Third Party Collection (TPC) operations are efficient, effective, and result in maximized collections within Uniform Business Office (UBO) compliance guidelines. Contractor, in conjunction with MTF staff, shall improve the methodology and management of billing processes, improve data quality of coding through billing audits of claims, and optimize implementation of electronic itemized-billing practices as directed by DOD and DA. The Contractor provides all personnel, supervision, training, and services necessary to perform their augmentation of the Government’s automated billing, collection for outpatient, inpatient and ancillary services (pharmacy, laboratory, radiology, EKGs, EEGs, anesthesia, ambulance services, etc.) to include emergency room visits and ambulatory procedure visits and other health insurance management for TPCP within RHC-A. The Government provides all personnel, supervision, training, and services necessary to perform their portion of the Government’s automated billing, collection for outpatient, inpatient and ancillary services (pharmacy, laboratory, radiology, EKGs, EEGs, anesthesia, ambulance services, etc.) to include emergency room visits and ambulatory procedure visits and other health insurance management for TPCP within RHC-A . This is achieved through optimized processes or systems for:

2.1 Electronic discovery (identification and verification) of Other Health Insurance (eOHI) to include scope & dimension of such coverage (i.e., co-pays, deductibles, time limits, min/max order limitations, etc.) -- MTF and/or Contractor.

2.2 Manual discovery (identification and verification) of Other Health Insurance (eOHI) to include scope & dimension of such coverage (i.e., co-pays, deductibles, time limits, min/max order limitations, etc.) -- MTF and/or Contractor.

2.3 Pre-certification & verification of OHI coverage(s) to include scope & dimension of such coverage (i.e., co-pays, deductibles, time limits, min/max order limitations, etc.) – MTF and/or Contractor.

2.4 As coordinated with MTF billing staff claims preparation, submission (to OHIs), processing & follow-up with OHIs, from initial claim file through to claim(s) resolution and monetary transfers -- MTF and Contractor.

2.5 Electronic document imaging, records management, including remote storage and retrieval of records -- MTF and Contractor.

2.6 Aged accounts receivable tracking, processing, and follow-up to resolution -- MTF and Contractor.

2.7 Back-billing of claims (for newly discovered beneficiaries possessing OHI) through claims follow-up through to claims resolution -- MTF and Contractor.

2.8 Denials management and refund request review and resolution -- MTF and Contractor.

3.0 PERFORMANCE MEASURES.

3.0.1 The contractor, in conjunction with the Government, shall establish and maintain a performance goal for the optimization of outpatient and inpatient revenue collection activities across the RHC-A region, ensuring the requirements of this PWS are provided as specified. The performance goal(s) will be stated in terms of the total annual TPCP outpatient and inpatient collections (in $) the contractor is expected to meet or exceed in the base year and in the option periods if exercised. The contractor’s performance (measures) expectations will be incorporated into the resulting contract. The contractor and RHC-A, Chief Patient Administration Officer or Resource Management Officer, and the Contracting Officer Representative (COR) shall meet at least Quarterly to discuss past performance, current status, and review the QASP and future planning reference operations associated with TPC throughout the RHC-A.

4.0 OTHER HEALTH INSURANCE (OHI) IDENTIFICATION AND VERIFICATION.

4.0.1 The contractor shall, in conjunction with the Government, establish and maintain a performance goal for the identification and verification of OHI for non-Active Duty DOD beneficiaries who receive medical treatments from MTFs within the RHC-A region, ensuring the requirements of this PWS are provided as specified. The performance goal(s) will be stated in terms of discovery rates, with the plan for obtaining OHI described through the use of any variety of means (electronic database(s), direct patient interviews, mailings, phone calls, and/or pamphlets). The contractor’s and government’s OHI identification and verification program should describe the level of contractor and MTF personnel task breakdown in the OHI discovery process to define the OHI discovery process.

4.1 CONTRACTOR/MTF TASKS INCLUDE:

4.1.1 OHI DISCOVERY. The Contractor, in conjunction with MTF staff, will be responsible for gathering all relevant information regarding OHI from non-Active Duty DOD beneficiaries as they present themselves to the MTF for care/services. The Contractor will be responsible for all personnel-related issues for the Contractor’s personnel located at the MTF. The contractor will assure that applicable training and education related to DOD, Army and Command regulations applicable to OHI is provided to the assigned Contractor employee prior to their performance of any work set forth in this PWS. All training will be at the Contractor’s expense. The training includes, but is not limited to, procedures necessary for identification of billable insurance under DOD guidelines for the TPC program.

The Contractor will be allowed to use various means of discovery to include but not limited to personal interviews, electronic discovery and mailings.

Once the Contractor and/or MTF personnel obtain the necessary OHI information they shall verify the information as noted below and enter this verified information in the Composite Health Care System (CHCS) or MHS Genesis via remote access at the Contractors place of business; a DOD approved hub or the MTF. The original of the DD Form 2569 received from the beneficiary/patient will then be provided to the Uniform Business Office (UBO) staff for proper facilitation and storage. At the minimum, the data obtained should include the following elements:

A. Name of insurance; Company;

B. Name of insured;

C. Name of beneficiary;

D. Type of coverage;

E. Policy number and/or group number;

F. Effective date of policy;

G. Ending date of policy; and, H. Appropriate mailing address.

4.1.2 DD FORM 2569. The DD Form 2569 “Third Party Collection Program/Medical Services Account/Other Health Insurance,” can be found in Attachment 5. The signed DD Form 2569 may be retained in hard copy or electronic format as long as it is available for purposes of assignment of benefits. Beneficiaries found to have OHI by means other than direct patient contact (i.e. through eOHI or external databases), will be contacted to properly sign the DOD OHI form - DD Form 2569. Regardless of receipt of patient signature, billing shall be initiated. The contractor and/or MTF staff shall collect the data elements required on the DD2569 from the uniformed services beneficiary. Once collected, the contractor/MTF staff will contact the appropriate insurance company/employer to verify that the information is current and accurate. Verification will be made before it is used for billing purposes under OHI, which will then be used to input into the CHCS. The DD Form 2569 must also be completed by the non-beneficiary Medical Service Account (MSA) patient and provided to the MTF MSA office.

4.1.3 CLAIM PREPARATION. Inpatient, Outpatient, Ancillary and Pharmacy. Contractor, in conjunction with MTF staff, will prepare inpatient, outpatient, ancillary and pharmacy claims and submit either electronically or hard copy to insurance and pharmacy payers. The Contractor will be provided by the government access to necessary data via remote access to government systems, such as but not limited to CHCS and Armed Forces Billing and Collection Utilization System (ABACUS), or other designated systems at the Contractors place of business and/or an approved DOD hub. This will include patient demographic and insurance data, treatment/service data and prescription data as needed for claim preparation and submission. Contractor will prepare claims using UB-04 or CMS-1500 billing forms (or any superseding version thereof). Claims will be submitted either electronically or, when necessary, in hard copy. Claims will be complete and accurate (clean claim) in accordance with specifications adopted by the National Uniform Billing Committee. To avoid improper claims being submitted the Contractor or MTF will prepare and submit claims adhering to the DOD defined hold periods for each type of claim. This assures that MTF has adequate time to manage items such as prescriptions being returned to stock preventing claims being submitted for pharmacy items not picked up by a patient.

4.1.4 CONTRACTOR ACCESS. The Contractor will be provided by the government access to necessary data via remote access to government systems, such as but not limited to CHCS and Armed Forces Billing and Collection Utilization System (ABACUS), or other designated systems at the Contractors place of business and/or an approved DOD hub.

4.1.5 ABACUS ACCESS. With the assistance of the COR, the contractor will request access to ABACUS through the RHC-A UBO Manager. The following documents are needed before the contractor is granted access to ABACUS:

1. DD Form 2875 – SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)

Example on how to complete DD Form 2875

* Location (physical location of system) is DoD Private Cloud.

* System name is Armed Forces Billing and Collection Utilization Solution (ABACUS).

* Fields 21, 21a, and 21b MUST be completed by the person granting access to ABACUS (UBO Mgr, Regional UBO, etc).

* Fields 22, 23, 24, and 25 MUST be completed by the Contractor CIO (IT/IMD).

* Part III, fields 28, 28a, 28b, 28c, 29, 30, 31, and 32 MUST be completed by the appropriate security officer.

Every other field is self-explanatory.

2. HIPAA Certification - Valid/current HIPAA training is a mandatory requirement to access ABACUS. JKO is the only authorize site for HIPAA training: https://jkodirect.jten.mil/Atlas2/page/login/Login.jsf

3. Information Assurance/Cyber Awareness - Valid/current IA/Cyber Awareness is an annual MEDCOM requirement. Cyber Security Training Center is the only authorize site for IA training: https://ia.signal.army.mil/login.asp.

4. Valid Common Access Card (CAC) – Upon completion of required training and documents, the contract employee will be authorized by the Trusted Agent to obtain his/her CAC. Upon notification by the COR, the contract employee will go to the nearest CAC processing center to obtain his/her CAC.

4.1.6 Composite Health Care System (CHCS). With the assistance of the COR, the contractor will request access through the POC at each MTF. Each MTF has its own process for granting access to MHS GENESIS ACCESS; however, as a minimum each contract employee must submit the following documents:

DD Form 2875 – SYSTEM AUTHORIZATION ACCESS REQUEST (SAAR)

HIPAA Certification - Valid/current HIPAA training is a mandatory requirement to access ABACUS. JKO is the only authorize site for HIPAA training: https://jkodirect.jten.mil/Atlas2/page/login/Login.jsf

Information Assurance/Cyber Awareness - Valid/current IA/Cyber Awareness is an annual MEDCOM requirement. Cyber Security Training Center is the only authorize site for IA training: https://ia.signal.army.mil/login.asp.

Valid Common Access Card (CAC) – Upon completion of required training and documents, the contract employee will be authorized by the Trusted Agent to obtain his/her CAC. Upon notification by the COR, the contract employee will go to the nearest CAC processing center to obtain his/her CAC.

CHCS ACCESS Training Certificate - http://jko.jfcom.mil/

In addition to the above documents already noted, please see the table below for additional requirements for each MTF.

MTF REQUIREMENTS TO OBTAIN CHCS ACCESS

2. Ft. Benning Acceptable Use Policy

3. HIPAA Certificate

4. Cyber Security Certificate

2. HIPAA Certificate

3. WAMC Acceptable Use Policy

4. WAMC System Access Form

2. Acceptable Use Policy

3. HIPAA Certificate

4. Cyber Awareness Training Certificate

5. Systems Training Certificate (Training Center)

2. Cyber Awareness Training Certificate

3. HIPAA Certificate

4. Security Refresher Training Certificate

2. HIPAA Certificate

3. Acceptable Use Policy

2. HIPAA Certificate

3. Information Assurance/Cyber Awareness Certificate

2. HIPAA Certificate

3. Cyber Awareness Certificate

2. HIPAA Certificate

3. Cyber Awareness Certificate

4. DD Form 2875

4. Account Request InfoBottom of Form

2. Information Assurance/Cyber Awareness Certificate

3. HIPAA Certificate

2. Information Assurance/Cyber Awareness Certificate

3. HIPAA Certificate

2. LAHC DD2875/CHCS/AHLTA Addendum

3. HIPAA Certificate

4. Information Assurance/Cyber Awareness Certificate

5. LAHC Acceptable Use Policy

2. HIPAA Certificate

3. HEART Certificate (local training)

4. WINNACH Form 1431 AHLTA/CHCS/Essentris Account

2. Fox AHC In-Processing Form

3. HIPAA Certificate

4. Information Assurance/Cyber Awareness Certificate

5. LIP - Valid credential statement and approval from credentials committee

2. HIPAA Certificate

4.1.7 NOTIFICATION TO MTF OF MISSING DATA REQUIRED FOR CLAIM SUBMISSION. When the coding of the diagnosis, evaluation, management, procedures, or any other codes required for the complete and accurate preparation of a claim is not provided by the MTF, the Contractor shall indicate to the MTF, the specific information needed to complete the claim in a mutually approved format. After the Contractor receives the needed element of information they will be responsible for completing the claim and submitting it to the proper insurance plan.

4.1.8 ROUTINE AND LATE CLAIMS PAYMENT PROCESSING. The Contractor, in conjunction with MTF personnel, shall insure that the required follow-up and unpaid claims are completed at intervals that are effective and achieve maximum recovery of TPC revenue for the MTF. At the earliest, 60 days from claims submission follow-up will begin, this allows insurance payers and prescription plans adequate time to process the claims submitted in accordance with the DOD regulations, which in many cases requires manual processing at the payer sites.

4.1.9 The MTF will be responsible for scanning or faxing or otherwise forwarding to the Contractor’s place of business, or approved DOD hub, the contractor’s portion of Explanation of Benefits (EOB) and copies of checks or evidence of electronic payments received from the insurance plans at the MTF. The check copies or evidence of electronic payments and associated EOBs will be utilized by the Contractor and MTF personnel for posting to the appropriate accounts within the ABACUS and CHCS systems.

4.1.10 The MTF will remain responsible for opening mail and depositing of funds. The frequency of checks and EOBs being submitted to the Contractor must be at a minimum a weekly occurrence.

4.1.11 The MTF will be responsible for scanning or faxing or otherwise forwarding to the Contractor’s place of business or an approved DOD hub, the contractor’s portion of the non-payment EOBs that are received for proper follow-up, denial management and appeals processing to occur. This submission to the Contractor should also be a weekly occurrence.

4.1.12 If payment is not received within 60 days from the date the original claim was submitted to the insurance plan, the Contractor and/or MTF personnel shall identify and follow-up by phone call, letter, or claim re-submittal.

4.1.13 If the denial received is deemed to be invalid the Contractor and/or MTF personnel shall contact the insurance plan to request the claim be reprocessed in accordance with the 32 CFR 220 and/or Army Specific Guidelines. The Contractor and/or MTF personnel will file any necessary appeals needed to resolve the claim. The contractor shall not perform functions however that are inherently governmental in nature. Final decisions regarding appeals and claims shall be made by appropriate government officials.

4.1.14 If these actions fail to resolve the disputed claim within 180 days post initial billing, but no more than 270 days postdate of service unless there is clear evidence the claim will be paid, the Contractor, in conjunction with the MTF staff, will consider the claim delinquent and will then forward a report listing the claim as disputed for referral to MEDCOM OSJA. The Contractor and/or MTF personnel will reflect claim referral in the system of record per MEDCOM UBO published guidance.

4.1.15 The MTF will be responsible for any further release of patient record requests made by the insurance company. The Contractor will submit to the MTF the patient name and Date of Service needed. The MTF will then keep a record of what is released.

5.0 REVENUE CYCLE COMPLIANCE EDUCATION AND TRAINING. The contractor, in conjunction with MTFs, shall implement and maintain regular billing compliance education and training programs, with periodic updates for all personnel involved. The contractor shall coordinate with the Contracting Officer’s Representative to receive latest updates and policy changes that affect the UBO program. The MTF or Region UBO remains responsible for ensuring a UBO Compliance Plan/Program is implemented.

6.0 THIRD PARTY BILLING PROCEDURES.

The contractor and MTF personnel shall bill for the costs of health care provided in any Government facility of the uniformed services to non-Active Duty DOD beneficiaries who have OHI coverage, and who receive medical treatments from Medical Treatment Facilities (MTFs)named herein, per USC Section 1095, and as outlined in 32 CFR Part 220. It will be incumbent on the contractor and MTF personnel to identify opportunities to manually bill and collect for various types of care not captured. The contractor and MTF personnel may only bill for services that have a DOD/DHA established rate. The contractor shall post all applicable payments and write-offs in ABACUS. MTF’s shall maintain the responsibility and accountability for depositing payments and making required entries into GFEBS. The MTF personnel shall ensure all checks are mailed from the payer(s) to the correct MTF for posting and deposit. The MTF will make copies of all checks and provide copies of the checks or evidence of electronic payment to the contractor. Contractor shall coordinate with MTFs UBO staff when medical documentation is needed for clarification of medical treatment, history of illness, medical tests, accident information, or any other clarification for billing purposes. The Contractor shall release only medical information required for billing and collection purposes. Other requests shall be referred through the C, TPC (or chief of UBO operations) to the C, PAD, Resource Management, or other MTF personnel as applicable.

6.1 DISPOSITION OF EXISTING ACCOUNTS RECEIVABLE (A/R). Upon receipt of an MTF Task Order, the MTF will coordinate with the Contractor to make available and accessible its ABACUS Account Receivable inventory. The Contractor shall undertake such steps and processes as are necessary to effect the identification and processing to resolution the existing ABACUS A/R inventory of the MTF. Resolution is herein defined as the recovering and posting of the full payment; the partial payment; or establishing the individual claim as written off. The contractor shall review, evaluate, and tranche the inventory of the MTF’s patient A/R file(s) in the making of his assessment of their collectability. The Contractor shall than take such efforts (in accordance with this tranche) to expeditiously collect the amounts owed to the Government by the Insurance payer. The Contractor shall account for his results in this effort by recording; and, (if successful) posting, the full payment; the partial payment; or establishing the individual claim as written off by the Contractor; in accordance with DOD guidelines; as: “Claim Not Recoverable” for identified or unknown reasons.

7.0 BEST PRACTICES. The contractor and MTF personnel shall continually review their processes to ensure that the generally accepted and acknowledged “best practices” in the industry, with respect to government healthcare and health insurance and claims processing, are applied in the execution of the work.

8.0 CONTRACTOR PAYMENT. The work performed under this PWS shall be through a contract of the Task Order type. When awarded, the delivery of services performed under all CLINs and their sub-CLINs of this PWS shall be performed only through Task Orders placed by a U.S. Army Hub Contracting Activity warranted Contracting Officer, in the U.S. Army Contracting Office on behalf of the individual MTFs’ place of performance as named on each sub-CLIN and in the Task Order. Orders for services shall be in writing only; placed by mail, facsimile, or through electronic mail IAW the terms and conditions of the contract. All accounting and appropriation data in support of invoicing for payments shall be found only upon subsequent Task Order(s).

8.1. The amount of the monthly payments to the contractor for all work performed under this contract will be in the form of a Performance-Based Percentage (PBP), which is the percentage (%) of the Third Party Collections (TPC) POSTED in the system of record of the MTF for the contract period for which the invoice upon this contract’s MTFs Task Order is filed; up to, the not to exceed (NTE) amount found in the Task Order and Contract schedule for the MTF’s sub-CLIN. The payment shall be made in the form of the stated PBP for ALL collections posted in the system of record regardless of whether the collection was posted by MTF staff or contracted staff, provided that the contractor electronically or manually submits all claims whether generated by the MTF staff or contracted staff. The Offeror shall indicate in his/her response to the Solicitation his/her proposed Performance Based Percentage (PBP) in percent, where indicated in the narrative section of each sub- CLIN of the RFP. This percentage (%) shall be incorporated in the narrative of each sub-CLIN in any subsequent contract; base period, exercised option period, and in any Task Order issued against this contract.

8.2 The monthly payment(s) the contractor shall invoice for under the Task Order(s) issued by authority of this contract shall be constructed by multiplying the PBP of each of the MTF’s by each MTF’s ABACUS amount POSTED for the month that the invoice is requesting payment for, of the MTF. THERE IS NO MINIMUM PAYMENT WHEN THE AMOUNT POSTED TO THE SYSTEM OF RECORD IS ZERO ($0.00) FOR THE CONTRACT PERIOD FOR WHICH AN INVOICE IS FILED, THAT AMOUNT ($0.00), TIMES THE PBP (SYSTEM OF RECORD x PBP) EQUALS ZERO ($0.00). Payments under this contract do not recognize any “start-up” or “up-front” costs associated with the initiation of the contract. This includes, but is not limited to transfer of billing data or associated files from that information’s current location(s).

9.0 SPECIFIC DESCRIPTION AND SPECIFICATION OF TASKS. RHC-A MTFs require a specific element of claims processing services outlined below and the ability to continue development and use of prescription processing procedures developed and implemented at the facility.

9.1 Claims Follow-up and Denial Management. Outpatient, Inpatient and Ancillary Claims.1 Other Health Insurance Discovery – Personal interviews, electronic discovery, and mailings.

9.2 Insurance Verification to include scope & dimension of such coverage (i.e., co-pays, deductibles, time limits, min/max order limitations, etc.)

9.3 CHCS entry of verified insurance information

9.4 Outpatient, Inpatient and Ancillary Claims preparation and submission – electronic and hard copy.

9.5 Payment posting within ABACUS or other designated system all payments for Outpatient and ancillary claims

9.6 Outpatient, Inpatient and Ancillary Write off posting

9.8 Outpatient, Inpatient and Ancillary Claims Appeals processing

10.0 PERIOD OF PERFORMANCE. The base year period of performance is January 1, 2023 through December 31, 2023. There are three additional option periods of twelve months each, for a total period of performance of 48 months, if options are exercised. Exercise of the option periods are at the sole discretion of the Government.

10.01 TRANSITION PERIOD. The Contractor shall complete its work on the last day of the contract. The Contractor will be paid only on that work that the contractor has posted on or before the ending date of the contract. In the event that this contract is followed by a new contract, the succeeding contractor will be paid on that work posted on or after the beginning date of the new contract.

11.0 NON ACTIVE DUTY OUTPATIENTS. Appendix 1 of this PWS identifies the Military Treatment Facilities (MTFs) within the RHC-A in FY 2023.

12.0 PLACE and HOURS OF OPERTATION. The Contractor shall perform its work at the Contractor’s designated non-MTF facility. The Contractor’s work hours must be consistent with the normal working hours of the MTF named herein where there is a Task Order in place for TPCP services. The Contractor is not required to perform services on any Government observed holidays (published annually and available from the KO, COR, or C, TPC). Anticipated closures of the MTF due to Command declared training holidays or unplanned closures of the MTF due to natural disasters, military emergencies, severe weather, or otherwise, does not preclude the Contractor from performing its assigned duties. Any decision to suspend work activity due to any of the above will be solely the responsibility of the Contractor. The Government will not be liable to the Contractor for any such decision made by the Contractor.

13.0 GOVERNMENT FURNISHED EQUIPMENT. Contractor shall centrally process and remotely bill its portion of OHI and all other tasks of this PWS using vendor software. Specifically the Government shall be financially responsible for the purchase, maintenance, support, and replacement of Government assigned or designated hardware/software systems, with the exception of the Contractor’s own IT solutions.

13.1 Contractors shall utilize contractor provided computerized billing systems. The contractor shall be responsible for establishing interfaces between its IT systems and services used by its personnel at its location(s) for all work under this PWS and the Government’s systems. If the contractor’s existing or a contractor proposed IT solution is developed to parallel the Government’s existing billing systems infrastructure, or if an IT platform is recommended for use by the contractor, the contractor shall be required to establish and demonstrate how such system’s application shall interface with government IT systems, with the Army Financial System and with any future central electronic data warehouse. All contractors’ IT interfaces must meet with Army and DOD communications and computer systems security requirements and shall be at the expense of the contractor. All other developed tools (i.e. in Microsoft Word, Access, Excel, PowerPoint, or other software developed databases) shall become and remains the property of the US Government and shall have no affect or impact on monies owed to the contractor by the Government. All data remains the property of the US Government and will be surrendered upon demand.

14.0 CONTRACTOR FURNISHED FACILITIES AND EQUIPMENT. The Contractor shall execute its tasks as set forth in this PWS through facilities established and sustained for, and by the Contractor. Only those tasks that require its routine, direct, and continuing interface with physical Government files and/or personnel shall be deemed required to have a contractor presence at Government installations. The contractor is required to sustain from its own primary place of TPCP work, the execution of the work of this contract using such electronic data connections that it shall provide itself, which the contractor shall be responsible to ensure that they shall interface with Government systems and which shall support all phases of his work under this PWS. The contractor shall ensure that his primary IT and data systems shall be compatible with, support, interface and/or use Government client software.

15.0 CONTRACTOR-FURNISHED FACILITIES OHI DISCOVERY. To perform OHI discovery, in conjunction with current MTF staff, the contractor shall provide the staffing deemed necessary to optimize services and functions associated with identification and verification of OHI within the MTFs, including equipment, supplies, and other items and services necessary to perform the PWS at the MTF level. To advance TPC program goals, the contractor shall provide the necessary personnel, systems (both manual and electronic), supervision, equipment, supplies, material, transportation, and other items and services necessary to perform the PWS requirements at a remote location. The information on each contract employee may be used for input into the MTF’s Contractor/Other Personnel File Systems. All information given by Contractor shall be protected by the Privacy Act of 1974 (PL 93- 579). This information is necessary to assure hospital records can be maintained correctly, therefore complying with The Joint Commission (TJC) accreditation standards, Occupational Safety and Health Association (OSHA) and Center for Disease Control (CDC).

16.0 GENERAL INFORMATION. The quality of practice shall meet or exceed reasonable standards of professional practice for billing and revenue cycle management services as determined by the same authority that governs military treatment facilities and civilian medical professionals working in Cost Recovery Programs as defined in the MTF UBO Manual DOD 6010.15M, the Financial Management Regulation and Army Specific Guidelines.

16.1 IM/IT Requirements for All Government Data Including Protected Health Information

16.1.2 General Government Oversight Instructions

16.1.3 The Government will retain overall responsibility for all functions and operations associated with the Third Party Collection Program.

16.1.4 Program/Project Managers will follow the policies and procedures identified in the contract language. Specifically, Program/Project Managers will ensure compliance by periodically auditing for compliance. Examples of audits for this purpose include:

16.1.5 Auditing invoices submitted by contractors to verify that only those personnel who have been processed for an appropriate background check are being billed against the contract (Personnel Security).

16.1.6 Performing periodic audits of Vendor sites to ensure Vendor compliance to the requirements of the Physical Security Audit Matrix. Army personnel will monitor and re- inspect to check for resolution of identified deficiencies (Physical Security).

16.1.7 Ensuring vendors acquire, develop, and maintain the Certification & Accreditation (C&A) documentation to ensure both initial and continued compliance with C&A requirements as specified by Army Information Assurance requirements for all contractor systems/networks that receive, process, store, display, or transmit Army data, or has a physical or logical connections to an Army certified network (Electronic Security). All contractor systems/networks that receive, process, maintain, store, or transmit Protected Health Information (PHI) will also have to comply with all C&A requirements (Electronic Security).

16.1.8 Auditing all new systems at delivery to ensure all applicable electronic patches are installed on the system before the Army accepts the product (Electronic Security).

16.1.9 Random security auditing of any Vendor sites where PHI files are collected, used, or stored. Prior to accessing PHI all Vendors must have an approved Business Associates Agreement (BAA). The audit will ensure the vendor has complied with all terms stated in the BAA regarding physical, personnel and electronic security measures as reflected in the Privacy Act (5 U.S.C. 55a et seq), HIPAA Privacy Rule (PL 104-191), and DoD Health Information Regulation Privacy Regulation (6025.18-R) (Protected Health Information Security).

16.2 Information Assurance Standard Contract Language

16.2.1 General Security Requirements. The Contractor shall establish appropriate administrative, technical, and physical safeguards to protect any and all Army data, to ensure the confidentiality, integrity, and availability of Army data. As a minimum, this shall include provisions for personnel security, electronic security and physical security as listed in the sections that follow:

16.2.2 Health Insurance Portability and Accountability Act (HIPAA). Health Insurance Portability and Accountability Act of 1996 (HIPAA) Requirement. The HIPAA standard contract language is mandatory whenever a business associate, (i.e., outside person or agency) creates, receives, maintains, or transmits electronic protected health information (PHI) on behalf of a covered entity. This contract or agreement requires the business associate to:

16.2.2.1 Implement administrative, physical, and technical safeguards that will protect the confidentiality, integrity, and availability of the PHI

16.2.2.2. Ensure all agents or subcontractors to whom the business associate provides PHI will also implement reasonable and appropriate safeguards to protect the information.

16.2.2.3 Report all security incident.

16.2.2.4. Authorize termination of the contract if the organization finds that the business associate has violated the terms of the contract.

16.3 The standard HIPAA standard contract language is available at: http://health.mil/Military-HealthTopics/Privacy-and-Civil-Liberties Additional guidance can be found in DoD 8580.02 –R, Health Information Security Regulation.

16.4 Personnel Security

16.4.1 The contractor shall comply with Army Regulation 25–2, "Information Assurance” (IA), Army Regulation 25–1, “Army Knowledge Management and Information Technology,” and " DoD Health Information Privacy Regulation."

16.4.2 Contractor responsibilities for ensuring personnel security include, but are not limited to, meeting the following requirements:

16.4.2.1 Follow the Army guidelines for submittal of Information Technology (IT) security background checks and ensure all contractor personnel are designated as IT-I, IT-II, or IT-III where their duties meet the criteria of the position sensitivity designations. Contact the RHC-A’s UBO manager for guidance on the appropriate IT levels for personnel on the contract.

16.4.2.2 Initiate, maintain, and document personnel security investigations appropriate to the individual's responsibilities and required access to MEDCOM Sensitive Information (SI).

16.4.2.3 Immediately report to the RHC-A’s UBO manager and deny access to any automated information system (AIS), network, or MEDCOM SI information if a contractor employee filling a sensitive position receives an unfavorable adjudication, if information that would result in an unfavorable adjudication becomes available, or if directed to do so by the appropriate Army representative for security reasons. Ensure that all contractor personnel receive information assurance (IA) training before being granted access to Army AISs/networks, and/or MEDCOM SI information.

16.5 Electronic Security

16.5.1 Contractor Information Systems (IS)/networks that are involved in the operation of systems in support of the Army’s Health System shall operate in accordance with controlling laws, regulations, and Army policy.

16.5.2 Certification & Accreditation (C&A) requirements apply to all Army and contractor's IS/networks that receive, process, display, store or transmit Army information. The contractor shall comply with the C&A process for safeguarding Sensitive Information. Certification is the determination of the appropriate level of protection required for IS/networks. Certification also includes a comprehensive evaluation of the technical and nontechnical security features and countermeasures required for each system/network.

16.5.3 Accreditation is the formal approval by the Army to operate the contractor's IS/networks in a particular security mode using a prescribed set of safeguards at an acceptable level of risk. In addition, accreditation allows IS/networks to operate within the given operational environment with stated interconnections; and with appropriate level of protection for the specified period.

16.5.4 The contractor shall comply with C&A requirements, as specified by the Army that meet appropriate Army Information Assurance requirements. The C&A requirements shall be met before the contractor's system is authorized to access Army data or interconnect with any Army IS/network that receives, processes, stores, displays or transmits Army data. The contractor shall initiate the C&A process by providing the Contracting Officer, within 60 days following contract award, the required documentation necessary to receive an Approval to Operate (ATO). The contractor shall make their IS/networks available for testing, and initiate the C&A testing four months (120 days) in advance of accessing Army data or interconnecting with Army IS/networks. The contractor shall ensure the proper contractor support staff is available to participate in all phases of the C&A process. They include, but are not limited to:

16.5.4.1 Attending and supporting C&A meetings with the Army

16.5.4.2 Supporting/conducting the vulnerability mitigation process

16.5.4.3 Supporting the C&A Team during system security testing

16.5.5 Contractors must confirm that there IS/networks are locked down prior to initiating testing.

16.5.6 Conformation of system lock down shall be agreed upon during the definition of the C&A boundary and be signed and documented as part of the Department of Defense Information Assurance Certification and Accreditation Process (DIACAP).

16.5.7 Locking down the system means that there shall be no changes made to the configuration of the system (within the C&A boundary) during the C&A process

16.5.8 Any re-configuration or change in the system during the C&A testing process will require a re-base lining of the system and documentation of system changes.

16.5.9 Vulnerabilities that have been identified by the Army as "must-fix" issues during C&A process must be mitigated according to the timeline identified by the Army Representative. C&A Checklists are provided for complying Army C&A requirements. Reference material and C&A tools may be obtained at the USAMITC IA Document Library (Portal): https://mitc.amedd.army.mil/IA.

16.5.10 A request for a waiver to the C&A requirements may be submitted for temporary testing and other usual circumstances. A waiver request must be submitted, in writing, to the Designated Approving Authority (DAA). The request must include mitigation strategies that ensure adequate protection measures and security controls are in place (i.e., air gapping a testing network).

16.5.11 Information Assurance Vulnerability Management (IAVM): The contractor shall implement an information assurance vulnerability management program. The Army IAVM program provides electronic security protections against known threats and vulnerabilities. The IAVM program requires the registration of AIS system assets, which then allows for the timely dissemination of critical vulnerability Information. It also assists in the documentation and tracking of compliance, providing increased electronic security to MEDCOM systems. As part of the program, the contractor shall provide a primary and secondary point of contact in the Asset & Vulnerability Tracking Resource (A&VTR). The point of contact shall provide, upon receipt of a vulnerability message, an acknowledgment of receipt via the A&VTR. The contactor shall thoroughly test all mitigations for the vulnerability, and upon applying the mitigation to the system, report compliance in the A&VTR. Receipt and compliance messages to the Army shall occur within the stipulated time window, as stated in the vulnerability message or in the A&VTR.

16.5.12 The contractor shall ensure AIS assets that are under development are registered in the A&VTR and have all applicable electronic patches installed for the system (1) when the system is delivered to MEDCOM, or (2) if the AIS assets are used to store or process Army data prior to delivery (such as when being used in testing and development).

16.5.13 Guidance regarding the requirement for IAVM is contained in the Army Regulation 25–2, "Information Assurance” and Army Regulation 25–1, “Army Knowledge Management and Information Technology.” An asset is defined as any hardware device, such as a router, firewall, server, or an operating system image accessed by more than one user. Primary servers and the workstations that they support are assets that must be registered in the A&VTR. The “Army IAVM Community” is used to disseminate IAVAs, Information Assurance Vulnerability Bulletins (IAVBs), and Information Assurance Technical Advisories down to the System Administrator (SA) and applicable personnel throughout the chain of command

16.5.1.4 The contractor shall maintain any development environments in accordance with MEDCOM Information Assurance (IA) best practices and operational requirements. During product development for the Army, the contractor shall ensure that all IA mitigation strategies have been applied to the development environment prior to any Army data being loaded onto any assets or software for testing or delivery.

16.5.15 IA mitigation strategies include security updates, service packs, and changes to operating procedures as physical and cyber vulnerabilities are detected. Operating system, routers, servers, development platforms and the application being delivered to the Army shall be in compliance with all known applicable Army Computer Emergency Response Team (ACERT) Alert, Bulletin, and Technical Advisory Notices published during the past 36 months.

16.5.16 Disposing of Electronic Media. Vendors shall follow the Army standards, procedures, and use approved products to dispose of unclassified hard drives and other electronic media, as appropriate, in accordance with Army Regulation 25–2, "Information Assurance” and Army Best Business Practices (BBP), “Reuse of Computer Hard Drives.”

16.5.16 Ports Protocols and Services. Vendors shall follow all current Army standards and requirements for acceptable Ports, Protocols, and Services. Any requests for exception to using the current Army Ports, Protocols, and Services standards requires an request for exception sent through the Program Manager to the DAA.

16.5.18 Public Key Infrastructure and Encryption. Vendors shall follow the Army standards, policies, and procedures related to the use of Public Key Infrastructure (PKI) certificates and biometrics for positive authentication. Where interoperable PKI is required for the exchange of unclassified information between the Army and its vendors and contractors, industry partners shall obtain all necessary certificates. Vendors must turn over to the Army all encryption keys for deployed systems, backdoor algorithms, and procedures for their use in remote support. The Vendor must provide a written report detailing all of the above, prior to task order expiration, regardless of modifications or extensions.

16.6 Information Systems (IS)/Networks Physical Security.

16.6.1 The contractor shall employ physical security safeguards for…