A05 - SOW FPSU Claims Management Services.docx

FORT PECK SERVICE UNIT INDIAN HEALTH SERVICE STATEMENT OF WORK FOR HEALTH INSURANCE VERIFICATION AND CLAIMS MANAGEMENT SERVICES

1. PROJECT TITLE: Medicare and Private Insurance Claims Management and Insurance Eligibility Services

2. BACKGROUND/PURPOSE:

The Mission of the Fort Peck Service Unit is to provide the best possible healthcare services to the Fort Peck Service Unit community members and all other eligible Native Americans. The purpose of this contract is to enhance and to maximize third party revenue and collection activities for the business aspect of health care and its revenue generation activities.

The Fort Peck Service Unit aims to create an efficient, streamlined process for claims management and insurance eligibility verification services through the vendor, Inovalon Provider Inc. To meet this mission, the Fort Peck Indian Health Service has identified a need for an online claims management and eligibility verification software to provide a centralized service for billing services and to track revenue generation.

The vendor will provide technology that identified third party eligibility information and workflow plus Medicare AR reporting and workflow for the Fort Peck Service Unit. The need to verify eligibility for the various health insurance programs in real time will enhance operations for the business aspect of health care. Effective services for both Medicare and Private Insurance claims will keep the hospital on top of capturing reimbursement dollars from the patient’s initial point of service. These services make an impact on the reduction of staff overtime costs and will drastically reduce the need for follow-up of the claims denied.

The Fort Peck Service Unit requires an application that will provide daily Medicare AR report for efficient account management. These services shall follow HIPAA, IHS OIT mandates, and the Privacy Act.

3. SCOPE:

The contract shall:

· Attain comprehensive eligibility information– make eligibility requests to Medicare and commercial (Private Insurance) payors.

· Perform batch eligibility checks – determine eligibility status for multiple patients at one time.

· Better manage workflow with a customizable dashboard that prioritizes and assigns patients, payers and daily task lists. The application allows user to set up reminders and notes to staff at multiple locations.

· Experience integration between eligibility and claims functions.

· Eliminate repetitive tasks with the ability to run multiple payers and patients in one session.

· Increase efficiency when checking eligibility – verify a patient’s eligibility status with multiple payers.

· Save significant time using batch imports of eligibility data files.

· Enhance record-keeping with access to all eligibility transaction history.

The contractor shall provide a secure exchange data software solution that provides technology for:

· Connectivity to the Medicare DDE (Direct Data Entry/FISS (Fiscal Intermediary Standard System) and automated claims status reporting, payment floor details and other reports

· Eligibility verification for third party payers to include Medicare

· Eligibility results must include start and end dates of coverage

· Capability to search eligibility for third party coverage for patients

· Third party insurance medical claims validation, approval and processing services via a clearinghouse for Medicare, Medicaid, VA and Commercial Payers for the Fort Belknap Service Unit

· Processes all claim types: Emergency, Inpatient, Outpatient and Specialty Clinics; and provide both solicited and unsolicited claims status

· The software must provide rigorous and thorough claims rules and business custom rules

· Capability for self-monitoring usage of services for thresholds

· Training and support related to scope of work-training provided either on-site or via teleconference

The software services shall comply with the following constraints:

· The software service shall not require the Fort Peck Service Unit to install contractor software within the Fort Peck Service Unit or Indian Health Service network.

· The service shall enable the Fort Peck Service Unit to exchange data utilizing a Secure File Transfer Protocol (SFTP) as approved by the Indian Health Service Office of Information Technology.

· The service shall support Electronic Data Interchange (EDI) transactions and interactive Telnet application protocol sessions.

· The service shall support unlimited users and access shall be workstation independent.

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

4. APPLICABLE DOCUMENTS:

Secure internet-based connectivity to all current fiscal intermediaries.

Ability to send medical emergency, Inpatient, Outpatient, and Specialty claims to Medicare Contractor and other Payers using secure date exchange technology.

Unlimited Direct Data Entry (DDE) online Medicare claims status/corrections for Medicare Part A.

All electronic transactions and DDE/FISS shall provide confidentiality, authentication, integrity and non-repudiation.

Automated batch 837/835 file transfers.

Automated batch 276/277 claims status capability.

Accept electronic claims from Resource Patient Management System (RPMS).

Reports and acknowledgements on all claims sent.

5. TASKS:

Simple user-friendly interface with a single sign-on login and ID. Eligibility verification for hundreds of payers, with information that includes co-pays, termination dates, deductibles and coinsurance

· Consistent data displays of response results by payer class

· Quick batch entry – check eligibility status for multiple patients with a single payer

· Multiple insurance eligibility verification – check a patient’s eligibility status at multiple insurance plans simultaneously

· Alerts to indicate other coverage for Medicare patients – instances of HMO enrollment, dual eligibility, Medicare as a Secondary Payer, and many more admissions scenarios are brought to the attention of designated personnel

· Ability to filter Service Type Code (STC) queries and responses and save your favorites, organized by payer

· All-payer eligibility access 24/7 – easily verify data after hours and on weekends

· Storage of all validation transactions for historical proof of eligibility status when eligibility is challenged retroactively

· Flexible revalidation option for either an individual patient or batch without having to rekey demographic data

· Option to run recurring batches for your patient census to regularly monitor insurance coverage

· Easy implementation, with minimal IT involvement – ABILITY web-based services are compatible with current versions of industry-leading browsers

6. DELIVERABLES AND DELIVERY SCHEDULE:

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

Verify Medicare and Commercial Payer eligibility in real time and batches.

Provide knowledgeable support personnel to assist with any issues regarding the processing of the medical claims.

The Contractor shall provide toll free telephone/technical support during normal business hours, 7 AM to 7 PM, Monday thru Friday, except Government holidays.

The Contractor shall provide a two (2) hour minimum response time from notification by IHS at no additional cost to the Fort Belknap Service Unit.

The medical claim processing services shall meet the following standards:

· Third party insurance medical claims shall be submitted to the appropriate carrier/payer via the Contractor provided clearinghouse by the close of the next business day after receipt from IHS.

· Third Party Insurance medical shall be transmitted electronically to the appropriate carrier/payer.

· The Contractor shall use routine editing procedures to detect defects in medical claims information supplied by the government. The Contractor shall reject and not process all medical claims with defects. The Contractor shall provide the service location with edit status reports listing the defect to aid the service location in the correction of the detected defects.

· The Contractor shall provide for correction all claims rejected by all the carriers/payers for any reason other than the inappropriate format to the claims.

· The Contractor shall provide the capability for medical claim errors to be corrected and resubmitted electronically and provide a report of rejected medical claims within 4 hours of batch submission.

· The Contractor shall make available productivity and submission reports within 24 hours of batch transmission.

7. GOVERNMENT-FURNISHED EQUIPMENT AND INFORMATION:

Secure internet-based connectivity to all current fiscal intermediaries.

· Ability to send medical emergency, Inpatient, Outpatient, and Specialty claims to Medicare Contractor using secure date exchange technology.

· Unlimited Direct Data Entry (DDE) online Medicare claims status/corrections for Medicare Part A.

· All electronic transactions and DDE/FISS shall provide confidentiality, authentication, integrity and non-repudiation.

· Automated batch 837/835 file transfers.

· Automated batch 276/277 claims status capability.

· Accept electronic claims from Resource Patient Management System (RPMS).

· Reports and acknowledgements on all claims sent.

8. PLACE OF PERFORMANCE:

Fort Peck Service Unit 107 H. Street, Poplar MT. 59255 via online insurance verification software access

9. PERIOD OF PERFORMANCE: Base Year 04/01/2026 to 03/31/2027 Plus 4 option years

10. SECURITY:

Secure internet-based connectivity to all current fiscal intermediaries.

11. Section 508 and Accessibility

· This product must conform to the Revised Section 508 (https://www.accesss-board.gov/guidelines-and-standards/communications-and-it/about-the-ict-refresh/final-rule/text-of-the-standards-and-guidelines) and WCAG 2.0 Level AA standards as outlined below.

· Solicitations for supplies and services shall require the submission of a Section 5085 Product Assessment Template. The template can be found at https://www.itic/org/policy/accessibility/vpat.

All information and Communication Technology (ICT) deliverables under this contract (e.g., websites, applications, electronic documents, and multimedia) must comply with the Revised Section 508 Standards (36 CFR Part 1194) and the Web Content Accessibility Guidelines (WCAG) 2.1 Level AA Standards. The Contractor shall ensure accessibility of all ICT deliverables and provide conformance documentation in the form of all Voluntary Product Accessibility Template (VPAT/Accessibility Conformance Report (ACR), or by completing the HHS Section 508 Accessibility Checklists. The current VPAT 2.5 template includes fields for reporting conformance to WCAG 2.1 and shall be used to document accessibility issues at no additional cost. The Contracting Officer will include the applicable Health and Human Services Acquisition Regulation (HHSAR) clauses 352.239-73 and 352.239-74 in the solicitation and resulting contract.

12. Privacy Act Clauses:

Privacy or Security Safeguards (Aug 1996)

(a) The Contractor shall not publish or disclose in any manner, without the Contracting Officer’s written consent, the details of any safeguards either designed or developed by the Contractor under this contract or otherwise provided by the Government.

(b) To the extent required to carry out a program of inspection to safeguard against threats and hazards to the security, integrity, and confidentiality of Government data, the Contractor shall afford the Government access to the Contractor’s facilities, installations, technical capabilities, operations, documentation, records, and databases.

(c) If new or unanticipated threats or hazards are discovered by either the Government or the Contractor, or if existing safeguards have ceased to function, the discoverer shall immediately bring the situation to the attention of the other party.

Privacy Act (December 18, 2015)

This contract requires the Contractor to perform one or more of the following: (a) design; (b) develop; or (c) operate a federal agency system of records to accomplish an agency function in accordance with the Privacy Act of 1974 (Act) (5 U.S.C. 552a(m)(1)) and applicable agency regulations.

The term system of records means a group of any records under the control of any agency from which information is retrieved by the name of the individual or by some identifying number, symbol, or other identifier assigned to the individual. Violations of the Act by the Contractor and/or its employees may result in the imposition of criminal penalties (5 U.S.C. 552a(i)).

The Contractor shall ensure that each of its employees knows the prescribed rules of conduct in 45 CFR part 5b and that each employee is aware that he/she is subject to criminal penalties for violation of the Act to the same extent as Department of Health and Human Services employees. These provisions also apply to all subcontracts the Contractor awards under this contract which require the design, development or operation of the designated system(s) of records (5 U.S.C. 552a(m)(1)). The contract work statement:

(a) Identifies the system(s) of records and the design, development, or operation work the Contractor is to perform; and

(b) Specifies the disposition to be made of such records upon completion of contract performance.

Confidential Information (December 18, 2015)

(a) Confidential Information, as used in this clause, means information or data of a personal nature about an individual, or proprietary information or data submitted by or pertaining to an institution or organization.

(b) Specific information or categories of information that the Government will furnish to the Contractor, or that the Contractor is expected to generate, which are confidential may be identified elsewhere in this contract. The Contracting Officer may modify this contract to identify Confidential Information from time to time during performance.

(c) Confidential Information or records shall not be disclosed by the Contractor until:

(1) Written advance notice of at least 45 days shall be provided to the Contracting Officer of the Contractor's intent to release findings of studies or research, to which an agency response may be appropriate to protect the public interest or that of the agency.

(2) For information provided by or on behalf of the government,

(i) The publication or dissemination of the following types of information are restricted under this contract: Restricted types of patient information include patient identifying information,

(ii) The reason(s) for restricting the types of information identified in subparagraph (i) is/are: Restrictions are required to protect the privacy of patient information and prevent unauthorized disclosure.

(iii) Written advance notice of at least 45 days shall be provided to the Contracting Officer of the Contractor's intent to disseminate or publish information identified in subparagraph (2)(i). The contractor shall not disseminate or publish such information without the written consent of the Contracting Officer.

(d) Whenever the Contractor is uncertain regarding the confidentiality of or a property interest in information under this contract, the Contractor should consult with the Contracting Officer prior to any release, disclosure, dissemination, or publication.