Appendix 1 - MDH Medicaid Hospital Claims Audit Contractor OCMP 26-25113.pdf

Appendix 1. Abbreviations and Definitions

For purposes of this RFP, the following abbreviations or terms have the meanings indicated below:

1. .

2. Access – The ability or the means necessary to read, write, modify, or communicate data/information or otherwise use any information system resource.

3. .

4. Audit - A comprehensive review, Automated, Complex or both, of medical documentation performed by the Contractor to verify that the Provider properly billed Maryland Medicaid for goods and services rendered to Maryland Medicaid recipients.

5. Automated Review - Has the meaning as provided in Section 2.3.3.8. A.

11. Business Day(s) – The official working days of the week to include Monday through Friday.

Official working days excluding State Holidays (see definition of “Normal State Business Hours” below).

12. COMAR – Code of Maryland Regulations available on-line at https://dsd.maryland.gov/Pages/COMARHome.aspx.

13. Complex Review - Has the meaning as provided in Section 2.3.3.8 B.

14. Contingency Fee – A form of compensation that is only paid when a specific objective has been achieved.

15. Contract Commencement - Has the same meaning as Contract Effective Date.

16. Contract Effective Date (CED) - As per Section 3.1 of Exhibit 2 - the Contract - the date the Contract is signed by the Department following any required approvals of the Contract, including approval by the Board of Public Works, if such approval is required.

17. Contract – The Contract awarded to the successful Offeror pursuant to this RFP. The Contract will be in the form of Exhibit 2.

18. Contract Monitor – The State representative for this Contract who is primarily responsible for Contract administration functions, including issuing written direction, invoice approval, monitoring this Contract to ensure compliance with the terms and conditions of the Contract, monitoring MBE and VSBE compliance, and achieving completion of the Contract on budget, on time, and within scope. The Contract Monitor may authorize in writing one or more State representatives to act on behalf of the Contract Monitor in the performance of the Contract Monitor’s responsibilities. The Department may change the Contract Monitor at any time by written notice to the Contractor.

19. Contract Officer – The State representative for the Contract who is designated and authorized by the Procurement Officer to act on behalf of the Procurement Officer. The Maryland Department of Health may change the Contract Officer at any time by written notice to the Contractor.

20. Contract Year - As described in Section 17, Contract Duration and Expected Start Date, of the Key Information Summary Sheet (KISS) and RFP Table 2.2, the Contract may run longer than a base term of three (3) years, depending upon when the Contractor indicates in its Proposal in response to RFP item 5.3.2.F. that it can commence actual audit work under the Contract. (*Any preparatory startup period will not be considered to be part of the base Contract term.) Although the base Contract term must begin by August 1, 2027, any duration of time prior to that date that

Appendix 1. Abbreviations and Definitions OCMP-24-XXXXX Page 1 of 6 https://dsd.maryland.gov/Pages/COMARHome.aspx the Contractor commences audit work under the Contract (*excluding startup time) will be added to the base Contract term and specifically to the first year of the Contract (Contract Year 1).

21. Contractor – The selected Offeror that is awarded a Contract by the State.

22. Contractor Personnel – Employees and agents and subcontractor employees and agents performing work at the direction of the Contractor under the terms of the Contract awarded from this RFP.

23. CPT - Current Procedural Terminology - A set of codes maintained by the American Medical Association which describes medical, surgical, and diagnostic services, and communicates uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations.

24. CPT Assistant - Monthly newsletters that assist the coding industry with keeping up-to-date on the latest codes and trends.

25. CY – Calendar Year

26. Data Breach – The unauthorized acquisition, use, modification or disclosure of State data, or other Sensitive Data.

27. Department - The Maryland Department of Health (MDH).

28. eMMA – eMaryland Marketplace Advantage (see RFP Section 4.1).

29. Extrapolation - A statistical method of predicting the value of a variable, such as claims Overpayments, based on the known claims that were audited.

30. Fee-For-Service - Claims submitted to Medical Assistance and its Administration for procedures submitted to the Medicaid Program for payment.

31. FTE – Full Time Employee

32. Go-Live Date - The date, as specified in the initial Notice to Proceed, when the Contractor must begin providing some or all of the services required by this solicitation as specified in the Notice to Proceed. i.e., the Notice to Proceed Date,

33. HCPCS - Healthcare Common Procedure Coding System - A set of codes used to help insurance Providers and medical staff communicate when billing for medical services, products and procedures.

34. ICD-9 - International Classification of Diseases, 9th Revision

35. ICD-10 - International Classification of Diseases, 10th Revision

36. ICN (Internal Control Number) - A number assigned by the Maryland Medicaid Program to assist in the identification of specific billing and payment items or activities.

37. Improper Payment - Payment to a Provider that is either an Overpayment or Underpayment.

Situations where the Provider submits a claim containing an incorrect procedural code, but the mistake does not change the payment amount are NOT considered Improper Payments.

38. Information System – A discrete set of information resources organized for the collection, processing, maintenance, use, sharing, dissemination, or disposition of information.

39. Information Technology (IT) – All electronic information-processing hardware and software, including: (a) maintenance; (b) telecommunications; and (c) associated consulting services.

40. Key Personnel – All Contractor Personnel identified in the solicitation as such that are essential to the work being performed under the Contract. See RFP Sections 2.4.

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41. LEIE – The federal List of Excluded Individuals and Entities.

42. Local Time – Time in the Eastern Time Zone as observed by the State of Maryland. Unless otherwise specified, all stated times shall be Local Time, even if not expressly designated as such.

43. Long Term Care Providers – A facility or entity authorized, licensed or certified to provide skilled services to individuals with a chronic illness or related conditions. The term Long Term Care Providers does not include care in an acute hospital or specialty hospital.

44. Medicaid Management Information System (MMIS) -The Department’s automated claims processing and information retrieval system certified by the Centers for Medicare & Medicaid Services (CMS). Data entered in MMIS enables consumers to access needed medical services.

The MMIS system is used to pay medical claims submitted by Maryland Medicaid providers.

45. Medicaid Fraud Control Unit (MFCU) - Unit within the Maryland Office of the Attorney General responsible for prosecuting health care Provider cases of Medicaid fraud or civil false claims actions.

46. Medicaid Fraud, Waste, and Abuse – The Medicaid rules define abuse as practices “inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.”

47. Medicaid Hospital Claims Audit Contractor – The Contractor retained through this RFP to perform audits of claims submitted to and reimbursed by the Maryland Medicaid program. i.e., the Contractor.

48. Maryland Department of Health or (MDH or the “Department”). The single State agency designated to administer the Maryland Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

49. Minority Business Enterprise (MBE) – Any legal entity certified as defined at COMAR 21.01.02.01B (54) which is certified by the Maryland Department of Transportation under

COMAR 21.11.03.

50. NCCI – National Correct Coding Initiative – Policies used to support the correct coding methodologies and to control improper coding which may lead to inappropriate payment in Medicare Part B claims.

51. Normal State Business Hours - Normal State business hours are 8:00 a.m. – 5:00 p.m. Monday through Friday except State Holidays, which can be found at:

https://dbm.maryland.gov/pages/default.aspx – keyword: State Holidays.

52. Notice of Acceptance - A formal letter or other document issued by the Contract Monitor that officially acknowledges that some plan or other aspect of the Contractors proposed means to successfully perform one or more requirements of the Contract is approved and may now be implemented within any indicated timeframe.

53. Notice to Proceed (NTP) – A written notice from the Procurement Officer that work under the Contract, project, Task Order or Work Order (as applicable) is to begin as of a specified date. The NTP Date is the start date of work under the Contract, project, Task Order or Work Order.

Additional NTPs may be issued by either the Procurement Officer or the Contract Monitor regarding the start date for any service included within this solicitation with a delayed or non-specified implementation date.

54. NTP Date – The date specified in a NTP for work on Contract, project, Task Order or Work Order to begin.

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55. Offeror – An entity that submits a Proposal in response to this RFP.

56. On-Site – At a location of the Provider.

57. Overpayments - Any payment made by the Maryland Medicaid Program to a Provider which at the time of payment, or at a subsequent date, is determined to be inaccurate and/or in excess of the correct amount for the procedural code billed. Any amount that is not authorized to be paid by the Medicaid program whether paid as a result of improper claiming, lack of medical necessity, unacceptable practices, fraud, abuse or mistake, etc. Payments made by the Program to a Provider in excess of the correct Program payment amount for a service is an Overpayment.

58. Personally Identifiable Information (PII) – Any information about an individual maintained by the State, including (1) any information that can be used to distinguish or trace an individual identity, such as name, social security number, date and place of birth, mother’s maiden name, or biometric records; and (2) any other information that is linked or linkable to an individual, such as medical, educational, financial, and employment information.

59. Procurement Officer – Prior to the award of any Contract, the sole point of contact in the State for purposes of this solicitation. After the Contract award, the Procurement Officer has responsibilities as detailed in the Contract (Exhibit 2) and is the only State representative who can authorize changes to the Contract. The Department may change the Procurement Officer at any time by written notice to the Contractor.

60. Program – Maryland Medicaid Program.

61. Proposal – As appropriate, either or both of the Offeror’s Technical or Financial Proposal.

62. Protected Health Information (PHI) – Information that relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual;

and (i) that identifies the individual; or (ii) with respect to which there is a reasonable basis to believe the information can be used to identify the individual.

63. Provider - An individual, association, partnership, corporation, unincorporated group, or any other person or entity authorized, licensed or certified to provide goods or services to recipients of the Maryland Medical Assistance program and which has been approved by the Department by the issuance of a Medicaid Provider Number.

64. Request for Proposals (RFP) – This Request for Proposals issued by the Maryland Department of Health (Department), with the Solicitation Number and date of issuance indicated in the Key Information Summary Sheet, including any amendments thereto.

65. Security Incident – A violation or imminent threat of violation of computer security policies, Security Measures, acceptable use policies, or standard security practices. “Imminent threat of violation” is a situation in which the organization has a factual basis for believing that a specific incident is about to occur.

66. Security or Security Measures – The technology, policy and procedures that a) protects and b) controls access to networks, systems, and data.

67. Sensitive Data - Means PII;PHI; other proprietary or confidential data as defined by the State, including but not limited to “personal information” under Md. Code Ann., Commercial Law § 14-3501(e) and Md. Code Ann., St. Govt. § 10-1301(c) and information not subject to disclosure under the Public Information Act, Title 4 of the General Provisions Article; and information about an individual that (1) can be used to distinguish or trace an individual‘s identity, such as name, social security number, date and place of birth, mother‘s maiden name, or biometric records; or

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(2) is linked or linkable to an individual, such as medical, educational, financial, and employment information.

68. Service Level Agreement (SLA) - Commitment by the Contractor to the Department that defines the performance standards the Contractor is obligated to meet.

69. SLA Activation Date - The date on which SLA charges commence under this Contract, which may include, but to, the date of (a) completion of Transition in, (b) a delivery, or (c) releases of work.

70. Software - The object code version of computer programs licensed pursuant to this Contract.

Embedded code, firmware, internal code, microcode, and any other term referring to software that is necessary for proper operation is included in this definition of Software. Software includes all prior, current, and future versions of the Software and all maintenance updates and error corrections. Software also includes any upgrades, updates, bug fixes or modified versions or backup copies of the Software licensed to the State by Contractor or an authorized distributor.

71. Solution - All Software, deliverables, services and activities necessary to fully provide and support the RFP scope of work. This definition of Solution includes all System Documentation developed as a result of this Contract. Also included are all Upgrades, patches, break/fix activities, enhancements and general maintenance and support of the Solution and its infrastructure.

72. Special Report - As described in Section 2.3.1.10..2, a formal notification by the Contractor to State personnel of any event, activity, condition, circumstance, practice, etc., that: (1). In its professional judgment it should disclose prior to a regularly scheduled monthly or quarterly report.(2). It is directed by the Contract Monitor to provide based upon disclosure of the event, activity, condition, circumstance, practice, etc., during a Weekly Call.

73. Start-up Plan - comprehensive plan outlining the strategy, goals, and operational details of the business to guide their decision making.

74. Start-up Period – The period of time, if any, between Contract Commencement (see Definition) and the Contract Go-Live Date (see Definition). During any Start-up Period the Contractor is to undertake whatever actions are needed to begin the successful performance of the Contract as of the Go-Live Date. Unless special Start-up pricing is requested in Attachment B, the Financial Proposal Form, there will be no payment made to the Contractor for any Start-up activities.

75. State – The State of Maryland.

76. System Availability – The period of time the Solution works as required excluding non-operational periods associated with planned maintenance.

77. System Documentation – Those materials necessary to wholly reproduce and fully operate the most current deployed version of the Solution in a manner equivalent to the original Solution.

78. Technical Safeguards – The technology and the policy and procedures for its use that protect State Data and control access to it.

79. Third Party Software – Software and supporting documentation that:

a. are owned by a third party, not by the State, the Contractor, or a subcontractor;

b. are included in, or necessary or helpful to the operation, maintenance, support or modification of the Solution; and

c. are specifically identified and listed as Third Party Software in the Proposal.

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80. Total Proposal Price - The Offeror’s total price for goods and services in response to this solicitation, included in Financial Proposal Attachment B – Financial Proposal Form.

81. Underpayment – A line or payment group on a claim that was billed at a low level of payment, but which should have been billed at a higher level of payment.

82. Upgrade - A new release of any component of the Solution containing major new features, functionality and/or performance improvements.

83. Veteran-owned Small Business Enterprise (VSBE) – A business that is verified by the Center for Verification and Evaluation (CVE) of the United States Department of Veterans Affairs as a veteran-owned small business. See Code of Maryland Regulations (COMAR) 21.11.13.

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