Area-Wide Software Application SOW.docx

Scope of Work

Purpose:

The Oklahoma City Area Indian Health Service requires a software application that provides a secure exchange, that assures all electronic transactions and DDE(Direct Data Entry) /FISS (Florida Information Shared System) access provide confidentiality, authentication, integrity and non-repudiation for the twelve IHS facilities.

It is mandated by IHS Headquarters that payment systems are updated to reflect changes in medical practice and relative value of services. Based on this; secure exchange managed services are needed for claims process to keep in compliance.

Statement of Work:

The contractor shall provide a secure exchange data software solution that provides a unique technology approach for connectivity to the Medicare DDE(Direct Data Entry) /FISS (Florida Information Shared System) products, eligibility verification and third party insurance claims validation, approval and processing services via a clearinghouse for Medicare, Medicaid, VA and Commercial Payers for the Oklahoma City Area (OCA). The contractor shall be able to process both medical and dental claims.

The OCA facilities include the Claremore Indian Hospital, Lawton Indian Hospital, Anadarko Indian Health Center, Carnegie Indian Health Center, Pawnee Indian Health Center, Clinton Indian Health Center, EL Reno Indian Health Center, Watonga Indian Health Center, Wewoka Indian Health Center and the Oklahoma City Area Office all located in Oklahoma and the Haskell Indian Health Center and White Cloud Indian Health Station located in Kansas.

The software services shall comply with the following constraints:

The service shall not require OCA facilities to install contractor software within the Oklahoma City Area Indian Health Service Environment The service shall enable OCA facilities to exchange data utilizing a 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 Indian Health Service and the Contractor.

The service shall also conform to a business associate agreement to be established between the OCA facilities and the Contractor.

The contractor shall support end-to-end communication testing, implementation and daily operations of the data transfers from the contractor to the OCA facilities, 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 OCA 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 OCA point of contact of any issues as their facilities or at the contractor that result 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 the OCA technical staff during the period 8:00 am to 5:00 pm central standard time.

The contractor shall provide:

Secure internet based connectivity to all current fiscal intermediaries.

Ability to send claims to Medicare Contractor using a secure date exchange technology.

Unlimited DDE and PPTN online Medicare claims status/corrections, etc. for Medicare Part A.

All electronic transactions DDE/FISS access provides confidentiality, authentication, integrity and non-repudiation Automated batch 837/835 file transfers.

Automated batch 276/277 claims correction capability.

Accept electronic claims from RPMS.

Obtain reports and acknowledgements on claims sent.

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

Verify Medicare and Commercial Payer eligibility in real time.

Flat fee for unlimited transactions.

Provide knowledgeable support personnel.

The Contractor shall provide toll free telephone/technical support during normal business hours, 8 am to 5 pm, Monday thru Friday, except Government holidays. The Contractor shall provide a two (2) hour minimum response time from notification by IHS as no additional cost to each IHS facility The Clearinghouse services must meet the following:

Third party insurance 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 claims shall be transmitted electronically to the appropriate carrier/payer.

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

The Contractor shall return to the appropriate IHS facility for correction any claims rejected by the carrier/payer for a reason other than the inappropriate format to the claims. The Contractor shall not charge for any claims rejected prior to the submission to the carrier/payer.

Errors in processing or submission of claims shall be limited to reprocessing and resubmission at the Contractor’s expense.

The Contractor shall provide a productivity spreadsheet within 24 hours of batch transmission to be submitted to the originating facility.

Contractor Compliance:

The Contractor shall adhere to all official coding rules as published by the American Hospital Association (AHA), regulations and guidelines in order to ensure the highest levels of integrity compliance and ethics.

The Contractor shall maintain a record of confidentiality in accordance with the Health Insurance Portability and Accountability Act (HIPPA), Privacy Act of 1974, Alcohol and Drug Abuse Patient Records, Freedom of Information Act and other pertinent Federal regulations.

Administrative:

Billing: Billing will be at a flat rate for all services.

Meetings/Conference Calls: The Contractor shall attend meetings or conference calls schedule by the PO to address areas of concern and exchange information to ensure consistent high levels of professional services. The PO shall be responsible for scheduling and coordination of all meetings and conference calls.

Equipment Failure: Any delays or downtime due to Contractor equipment failure shall be communicated to the COR or their designee within two hours via telephone. The Contractor shall not be penalized for delays due to equipment failure beyond the Contractor’s control. (e.g., IHS server downtime).

Reports:

Claims Approval: The Contractor shall deliver a standardized report to each facility on a weekly basis, which includes at the minimum the following:

c. Total Amount Billed

Clearinghouse: The Contractor shall deliver a standardized report to each facility on a weekly basis, which includes at a minimum the following:

f. Type of transmission (paper/electronic)

Period of Performance:

One Year with an Option to extend 4 additional Option Years.