Attachment 1 Requirements and Core Functions.xlsx
XLSX spreadsheet 16 KB Posted
- Solicitation number
- RFI_011900
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Other files
| File | Type | Posted |
|---|---|---|
| Questions and Answers WTCHP NPN RFI.docx | DOCX document | |
| Request for Information-Nationwide Provider Network.docx | DOCX document |
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Sheet1
| ID | Requirement | Requirement explanation | Fill out this field with a short response (or white paper page #) or in your white paper with no more than one page for each requirement | Brief response-Established capability with minimum transition time (estimated timeline) | Brief response-Required transition time to fully operationalized (estimated timeline) | Brief response-Required sub-contractor to provide the capability (scope and oversight) | Brief response-Key performance indicator to continuously monitor and evaluate the NPN program: process, impact and outcome |
| NPN1 | Demonstrate understanding of the James Zadroga 9/11 Health and Compensation Act (2010) and Reauthorization Act (2015) (Zadroga Act) | Describe requirements for the Nationwide Provider Network (NPN), especially Section 3313, 3312(b)(4)(C), and 3305(a)(2)(A)(iv) with capabilities and capacities to implement the NPN program | |||||
| NPN2 | Provide expertise in delivering federal health care benefits to members of the World Trade Center (WTC) Health Program with | Describe relevant experience serving first responder and survivor populations impacted by a traumatic event similar the WTC Health Program members nationwide (excluding the in the New York City Metropolitan Area (NYCMA), including those responders from Shanksville, PA and Arlington, VA, the site of the Pentagon, and values of expertise added to the WTC Health Program | |||||
| NPN3 | Provide a nationwide mechanism to deliver WTC Health Program benefits, including dedicated clinics for in-person services and nationwide access for members as they are geographically spread | Describe how the WTC Health Program benefits will be delivered in a geographically spread member population including providing at least one dedicated clinic site for a community with 1,000 - 2,000 members within a 75-100 mile radius. To be cost-effective and compassionate, the dedicated clinic must provide a comprehensive service, including members services and medical benefits. The services should include screening, initial and annual health evaluation (monitoring), diagnostic, pharmacy, case management and utilization management (See claims requirement). Solutions should be provided for a less populated community and address how members will have access to services. | |||||
| NPN3 | Provide capability to continue performance of essential functions under a broad range of circumstances to transition and bridge the gaps as we and our contractors have an obligation to continue services | Describe how the WTC Health Program benefits will be delivered during emergencies at a local, regional or national scale of disruption including a major public health and medical emergency, such as the COVID-19 pandemic in order to deliver services including medical, pharmacy and other benefits, particularly for those members who have ongoing needs for services/supplies. | |||||
| NPN4 | Administer Medical Benefits and Services | Describe how medical benefits and services including roles and responsibilities, scope of treatment services and medially necessary treatment that will be delivered for desired outcomes | |||||
| NPN5 | Process certification of health conditions | Describe how enrolled members' s request for certification of health conditions will be processed, tracked, appealed, linked to benefits and assessed for desired outcome | |||||
| NPN6 | Process claims and billing according to established requirements and guidelines | Describe how claims and bills for payment for initial health evaluation, monitoring, and treatment of WTC-related health conditions will be performed according to established requirements and guidelines, including the following: |
| -Network flexibility and custom solutions | ||
| -Fee schedules | ||
| -Rates, including Federal Employees' Compensation Act (FECA), Diagnosis-Related Group (DRG), ICD-10 principle procedure codes, and the WTC Health Program | ||
| NPN7 | Perform a comprehensive coordination of benefit (COB) to avoid inappropriate claims payments, billing and collections | Describe a comprehensive approach to conduct COB for all survivor members' claims prior to submission for payment with explanation of benefit and validation of benefits with or without primary insurance in accordance with the Affordable Care Act as the WTC Health Program is the payer of last resource |
| NPN8 | Perform health insurance benefits assessment and maintain up-to-date information for all survivor members | Describe a comprehensive approach to assess, collect and manage health insurance coverage information for medical and pharmacy benefits, and transmission of data to the WTC Health Program |
| NPN9 | Provide a comprehensive approach to avoid inappropriate billing to beneficiaries. | Describe a comprehensive approach to prevent, detect and address inappropriate billing being sent to eligible members and minimize any negative effects in timely manner. |
| NPN10 | Provide a comprehensive approach to manage member data and health records with analytic capability to support operational decisions. | Describe a comprehensive approach to manage data securely. Include collection and maintenance of: |
-Up-to-date member information, health insurance and coverage information for medical and pharmacy benefits -Health records with the ability to analyze and transmit data and reports to World Trade Center Health Program. Data must be made available for audit and review upon request.
| NPN11 | Provide pharmacy benefits | Describe how the pharmacy benefits will be managed and delivered for approved formularies and prescriptions including Durable Medical Equipment (DME) and required supplies |
| NPN12 | Provide a comprehensive Case Management service that facilitates effective resource coordination throughout the continuum of care to promote and maintain optimal health and quality of life. | Describe clearly and specifically on how case management benefits will be administered, including the following elements: |
- Care delivery models Assessment tools
- Performance measures
- Integration of services (e.g., digital and telemedicine, transition of care, etc.)
- Quality and outcomes measures
- Team structure
- Case management-required experience and credentialing
- Standards of practice
| NPN13 | Provide maintain a viable provider network to provide access to convenient, competent, compassionate and comprehensive care for medical, mental health, and benefits needs related to certified WTC-related health conditions | Describe how a viable provider network with quality and efficiency for medical benefits with services available for responder and survivor members who live outside of the NY Metropolitan Area where it would be provided and managed with any national recognition and accreditation programs. |
| NPN14 | Provide a comprehensive Member Services program to assist all members from enrollment, transfer, retention to ongoing services | Describe how a comprehensive Member Services program will be provided and managed to ensure all members received competent and compassionate services including development all member services and benefits documents and dissemination. |
| NPN15 | Provide a call center operation to support potential and enrolled members and stakeholders and should be manned by personnel who are knowledgeable about the entire WTC Health Program and the NPN program | Describe how a call center service, including WTC Health Program Member Phone Bank/Resource Line, will be provided and managed including center workflow, triaging and priorities process and how the nature of the calls are addressed and monitored for timeliness and appropriateness, and calls should be referred to the WTC Health Program Call Center or next level of services-such as case managers |
| NPN17 | Provide collaborative, competent and compassionate member benefits and services | Describe how members' inquiries and / or complaints will be processed with collaborative, efficient and prompt resolutions using multiple means of communication including de different means of communication with members, including a secure electronic web portal |
| NPN18 | Provide benefits counseling to enrolled members | Describe how Benefits Counseling Eligibility Assessment and Screening Tool (BEAST), an electronic tool, will be implemented and used to generate a customized benefits counseling plan for a unique member based on the member’s responses to the BEAST questions. Benefits counseling includes but not limited to all program benefits, changes to benefits and information on workers’ compensation, other health insurance, health insurance under the Affordable Care Act, and social services to facilitate their efforts to acquire those benefits. |
| NPN19 | Provide translational and interpretive services for all interactions with members | Providing translational and interpretive services for program participants who are not English-language proficient including all formats such as sign, written and verbal |
| NPN20 | Provide outreach and education to enrolled members and targeted future members | Describe how outreach and education to enrolled members and targeted future members will be provided, including strategic and technical approach for proposed outreach activities |
| NPN21 | Provide communication capability | Provide information on capability to prepare communication materials to current and future members. |
| NPN22 | Provide customer satisfaction survey | Describe how member expectations will be measured and improved and what tools will be used to capture and analyze the data, including an annual customer satisfaction survey and each interaction survey to all members (active and others). |
| NPN26 | Provide a call center operation to support potential and enrolled members and stakeholder outreach and communication | Describe call center workflow, triaging and priorities process and how the nature of the calls are addressed and monitored for timeliness and appropriateness. |
| NPN27 | Process member enrollment | Describe member enrollment and disenrollment processes. |
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