Attachment A - SOW CAF 20211022.pdf

Attachment A

Performance Work Statement (PWS)

COVID-19 Coverage Assistance Fund (CAF) Program

Date: October 22, 2021

I. Background

A primary goal of President Biden’s National Strategy for the COVID-19 Response and

Pandemic Preparedness is to administer the Food and Drug Administration (FDA) authorized or licensed COVID-19 vaccines to as many people as possible, and as fast as possible, to reduce transmission, illness, and mortality. While the Federal government has purchased millions of vaccine doses and there is no cost to providers for the vaccine itself, health care providers can bill a patient’s health plan for the costs associated with COVID-19 vaccine administration.

Section 3203 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-

136) and its implementing regulations generally requires non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage to cover any qualifying coronavirus preventive service, including recommended

COVID-19 vaccines and their administration, without imposing any cost-sharing requirements, such as a copay, coinsurance, or deductible, during the COVID-19 public health emergency.

However, certain health plans are not subject to this requirement. Examples include grandfathered health plans, excepted benefits, or short-term limited duration insurance plans.

At present, all organizations and providers participating in the Centers for Disease Control and

Prevention (CDC) COVID-19 Vaccination Program (which currently includes any provider administering COVID-19 vaccine) may seek appropriate reimbursement from a program or plan that covers COVID-19 vaccine administration fees for the vaccine recipient, but they cannot seek any reimbursement, including through balance billing, from the vaccine recipient. This program will therefore become especially important to providers serving individuals whose health plans do not cover vaccine administration fees.

The CAF also draws from funding allocated through the American Rescue Plan Act (ARPA)

(P.L. 117-2). For ARPA specifically, $4.8 billion was allocated to support provider reimbursement for conducting COVID-19 testing for uninsured and underinsured individuals.

Approximately $1 billion of these funds will reimburse testing claims in the CAF.

Contract number 75R60221C00001 was originally awarded to the SSI Group, LLC on December

14, 2020 to meet the needs of the Government. At the time, the name of the program was entitled the COVID-19 Claims Reimbursement for Health Care Providers for Vaccine

Administration Fees for the Underinsured.

II. Purpose / General Description

The purpose of this contract is to process and distribute reimbursement to health care providers for COVID-19 vaccine administration fees and COVID testing on behalf of individuals with a health plan that does not fully cover COVID-19 vaccine administration or COVID testing as a benefit.

A. The general scope of the contract includes:

1. Project Management

2. Provider Education and Outreach

3. Eligibility and Provider Reimbursement

a. Terms and Conditions

b. Provider Portal

c. Patient Eligibility Verification

d. Insurance Plan Coverage Verification

4. Electronic Claims Intake

a. Electronic Data Interchange

5. Claim Adjudication

a. General Claims Processing

b. Back-End Processing

c. Remittance Advice

6. Financial Management and Claims Reimbursements

a. Reimbursement System

b. Approved Bank Account

c. Financial Management and Reporting

d. Payment Returns and Recovery

e. Remittance Support

7. Provider Call Support

a. Call Center

8. Support for Program Operations

a. Compliance

b. Research, and Data Support

c. Records Management

d. Training

9. IT Services

a. Software Quality Control and Systems Development Management Plan

b. Secure Data Transfer

c. Security Requirements

B. Assumptions:

1. The Contractor shall have the following technical assumptions when developing the

Claims Processing Services for the COVID-19 Coverage Assistance Fund:

This is a National contract for providers to submit and receive payment on COVID-

19 vaccine administration claims.

Systems leveraged for this program are hosted and managed by the contractor.

Now that COVID-19 vaccines are authorized by the FDA, vaccine administration fees will be covered by this program. (See also Appendix Q: Severe Acute Respiratory

Syndrome Coronavirus 2 (SARS-CoV2) (Coronavirus disease [COVID-19])

Vaccines).

The U.S. Department of Health and Human Services (HHS) may require an independent Authority to Operate (ATO) for this system, which will not be feasible to execute fully in order to meet the timelines being proposed, and a provisional ATO may be required in the interim and the Contractor will work to address any gaps between existing ATO’s and any required for this program.

Patient identifiers are required for insurance status verification that shall need to be validated or verified.

Required fields for electronic data interchange (EDI) and Paper claims (claims will be rejected/returned without these fields populated) – shall be used for patient verification demographics:

Health care provider attestation.

Name (First & Last).

Date of Birth.

Gender.

Patient Account Number.

Date of Service.

Name and identifiers for the patient’s insurance o The providers shall also provide in the claims submission:

Middle Initial/Name.

Address.

Patient date of birth.

o The Contractor shall encourage providers to include in the claims submission:

Race

Ethnicity https://www.ama-assn.org/system/files/2021-01/covid-19-immunizations-appendix-q-table.pdf o Provider Verification Assumptions Contact Center shall ask for the following to validate providers who call into the call center:

Name (First & Last).

National Provider Identifier (NPI).

Taxpayer Identification Number (TIN).

Contractor shall not make payments directly to patients.

Contractor shall ensure that there is coordination of benefits before payment.

Claims will be submitted electronically using either The Electronic Data Interchange

837 Professional transaction or the National Council for Prescription Drug Programs

(NCPDP) Telecommunication Standard Version D.0 (or the most current standard), NCPDP Batch Standard Version 1.2 (or the most current standard).

EDI files will only receive an Electronic Data Interchange (EDI) 999 acknowledgement transaction, the Electronic Data Interchange 277CA (claims acknowledgment) shall be generated (not required by HIPAA).

As applicable, the Common Electronic Data Interchange (CEDI) will return the TRN

Acknowledgement and the NCPDP Transmission Response Report showing accepted and rejected files and/or claims.

One (1) contract ID code will be used for insurance status for COVID-19 CAF claims.

Leverage clearinghouses that Contractor may have existing relationships with to accept EDI and NCPDP claims, rather than requiring each individual provider to enroll in EDI or CEDI directly with Contractor.

Contractor shall provide the banking entity.

Contractor shall be able to commence reimbursement within 30 days of contract award.

Contractor shall not charge participating providers with fees for their utilization of the

CAF.

III. Place of Performance

The place of performance shall primarily be the contractor’s facilities.

IV. Tasks

Task 1 – Records Management

The contractor shall:

Manage and maintain Federal records, including electronic records, ensuing from this contract in accordance with all applicable records management laws and regulations, including but not limited to:

The Federal Records Act (44 U.S.C. Chapters. 21, 29, 31, 33); 36 CFR,

1236.20 “What are appropriate recordkeeping systems for electronic records?”, and

1236.22 “What are the additional requirements for managing electronic mail records?”

(http://www.ecfr.gov/cgi-bin/text-idx?rgn=div5&node=36:3.0.10.2.25);

NARA Bulletin 2013-02, August 29, 2013, “Guidance on a New Approach to Managing

Email Records”

(https://www.archives.gov/records-mgmt/bulletins/2013/2013-02.html); and

NARA Bulletin 2010-05 September 08, 2010, “Guidance on Managing Records in Cloud

Computing Environments”

(http://www.archives.gov/records-mgmt/bulletins/2010/2010-05.html).

National Archives and Records Administration (NARA) and Office of Management and

Budget (OMB), Memorandum M-19-21, July 28, 2019 "Transition to Electronic

Records"

Managing the records includes, maintaining records to retain functionality and integrity throughout the records’ full lifecycle including: (1) maintenance of links between records and metadata, and (2) categorization of records to manage retention and disposal, either through transfer of permanent records to NARA or deletion of temporary records in accordance with

NARA-approved retention schedules.

Task 2 – Records Management Training

Ensure that all employees having access to (1) Federal information or a Federal information system, or (2) personally identifiable information (PII), complete the HRSA Records

Management Training before performing work under this contract, and thereafter completing the annual refresher course during the life of the contract. The training is located at https://humancapital.learning.hhs.gov/courses/2020recordsmanagement/01_index.html. At the end of the Records Management training, the “Congratulations" slide is considered your certificate of completion. Please send the completion certificates to the Contracting Officer

Representative (COR) of the contract. The listing of completed training shall be included in the first progress report. Any revisions to this listing as a result of staffing changes shall be submitted with next required progress report.

Task 3 – Contract Administration

Task 3.1 – Program and Project Management

The Contractor shall:

Provide a Program and Project Manager to ensure performance of the tasks under the contract. Maintain program and project objectives and priorities consistent with overall program guidance and direction provided by HRSA. Responsibility for overall direction and administrative support for execution of HRSA program guidance for program project work will fall under the direction of the Contractor’s Project Manager.

Submit Program/Project Management Plan to COR.

Program Management activities include:

o Management of contractor personnel.

o Establishment of processes and procedures for effective operations of contract management.

o Establishment effective communications and reporting procedures with HRSA.

o Provision of full systems life cycle project management support for new and existing system functionality.

o Overall scheduling and resource management to minimize the risk of scheduling conflicts.

o Management of system testing.

o Risk management; document control.

Establish and maintain the process for the claims reimbursement workflow with an end-to-end process.

Document HRSA direction to implement claims reimbursement processing for the

COVID-19 vaccine administration and testing claims.

Meet reporting and analytics requirements for claims processing in accordance with the

Quality Assurance Surveillance Plan.

Task 3.2 – Single Point of Contact

Provide a single point of contact for the management of all aspects of this contract to the

COR. The point of contact shall be responsible for ensuring that the services and deliverables required by HHS/HRSA are provided in accordance with the contract.

Task 3.3 – Kickoff Meeting

Meet with the COR within two (2) business days of the effective date of the contract

(EDOC) to discuss all current activities and the scope of work. One (1) day prior to the kickoff meeting, the Contractor shall provide an agenda for the meeting. At the kickoff meeting, the Contractor shall discuss project timeline, review scope and assumptions, projects guiding principles, contact information of key personnel, and proposed communication schedule/plan.

Submit detailed minutes of the meeting to the COR within one (1) week.

The objectives of the kickoff meeting are to:

1. Initiate the communication process between HHS/HRSA and the Contractor.

2. Review scope and assumptions as outlined in the proposal to ensure alignment on the work, deliverables, and outcomes and ensure the contractor understands the expectations of key stakeholders regarding the scope of work and the effort.

3. Review communication approach and ground rules.

4. Define a roadmap to a successful project.

5. Provide a live demonstration of the system.

Task 3.4 – COR Update Meetings

Chair semi-weekly conference calls with the COR, providing an agenda by 5:00 PM

Eastern Time (ET) the day prior, and update the agenda with action items and any corrections within 24 hours of the meeting.

Provide project updates at these semi-weekly conference call meetings. Two (2) Ad hoc meetings will be scheduled per month to cover emerging issues that arise between regularly scheduled meetings. This is a total of twenty-four (24) meetings per year.

Submit detailed minutes of each meeting to the COR within two (2) days of each update meeting.

Task 3.5 – Reports

Task 3.5.1 – Monthly Status Reports

Provide the COR a monthly status report for each monthly reporting period, due on or before the 10th of each month. This report shall contain, as applicable, the following sections:

Project description.

Activities planned for the upcoming reporting period.

Activities performed during the prior reporting period.

Progress on deliverables as stated in the Project Management Plan.

Project issues and risks that may impact schedule, budget, and/or quality.

Performance Metrics.

Number of claims reimbursed.

The number of attestations and claims reimbursements completed. This list must include information on Provider types and the geographic distribution.

Providers with claims held due to OIG, CMS and other program integrity concerns.

Total dollar amount of reimbursements.

A data dictionary defining, in plain language, all data elements in the report.

Task 3.5.2 – Weekly Reports

Provide a weekly report to the COR due on each Wednesday by 6 PM ET. The Weekly

Status Report shall be cumulative and contain key data, such as customer service summary statistics, and reimbursement and return details. Each report shall contain data dictionary defining, in plain language, all data elements in the report.

Identified Weekly Report Titles:

Frequency and dollar amount of Vaccine Administration Fees found on Claims-

Weekly File rolling up by Codes found on Claims.

Member Rollup-Provider, Member, totals by week.

Provider Demographic Data-Weekly file for providers, by specialty type who have submitted claims that week showing their demographics as defined by HRSA.

Public File Report-Cumulative Report showing all data for Billing Provider.

White House Report-Cumulative Provider, Member, claim roll- up, to ensure the performance of the CAF Program.

Report on types of visits (for example, hospital, clinic, pharmacy clinic, inpatient, etc.).

Report on Coverage types. This shall include carriers and be cumulative.

Report on the patients served by this Program, including demographics regarding different age bands, race/ethnicity, states and gender.

Task 3.5.3 – Daily Reports

Provide daily status reports to the COR on claims reimbursement as outlined in the schedule of deliverables.

Identified Daily Reports:

Daily Executive Email. This shall provide cumulative daily metrics showing:

1) The status and health of the program.

2) Projected and actual reimbursements for Vaccine Administration Fees.

3) The number of claims rejected.

4) Top 10 reasons for claim rejections.

5) The number and dollar amount of payment errors.

6) Number of providers excluded from payment as a result of OIG and CMS eligibility checks

7) Payment returns.

8) Number of Distinct members (patients) served.

9) Patients served broken down by race and ethnicity, when provided.

10) Number of distinct providers with claims.

11) Number of validated NPIs.

12) Number of pending and completed ACH enrollments.

13) Types of existing insurance.

14) Heat maps showing Providers paid by city, state, and zip code.

15) Heat maps showing claims reimbursed by Provider state.

16) Heat maps showing eligible patients submitted/state population.

17) Heat map showing eligible patients submitted.

18) Customer support call volume.

The daily executive email shall include a data dictionary defining, in plain language, all data elements in the report.

Daily Financial Report. This shall provide a daily payment reconciliation report to the

COR and the Chief, Budget Execution and Management Branch that includes cumulative reimbursements to providers for reimbursement of vaccine administration fees.

Task 3.5.4 – Final Reports

Submit a final report to the COR 30 days prior to the end of the period of performance memorializing the Contractor’s scope, role, duties, key challenges, risks, decisions, and solutions, and timeline of events. The timeline of events shall be written as a narrative.

This report may be a compendium of other deliverables.

Submit a final claims reimbursement reconciliation report to the COR.

Task 3.6 – Risk Management

Create, maintain and submit to the COR a Risk Management Plan by identifying, documenting, analyzing, and prioritizing risks associated with the CAF Program.

Manage and develop strategies to handle identified risks, and monitor the health of the program throughout its life cycle.

Task 3.7 – Communication and Correspondence

Include the COR on all correspondence with the Government.

Send all reports and deliverables to the COR and/or CO and designee.

Include the COR in all teleconferences/meetings with the Government.

Send any and all requests for changes, such as modifications to the COR and/or CO.

Task 3.8 – Documents

Develop and submit the following project management documents to the COR:

One (1) graphic business workflow for the claims reimbursement process. An updated visual business workflow shall be required to reflect any change in the process.

Claims reimbursement methodology.

Provider support (call center) plan.

Systems security and privacy artifacts (see Task 12).

Task 3.9 – Performance and Quality Metrics

Implement Contractor performance and quality metrics in the Quality Assurance Surveillance

Plan (QASP). The COR will evaluate the Contractor using these metrics on a weekly basis.

HHS/HRSA will require frequent updates on total claims reimbursements to ensure that the

COVID-19 Vaccine Administration Assistance Fund stays within statutory funding limits.

Task 4 –Stakeholder Outreach and Education

Task 4.1 – Strategic Communications Plan

Create one (1) draft strategic communications plan to promote the program, including proposed metrics developed by the contractor to measure success of the communications plan.

Create accompanying timelines to execute each component of the above plan.

Revise draft strategic communications plan in response to HRSA comments. Requested revisions should be submitted within 1 week of request.

Implement strategic communications plan

Task 4.2 Provider Outreach

The contractor shall:

Draft and send mass email communications:

o 15 emails to 700,000 recipients

Draft content and conduct educational webinars for providers (capacity over 10,000 attendees) via a contractor-provided platform:

o Four (4) webinars

Develop and distribute testimonial videos. Leverage HHS and HRSA’s existing social media channels (e.g., Facebook, Instagram, LinkedIn and Twitter) as distribution platforms. Contractor shall also identify and utilize additional distribution measures.

o Three (3) videos

Develop and submit three (3) social media posts for HRSA to distribute, including graphics and text, per month. Provide graphics in multiple sizes for various platforms.

All communications materials shall be reviewed and approved by the COR and the

HRSA Office of Communications (OC) and the HHS Office of the Assistant Secretary for Public Affairs (ASPA).

Revise materials in response to HRSA comments. Requested revisions shall be submitted within 1 week of request.

Materials shall display HHS and HRSA branding. Contractor logo shall not be included on these materials.

Source files for video and graphic shall be provided to HRSA at the end of the contract.

Clearly communicate to providers the program’s restrictions against balance billing as required for participation in the CDC COVID-19 Vaccination Program. For more information, visit: https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html.

Task 4.3 – Website Content

Provide input into the development of a landing page to communicate overall program, FAQ’s and provide key links for Health Care Providers to input data necessary for reimbursement of eligible COVID-19 vaccine administration claims.

Develop content to support a provider educational website at https://www.hrsa.gov/covid-vaccine-adminclaim (The primary audience of the website will be the provider community serving the underinsured across the country.) The website shall offer providers step-by-step instructions, including narrative and screen shots, to instruct and guide providers in successfully completing every step in the CAF enrollment and claims reimbursement process.

Provide up-to-date information on provider billing for claims related to the COVID 19

Vaccine Administration Assistance Fund and include links to the CDC and other responsible sources for public health updates on this website. Site content shall follow

Federal plain language guidelines at https://plainlanguage.gov/guidelines/.

Task 4.4 – Website Creation and Maintenance

Create and maintain a website that complements the portal hosted outside of HRSA’s domain, which communicates about the program, provides technical assistance materials including a portal user guide and recordings of educational webinars, and links to the

Frequently Asked Questions (FAQs) developed and posted online by HRSA. The primary audience of the website will be the provider community serving the underinsured across the country.

Provide up-to-date information on provider billing for COVID-19 related claims for the underinsured and include links to the CDC and other responsible sources for public health updates on this website.

Site content shall follow Federal plain language guidelines at https://plainlanguage.gov/guidelines/.

Task 4.5 – Stakeholder Outreach

The contractor shall:

Create and execute a stakeholder outreach plan that provides information and updates about the program for stakeholders such as associations, state and local governments, etc.

Develop and maintain a list of relevant stakeholder email addresses.

Create and maintain promotional materials that are updated bi-monthly.

o Educational toolkit (1) o Provider Fact sheet (1) o Clearinghouse Fact sheet (1) o Additional Fact Sheets or technical assistance documents (2) https://www.hrsa.gov/covid-vaccine-adminclaim https://plainlanguage.gov/guidelines/ https://plainlanguage.gov/guidelines/

Draft content and conduct educational webinars for stakeholders (capacity up to 200 attendees) via a contractor-provided platform:

o 8 webinars

Develop and maintain social media outreach plan with accompanying graphic images and messages to help inform eligible providers about the program in coordination with the

COR and subject to HRSA OC and HHS Office of the Assistant Secretary for Public

Affairs (ASPA) approval.

Task 4.5.1 – Respond to Data Requests from Within Federal Government

Some requests may involve data that may be withheld under the terms of the Privacy Act of

1974, as amended (5 U.S.C. ' 552a), the Trade Secrets Act (18 U.S.C. ' 1905), the Freedom of

Information Act (FOIA) (5 U.S.C. ' 552), or other applicable laws. For example, any personally-identified or personally identifiable data maintained in the OPTN/SRTR/HRSA Data System of

Records, HHS/HRSA/HSB/DoT, No. 09- 15-0055, including data maintained electronically, must be disclosed consistent with the Privacy Act and the Systems Routine Uses, outlined in the applicable System of Records Notice (73 Fed. Reg. 19519, as amended).

Provide data reports (through the COR) to components within Federal Government.

Respond to TIN investigation requests:

o 50 individual NPI investigations

Respond to A-123 audits.

o 1 A-123 audit

Respond to OIG interview requests.

o 10 interviews

Fulfill data requests within three (3) business days of request from the COR. Where circumstances make meeting that deadline unfeasible, notify COR within two (2) business days with the reason(s) for the delay and request new data submission date.

Fulfill urgent data reports within one (1) business days of request. Reports shall be considered urgent if requested by the White House, a member of Congress, the HHS

Secretary, the HRSA Administrator, OIG or similarly situated entity.

Submit written extension request to the above timeframes to the COR for approval

Notify the COR within three (3) days of the request if: (1) the data are not collected and/or available; (2) release of the data violates the Privacy Act or applicable laws; (3) the use of the data is not sufficiently valuable to warrant a large scale expenditure of time and effort; or (4) the data and information are otherwise exempted from disclosure under the FOIA, when applicable.

Give the highest priority of data requests from within the Federal government.

Create and maintain a Log of all the data request. The log shall include the number of routine and complex data requests from inside the Government and report this information in the monthly progress report.

Task 5 – Eligibility and Provider Reimbursement Terms and Conditions Attestations

Task 5.1 – Provider Portal

Per HRSA guidance and direction, develop, and maintain a portal based on program requirements to allow healthcare providers to confirm and/or submit data required for

ACH transactions, and submit provider and patient rosters for validation to program guidelines.

Create a step-by-step technical user guide providing detailed instructions on how to utilize the portal to enroll in the program and submit claims.

Prior to portal launch, the Contractor shall perform user acceptance testing (UAT) among a representative random sample of twelve (12) potential system users in order to evaluate and improve the user experience with the portal.

Have customer satisfaction survey question prompts at the provider’s completion of CAF portal registration. Contractor shall maintain feature on https://covid19coverageassistance.ssigroup.com/ from which providers can offer feedback on program clarity, ease of use, and Contractor shall review, on a weekly basis, feedback submitted via this feature to identify critical issues. On a monthly basis, Contractor shall summarize feedback and describe for HRSA efforts made to respond.

Configure the portal so that it can be closed, once funding thresholds are met.

Perform retrospective review of claims reimbursements to ensure that Providers’ claims were compliant with their patients’ defined “Underinsured” status.

Maintain the integrity of the original provider records.

Provide twelve (12) monthly reports on portal use and data submitted to the portal, including number of new and cumulative enrolled providers, claims volume, and claims processing time. One Ad hoc report per week may be requested.

Establish and maintain the process for providers not currently enrolled with the https://covid19coverageassistance.ssigroup.com/

Contractor to register on the Contractor’s program portal.

Establish and maintain process for providers to set up a bank account with the

Contractor’s designated bank for electronic reimbursement of claims submissions.

Task 5.2 – Patient Eligibility Verification – Coordination of Benefits

For each claim, perform prepayment verification of patients’ insurance coverage status at time of service. This should include comparing submitted information about a patient’s coverage with information in Clearinghouses.

For individual(s) (patient(s)) where eligibility is determined to be covered under the

Vaccine Administration Assistance Fund Program, issue temporary member IDs for the use of claims submissions and processing.

For individual(s) (patient(s) where eligibility is determined to be insured, send claims to qualified plans.

Establish and manage a process for reconsideration of eligibility for providers who have received a denial of eligibility based on insurance coverage found for submitted individual(s) (patient(s)).

Task 6 – Electronic Claims Intake and Data Interchange

Set up an electronic system for health care providers to submit COVID-19 837 and

NCPDP claims for individuals with a health and/or prescription benefit plan that does not include COVID-19 vaccine administration as a covered benefit or covers COVID-19 vaccine administration, but with cost sharing.

Implement a system of edits at the EDI gateway or where applicable to identify claims not meeting program eligibility or reimbursement guidelines resulting in rejection of non-compliant claims.

Mask the data extract file to avoid PII intake.

Establish and control reimbursement requests, chain of custody, and money transfer workflow.

Implement appropriate controls to ensure reimbursement transfer accuracy.

Recommend and establish processes to ensure reimbursement integrity and improve efficiencies.

Maintain any and all necessary efforts, such as oversight, auditing, program integrity, etc.

Establish and maintain a reimbursement management system by which providers’ submitted claims are adjudicated, rejected with explanation, or processed and paid, that manages all financial transactions, such as:

o Interface with the bank.

o Accept wire transfers.

o Return any returned funds to HHS on a daily basis.

Disburse claims reimbursements daily, Monday through Friday.

Task 7 – Claim Processing

Task 7.1 – Claim Adjudication

Implement fraud detection processes equivalent to commercial standards for reviewing and adjudicating claims. Detect and notify the COR within one (1) hour from when fraudulent activity is detected and/or when an entity that is under investigation by any other Federal Government agency that submits a claim. Payments shall not be issued to an entity in the event that fraudulent activity is detected and/or the entity is under investigation by any other Federal Government unless approval is given by the COR.

Send provider (including billing agents or clearing houses, acting on behalf of the provider) claims to a collection point that houses preprocessing functionality before entry into the adjudication systems.

Accept claims that meet eligibility requirements during established dates of service submitted by eligible provider(s) and only contains patients that have been determined eligible, defined as having insurance which does not cover vaccine administration, or covers vaccine administration but with patient cost sharing.

Perform coordination of benefits for individuals with other insurance coverage.

Provide a capability in contractor system for HRSA to review the approved claims.

Send encrypted email version of the approved claims file for HRSA review and approval.

Task 7.2 – General Claims Processing

Establish and maintain written process that shall be shared with the COR that outlines the

Contractor’s claims verification process to ensure that claims are accurate and meet all eligibility requirements as indicated in HHS policies and regulations.

The claims verification process shall include the following:

Appropriate Diagnosis/Code (Healthcare Common Procedure Coding System (HCPS) code for COVID Vaccine Administration fee).

Provider Eligibility.

Verify the Providers status using the following lists:

o Office of Inspector General's List of Excluded Individuals/Entities (LEIE), updated monthly;

o Medicare Revocation List, updated weekly;

o Medicaid Termination List, updated monthly;

o CMS Compliance Hold List, updated monthly;

o Notify the COR and appropriate HRSA Team in writing immediately, in the event that a provider that is on either of the above lists has been reimbursed.

Establish and maintain a written retroactive claim verification process that shall be used to validate the above information.

Task 7.2.1 – Patient Verification

Evaluate and confirm patient eligibility. Perform prepayment verifications of Patients’ insurance status for each submitted claim (use other health information and patient information at the time of service) and service coverage by that insurance.

Implement fraud detection processes equivalent to commercial standards for processing claims.

Detect and notify the COR within one (1) hour from when fraudulent activity is detected and/or when an entity that is under investigation by any other Federal Government agency that submits a claim.

NOT issue payment to an entity in the event that fraudulent activity is detected and/or the entity is under investigation by any other Federal Government unless approval is given by the COR.

Task 7.3 – Back-End Processing

Provide a weekly report to HRSA identifying overpayments or improper payments.

For claim overpayments, offset future claims to correct for overpayments.

Identify and send a report of all open overpayment inventory for which offsets have been exhausted. HRSA will direct contractor to pursue collection of the overpayment from the eligible provider and return recovered overpayments to HRSA.

Conduct monthly post pay review on a random sample of claims for the purposes of identifying and detecting patterns of abuse, and flag any and all potential fraud and notify the COR within one (1) hour from when fraudulent activity is detected.

Task 7.4 – Remittance Advice

Generate timely and accurate payment and delivery of Electronic Remittance Advices

(ERAs) and make ERAs available to provider’s Bank Account EPS (electronic payments and statements).

Task 8 – Financial Management and Claims Reimbursements

Task 8.1 – Claims Reimbursement

Distribute claim reimbursements to eligible providers based on verified and adjudicated vaccine administration claims submitted through Contractor’s EDI gateway.

The reimbursements shall be based on required coding, dates of service, provider and patient information and shall be made to providers who currently have an ACH account with Contractor’s Bank or who register to start such an account as part of the

Vaccine Administration Assistance Fund Program.

The Contractor’s Bank shall use this information to make ACH payments to providers who have administered COVID-19 vaccines to patients who have a health plan that does not fully cover COVID-19 vaccine administration as a benefit.

Use the approved funding processes using an FDIC-protected Bank Account (“Bank

Account”) as described in the Tripartite Agreement among the parties dated March 2, 2021.

Validate that the funds have been received in the Contractor’s designated Bank

Account.

Maintain a record of the claims reimbursed to eligible providers for vaccine administration fees and submit to the COR twice monthly.

Task 8.2 – Reimbursement System

Establish and maintain a reimbursement system that distributes reimbursements to healthcare providers serving individuals with a health plan that does not include COVID

19 vaccine administration as a covered benefit or covers these services, but with cost sharing, without undue delay.

Send daily payment requests to the COR and the HRSA Office of Budget and Finance for approval and funds certification. The payment requests shall be for the total funds required.

Payment request shall include the gross payment total for the program, the Contractor

EIN associated with the program bank account, the Contractor’s legal business name, and the date of the request.

Send reimbursements via electronic funds transfer to healthcare providers.

Process any rejections, failed transactions and payment errors arising from the reimbursements and provide this data to the COR within 72 hours, or as soon as possible given the nature of the rejection.

Contact providers to obtain corrected ACH information (as directed by the COR).

Task 8.3 –Return Payments

Establish and maintain a process for return of over-payment and other forms of non-acceptance or return by the providers and submit this process to the COR for approval.

Return overpayments returned by healthcare providers to HRSA per Treasury instructions.

Manage, maintain and report reimbursement over-payments and status of returns through weekly file submission to COR and CAF Team. Review with CAF Program team twice monthly.

Maintain an auditable system of records for all claims reimbursements.

Maintain auditable funds control and management of all deposits and transactions.

Utilize quality assurance and payment integrity capabilities to ensure reimbursements are processed accurately and without duplication.

Maintain reporting capability consistent with reporting requirements of this program for claims reimbursement transactions and audits, and comply with all HHS/HRSA Security requirements.

Task 8.4 – Approved Bank Account

Maintain a bank account capable of processing and managing all financial transactions in accordance with the Tripartite Agreement.

Establish and maintain bank account for the CAF Program (the “Bank Account”) for vaccine administration fees reimbursements.

Return any and all interest gained on net balances in the account to HRSA via wire transfer. Returns of interest gained shall occur on a monthly basis.

Provide account safeguards, monitoring and access controls to CAF related financial transactions.

Use the Bank Account to process and make claims payments.

Submit a monthly utilization report to the COR to validate the total monthly utilization for the account. The bank shall submit a monthly invoice to HHS/HRSA for the total cost of the bank account.

Coordinate with Contractor affiliates to maintain a lockbox to receive payments from

Providers, if needed.

Complete, sign, and send a form to HRSA’s Office of Budget and Finance (OBF) and

HHS’s Program Support Center (PSC) to establish and maintain a vendor account (also known as supplier site) in the UFMS system that identifies Contractor’s bank account.

Treasury will deposit funds into the bank account during each payment cycle.

Ensure that the bank account maintains a near zero balance unless otherwise approved by the COR and the HRSA Office of Budget and Finance. Non-zero balances may be necessary for managing obligated funds to cover electronic funds payments in process.

Return surplus funds received from providers to HHS on a daily basis. Returned funds shall include the principal, interest, total amount, total count and allowance.

Include a final claims reimbursement reconciliation report as part of Task 3.5.4 and return any unobligated funds.

Task 8.5 – Financial Management and Reporting

Provide documentation annually to the HRSA Provider Relief Fund Program Integrity

Team for A-123 assessment demonstrating that adequate internal control policies and procedures have been established by the Contractor for all financial transactions conducted under this contract.

Utilize the required accounting, logical partitions, firewalls, and funds control capabilities to ensure that all Treasury deposits and financial transactions are managed, maintained, and reported separately in a bank account.

Establish and maintain payment integrity plan that ensures internal contractor controls comply with the A-123 assessment to implement appropriate cost-effective management controls for results-oriented management; assess the adequacy of management controls;

identify deficiencies; take corresponding corrective action, and report on management of those controls.

Task 8.5.1 – Financial Accounting System

Host the financial accounting systems responsible for processing and reimbursing claims.

Secure routine execution of claims reimbursement files.

Secure processing and storage of millions of claims reimbursement records.

Secure reporting and file transfer capabilities.

Secure interface with other HHS/HRSA internal systems and external systems such as US

Treasury.

Ensure disaster recovery capabilities.

Operate and maintain the financial accounting system.

Secure routine execution of claims reimbursement files.

Secure processing and storage of payment records per HHS/HRSA records retention requirements.

Secure reporting and file transfer capabilities.

Secure interface with other internal systems and external systems such as US Treasury;

and Disaster recovery capabilities.

Provide HRSA’s Director, Division of Financial Policy and Analysis and COR with a daily extract of financial data from Contractor’s financial accounting system.

Provide a scheduled banking data file(s) every banking day (unless there are no claims) from the financial accounting system that provides details of all financial transactions, commitments, obligations, returns, and originating ACH, re-issued, flagged for stop payment, cashed, etc. with the fields and columns determined by HRSA financial oversight designee.

Provide a secure file transfer process.

Coordinate with and provide the file structure, data elements, data dictionary, etc. to the

HRSA financial oversight designee.

Reconcile the reimbursement files with the actual reimbursements made for vaccine administration and testing fees to ensure the reimbursements can be tied back to the initial funding request and the appropriate Legislation and accounting CANS.

Task 8.5.2 – Accounting System Database

Manage and operate an accounting system responsible for making payments.

o Secure routine execution of payment files.

o Secure processing and storage of millions of payment records.

o Secure reporting and file transfer capabilities.

o Secure interface with other HHS internal systems and external systems such as US o Ensure disaster recovery capabilities.

Operate and maintain accounting system.

o Secure routine execution of payment files.

o Secure processing and storage of payment records per HHS records retention requirements.

o Secure reporting and file transfer capabilities.

o Secure interface with other HRSA internal systems and external systems such as US o Disaster recovery capabilities.

Provide a daily incremental extract file from the banking system to HRSA’s Director, Division of Financial Policy and Analysis by 1PM ET that provides details of all financial reimbursement transactions, including payment date, amount, TIN, customer name, and total vaccine administration fee amount.

Establish and maintain a trusted and secure file exchange process between the Contractor and HRSA’s IRMS.

Specifics of the file structure, data elements, data dictionary, etc., to be provided to COR and financial oversight designee after initial kickoff meeting with Contractor.

Ensure compliance with all necessary FISMA security requirements such as

Interconnection Security Agreements, Authority to Operate, etc.

Note: IRMS is financial data warehouse managed by HRSA to collect and store financial commitments, obligations and disbursements, and is used by Agency staff to verify the status and availability of funds, support internal controls testing, and other enterprise risk management activities.

Task 8.5.3 – Claims Reimbursement Files

Establish and maintain a standardized reimbursement file format.

Ensure each claims reimbursement file has an ACH.

Track each claims reimbursement file distribution amount, ACH addenda record.

Review the claims reimbursement file for quality controls.

Ensure each provider payment has a TIN.

Identify reimbursements to providers that are over $500,000 and perform outreach to those providers to validate ACH banking information.

Task 8.5.4 – Reimbursement Requests

Send a reimbursement request to the COR for approval and funds certification prior to the initiation of a transfer to the Contractor’s Bank Account.

Provide the total funds requested with each reimbursement request. Requests are to initiate payments to Contractor’s Bank account for HRSA COVID-19 Vaccine

Administration Assistance Funds. Upon receipt, Contractor Bank will release the corresponding ACH reimbursements to health care providers providing vaccines to individuals with a health plan that does not include COVID-19 vaccination administration as a covered benefit or that covers COVID-19 vaccine administration, but with cost sharing.

Ensure that the reimbursement request includes, the contract number associated with the program, the Contractor’s legal business name, and the date of the request.

Task 8.6 – Payment Returns and Recovery

Develop and maintain a process to handle funds returned by providers. The Contractor will receive the returned funds from the provider and allocate funds back to the HRSA

COVID-19 Vaccine Administration Assistance Fund.

Develop and maintain a process to identify an overpayment to a provider, offset the overpayment against a future claim by the provider or obtain repayment from the provider of the overpayment and allocate funds back to the HRSA COVID-19 Vaccine

Administration Assistance Fund. Submit this process to the COR.

If the HRSA COVID-19 Vaccine Administration Assistance Fund is exhausted, identify and send a report of all open overpayment inventory to the COR. HRSA will direct

Contractor to pursue collection of the overpayment from the eligible provider and return recovered overpayments to HRSA.

Assist HHS/HRSA in recovering funds from identified providers.

Develop a methodology or procedure to recover claims reimbursements, including:

contacting the provider, bank returns, letter of identification, issuing demand letters, etc.

Include an adjustment flag within the daily incremental extract file that identifies the provider, TIN, amount, etc., for all return transactions, Task 8.7 – FPLP Withholding to Payments

Ensure that all payments are subjected to the Federal Payment Levy Program (FPLP) or non-tax debt withholding in accordance with Treasury policy and procedure.

Construct an extract file of the reimbursement information file including legal business name and TIN.

Send the extract file to the Treasury to match against the debt database.

Receive a match file from to the Treasury for any payee with outstanding tax or non-tax debt.

Offset payment to the payee in accordance with the Treasury withholding requirements and send offset file to the Treasury with the debt amounts withheld.

Receive an acknowledgement file from the Treasury.

Forward all FPLP withholdings to the Treasury within 10 business days.

Ensure that the payment remittance advice is designated with the appropriate reason code for the FPLP withholding.

Task 8.8 – IRS 1099s to Payees

Prepare and send IRS 1099-MISC, in accordance with IRS regulations

(https://www.irs.gov/newsroom/frequently-asked-questions-about-taxation-of-provider-relief-payments, no later than December 13, of the respective tax year, to all payees that received payments during the specific calendar year.

Send the electronic 1099 file with this information to the IRS in accordance with the IRS reporting deadline.

Task 8.9 – IRS Backup Withholding

Maintain the capability to apply backup withholding to affected payments in compliance with IRS and Treasury laws and regulations.

Task 9 – Provider Call Support

Task 9.1 – Customer Service

Establish a Customer Service Program to respond to provider inquiries and educate providers about the COVID-19 Vaccine Administration Assistance Fund. The

Contractor’s Customer Service Center serves as the primary point of contact with the providers needing CAF program support on a day-to-day basis.

Provide customer service:

o Provide Call Center Services from 8:00am to 8:00pm EST to respond to provider telephone inquiries.

o Establish the infrastructure to adequately support call volume.

o Respond to provider telephone and email (for off-hour inquiries) inquiries promptly, clearly, and accurately.

https://www.irs.gov/newsroom/frequently-asked-questions-about-taxation-of-provider-relief-payments https://www.irs.gov/newsroom/frequently-asked-questions-about-taxation-of-provider-relief-payments o Coordinate HHS/HRSA on response plans for external correspondence.

o Maintain a high level of provider service and satisfaction through good communication and relationships with providers.

o Train and prepare call center staff to receive and respond to calls from health care providers regarding CAF reimbursements.

o Define FAQ scripts using the available information including talking points and manager talking points, Q&A, train call center staff, and develop a plan to train to interface with the Providers.

o Monitor provider contact centers as needed to ensure satisfactory quality and performance standards are met for all PCC telephone inquiries.

o Provide Federal Telecommunications Services (FTS) lines for toll-free access to the customer support service.

o Meet the requirements for the Americans with Disabilities Act (ADA).

o Develop and update efficient protocols, SOPs, and training manuals for referring, tracking and monitoring user requests. Protocols, SOPs, and training manuals shall be made available to the COR anytime upon request.

o Support eligible provider inquiries related to technical issues, such as Attestation and accessing microsite/portal.

o Establish and maintain a defined internal escalation and issue tracking process with input from HRSA to review and respond to questions and to transfer escalated issue to HRSA to support resolution. Submit this defined process to the COR within 30 days of EDOC.

o Coordinate responses with other HRSA contractors.

Task 9.2 – Email

The program issues a variety of documents via email. All emails must comply with the HHS

Visual Style Guide and HHS logo policy.

Establish, operate and maintain email operations.

Manage the inventory of all the forms and templates incoming and outgoing correspondence.

Track and electronically store any and all information related to outgoing and returned email correspondence.

Task 10 – IT Services

Task 10.1 – Software

Manage Contractor provided software resources and for coordinating with other program systems (e.g. JIRA, etc.) to perform the activities of the CAF.

Provide operations and corrective maintenance of supporting software.

Provide a demo and screenshots of each provider facing system after each system change to the COR.

Provide both routine and emergency system support during the period of performance to ensure seamless program operation.

Ensure all contractor owned contractor operated (COCO) and commercial off the shelf software (COTS) software is…