B01 - SOW FBSU Claims Management Services.pdf

FORT BELKNAP INDIAN HEALTH SERVICE

STATEMENT OF WORK FOR HEALTH INSURANCE VERIFICATION AND

MEDICARE CLAIMS MANAGEMENT SERVICES

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

2. BACKGROUND/PURPOSE:

The Mission of the Fort Belknap Service Unit is to provide the best possible healthcare services to the Fort Belknap 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 Belknap Service Unit aims to maintain and to create an efficient, streamlined process for claims management and insurance eligibility verification services. To meet this mission, the Fort Belknap 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 works with the Electronic Health Record of Indian Health Service and identified third party eligibility information and workflow plus Medicare AR reporting and workflow for the Fort Belknap 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 Medicare 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 Belknap Service Unit requires an application that will provide daily Medicare AR report for efficient account management. These services shall be in compliance with HIPAA, IHS OIT mandates, and the Privacy Act.

3. SCOPE:

The contract resulting from this solicitation shall:

1. Attain comprehensive eligibility information– make eligibility requests to Medicare.

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

3. 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.

4. Experience integration between eligibility and claims functions.

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

6. Increase efficiency when checking eligibility – verify a patient’s eligibility status with Medicare.

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

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

Claims Management Monthly Estimated Number of Claims

Annual Estimated Number of Claims

Medicare 310 3,720 Private Insurance 360 4,320

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 Medicare

• Eligibility results must include start and end dates of coverage

• 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 custom business 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 Belknap Service Unit to install contractor software within the Fort Belknap Service Unit or Indian Health Service network.

• The service shall enable the Fort Belknap 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 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

1. Consistent data displays of response results by payer class

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

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

4. 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

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

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

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

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

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

10. Easy implementation, with minimal IT involvement –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:

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

IHS.

Medical insurance 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 the all 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:

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:

Online insurance verification software access.

9. PERIOD OF PERFORMANCE:

Base Year: 10/01/2026 – 09/30/2027 Option Year 1: 10/01/2027 – 09/30/2028 Option Year 2: 10/01/2028 - 09/30/2029 Option Year 3: 10/01/2029 – 09/30/2030 Option Year 4: 10/01/2030 – 09/30/2031

10. SECURITY:

11. 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 identifying particular 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: The 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 with regard to 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.