Bidder Q&A.pdf

Michigan.gov/MiProcurement

BIDDER QUESTIONS & ANSWERS

Version 2021-2

RFP 260000002170

Medical Bill Review

Q # Bidder Question Answer (to be completed by the State)

Is the current vendor's technical bill review services still active?

Also, is this RFP for the full replacement of all services or only the professional review component?

The current vendor is still providing services. This RFP is for all services specified in Schedule A.

Please provide the total annual number of medical bills processed per fund (SISF, VHP, and CRSFRPC) for each of the last three fiscal years (FY2022, FY2023, FY2024), along with the average billed amount per bill and the total annual medical payments made per fund.

See attached PDF 2022-2025 Medical Bill Count

Of the total bills processed annually across all three funds, approximately what percentage historically have triggered the professional health care review thresholds (i.e., inpatient hospital care, total claim medical payments exceeding $20,000, or suspected inappropriate care)?

The percentage of bills that need professional healthcare review will be approximately 85%.

For purposes of the professional health care review program certification under R418.101204, are licensed health care professionals (RNs, MDs, DOs) required to hold an active Michigan state license specifically, or is licensure in any U.S.

state acceptable provided they meet the occupational injury expertise requirements of the HCS rules?

They must be licensed, but do not need to be licensed in Michigan.

Does the State require the awarded vendor to be fully WDCA-certified prior to contract start on October 1, 2026, or will the State allow a provisional start with certification to be completed within a defined period after contract execution? If pre-certification is required, please confirm the typical WDCA certification review timeline so bidders can plan accordingly.

Per Mandatory Minimum requirements the Bidder must be WDCA-certified or qualify by the time of bid review to be recommended for award.

Bidders can email the solicitation manager for requirements to be submitted with their bid.

Responses to emails will be submitted on July 6th.

Please provide the technical specifications for the SFTP file transmission process, including: (a) file format requirements for inbound medical bills (e.g., ANSI 837, paper bill image, PDF); (b) EOR file format requirements for outbound transmission; (c) the specified daily SFTP batch drop time; and (d) whether there is an existing SFTP infrastructure the awarded vendor must connect to or whether the vendor establishes the SFTP environment.

The SFTP file transmission process will be utilizing the tool, MOVEit that is State of Michigan hosted (existing infrastructure). An inbound and outbound mailbox will be setup for PDF transmission(s) (file format). Deadline will be determined before the completion of the contract.

The RFP references three funds: SISF, VHP, and CRSFRPC. Please confirm the full legal name and description of CRSFRPC and clarify whether each fund operates under separate billing workflows, separate EOR formats, or separate reporting requirements, or whether a single unified process covers all three funds.

Christopher R. Slezak First Responder Presumed Coverage Fund (CRSFRPCF) - The Christopher R.

Slezak First Responder Presumed Coverage Fund (the fund) was created by the legislature and is administered by the Director of the Workers' Disability Compensation Agency. The fund provides workers' disability compensation benefits to certain first responders as provided in statute, MCL 418.405(2). The billing workflows and EOR formats are the same across all Funds;

however, the specific Fund is indicated on the EOR. We do require reporting broken down per Fund, and totals across all Funds combined.

Will the State accept a pricing structure that separates technical bill review fees (priced on a per-bill basis) from professional health care review fees (priced on a per-case basis, triggered only when professional review thresholds are met)? Or does the State require a single bundled per-bill price covering all services?

Clarification is needed before bidders can complete Schedule B accurately.

Yes

For a bidder that is not currently certified by WDCA but meets WDCA’s certification requirements, please identify the documentation that must be submitted with the proposal to satisfy the mandatory minimum requirement. Please also confirm whether final WDCA certification must be obtained before award, before the October 1, 2026 contract effective date, or by another specified date.

Per Mandatory Minimum requirements the Bidder must be WDCA-certified or qualify by the time of bid review to be recommended for award.

Section 1.1.5 and the SLA require completed reviews within seven business days, while the Service Requirements section states seven to ten business days. Please confirm the applicable timeframe for technical reviews, professional reviews, physician peer reviews, and provider reconsiderations. Please also clarify whether the turnaround period is suspended when required medical records or supporting information are incomplete.

Confirming the turnaround time is 7 days. This will be updated in the contract.

11 Please define the unit of measure intended for the “Price” column for each service category, such as per bill, per bill line, per review, per case, monthly fee, or another unit. Please confirm whether bidders must complete both the “Price” and “% of Savings” columns and whether professional reviews, physician peer reviews, provider reconsiderations, and reprocessed bills should be included under Utilization Review Services or separately priced.

The unit of measure is intended to be each.

Bidders can add lines to fit their needs or provide alternate pricing.

12 Please clarify the required scope of PPO Services and Negotiations/Out-of-Network Services. Must the contractor provide access to its own PPO network, administer a State-provided network, or both? Please also clarify the required order of application among Michigan fee-schedule adjustments, coding reductions, PPO discounts, utilization-review reductions, and negotiated reductions.

The State does not administer it's own PPO network. The State is open to negotiating various PPO networks. Contractor must follow Michigan Healthcare Service Rules pertaining to fee schedules. Reference: Health Care Services

Rules R 418.10117 (5) Carrier responsibilities.

13 Schedule C identifies “Privacy and Security Liability (Cyber Liability) Insurance,” but the stated employee-theft limit and the forgery, theft, computer-fraud, and funds-transfer-fraud requirements appear to describe crime or fidelity coverage.

Please confirm whether the State requires cyber/privacy liability insurance, crime/fidelity insurance, or both, and provide the applicable limits for each required coverage.

It should read Minimum Limits:

$1,000,000 Each Occurrence.

14 Are the terms negotiable?

Bidders may provide their redlines or suggestions to be reviewed.

15 Who handles the claims for the Department? Self Admin or

TPA?

Self Admin

16 What is your Claims System?

In house developed claims system

17 Who is the incumbent?

N/A. There is no current contract.

18 Who ultimately make the provider payments?

LEO Funds Admin makes the payments.

19 Can you please provide your Professional (Utilization ) Review and Peer Review numbers for YTD 2026 and YE 2025?

Not available at this time, refer to the numbers provided.

20 What is the current pricing for this scope of work?

N/A. Bidder must provide their own pricing.

21 Does the State have preferred PPO's it would like to have access to?

No.

22 The anticipated contract begin date is indcated as 10/01/2026.

Is this date flexible given the amount of work and effort that is needed to move a program?

The target start date is 10/1/26.

23 The Contract is set to begin on October 1, 2026; however, what is the projected award notification date?

No later than September 4th. The Solicitation Manager will send an email to all bidders to alert them when the award synopsis is posted.

24 Will performance of the services require access to a Federal Government database?

No

25 Are any amounts under the contract funded by the Federal Government?

None https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.michigan.gov%2Fleo%2F-%2Fmedia%2FProject%2FWebsites%2Fleo%2FDocuments%2FWDCA-HEALTHCARE%2F2025%2FR-41810101-to-R-418101504.pdf%3Frev%3D91304c34d65745eb8215b65177b01e0c%26hash%3D6B27F2E7004A7F8516EE3985A09E700E&data=05%7C02%7CFrankJ4%40michigan.gov%7Cf7af54e6966f481d090708ded2f2e0e5%7Cd5fb7087377742ad966a892ef47225d1%7C0%7C0%7C639180137747430036%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=2vmKAdWHuKFZJPmeasQ8SadOdMvrKHnoE%2BAcF2lUUgI%3D&reserved=0 https://gcc02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.michigan.gov%2Fleo%2F-%2Fmedia%2FProject%2FWebsites%2Fleo%2FDocuments%2FWDCA-HEALTHCARE%2F2025%2FR-41810101-to-R-418101504.pdf%3Frev%3D91304c34d65745eb8215b65177b01e0c%26hash%3D6B27F2E7004A7F8516EE3985A09E700E&data=05%7C02%7CFrankJ4%40michigan.gov%7Cf7af54e6966f481d090708ded2f2e0e5%7Cd5fb7087377742ad966a892ef47225d1%7C0%7C0%7C639180137747430036%7CUnknown%7CTWFpbGZsb3d8eyJFbXB0eU1hcGkiOnRydWUsIlYiOiIwLjAuMDAwMCIsIlAiOiJXaW4zMiIsIkFOIjoiTWFpbCIsIldUIjoyfQ%3D%3D%7C0%7C%7C%7C&sdata=2vmKAdWHuKFZJPmeasQ8SadOdMvrKHnoE%2BAcF2lUUgI%3D&reserved=0

26 Are the claims subject to the HIPAA Privacy Rule? The sample agreement references PHI; however, the services appear limited to review of workers' compensation claims, which are generally exempt from HIPAA.

The state will continue to protect healthcare information.

27 Re: unauthorized removal of Key Personnel will cause a $25,000–$50,000 credit to State per person. Please advise of your definition of “Key Personnel”? For example, is this related to the account management team or individuals performing the bill review function?

Key Personnel can be and staff responsible for completing contract activities. If removal of a staff person assigned to this contract is removed and causes delays, this is the consequence.

28 Regarding your request for a 30-day shadowing requirement for replacement of staff, which staff members does this include and what is involved in the “shadowing” process?

It is up to the bidder.

29 For non-compliance of turnaround time standards, you are requiring a monthly late fee of 3% of fees? Is this based upon bill review fees only or fees generated by other products, including PPO network? Is the late fee based upon an aggregate of the entire program, meaning the average bill turnaround time?

The vendor will be responsible for any fees placed on the State for delays on the vendor’s side.

30 If a bill presents an opportunity for significant additional savings that would require review beyond the stated turnaround timeframe, would the Funds Administration consider allowing an extended review period on a case-by-case basis to maximize cost savings?

All deadlines must be met, unless exigent circumstances exist, requiring prior approval from the State.

31 Are there any additional State of Michigan security policies, standards, controls, certifications, or compliance requirements that are not specifically detailed in the RFP? If so, please provide those requirements.

Here is a link to find State policies: DTMB -

Vendor Innovation Portal https://www.michigan.gov/en/dtmb/procurement/contractconnect/vendor-innovation-portal https://www.michigan.gov/en/dtmb/procurement/contractconnect/vendor-innovation-portal