Section_C_-_Performance_Work_Statement_.pdf

United States Department of Labor

(DOL)

Workers’ Compensation Medical Bill Process

(WCMBP)

Section C -

Performance Work Statement

Office of Workers’ Compensation Programs (OWCP)

Section C – PWS TABLE OF CONTENTS

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TABLE OF CONTENTS

1 GENERAL OVERVIEW 1-1

1.1 Background 1-1

1.1.1 Division of Administration and Operations (DAO) 1-3

1.1.2 Division of Federal Employees’ Compensation 1-3

1.1.3 Division of Coal Mine Workers’ Compensation 1-3

1.1.4 Division of Energy Employees Occupational Illness Compensation 1-4

1.1.5 Division of Longshore and Harbor Workers’ Compensation 1-4

1.1.6 Projected Operational Volumes 1-4

1.2 Purpose 1-4

1.3 Global Requirements 1-6

1.3.1 Federal Laws and Regulations 1-6

1.3.2 Financial and Security Audit Requirements 1-7

1.3.3 Implementation 1-8

1.3.4 Operations 1-11

1.3.5 Maintenance 1-14

1.4 Organization of this Document 1-15

2 PROJECT PLANNING AND CONTROL 2-1

2.1 Implementation Phase 2-2

2.1.1 Transition-In 2-2

2.1.2 requirements analysis 2-4

2.1.3 Customization 2-5

2.1.4 Comprehensive Testing Program 2-6

2.1.5 Assumption of Operations 2-13

2.2 Operations Phase 2-14

2.2.1 Operations 2-14

2.2.2 Transition-Out 2-15

3 INFORMATION SECURITY STANDARDS 3-1

3.1 Overview 3-1

3.2 Processing Requirements 3-2

3.2.1 Physical Security 3-2

3.2.2 Logical Security 3-4

3.2.3 Mobile Devices 3-6

3.2.4 Disaster Recovery and Back-up 3-7

3.3 Government Financial and Accountability Audits 3-9

4 STAFFING 4-1

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4.1 Staffing Requirements 4-1

4.2 Staffing Plan 4-2

4.3 Background Investigations 4-3

4.4 Key Position Requirements for Implementation Phase 4-5

4.4.1 Program Manager 4-5

4.4.2 Quality Assurance Manager 4-6

4.4.3 Deputy Program Manager 4-8

4.4.4 Technical Manager 4-10

4.4.5 Requirements Manager 4-12

4.4.6 Test Manager 4-14

4.4.7 Lead Software Engineer 4-15

4.4.8 Data Migration manager 4-17

4.4.9 Training Manager 4-18

4.5 Key Position Requirements for Operations Phase 4-19

4.5.1 Program Manager 4-19

4.5.2 Deputy Program Manager 4-20

4.5.3 Quality Assurance Manager 4-21

4.5.4 Program Liaison Managers 4-22

4.5.5 Pharmacy Manager 4-23

4.5.6 Technical Manager 4-24

4.5.7 Lead Software Engineer 4-26

4.5.8 Call Center Manager 4-27

4.5.9 Resolution and Adjustment Supervisor 4-28

4.5.10 Provider Outreach Supervisor 4-29

4.5.11 Training Manager 4-31

4.5.12 Authorization/Triage Nurse 4-32

4.6 Categorized Position Requirements for Operations Phase 4-32

4.6.1 DFEC District Office Troubleshooter (DOT) Liaisons 4-32

4.6.2 Resolution and Adjustment Specialists 4-33

5 CENTRAL MAILROOM 5-1

5.1 Overview 5-1

5.2 Implementation 5-5

5.2.1 Contractor Responsibilities 5-5

5.3 Operations 5-5

5.3.1 Contractor Responsibilities 5-5

5.4 Maintenance 5-6

5.4.1 Contractor Responsibilities 5-6

6 DOCUMENT IMAGING 6-1

6.1 Overview 6-1

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6.2 Implementation 6-3

6.3 Operations 6-3

6.3.1 OWCP Imaging Services 6-3

7 CLAIMANT BILL DEVELOPMENT 7-1

7.1 Overview 7-1

7.2 Implementation 7-4

7.3 Operations 7-5

7.3.1 External Interfaces 7-5

7.3.2 Inputs 7-5

7.3.3 Outputs 7-5

7.4 Return and Communication 7-6

8 BILL SCAN/DATA ENTRY 8-1

8.1 Overview 8-1

8.2 Implementation 8-8

8.3 Operations 8-8

8.3.1 External Interfaces 8-8

8.3.2 Inputs 8-8

8.3.3 Outputs 8-8

8.4 Bill Scan/Data Entry Maintenance 8-12

9 BILL PROCESSING 9-1

9.1 Overview 9-1

9.2 Implementation 9-5

9.3 Operations 9-6

9.3.1 External Interfaces—INCLUDE BUT NOT LIMITED TO: 9-6

9.3.2 Inputs 9-6

9.3.3 Outputs 9-7

9.4 Communication 9-11

9.4.1 External Interfaces 9-11

9.4.2 Inputs 9-11

9.4.3 Outputs 9-11

10 THIRD PARTY LIABILITY 10-1

11 PROMPT PAYMENT BILL PROCESSING 11-1

11.1 Overview 11-1

11.2 Implementation 11-9

11.3 Operations 11-9

11.3.1 External Interfaces 11-10

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11.3.2 Inputs 11-10

11.3.3 Outputs 11-10

11.4 Communications 11-13

12 RETURNING BILLS/DOCUMENTS (RTP/RTC/RTD) 12-1

12.1 Overview 12-1

12.2 Implementation 12-4

12.3 Operations 12-5

12.3.1 External Interfaces 12-5

12.3.2 Inputs 12-5

12.3.3 Outputs 12-5

12.4 Maintenance 12-6

13 EDITS AND AUDITS 13-1

13.1 Overview 13-1

13.2 Implementation 13-12

13.3 Operations 13-14

13.3.1 External Interfaces 13-14

13.3.2 Inputs 13-14

13.3.3 Outputs 13-14

14 CLAIMANT ELIGIBILITY 14-1

14.1 Overview 14-1

14.2 Implementation 14-1

14.3 Operations 14-3

14.3.1 Input 14-3

14.3.2 Outputs 14-3

14.3.3 DFEC 14-4

14.3.4 DCMWC 14-9

14.3.5 DEEOIC 14-14

15 PROVIDER ENROLLMENT AND MANAGEMENT 15-1

15.1 Overview 15-1

15.2 Implementation 15-1

15.3 Operations 15-3

15.3.1 External Interfaces 15-4

15.3.2 Inputs 15-4

15.3.3 Outputs 15-4

15.4 Maintenance 15-16

15.5 Communications 15-16

15.5.1 External Interfaces 15-16

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15.5.2 Inputs 15-16

15.5.3 Outputs 15-17

15.6 Maintenance 15-19

15.6.1 External Interfaces 15-19

15.6.2 Inputs 15-20

15.6.3 Outputs 15-20

16 AUTHORIZATIONS 16-1

16.1 Overview 16-1

16.2 Implementation 16-5

16.3 Operations 16-5

16.3.1 External Interfaces 16-5

16.3.2 Inputs 16-6

16.3.3 Outputs 16-6

16.4 Communications 16-11

17 TREATMENT SUITES 17-1

17.1 Overview 17-1

17.2 Implementation 17-20

17.3 Operations 17-21

17.3.1 External Interfaces 17-22

17.3.2 Inputs 17-22

17.3.3 Outputs 17-22

17.4 Maintenance 17-23

17.4.1 Outputs 17-23

18 BILL PRICING 18-1

18.1 Overview 18-1

18.2 Implementation 18-15

18.3 Operations 18-16

18.4 Maintenance 18-18

18.4.1 External Interfaces 18-19

18.4.2 Inputs 18-19

18.4.3 Outputs 18-19

18.5 DCMWC Inpatient Processing and Pricing Logic 18-19

18.6 DCMWC Outpatient 18-20

18.6.1 Inputs 18-20

18.6.2 Outputs 18-20

19 PHARMACY 19-1

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19.1 Overview 19-1

19.2 Implementation 19-2

19.3 Operations 19-4

19.3.1 External Interfaces 19-4

19.3.2 Inputs 19-4

19.3.3 Outputs 19-5

19.4 Maintenance 19-5

19.4.1 External Interfaces 19-5

20 BILL RESOLUTION 20-1

20.1 Overview 20-1

20.2 Implementation 20-4

20.3 Operations 20-6

20.3.1 External Interfaces 20-6

20.3.2 Inputs 20-6

20.3.3 Outputs 20-6

20.4 Communication 20-6

21 PAYMENT FILES PROCESS: RV/EFT and 1099 21-1

21.1 Overview 21-1

21.2 RV/EFT Process 21-1

21.2.1 Implementation 21-2

21.2.2 Operations 21-9

21.2.3 Maintenance 21-12

21.3 1099 Process 21-13

21.3.1 Implementation 21-13

21.3.2 Operations 21-13

21.3.3 Communication 21-14

21.3.4 Maintenance 21-14

22 FEE SCHEDULE APPEALS 22-1

22.1 Overview 22-1

22.2 Implementation 22-5

22.3 Operations 22-5

22.3.1 External Interfaces 22-5

22.3.2 Inputs 22-5

22.3.3 Outputs 22-6

22.4 Maintenance 22-7

23 ADJUSTMENT PROCESSING 23-1

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23.1 Overview 23-1

23.2 Implementation 23-11

23.3 Operations 23-11

23.3.1 External Interfaces 23-12

23.3.2 Inputs 23-12

23.3.3 Outputs 23-12

24 FRAUD AND ABUSE DETECTION 24-1

24.1 Overview 24-1

24.2 Implementation 24-1

24.3 Operations 24-3

24.3.1 Inputs 24-3

24.3.2 Outputs 24-3

24.4 Communication 24-4

24.5 FAD Maintenance 24-5

25 MANAGEMENT REPORTING 25-1

25.1 Overview 25-1

25.2 Implementation 25-1

25.3 Operations 25-3

25.3.1 Input 25-3

25.3.2 Output 25-3

26 CHANGE MANAGEMENT 26-1

26.1 Overview 26-1

26.2 Implementation 26-2

26.3 Operations 26-4

26.4 Communication 26-6

26.5 Maintenance 26-6

27 COMMUNICATIONS 27-1

27.1 Communications Overview 27-1

27.2 Data Transmission 27-1

27.2.1 Overview 27-1

27.2.2 SECURE CONNECTION 27-2

27.3 Call Center 27-3

27.3.1 Implementation 27-4

27.3.2 Operations 27-8

27.4 Direct Electronic Access to Data 27-10

27.4.1 Overview 27-10

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27.4.2 Implementation 27-10

27.4.3 Operations 27-18

27.5 Telephonic IVR 27-19

27.5.1 Overview 27-19

27.5.2 Implementation 27-19

27.5.3 Operations 27-21

27.5.4 Maintenance 27-21

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LIST OF FIGURES

Figure 1 Project Phases ........................................................................................... 2-1 Figure 2 Central Mailroom Process DFEC ............................................................... 5-2 Figure 3 Central Mailroom Process DEEOIC ........................................................... 5-3 Figure 4 Central Mailroom Process DCMWC ........................................................... 5-4

Figure 5 Sample OWCP Document Imaging Process .............................................. 6-2 Figure 6 Claimant Bill Development Process DFEC ............................................... 7-2 Figure 7 Claimant Bill Development Process DEEOIC ........................................... 7-3 Figure 8 Claimant Bill Development Process DCMWC ........................................... 7-4 Figure 9 Bill Scan/Data Entry Process DFEC........................................................... 8-2

Figure 10 Bill Scan/Data Entry Process DFEC Non-Bill Correspondence .................. 8-3 Figure 11 Bill Scan/Data Entry Process DEEOIC ....................................................... 8-4

Figure 12 Bill Scan/Data Entry Process DEEOIC Non-Bill Correspondence .............. 8-5 Figure 13 Bill Scan/Data Entry Process DCMWC ...................................................... 8-6 Figure 14 Bill Scan/Data Entry Process Non-Bill Correspondence DCMWC ............. 8-7 Figure 15 Bill Processing Flow DFEC ........................................................................ 9-2

Figure 16 Bill Processing Flow DEEOIC .................................................................... 9-3 Figure 17 Bill Processing Flow DCMWC .................................................................... 9-4

Figure 18 DFEC PPA Process 1 .............................................................................. 11-2 Figure 19 DFEC PPA Process 2 .............................................................................. 11-3 Figure 20 DFEC PPA Process 3 .............................................................................. 11-4

Figure 21 DEEOIC PPA Process 1 .......................................................................... 11-5

Figure 22 DEEOIC PPA Process 2 .......................................................................... 11-6

Figure 23 DCMWC PPA Process 1 .......................................................................... 11-7 Figure 24 DCMWC PPA Process 2 .......................................................................... 11-8

Figure 25 DFEC Return to Provider/Return to Claimant Business Flow .................. 12-2 Figure 26 DEEOIC Return to Provider/Return to Claimant Business Flow .............. 12-3 Figure 27 DCMWC Return to Provider/Return to Claimant Business Flow .............. 12-4

Figure 28 Edit/Audit Overview all programs ............................................................. 13-2 Figure 29 DFEC Edit/Audit Process Flow 1 ............................................................. 13-3

Figure 30 DFEC Edit/Audit Process Flow 2 ............................................................. 13-4 Figure 31 DFEC Edit/Audit Process Flow 3 ............................................................. 13-5 Figure 32 DEEOIC Edit/Audit Process Flow 1 ......................................................... 13-6

Figure 33 DEEOIC Edit/Audit Process Flow 2 ......................................................... 13-7

Figure 34 DEEOIC Edit/Audit Process Flow 3 ......................................................... 13-8 Figure 35 DCMWC Edit/Audit Process Flow 1 ......................................................... 13-9 Figure 36 DCMWC Edit/Audit Process Flow 2 ....................................................... 13-10

Figure 37 DCMWC Edit/Audit Process Flow 3 ....................................................... 13-11 Figure 38 DFEC Claimant Eligibility Editing Process ............................................... 14-5 Figure 39 DFEC Claimant Eligibility Transmission process ..................................... 14-6 Figure 40 DFEC Claimant On Review process ........................................................ 14-7 Figure 41 DCMWC Claimant Eligibility Editing Process ......................................... 14-11

Figure 42 DCMWC Claimant Eligibility File Transmission Process ........................ 14-12 Figure 43 DCMWC Claimant On Review Process ................................................. 14-13

Figure 44 DEEOIC Claimant Eligibility Editing process .......................................... 14-16 file:///P:/RFP/RFP%20Working%20Files/RFP%20Section%20C%20-%20PWS%20-%20SOW/WCMBP%20Performance%20Work%20Statement%2020131216final.doc%23_Toc375045923 file:///P:/RFP/RFP%20Working%20Files/RFP%20Section%20C%20-%20PWS%20-%20SOW/WCMBP%20Performance%20Work%20Statement%2020131216final.doc%23_Toc375045924

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Figure 45 DEEOIC Claimant Eligibility Records Transmission ............................... 14-17 Figure 46 DEEOIC Claimant On Review Process .................................................. 14-18

Figure 47 Provider Eligibility Edit Flow ..................................................................... 15-7 Figure 48 OWCP Provider Enrollment Process via hardcopy .................................. 15-8 Figure 49 OWCP Provider Enrollment Process via Portal ........................................ 15-9 Figure 50 OWCP Provider Enrollment Process from DO fax ................................. 15-10 Figure 51 OWCP Provider Maintenance Process .................................................. 15-11

Figure 52 DFEC Authorization Process Overview.................................................... 16-2 Figure 53 DEEOIC Authorization Process Overview ................................................ 16-3 Figure 54 DCMWC Authorization Process Overview ............................................... 16-4 Figure 55 DFEC Pre-Process Overview ................................................................... 17-3

Figure 56 DFEC Prompt Pay Process ...................................................................... 17-4 Figure 57 DFEC CA-16 Process .............................................................................. 17-5 Figure 58 DFEC Short Form Closure Process ......................................................... 17-6

Figure 59 DFEC Diagnostic with no Prompt Pay (999.98) Process ......................... 17-7 Figure 60 DFEC HCFA-1500 Process ..................................................................... 17-8

Figure 61 DFEC UB-04 Outpatient Process ............................................................. 17-9 Figure 62 DFEC UB-04 Inpatient Process ............................................................. 17-10 Figure 63 DFEC Pharmacy Process ...................................................................... 17-11

Figure 64 DFEC Authorizations Process ................................................................ 17-12 Figure 65 DEEOIC HCFA 1500 Process ................................................................ 17-13

Figure 66 DEEOIC UB-04 Outpatient Process ....................................................... 17-14 Figure 67 DEEOIC UB-04 Inpatient Process ......................................................... 17-15

Figure 68 DEEOIC Pharmacy Process .................................................................. 17-16 Figure 69 DEEOIC Authorizations Process ............................................................ 17-17

Figure 70 DCMWC HCFA 1500 Process ............................................................... 17-18 Figure 71 DCMWC Outpatient Bill Process ............................................................ 17-19 Figure 72 DCMWC Pharmacy Bill Process ............................................................ 17-20

Figure 73 DFEC HCFA 1500 Pricing process .......................................................... 18-2 Figure 74 DFEC UB04 Inpatient Pricing process ..................................................... 18-3

Figure 75 DFEC UB04 Outpatient Pricing process .................................................. 18-4

Figure 76 DFEC Travel Pricing process ................................................................... 18-5 Figure 77 DEEOIC HCFA 1500 Pricing process ...................................................... 18-6 Figure 78 DEEOIC UB04 Inpatient Pricing process ................................................. 18-7 Figure 79 DEEOIC UB04 Outpatient Pricing process .............................................. 18-8

Figure 80 DEEOIC Travel Pricing process ............................................................... 18-9 Figure 81 DEEOIC Travel Pricing process continued ............................................ 18-10 Figure 82 DCMWC HCFA 1500 Pricing process .................................................... 18-11 Figure 83 DCMWC UB04 Inpatient Pricing process ............................................... 18-12 Figure 84 DCMWC UB04 Outpatient Pricing process ............................................ 18-13

Figure 85 DCMWC Treatment Travel Pricing Process ........................................... 18-14 Figure 86 DCMWC Treatment Travel Pricing Process continued .......................... 18-15 Figure 87 Pharmacy Processing .............................................................................. 19-1 Figure 88 DFEC Bill Resolution Process .................................................................. 20-2 Figure 89 DEEOIC Bill Resolution Process .............................................................. 20-3 Figure 90 DCMWC Bill Resolution Process ............................................................. 20-4

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Figure 91 DFEC Payment Process .......................................................................... 21-2 Figure 92 DFEC A/R Processing .............................................................................. 21-3

Figure 93 DEEOIC Payment Process ...................................................................... 21-4 Figure 94 DEEOIC AR Processing ........................................................................... 21-5 Figure 95 DCMWC Payment Process ...................................................................... 21-6 Figure 96 DCMWC A/R Process .............................................................................. 21-7 Figure 97 DCMWC Adjustment Process .................................................................. 21-8

Figure 98 DFEC Fee Schedule Appeals process ..................................................... 22-2 Figure 99 DEEOIC Fee Schedule Appeals process ................................................. 22-3 Figure 100 DCMWC Fee Schedule Appeals process ................................................ 22-4 Figure 101 DFEC Adjustment Process ...................................................................... 23-2

Figure 102 DFEC Adjustment Process continued ...................................................... 23-3 Figure 103 DFEC Adjustment Processing continued ................................................. 23-4 Figure 104 DEEOIC Adjustment Process .................................................................. 23-5

Figure 105 DEEOIC Adjustment Process continued .................................................. 23-6 Figure 106 DEEOIC Adjustment Process continued .................................................. 23-7

Figure 107 DCMWC Adjustment Process .................................................................. 23-8 Figure 108 DCMWC Adjustment Process continued .................................................. 23-9 Figure 109 DCMWC Adjustment Process continued ................................................ 23-10

Figure 110 Site Interconnections................................................................................ 27-2

LIST OF TABLES

Table 1 Key Position Staffing Requirements ........................................................... 4-1

Table 2 Current Mailroom Addresses ..................................................................... 5-1 Table 3 Current WCMBP Telephone Numbers ..................................................... 27-4

Section C – PWS GENERAL OVERVIEW

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1 GENERAL OVERVIEW

1.1 BACKGROUND

The Office of Workers’ Compensation Programs (OWCP) under the Department of Labor’s (DOL) administers disability compensation programs which mitigate, through the provision of wage replacement and cash benefits, medical treatment, vocational rehabilitation, and other benefits, the financial burden on certain workers, or their dependents or survivors, resulting from work-related injury, disease, or death.

The OWCP is seeking a Contractor to provide medical bill processing services for OWCP’s Workers’ Compensation Medical Bill Process (WCMBP), to include all personnel, processes, and systems required to provide the services. WCMBP is a medical bill processing operation that processes bills currently for the following three OWCP programs using one centralized process, but with customized business rules for each program:

The Federal Employees’ Compensation Act (FECA) program, administered by the Division of Federal Employees Compensation (DFEC) provides wage replacement and medical benefits to civilian employees of the Federal Government who were injured at work and to certain other designated groups.

The Black Lung Benefits Act (BLBA) program administered by the Division of Coal Mine Workers’ Compensation (DCMWC) provides compensation benefits to eligible coal miners and their families and medical benefits to eligible coal miners in the event of total disability or death due to pneumoconiosis. These benefits are financed through direct Federal appropriations, earmarked tax revenues, and legislatively mandated private sector liability insurance arrangements.

The Energy Employees Occupational Illness Compensation Program Act (EEOICPA) administered by the Division of Energy Employees Occupational Illness Compensation (DEEOIC) provides lump sum compensation and medical benefits to employees or survivors of eligible Department of Energy (DOE) nuclear weapons workersincluding employees, former employees,contractors, and subcontractors;,as well as lump sum compensation to certain survivors of deceased workers. The EEOICPA also covers individuals who received an award from the Department of Justice (DOJ) under the Radiation Exposure Compensation Act (RECA) and individuals that worked in a mine, mill, or as an ore transporter at a facility covered by the RECA.

In the future, at the direction of the government, WCMBP may also support the Division of Longshore and Harbor Workers’ Compensation (DLHWC) that administers the Longshore and Harbor Workers' Compensation Act and its extensions (including the Defense Base Act). The mission of DLHWC is to minimize the impact of employment injuries and deaths of eligible employees and their families by ensuring that workers' compensation benefits are paid promptly and properly, and providing information, technical and compliance assistance, http://www.dol.gov/owcp/dlhwc/lsdba.htm

1-2 support, and informal dispute resolution services to workers, employers, and insurers.

Each OWCP program provides medical benefits only when the medical care is related to a valid injury/illness claim (case), the medical condition(s) treated are accepted for payment by OWCP program claims examiners (CE), and the treatment occurs within time period(s) of eligibility covered by legislative mandates. WCMBP differs from other bill processing operations by applying the concept of accepted condition. Specifically, workers are entitled to coverage for an injury/illness claim when the medical condition(s) is accepted by the Government as work-related.

The accepted condition(s) on a claim for the DFEC program is the only condition(s) in which services are payable for that case. Cases under the DFEC program may involve more than one accepted condition and workers (claimants) may have more than one case with unique conditions accepted for medical treatment.

The accepted condition(s) on claim for the DEEOIC program are the only conditions which services are payable for a employee/beneficiary (claimant) with a single case number. Accepted cases under this program may involve more than one accepted condition.

The accepted condition on a claim for the DCMWC program is the only condition on which services are payable for a miner (claimant) with a single case number.

The Claims Examiners (CE) for each program determine the accepted condition and authorize certain medical treatments. Data from the WCMBP keep the CE informed of the nature and quantity of treatment for a given accepted condition and case, and requests for treatment requiring prior authorization by the CE.

To support the independent and automated process of determining whether bills are related to a covered and/or accepted medical condition, business rules and decisions are grouped into “treatment suites”. Treatment suites consist of a diagnosis or group of related diagnoses (expressed as International Classification of Disease (ICD)-9/10CM codes) linked to the medical procedures, medications, and other services used in its (their) treatment. Services are identified in terms of Current Procedural Terminology (CPT) codes, Healthcare Common Procedural Coding System (HCPCS) codes, Diagnosis Related Group (DRG) codes, Therapeutic Class (TC) codes, National Drug Codes (NDC), Generic Code Nomenclature (GCN), and other nomenclatures. Common complications are part of the treatment suites and are considered in decision making.

OWCP-defined prior authorization requirements for medical procedures are embedded in the treatment suites. Incoming medical bills for all services are compared to the treatment suite(s) for accepted condition(s). Services included in the treatment suite(s) for an accepted condition or any complications are accepted for processing. Services not included in the treatment suites for an accepted condition are denied.

The treatment suite concept provides for the consistent application of OWCP medical policy across programs. However, its design is sufficiently flexible to support the application of each program’s individual standards and guidelines. Importantly, it

1-3 minimizes the need for the manual review of bills to determine whether the treatment is related to the accepted condition prior to payment.

OWCP medical bill processing assumes the use of medical bill processing industry standard requirements including, but not limited to validity edits; consistency edits;

correct coding initiative (CCI); checking for duplicates; service limitations; application of OWCP fee schedules; and financial accounting, auditing, and reporting.

In OWCP’s medical bill processing operations, the Contractor is not responsible for issuing checks; the Treasury Department is responsible for the issuance of payments, checks, and electronic fund transfers (EFTs). The Contractor will generate payment files which are sent to OWCP for certification and transmission to the Treasury Department for the subsequent issuance of check and EFT payments.

In addition to processing bills, the Contractor responds to all inquiries regarding bills, requests for adjustment, authorization of services, suspense resolution, provider enrollment and maintenance, and appeals processing.

The WCMBP Contractor interfaces (or will interface) with the OWCP divisions listed below:

1.1.1 DIVISION OF ADMINISTRATION AND OPERATIONS (DAO)

The OWCP National Office Division of Administration and Operations (DAO) manages the WCMBP implementation through its WCMBP Project Management Office (PMO) and coordinates all enhancements and maintenance activities ensuring that the WCMBP follows all Federal and Department information security standards. It provides support to the OWCP programs in medical bill processing matters and ancillary functions such as using the ICD-9/10CM disease coding nomenclature, etc.

1.1.2 DIVISION OF FEDERAL EMPLOYEES’ COMPENSATION

The Division of Federal Employees’ Compensation (DFEC) administers the FECA program. DFEC maintains a National Office responsible for policy setting, performance metrics, and other program-wide functions that support the FECA Program. Thirteen District Offices (DOs) located throughout the United States process compensation claims and authorize wage replacement and medical benefits.

DFEC claimants are not issued a medical benefits identification card (MBIC).

1.1.3 DIVISION OF COAL MINE WORKERS’ COMPENSATION

The Division of Coal Mine Workers’ Compensation (DCMWC) is composed of a National Office and eight District Offices. Additionally, DCMWC has staff stationed at a Contractor-run facility in Maryland that maintains the program’s case management and benefits payment systems.

The DCMWC National Office develops strategic plans, establishes policies, and performs certain program-wide functions. The eight District Offices process and adjudicate compensation claims, determine whether a claimant is totally disabled from pneumoconiosis (Black Lung Disease), adjudicate and input prior authorizations for certain medical procedures, and service program customers.

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DCMWC bill processing standards and business rules are unique to that program.

Primary differences between the DCMWC and the other programs are: (1) the prior authorization of certain services occurs primarily in the District Offices and electronic information is forwarded to the Contractor’s bill processing system to allow for the payment of these bills, and (2) the processing of inpatient hospital bills (does not currently utilize DRGs (but may do so in the future) and does not utilize the treatment suites to the extent of the other programs.

DCMWC claimants are issued medical benefits identification cards (MBIC) upon approval of an accepted condition.

1.1.4 DIVISION OF ENERGY EMPLOYEES OCCUPATIONAL ILLNESS

COMPENSATION

The Division of Energy Employees Occupational Illness Compensation (DEEOIC) is structured into a National Office and four District Offices. The DEEOIC National Office develops strategic plans, establishes policies, and performs certain program functions.

DEEOIC District Offices process and adjudicate compensation claims and service program customers.

In DEEOIC medical bill processing business rules and processes, claimants are issued a medical benefits identification card (MBIC), upon approval of an accepted condition.

1.1.5 DIVISION OF LONGSHORE AND HARBOR WORKERS’ COMPENSATION

The Division of Longshore and Harbor Workers’ Compensation (DLHWC) is comprised of a National Office and 12 District offices. The National Office develops and monitors public and financial policy issues and oversees authorized self-insured employers and Carriers. The Longshore program also manages run-off District of Columbia cases which occurred prior to 1982.

In cases where the authorized carrier or self-insured employer is insolvent, or the employer is uninsured and unable to pay appropriate medical related expenses, the Special Fund steps in to pay bills at the discretion of the Secretary of Labor.

DLHWC claimants are NOT issued a Medical Benefits Identification card (MBIC).

The Contractor is responsible for bill processing and support services to these OWCP programs in compliance with all functional and non-functional requirements addressed or referenced within this document.

1.1.6 PROJECTED OPERATIONAL VOLUMES

The projected operational volumes of work for the WCMBP project between Fiscal Years 2014 and 2025 are available in Section J (Attachment 18.1).

1.2 PURPOSE

To provide efficiency and consistency in meeting strategic objectives, OWCP is seeking a Contractor to provide services to support the consolidated processing of bills for each OWCP program, to support the prior authorization of services in each program, and to respond to inquiries related to medical services from claimants and providers. The

1-5 selected Contractor interfaces with the OWCP National Office and District Office staff for each program in the performance of these activities.

The Contractor provides medical bill processing capabilities that include:

Receipt of medical bills, attachments and other documents

Scanning and data entry of bills, attachments and other documents received.

Processing of bills to payment or denial.

Processing of requests for adjustment, authorization of services, suspense resolution, and appeals processing.

Process and respond to submitted correspondence received from medical providers and claimants, when applicable, and store the responses to the correspondence in an imaging system(s) from which the Government can retrieve for review.

Enrollment and management of providers.

A Call Center to handle voice inquiries from providers and claimants.

An interactive voice response (IVR) system to handle automated telephonic inquiries from providers and claimants.

Point of Sale pharmacy processing capability.

Secured access, available to Contractor and Government staff, to view images of bills, correspondence, and other documents.

A means of secured electronic access for Contractor, Government staff, providers, and claimants to ascertain the history of adjudication and final determination on payment of submitted bills.

The Treasury Department is responsible for the issuance of payments, checks, and EFTs. The Contractor sends weekly payment files, no later than a day/time specified by the Government, to OWCP for certification and transmission to the Treasury Department for payment.

The primary goals of OWCP bill processing include:

Efficient, accurate, and timely bill processing for OWCP providers and claimants.

Accurate processing refers to the correct implementation and maintenance of business rules and practices for each program and the application of industry standards for medical bill processing.

Reimbursement of only those medical services approved for claimants’ accepted conditions.

Timely authorization for covered benefits.

Achieving and reporting cost savings resulting from the standardization of functions across programs and the application of state-of-the-art capabilities, 1-6 including, but not limited to, utilization limits, fee schedules, and other industry standards.

Responsiveness to customer inquiries and requests.

Incorporation and maintenance of industry standard bill processing capabilities, including but not limited to, clinical guidelines for medical treatment and prescriptions, fraud and abuse protection programs, and CCI.

Providing standardized reports for contract management, production, and trend analysis.

Providing OWCP management access to all stored data to enable the tracking and analysis of the information necessary for identification of program trends, service limitation, etc.

Establishing a framework for continuous improvement.

Complying with Federal requirements for financial and benefit systems.

Implementing bill processing improvements that incorporate advancements in the field (e.g., International Classification of Diseases, version 10 [ICD-10]) and regulatory changes

1.3 GLOBAL REQUIREMENTS

The Government has defined a set of global requirements that are applicable across all WCMBP functional areas. The Government has included these global requirements in this General Overview Section to provide a more concise Request for Proposal (RFP).

The inclusion of these global requirements is not meant to de-emphasize their importance nor should bidders ignore them in discussions of functional capabilities.

The global requirements are presented below in the same order that other requirements are presented in this RFP. The global requirements are organized according to functional subsections (i.e., Implementation, Operations, and Maintenance).

1.3.1 FEDERAL LAWS AND REGULATIONS

R0001

The Contractor shall ensure that its WCMBP solution satisfies the requirements of the Federal Employees Compensation Act (FECA); the Black Lung Benefits Act (BLBA); and the Energy Employees Occupational Illness Compensation Program Act (EEOICPA), Parts B and E.

R1090

Upon the request of the government, the Contractor shall ensure that its WCMBP solution satisfies the requirements of the Longshore and Harbor

Workers' Compensation Act and its extensions (including the Defense Base Act).

R0002

The Contractor shall ensure that its WCMBP solution satisfies the requirements of the following Federal regulations:

The Americans with Disabilities Act and Section 508 of the Rehabilitation

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Act

The Clinger-Cohen Act of 1996

The Paperwork Reduction Act of 1995

Office of Management and Budget (OMB) Circular No. A-11, Part 7, Preparation, Submission and Execution of the Budget (Revised 08/03/2012).

Federal Financial Management Improvement Act (FFMIA) Core Financial System Requirements:

http://www.gao.gov/new.items/d05225g.pdf

FFMIA Benefit System Requirements:

http://www.gao.gov/new.items/d0422g.pdf

The solicitation contains a number of references to public web sites, using URL (Uniform Resource Locator) notation. The Government has verified each of the URLs during the development of the RFP, but cannot guarantee the subsequent validity of each URL. In the event URLs become invalid, the Contractor is expected to exercise due diligence in locating the correct URLs.

1.3.2 FINANCIAL AND SECURITY AUDIT REQUIREMENTS

R0003

The Contractor shall participate in audits (including adhoc audits) performed by DOL and its independent auditors, which may include IT security, financial statements and FISCAM, among others.

R0004

The Contractor shall obtain the services of an independent auditor on an annual basis, effective at commencement of operations, to perform an audit for the time period specified by the U.S. Department of Labor (DOL) on the general controls and application controls surrounding the business process outsourcing of claims and bill processing performed under the Workers’ Compensation Medical Bill Process (WCMBP) contract.

R0005

The Contractor shall ensure the audit is performed according to DOL’s current fiscal-year requirements, standards established by the American Institute of Certified Public Accountants, and guidelines of the General Accounting Office’s Federal Information System Controls Audit Manual (FISCAM) or other audit standards specified by the DOL.

R0006

The Contractor shall ensure the audit provides a means for reasonable assessment that stated control objectives fairly represent the WCMBP Contractor’s controls, policies and procedures relevant to OWCP internal control structure; and that control structure policies and procedures are suitably designed to achieve the specified objective.

R0007 The Contractor shall provide the following deliverables to the WCMBP http://www.gao.gov/new.items/d05225g.pdf http://www.gao.gov/new.items/d0422g.pdf

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Program Manager (PM) and Contracting Officer’s Representative (COR) by the dates specified in DOL’s current fiscal-year requirements:

Letter of Representation addressing WCMBP Contractor responsibility to identify control objectives and related policies and procedures

Auditor’s Letter of Representation as to independence and objectivity from the WCMBP Contractor and DOL

Auditor’s current resumes

Auditor’s most recent Peer Review

Auditor’s detailed scope document

Auditor’s letter documenting representations made by the WCMBP Contractor management during the audit

Electronic version and 5 hardcopies of the complete audit report

Plan of action and milestones (POA&M), according to OWCP specifications, for weaknesses identified in audits

R0008

The Contractor shall participate in audit planning, performance and follow-up activities, including but not limited to conference calls and clarifying questions with the Government and Government-contracted auditors.

R0009 The Contractor shall implement corrective actions to resolve identified weaknesses identified during audits.

1.3.3 IMPLEMENTATION

Contractor Responsibilities

R0010

The Contractor shall establish and maintain production facilities, located in the continental U.S. and no more than 180 minutes travel time by automobile from the destination airport that would be used when flying from/to Washington, DC.

R0011

The Contractor shall establish and maintain backup facilities, sufficiently distant from the primary facility that they would be available to assume operations in the event of a regional disaster.

R0012

The Contractor shall provide and maintain all infrastructures (facilities, hardware, software) necessary to meet the Government’s business, volume, and timeliness requirements.

R0013 The Contractor shall notify the Government of all facilities used to support the WCMBP.

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R0014 The Contractor shall develop, implement, and document all Government-approved processes required for each functional area.

R0015

The Contractor shall develop and implement the workflows, approved by the Government, for governing the rules and processing for each functional area process.

R0016

The Contractor shall implement project management controls to measure, report and control performance against Other Direct (ODC) costs and schedule. These project management controls shall apply to both implementation and operational phases of this contract.

R0017

The Contractor shall provide and use separate development and testing environments that replicate the production processing capabilities. The test environment(s) used for System Integration Test, Performance and Volume Test and Parallel Test shall exactly replicate the production environment.

R0018

The Contractor’s Government Acceptance Test Environment shall exactly replicate the production processing capabilities and allow Government users to perform comprehensive functional area process testing, system function testing, and user interface testing and validation. The Contractor shall provide all Government-identified support during the Government Acceptance Test.

R0019

The Contractor’s Training Environment shall exactly replicate the production processing capabilities and allow the Contractor and the Government to provide hands-on training to users.

R0020

The Contractor shall demonstrate the accuracy and performance of its processes by processing data in the new operational environment, comparing the results with the results from processing the same data in the current production operations, documenting these results, and resolving any inconsistencies to the satisfaction of the Government. (Parallel Test and Performance and Volume Test)

R0021

The Contractor shall develop and maintain all documentation for each functional and operational area, and provide the most current versions of that documentation to the Government.

R0022

The Contractor shall develop and maintain electronic versions of all WCMBP documents, (e.g., plans, training materials, and other publications) in a format that provides all authorized Government personnel with electronic access, on a 24/7 basis, to all electronic copies.

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R0023

The Contractor shall develop, submit to the Government for review and approval, and maintain the approved WCMBP Medical Bill Operations Manual (MBOM) for each OWCP program (each OWCP Program will have a separate MBOM) that details and includes by section all of the Contractor’s standard operating procedures (SOPs) for each aspect of OWCP’s medical bill processing operations (including, but not limited to scanning, data entry, authorizations, bill resolution, call center, triage nurse, etc

R0024

The Contractor shall deliver WCMBP deliverables/documentation in the formats required and approved by the Government. All deliverables submitted to the Government for initial review shall be in final form and complete, as far as the Contractor can determine.

R0025

The Contractor shall provide the capability for information to be transmitted to claimants and providers electronically (via messaging and/or email) and/or via U.S. Postal Service (USPS) letter (in that order of preference).

R0026

The Contractor shall be responsible for the accuracy of its products and deliverables, and implementation of technologies that are effective, and professional in presentation.

R0027

The Contractor shall provide all deliverables in a Government acceptable format (to include any requests for program specific deliverables applicable for each OWCP program). All deliverables must be approved by the Government.

R0028

The Contractor shall be responsible for all deliverables and for ensuring that they address 100 percent of the functionality and content specified in the WCMBP requirements.

R0029

The Contractor shall schedule deliverables to provide time to accommodate Government review, test and approval/rejection (if appropriate) and Contractor revision and resubmittal of any deliverable that is not accepted by the Government.

R0030

The Contractor shall provide all deliverables to the Government as scheduled so that the Government has adequate time to perform its review, make any comments, and/or perform any testing to the deliverable as applicable. This will allow time for the Contractor to perform any required updates and resubmit the deliverables for Government review and/or testing where applicable.

R1005

The Contractor shall maintain 7 years of bill history (to include complete history of paid, denied, adjustments, reports and reversal of bills and all bill-related document images) in a form that can be immediately accessed by users at any time (this does not apply to documents addressed in PWS

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Section 6 Document Imaging).

R1006

For data older than 7 years, the Contractor shall maintain such data in a medium that provides access to the data within 2 days of a users request, to include but not limited to: the complete history of paid, denied, adjustments, reports, and reversal of bills, and all bill related document images in a form that can be immediately accessed by the user. (This does not apply to documents addressed in PWS Section 6 Document Imaging).

R1013

The Contractor shall maintain call center phone call conversation recordings for the lifecycle of the call center operations for all OWCP programs. These recordings shall be cross-referenced to the case/claimant numbers and must be reviewable in a nonproprietary audio format.

1.3.4 OPERATIONS

Contractor Responsibilities

R0031

The Contractor shall staff and operate, on a schedule specified by the Government, the Call Center and Interactive Voice Response (IVR) functions to satisfy provider and claimant inquiries based upon core and unique requirements for all OWCP programs.

R1009 The Contractor shall generate all external correspondence based on the Government-approved templates for all OWCP programs.

R1010

The Contractor shall scan all documents (including all external correspondence) and create image files using standard Tagged Image File Format (TIFF) Group IV format at 200 x 200 dots per inch (DPI)/pixels per inch (PPI) and implement Forms Overlay to capture the images appropriately for red dropout documents (HCFA 1500, UB04, and NCPDP) and any other forms submitted in red dropout. The result of this shall be an imaged forms display equivalent in format to the hardcopy form. The Contractor shall provide ability to extract document images in .pdf format with Bates numbering assigned by the courts upon DOL request.

R0032

The Contractor shall maintain images of all correspondence in the Contractor’s image repository for immediate, secure access by Contractor and Government staff.

R0033 The Contractor shall perform QA and QC assessments of all functional area processes by reviewers independent of the staff performing the function.

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R0034

The Contractor shall monitor performance and work quality, using standards established by the Government, and provide periodic reports to the Government based on those monitoring activities. Periodic reports should include, but are not limited to, the following:

Monthly performance assessment data and trend analysis

Projected outlook for upcoming months and progress against expected trends, including a corrective action plan analysis (when appropriate)

Recommendations for improved efficiency and/or effectiveness

Issues and concerns for contractor side and government side

R0035

The Contractor shall initiate and maintain continuous improvement processes to improve functional area and system performance and quality and provide reports each quarter to the Government documenting the results of those processes.

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R0036

The Contractor shall notify the Government of any functional area or processing failure after identifying the failure. Notification timelines are as follows:

Severity Level

Severity Name / Definition Example Initial Client

Response Time Follow-up

System-wide failure or a module/product crashes, or the defect causes non-recoverable conditions (e.g., system-wide data loss).

It applies to the system as a whole or involves multiple components.

The defect prevents critical system-wide functionality or a loss of critical data.

It does not have a workaround.

Test execution cannot proceed for any functional component.

The entire application will not work. Examples include:

The system crashes

General Protection Faults

Database or file corruption

System-wide data loss

Program hangs requiring reboot

It prevents any further testing or results in severely corrupting the test environment.

Contractor shall notify the government immediately 100% of the time.

Hourly

Major component is unusable due to failure or incorrect functionality.

The defect prevents major subsystem functionality or creates a loss of major subsystem specific data

There is no acceptable workaround.

Test execution cannot proceed for a functional area.

An area of the application or primary path (Portal, Workflow) will not work or a subsystem specific data table is corrupt (e.g., Bill Edit table is corrupt).

Contractor shall notify the government immediately 100% of the time.

Hourly

Functionality within a component fails or there is incorrect functionality of component or process.

The defect affects all functionality or data not covered by Severity 1 or 2.

Can have a Level 3 with or without a workaround

Provider enrollment function within the portal fails.

Contract shall notify the government within 1 working day 100% of the time.

Weekly

Minor issue or cosmetic issue

Workaround not needed

Usability errors; screen or report errors that do not materially affect quality and correctness of function, intended use or results. A common one is spelling errors.

Contractor shall respond to the government within 3 working days of notification 100 % of the time.

Monthly

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R0038

The Contractor shall develop and submit a corrective action plan to the Government for approval, within three workdays of identifying processing deficiencies that adversely impact the efficiency or accuracy of processing or , for any item(s) that fail, during that reporting period, to meet (by four (4) or more percentage points) their performance standards with the monthly Performance Reports,. The Contractor shall make any required modifications to the plan within one workday of receiving feedback from the Government.