WCMBP_Section_C_-_Performance_Work_Statement_AMD_5.doc

United States Department of Labor

(DOL)

Workers’ Compensation Medical Bill Process (WCMBP)

Section C -

Performance Work Statement

Revised July 1, 2014 Office of Workers’ Compensation Programs (OWCP)

TABLE OF CONTENTS

1-11

GENERAL OVERVIEW

1-11.1 Background

1-31.1.1 Division of Administration and Operations (DAO)

1-31.1.2 Division of Federal Employees’ Compensation

1-31.1.3 Division of Coal Mine Workers’ Compensation

1-41.1.4 Division of Energy Employees Occupational Illness Compensation

1-41.1.5 Division of Longshore and Harbor Workers’ Compensation

1-41.1.6 Projected Operational Volumes

1-41.2 Purpose

1-61.3 Global Requirements

1-61.3.1 Federal Laws and Regulations

1-71.3.2 Financial and Security Audit Requirements

1-81.3.3 Implementation

1-111.3.4 Operations

1-141.3.5 Maintenance

1-151.4 Organization of this Document

2-12

PROJECT PLANNING AND CONTROL

2-22.1 Implementation Phase

2-22.1.1 Transition-In

2-42.1.2 requirements analysis

2-52.1.3 Customization

2-62.1.4 Comprehensive Testing Program

2-132.1.5 Assumption of Operations

2-142.2 Operations Phase

2-142.2.1

2-152.2.2 Transition-Out

3-13

INFORMATION SECURITY STANDARDS

3-13.1 Overview

3-23.2 Processing Requirements

3-23.2.1 Physical Security

3-43.2.2 Logical Security

3-63.2.3 Mobile Devices

3-73.2.4 Disaster Recovery and Back-up

3-93.3 Government Financial and Accountability Audits

4-14

STAFFING

4-14.1 Staffing Requirements

4-24.2 Staffing Plan

4-34.3 Background Investigations

4-54.4 Key Position Requirements for Implementation Phase

4-54.4.1 Program Manager

4-64.4.2 Quality Assurance Manager

4-84.4.3 Deputy Program Manager

4-104.4.4 Technical Manager

4-124.4.5 Requirements Manager

4-144.4.6 Test Manager

4-154.4.7 Lead Software Engineer

4-174.4.8 Data Migration manager

4-184.4.9 Training Manager

4-194.5 Key Position Requirements for Operations Phase

4-194.5.1 Program Manager

4-204.5.2 Deputy Program Manager

4-214.5.3 Quality Assurance Manager

4-224.5.4 Program Liaison Managers

4-234.5.5 Pharmacy Manager

4-244.5.6 Technical Manager

4-264.5.7 Lead Software Engineer

4-274.5.8 Call Center Manager

4-284.5.9 Resolution and Adjustment Supervisor

4-294.5.10 Provider Outreach Supervisor

4-314.5.11 Training Manager

4-324.5.12 Authorization/Triage Nurse

4-324.6 Categorized Position Requirements for Operations Phase

4-324.6.1 DFEC District Office Troubleshooter (DOT) Liaisons

4-334.6.2 Resolution and Adjustment Specialists

5-15

CENTRAL MAILROOM

5-15.1

5-55.2

5-55.2.1 Contractor Responsibilities

5-55.3

5-55.3.1

5-65.4

5-65.4.1

6-16

DOCUMENT IMAGING

6-16.1

6-36.2

6-36.3

6-36.3.1 OWCP Imaging Services

7-17

CLAIMANT BILL DEVELOPMENT

7-17.1

7-47.2

7-57.3

7-57.3.1 External Interfaces

7-57.3.2 Inputs

7-57.3.3 Outputs

7-67.4 Return and Communication

8-18

BILL SCAN/DATA ENTRY

8-18.1

8-88.2

8-88.3

8-88.3.1

8-88.3.2

8-88.3.3

8-128.4 Bill Scan/Data Entry Maintenance

9-19

BILL PROCESSING

9-19.1

9-59.2

9-69.3

9-69.3.1 External Interfaces—INCLUDE BUT NOT LIMITED TO:

9-69.3.2

9-79.3.3

9-119.4 Communication

9-119.4.1

9-119.4.2

9-119.4.3

10-110

THIRD PARTY LIABILITY

11-111

PROMPT PAYMENT BILL PROCESSING

11-111.1

11-911.2

11-911.3

11-1011.3.1

11-1011.3.2

11-1011.3.3

11-1311.4 Communications

12-112

RETURNING BILLS/DOCUMENTS (RTP/RTC/RTD)

12-112.1

12-412.2

12-512.3

12-512.3.1

12-512.3.2

12-512.3.3

12-612.4

13-113

EDITS AND AUDITS

13-113.1

13-1213.2

13-1413.3

13-1413.3.1

13-1413.3.2

13-1413.3.3

14-114

CLAIMANT ELIGIBILITY

14-114.1

14-114.2

14-314.3

14-314.3.1 Input

14-314.3.2

14-414.3.3

DFEC

14-914.3.4

DCMWC

14-1414.3.5

DEEOIC

15-115

PROVIDER ENROLLMENT AND MANAGEMENT

15-115.1

15-115.2

15-315.3

15-415.3.1

15-415.3.2

15-415.3.3

15-1615.4

15-1615.5

15-1615.5.1

15-1615.5.2

15-1715.5.3

15-1915.6

15-1915.6.1

15-2015.6.2

15-2015.6.3

16-116

AUTHORIZATIONS

16-116.1

16-516.2

16-516.3

16-516.3.1

16-616.3.2

16-616.3.3

16-1116.4

17-117

TREATMENT SUITES

17-117.1

17-2017.2

17-2117.3

17-2217.3.1

17-2217.3.2

17-2217.3.3

17-2317.4

17-2317.4.1

18-118

BILL PRICING

18-118.1

18-1518.2

18-1618.3

18-1818.4

18-1918.4.1

18-1918.4.2

18-1918.4.3

18-1918.5 DCMWC Inpatient Processing and Pricing Logic

18-2018.6 DCMWC Outpatient

18-2018.6.1

18-2018.6.2

19-119

PHARMACY

19-119.1

19-219.2

19-419.3

19-419.3.1

19-419.3.2

19-519.3.3

19-519.4

19-519.4.1

20-120

BILL RESOLUTION

20-120.1

20-420.2

20-620.3

20-620.3.1

20-620.3.2

20-620.3.3

20-620.4

21-121 PAYMENT FILES PROCESS: RV/EFT and 1099

21-121.1

21-121.2 RV/EFT Process

21-221.2.1

21-921.2.2

21-1221.2.3

21-1321.3 1099 Process

21-1321.3.1

21-1321.3.2

21-1421.3.3

21-1421.3.4

22-122

FEE SCHEDULE APPEALS

22-122.1

22-522.2

22-522.3

22-522.3.1

22-522.3.2

22-622.3.3

22-722.4

23-123

ADJUSTMENT PROCESSING

23-123.1

23-1123.2

23-1123.3

23-1223.3.1

23-1223.3.2

23-1223.3.3

24-124

FRAUD AND ABUSE DETECTION

24-124.1

24-124.2

24-324.3

24-324.3.1

24-324.3.2

24-424.4

24-524.5 FAD Maintenance

25-125

MANAGEMENT REPORTING

25-125.1

25-125.2

25-325.3

25-325.3.1 Input

25-325.3.2 Output

26-126

CHANGE MANAGEMENT

26-126.1

26-226.2

26-426.3

26-626.4

26-626.5

27-127

COMMUNICATIONS

27-127.1 Communications Overview

27-127.2 Data Transmission

27-127.2.1

27-227.2.2

SECURE CONNECTION

27-327.3 Call Center

27-427.3.1

27-827.3.2

27-1027.4 Direct Electronic Access to Data

27-1027.4.1

27-1027.4.2

27-1827.4.3

27-1927.5 Telephonic IVR

27-1927.5.1

27-1927.5.2

27-2127.5.3

27-2127.5.4

LIST OF FIGURES

2-1Figure 1 Project Phases

5-2Figure 2 Central Mailroom Process DFEC

5-3Figure 3 Central Mailroom Process DEEOIC

5-4Figure 4 Central Mailroom Process DCMWC

6-2Figure 5 Sample OWCP Document Imaging Process

7-2Figure 6 Claimant Bill Development Process DFEC

7-3Figure 7 Claimant Bill Development Process DEEOIC

7-4Figure 8 Claimant Bill Development Process DCMWC

8-2Figure 9 Bill Scan/Data Entry Process DFEC

8-3Figure 10 Bill Scan/Data Entry Process DFEC Non-Bill Correspondence

8-4Figure 11 Bill Scan/Data Entry Process DEEOIC

8-5Figure 12 Bill Scan/Data Entry Process DEEOIC Non-Bill Correspondence

8-6Figure 13 Bill Scan/Data Entry Process DCMWC

8-7Figure 14 Bill Scan/Data Entry Process Non-Bill Correspondence DCMWC

9-2Figure 15 Bill Processing Flow DFEC

9-3Figure 16 Bill Processing Flow DEEOIC

9-4Figure 17 Bill Processing Flow DCMWC

11-2Figure 18 DFEC PPA Process 1

11-3Figure 19 DFEC PPA Process 2

11-4Figure 20 DFEC PPA Process 3

11-5Figure 21 DEEOIC PPA Process 1

11-6Figure 22 DEEOIC PPA Process 2

11-7Figure 23 DCMWC PPA Process 1

11-8Figure 24 DCMWC PPA Process 2

12-2Figure 25 DFEC Return to Provider/Return to Claimant Business Flow

12-3Figure 26 DEEOIC Return to Provider/Return to Claimant Business Flow

12-4Figure 27 DCMWC Return to Provider/Return to Claimant Business Flow

13-2Figure 28 Edit/Audit Overview all programs

13-3Figure 29 DFEC Edit/Audit Process Flow 1

13-4Figure 30 DFEC Edit/Audit Process Flow 2

13-5Figure 31 DFEC Edit/Audit Process Flow 3

13-6Figure 32 DEEOIC Edit/Audit Process Flow 1

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

13-8Figure 34 DEEOIC Edit/Audit Process Flow 3

13-9Figure 35 DCMWC Edit/Audit Process Flow 1

13-10Figure 36 DCMWC Edit/Audit Process Flow 2

13-11Figure 37 DCMWC Edit/Audit Process Flow 3

14-6Figure 38 DFEC Claimant Eligibility Editing Process

14-7Figure 39 DFEC Claimant Eligibility Transmission process

14-8Figure 40 DFEC Claimant On Review process

14-12Figure 41 DCMWC Claimant Eligibility Editing Process

14-13Figure 42 DCMWC Claimant Eligibility File Transmission Process

14-14Figure 43 DCMWC Claimant On Review Process

14-17Figure 44 DEEOIC Claimant Eligibility Editing process

14-18Figure 45 DEEOIC Claimant Eligibility Records Transmission

14-19Figure 46 DEEOIC Claimant On Review Process

15-7Figure 47 Provider Eligibility Edit Flow

15-8Figure 48 OWCP Provider Enrollment Process via hardcopy

15-9Figure 49 OWCP Provider Enrollment Process via Portal

15-10Figure 50 OWCP Provider Enrollment Process from DO fax

15-11Figure 51 OWCP Provider Maintenance Process

16-2Figure 52 DFEC Authorization Process Overview

16-3Figure 53 DEEOIC Authorization Process Overview

16-4Figure 54 DCMWC Authorization Process Overview

17-3Figure 55 DFEC Pre-Process Overview

17-4Figure 56 DFEC Prompt Pay Process

17-5Figure 57 DFEC CA-16 Process

17-6Figure 58 DFEC Short Form Closure Process

17-7Figure 59 DFEC Diagnostic with no Prompt Pay (999.98) Process

17-8Figure 60 DFEC HCFA-1500 Process

17-9Figure 61 DFEC UB-04 Outpatient Process

17-10Figure 62 DFEC UB-04 Inpatient Process

17-11Figure 63 DFEC Pharmacy Process

17-12Figure 64 DFEC Authorizations Process

17-13Figure 65 DEEOIC HCFA 1500 Process

17-14Figure 66 DEEOIC UB-04 Outpatient Process

17-15Figure 67 DEEOIC UB-04 Inpatient Process

17-16Figure 68 DEEOIC Pharmacy Process

17-17Figure 69 DEEOIC Authorizations Process

17-18Figure 70 DCMWC HCFA 1500 Process

17-19Figure 71 DCMWC Outpatient Bill Process

17-20Figure 72 DCMWC Pharmacy Bill Process

18-2Figure 73 DFEC HCFA 1500 Pricing process

18-3Figure 74 DFEC UB04 Inpatient Pricing process

18-4Figure 75 DFEC UB04 Outpatient Pricing process

18-5Figure 76 DFEC Travel Pricing process

18-6Figure 77 DEEOIC HCFA 1500 Pricing process

18-7Figure 78 DEEOIC UB04 Inpatient Pricing process

18-8Figure 79 DEEOIC UB04 Outpatient Pricing process

18-9Figure 80 DEEOIC Travel Pricing process

18-10Figure 81 DEEOIC Travel Pricing process continued

18-11Figure 82 DCMWC HCFA 1500 Pricing process

18-12Figure 83 DCMWC UB04 Inpatient Pricing process

18-13Figure 84 DCMWC UB04 Outpatient Pricing process

18-14Figure 85 DCMWC Treatment Travel Pricing Process

18-15Figure 86 DCMWC Treatment Travel Pricing Process continued

19-1Figure 87 Pharmacy Processing

20-2Figure 88 DFEC Bill Resolution Process

20-3Figure 89 DEEOIC Bill Resolution Process

20-4Figure 90 DCMWC Bill Resolution Process

21-2Figure 91 DFEC Payment Process

21-3Figure 92 DFEC A/R Processing

21-4Figure 93 DEEOIC Payment Process

21-5Figure 94 DEEOIC AR Processing

21-6Figure 95 DCMWC Payment Process

21-7Figure 96 DCMWC A/R Process

21-8Figure 97 DCMWC Adjustment Process

22-2Figure 98 DFEC Fee Schedule Appeals process

22-3Figure 99 DEEOIC Fee Schedule Appeals process

22-4Figure 100 DCMWC Fee Schedule Appeals process

23-2Figure 101 DFEC Adjustment Process

23-3Figure 102 DFEC Adjustment Process continued

23-4Figure 103 DFEC Adjustment Processing continued

23-5Figure 104 DEEOIC Adjustment Process

23-6Figure 105 DEEOIC Adjustment Process continued

23-7Figure 106 DEEOIC Adjustment Process continued

23-8Figure 107 DCMWC Adjustment Process

23-9Figure 108 DCMWC Adjustment Process continued

23-10Figure 109 DCMWC Adjustment Process continued

27-2Figure 110 Site Interconnections

LIST OF TABLES

4-1Table 1 Key Position Staffing Requirements

5-1Table 2 Current Mailroom Addresses

27-4Table 3 Current WCMBP Telephone Numbers

1 GENERAL OVERVIEW

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 four 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.

· The Longshore and Harbor Workers' Compensation Act and its extensions (including the Defense Base Act), administered by the Division of Longshore and Harbor Workers’ Compensation (DLHWC). 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, 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 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.

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).

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 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, 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

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).

1.1.7 Federal Laws and Regulations

R1090

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).

· The Americans with Disabilities Act and Section 508 of the Rehabilitation 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.

1.1.8 Financial and Security Audit 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

1.1.9 Implementation

1.1.10 Operations

· 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

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

1.1.11 Maintenance

R1025

The Contractor shall follow Government established schedules for updating data, reference files and other supporting data for each WCMBP functional area.

R1026

The Contractor shall retain ICD-9 code processing capability (to include the treatment suite tools) for medical bills submitted on or after 10/1/2015 as directed by the Government and required for all functional areas of the OWCP WCMBP.

Organization of this Document

This document is organized into sections corresponding to the various functional components of OWCP’s Medical Bill Processing operations. Most sections contain the following subsections:

· Implementation

· Operations

· Communication

· Maintenance

The Implementation subsections specify the requirements to be addressed during the initial development and implementation of the WCMBP processes to operational capability according to the Government’s approved requirements. The Operations subsections specify the requirements that are a part of the routine, ongoing processing and management functions. The Communications subsections specify requirements to be addressed to effectively handle communications between the Contractor’s operations and external parties. The Maintenance subsections provide requirement specifications for the updating of processes and data that are required on a periodic basis.

In each subsection, inputs, outputs, and interfaces external to the section’s processes may also be provided. Core requirements identify the standard processes that are applicable to all OWCP programs. Each program may implement these standard processes differently. Additionally, each program has requirements that are unique to that program.

This document is also organized based on WCMBP functionality. Some requirements included in functional sections are replicated in other functional sections. This replication is intended to provide offerors with comprehensive overviews of each functional processing area. The offerors must ensure that these replicated requirements are addressed in their proposed solutions.

2 PROJECT PLANNING AND CONTROL

The Contractor manages its contract efforts through two phases of contract’s lifecycle -- Implementation and Operations, each with multiple sub-phases, see Figure 1. This section addresses the project planning and control requirements that apply throughout the project’s lifecycle. There are specific requirements for each phase and sub-phase.

Figure 1 Project Phases

As part of the project’s QA process, the Contractor establishes, for review and approval by the Government, entry and exit criteria/milestones for moving from the Implementation phase to the Operations phase. These criteria include, but are not limited to:

· Acceptance by the Government of all the deliverables required for the Implementation phase, including, but not limited to plans, functional demonstrations, test results, reports, and documentation, following review and/or testing by the Government and correction by the Contractor as required.

· Satisfaction of all Government WCMBP requirements relating to the deliverables.

R1124

To mitigate risk, all plans and schedules shall include adequate time for development and comprehensive testing (e.g., system integration, acceptance, regression testing, etc.) and time for the Government to review and accept/reject the deliverables.

The Contractor is responsible for ensuring that its schedule is adequate to provide for development and comprehensive testing, for Government certification to be completed by the Operations Readiness Review and for all activities required to assume operations to be completed by the Go-Live event (defined in Section F) to avoid the imposition of negative incentives and/or liquidated damages by the Government, should implementation not meet the Go-Live prescribed date.

The Government requires a comprehensive testing program.

R1125

The Contractor shall successfully test all requirements and the WCMBP system from end-to-end, in a System Integration Test, as well as complete volume and performance testing and parallel testing prior to releasing the system to the Government for Acceptance Testing.

R1126

The WCMBP system shall successfully pass all Government Acceptance Tests prior to receiving Government certification for Operational readiness.

R1130

Existing data, provided by the incumbent (with Government oversight), shall be converted by the Contractor and migrated to the test environment before this end-to-end test period begins.

Implementation of full WCMBP Contractor operations and completion of all activities required to assume operations by the Go-Live event are of critical importance to the Government. When the Contractor assumes responsibility for all contract activities, the Contractor ensures enough time and resources are available so that the processing of bills is not disrupted.

The following factors are critically important to the Government:

· Assumption of all operational activities without disruption in services or payments by the Go-Live date.

· Compliance with Privacy Act and Federal information security requirements.

· Development and implementation of components that improve efficiency and effectiveness of WCMBP processing.

All data, test materials, test documentation, and user documentation is and remains the property of the DOL\OWCP National Office\DAO.

Implementation Phase

This project involves multiple functional capabilities, processing modes, communications technologies, stakeholders, and types of services, data, and correspondence, etc.

During the Implementation phase, the Contractor implements and successfully tests a WCMBP solution that satisfies all the requirements of this RFP and the Requirements Traceability Matrix (RTM). As part of the implementation process the Contractor ensures that all required Government functional processes are available for use in the new WCMBP solution.

2.1.1 Transition-In

Transition-In encompasses all activities necessary to plan and manage the design, development, testing, and implementation of the WCMBP.

Contractor Responsibilities

The Contractor conducts all planning and control activities associated with the design, development, testing, and implementation of WCMBP capabilities and provide status reports to the Government.

R1027

The Contractor shall submit for Government review and approval templates for all contractual deliverables for which the Government has not furnished a template for the Contractor to use. (See Section F for list of contractual deliverables and Section J for list of templates that the Government will furnish)

R1028

The Contractor shall ensure that all data, deliverables, and reports generated under the terms of this contract are, and shall always remain, the property of the Government.