Draft PWS Clearinghouse Services 2026.pdf

Cheyenne River Health Center Performance Work Statement

Background Indian Health Service (IHS), a federal agency within the Department of Health & Human Services (DHHS), is responsible for providing health services to American Indians and Alaska Natives. IHS provides a comprehensive health service delivery system for approximately 1.14 million American Indians and Alaska Natives who belong to 573 federally recognized tribes, in 35 states. IHS Headquarters is located in Rockville, MD, and is divided into twelve physical areas: Alaska, Albuquerque, Bemidji, Billings, California, Great Plains, Nashville, Navajo, Oklahoma, Phoenix, Portland, and Tucson.

The Great Plains Area Office (GPAO) collaborates with its 19 IHS and Tribally managed service units to deliver healthcare to approximately 130,000 Native Americans residing in North Dakota, South Dakota, Nebraska, and Iowa. The Area Office’s service units include seven hospitals, eight health centers, and several smaller health stations and satellite clinics.

The Cheyenne River Health Center (CRHC) falls under the GPAO. CRHC provides medical care for approximately 11,000 tribal members living on the Cheyenne River Sioux Tribe (CRST) Reservation and within the established Purchased/Referred Care Delivery Area (PRCDA). Serving a rural area, many patients that travel approximately 165 miles round-trip to receive care. The CRHC was built in 2011 to provide an expanded level of health care services specifically designed to meet the needs of the CRST population. The CRST, through a 638 contract with IHS, operates four satellite health stations that offer basic ambulatory services in the Cherry Creek, Red Scaffold, Swiftbird, and Whitehorse communities. Services at CRHC include: Emergency Room Department, Primary Care Clinic, Pharmacy, Physical Therapy, Radiology, Immunization Clinic, Inpatient Care, Laboratory, Purchased/Referred Care, Dietary, Eye Care, Well-Child Clinic, and Specialty Clinics: Audiology, ENT, MRI, OB/GYN, Podiatry and Telemedicine (Cardiology, Dermatology, Endocrinology, Internal Medicine, Hepatology, Nephrology, and Rheumatology).

Purpose The Cheyenne River Health Center requires a secure exchange data software solution to provide connectivity to the Medicare DDE (Direct Data Entry)/FISS (Fiscal Intermediary Standard System), eligibility verification, eligibility searches, and perform third party insurance medical (emergency, inpatient, outpatient, and specialty clinic) claims (professional and facility) validation, approval and processing services for Medicare, Medicaid, VA and Commercial Payers for the Cheyenne River Health Center, providing confidentiality, authentication, integrity and non-repudiation for the Eagle Butte Hospital.

IHS Headquarters mandates that payment systems are updated to reflect changes in medical practice and the relative value of services. Based on this, secure exchange-managed services are necessary for the medical claims process to ensure compliance.

Work Schedule/Availability 24/7 availability of all payer eligibility verification and search services for health care center staff (with exceptions to scheduled service disruption)

Period of Performance Base Year: July 1, 2026, to June 30, 2027 Option Year One (1): July 1, 2027, to June 30, 2028 Option Year Two (2): July 1, 2028, to June 30, 2029 Option Year Three (3): July 1, 2029, to June 30, 2030 Option Year Four (4): July 1, 2030, to June 30, 2031

Place of Performance Cheyenne River Health Center Business Office/Patient Registration P.O. Box 1012 24276 166th Street Airport Road Eagle Butte, South Dakota 57625

Scope The contractor shall provide a secure exchange data software solution that includes technology for:

• Connectivity to the Medicare DDE (Direct Data Entry) /FISS (Fiscal Intermediary Standard System) and automated claims status reporting, payment floor details, and other reports.

• Eligibility verification for third-party payers to include Medicaid and Medicare. Anticipated monthly volume for Eligibility Checks: 100.

• Eligibility results must include start and end dates of coverage.

• Capability to search eligibility for third-party coverage for patients who do not provide or present insurance information. Anticipated volume for Insurance Searches per month: 1000.

• Third-party insurance medical claims validation, approval, and processing services via a clearinghouse for Medicare, Medicaid, VA, and Commercial Payers (not limited to but including United Health Group) for the Cheyenne River Health Center. Anticipated volume for Claims Submission per month: 2,500.

• Processes all claim types (professional and facility): Emergency, Inpatient, Outpatient, and Specialty Clinics; and provides both solicited and unsolicited claims status. Anticipated volume for Claims Status per month: 1000.

• The software must provide rigorous and thorough claims rules and custom business rules.

• Capability for self-monitoring usage of services for thresholds.

• Training and support related to the scope of work – training provided either on-site or via teleconference.

The software services shall comply with the following constraints:

The software service shall not require Cheyenne River Health Center to install contractor software within the Cheyenne River Health Center or the Indian Health Service network.

The service shall enable Cheyenne River Health Center to exchange data utilizing a Secure File Transfer Protocol (SFTP) as approved by the Indian Health Service Office of Information Technology.

The service shall support Electronic Data Interchange (EDI) transactions and interactive Telnet application protocol sessions.

The service should support an unlimited number of users, and access should be workstation independent.

The service shall not entail development of Health Insurance Portability and Accountability Act (HIPAA) transaction set translation or mapping processes, non-CMS or non-IHS-generated data or messages, or data reformatting.

The service shall also conform to a Business Associate Agreement to be established between the Cheyenne River Health Center and the Contractor.

The contractor shall support end-to-end communication testing, implementation, and daily operations of the data transfers from the contractor to the Cheyenne River Health Center, which shall include, at a minimum:

The contractor should provide routine technical support to implement corrections to services that occur as a result of errors, flaws, or other failures within their service.

The contractor shall notify a designated Cheyenne River Health Center point of contact (Contracting Officer’s Representative (COR)) of any scheduled maintenance that shall result in downtime at least two (2) days before the maintenance period.

The contractor shall notify a designated Cheyenne River Health Center point of contact of any issues that result in a disruption of data exchange capabilities. This notification shall occur as soon as possible after the disruption has been identified.

The contractor shall provide customer support for reporting, documenting, tracking, and resolving service problems, which shall be available via telephone and email to the Cheyenne River Health Center technical staff.

The contractor shall provide the capability for self-monitoring usage of services that have a threshold.

Contractor Responsibility

Secure internet-based connectivity to all current fiscal intermediaries.

Ability to send medical emergency, inpatient, outpatient, and specialty claims to Medicare Contractor and other payers using secure data exchange technology.

Unlimited Direct Data Entry (DDE) online Medicare claims status/corrections for Medicare Part A.

All electronic transactions and DDE/FISS shall provide confidentiality, authentication, integrity, and non-repudiation.

Reports and acknowledgements on all claims sent.

Automated batch 997/999 acknowledgement reports.

Automated batch 276/277 claims status capability.

Accept electronic claims from the Resource Patient Management System (RPMS).

Provide a single secure electronic location to manage all electronic claims, including VA claims.

Verify Medicaid, Medicare, and Commercial Payer eligibility in real-time and in batches.

Provide knowledgeable support personnel to assist with any issues related to the processing of medical claims.

The Contractor shall provide toll-free telephone/technical support during 7:00 am to 7:00 pm Mountain Standard Time, Monday through Friday, except Government holidays.

The Contractor shall provide a two (2) hour minimum response time from notification by IHS at no additional cost to the Cheyenne River Health Center.

The medical claim processing services shall meet the following standards:

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

Third-party insurance medical claims shall be transmitted electronically to the appropriate carrier/payer.

The Contractor shall use routine editing procedures to detect defects in medical claims information supplied by the government. The Contractor shall reject and not process all medical claims with defects. The Contractor shall provide the service location with edit status reports that list the deficiencies, enabling the service location to correct the detected issues.

The Contractor shall provide for the correction of all claims rejected by all carriers/payers for any reason other than the inappropriate format of the claims.

The Contractor shall provide the capability for medical claim errors to be corrected and resubmitted electronically and provide a report of rejected medical claims within 4 hours of batch submission.

The Contractor shall make available productivity and submission reports within 24 hours of batch transmission.

Past Performance:

If the Contractor has held previous contracts with the Indian Health Service, please provide supporting information, including the government contract number.

Performance-Based Service Delivery Summary

The contractor’s performance will be measured based on the following Performance Requirements. The Performance Requirements will be measured against Government Performance Standards and monitored in accordance with the following Methods of Government Surveillance, also known as a Quality Assurance Surveillance Plan (QASP), to determine compliance. A 5% deduction will be assigned to each Performance Requirement.

Deductions shall be assessed against individual invoices when services are not performed or do not meet contract requirements. The deficient category will make deductions.

Performance Standards/Requirements

REQUIRED

SERVICE

PERFORMAN

CE

INDICATOR

ACCEPTABLE

QUALITY

LEVEL (AQL)

METHOD OF

SURVEILLANCE

INCENTIVE

(POSITIVE OR

NEGATIVE)

Eligibility Services

Availability of services 24/7

Minimal disruption to services, lasting less than 1 hour, with the exception of scheduled service disruptions.

Staff and/or contractor notification of disruption of services

Loss of services, disruption greater than 1 day may result in withholding of PO until services restored or issue resolved

Unlimited Access/Multiple Users

Access to services

More than 1 staff member able to utilize the service at any given time.

Reporting of disruption, inability to access due to multiple users by staff

1% reduction in invoice if fails to meet indicator

Performance Evaluation: If the contractor fails to perform the required services to an acceptable quality level, payment may be withheld until the necessary corrections are made.

If the contractor fails to perform any needed services, the COR will provide written notice to the Contracting Specialist, CCO, and the contractor. The Contracting Office will issue the contractor a Contract Discrepancy Report (CDR). The contractor shall have seven (7) calendar days to provide the Contracting Office with their response to the CDR. Upon evaluation of the contractor’s response to the CDR for tasks surveilled, the contractor’s payment for the month in which the performance is questioned will be calculated as outlined below.

Contractor Payment: If the contractor fails to perform the required services to an acceptable quality level, payment may be withheld until the necessary corrections are made.

Contracting Officer’s Representative Designation The COR is responsible for:

1. Monitoring the Contractor’s technical progress.

2. Interpreting the statement of work.

3. Technical evaluation as required.

4. Technical inspections and acceptance required by this contract; and

5. Assisting the Contractor in the resolution of technical problems encountered during performance of this contract.

Carla Cheyenne, Business Office Manager Cheyenne River Health Center PO Box 1012 24276 166th Street, Airport Road Eagle Butte, SD 57625 Office: 605.964.0526 Fax: 605.964.1169

Contractor Compliance The Contractor shall adhere to all official coding and billing rules as published by the American Hospital Association (AHA) and Centers for Medicare and Medicaid Services (CMS) regulations and guidelines to ensure the highest levels of integrity, compliance, and ethics.

The Contractor shall maintain records of confidentiality in accordance with the Health Insurance Portability and Accountability Act (HIPAA), Privacy Act of 1974, Alcohol and Drug Abuse Patient Records, Freedom of Information Act (FOIA), and other pertinent Federal regulations.

Administrative Compensation – Billing will be at a fixed rate for all services.

Meetings/Conference Calls – The Contractor shall attend meetings or conference calls scheduled by the Contracting Officer’s Representative (COR) to address areas of concern and exchange information to ensure all contract requirements are being met. The COR shall be responsible for scheduling and coordinating all meetings and conference calls.

Equipment Failure – Any delays or downtime due to Contractor equipment failure shall be communicated to the COR or their designee as soon as possible via telephone or email. The Contractor shall not be penalized for delays due to our equipment failure or updates that are beyond the Contractor’s control (e.g., IHS server downtime.

Reports The Contractor shall deliver standard or custom reports upon request and/or via dashboard, to allow for monitoring monthly usage of the following:

• Claims Submissions

• Claims Status Checks

• Eligibility Checks

• Insurance Searches