Draft PWS Pre-75D301-21-R-71961.docx

WTCHP NPN Draft PWS – 75D301-21-R-71961 World Trade Center Health Program Nationwide Provider Network

NATIONWIDE PROVIDER NETWORK

RFP: PRE-75D301-21-R-71961

Statement of Work

SECTION 1- BACKGROUND

The James Zadroga 9/11 Health and Compensation Act of 2010 (Zadroga Act) was signed into law on January 2, 2011; the Act was subsequently reauthorized through 2090. Pub. L. 111-347, as amended by Pub. L. 114-113 and Pub. L. 116-59; codified at 42 U.S.C. §§ 300mm – 300mm-61. The Zadroga Act established the World Trade Center (WTC) Health Program within the Department of Health and Human Services’ Centers for Disease Control and Prevention (CDC) to provide medical monitoring, screening, and treatment for responders and survivors of the September 11, 2001, terrorist attacks. Responders include workers or volunteers who provided rescue, recovery, debris cleanup, and related support services on or in the aftermath of the September 11, 2001, terrorist attacks at the World Trade Center, the Pentagon, or the aircraft crash site near Shanksville, PA. Survivors include persons who were present in the New York City (NYC) Disaster Area in the dust or dust cloud on September 11, 2001 or who worked, resided, or attended school, childcare, or adult daycare in the NYC Disaster Area for a certain period following the September 11, 2001, terrorist attacks. In order to enroll in the Program, survivors and responders must meet certain eligibility criteria described in the Zadroga Act ( https://www.cdc.gov/wtc/eligiblegroups.html). The WTC Health Program has promulgated regulations implementing the Zadroga Act that govern the administration of the Program at 42 CFR pt. 88.

The WTC Health Program (the Program) is a limited benefit health program, meaning that treatment is covered for only specified health condition(s) resulting from exposure to airborne toxins, hazards, or other adverse conditions arising from the September 11, 2001, terrorist attacks. A provider affiliated with the WTC Health Program must diagnose a member with a covered health condition and determine that it is related to the member’s 9/11 exposure and the determination must then be certified by the Program for the member to receive treatment. An enrolled member must meet certain exposure, latency, and symptom-onset requirements for their health condition to be certified. Program eligibility and certification decisions are made by the WTC Health Program enrollment and certification specialists, respectively. A range of conditions are covered including mental health, aerodigestive disorders, and cancer; see 42 C.F.R. § 88.15 for the complete List of WTC-Related Health Conditions (List).

The Clinical Centers of Excellence (CCEs) and Nationwide Provider Network (NPN) provide treatment and medical monitoring for over 100,000 Program members, while the WTC Health Program administers Program policy, makes eligibility and certification decisions, and covers the costs associated with treatment and monitoring. The Zadroga Act encompasses myriad Program administration and performance responsibilities including those pertaining to enrollment, initial evaluation, medical monitoring, and care management of covered health conditions for eligible individuals through diagnostic and treatment services. There are currently seven (7) CCEs and one Short-term Survivor Clinic (SSC) in the New York Metropolitan Area, and one NPN that administers benefits to members. As of December 2020, there were a total of 80, 146 responders and 28,394 survivors enrolled in the Program; of these, 22, 122 live outside of the New York Metropolitan Area and are served by the NPN.

SECTION 1.1 – Definitions

Business Days: All days excluding Saturdays, Sundays, and designated federal holidays.

Calendar Days: All days including Saturdays, Sundays, and designated federal holidays.

Certification: WTC Health Program review for purposes of approval of coverage of the determination that a health condition in a particular WTC Health Program member is a WTC-related health condition, as included on the List of WTC-Related Health Conditions in 42 CFR 88.15, or a health condition medically associated with a WTC-related health condition and the member’s 9/11 exposures are substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition. See 42 CFR 88.1, 88.18.

Certified-eligible survivor: An individual who has been identified as eligible for medical monitoring and treatment as of January 2, 2011; or a screening-eligible survivor who is eligible for follow-up monitoring and treatment pursuant to § 88.12(b) of the Regulations (https://www.cdc.gov/wtc/regulations2.html). See 42 CFR 88.1.

Clinical Center of Excellence (CCE): A New York metropolitan area (NYMA)-based medical facility that, in accordance with the Zadroga Act and program regulations, operates under an individual contractual relationship with the WTC Health Program to provide medical monitoring, diagnosis, and treatment services for members in the NYMA. Members are assigned a CCE which is responsible for coordinating their care under the WTC Health Program. There are currently seven CCEs contracted with the Program and one Short-term Survivor Clinic: one for the survivor population and six for the responder population. See 42 CFR 88.1

Codebook: A list of medical codes (i.e., ICD-9 and ICD-10) managed by the Program that determines approved medical treatments covered by the Program, identifies care suites, provides prior authorization requirements, and other applicable coverage guidelines.

FDNY Responders: Active and retired FDNY members who performed 9/11-related rescue and recovery efforts in and around New York City.

Fraud: Any of the following:

· Knowingly submitting, or causing to be submitted, false claims or making misrepresentations of fact to obtain a Federal health care payment for which no entitlement would otherwise exist;

· Knowingly soliciting, receiving, offering, or paying remuneration (e.g., kickbacks, bribes, or rebates) to induce or reward referrals for items or services reimbursed by Federal health care programs;

· Making prohibited referrals for certain designated health services (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf).

General Responders: Responders identified as eligible for monitoring and treatment based on certain eligibility criteria, generally, onsite workers or volunteers who performed 9/11-related rescue, recovery, debris cleanup, and related support services in and around New York City. Includes certain active and retired NYPD, Port Authority Police, Port Authority Trans-Hudson Corporation Tunnel workers, employees of the NYC Chief Medical Examiner’s Office or other morgue workers, and vehicle-maintenance workers. See 42 CFR 88.1, 88.3, 88.4.

Initial health evaluation: The assessment of one or more symptoms that may be associated with a WTC-related health condition and includes a medical and exposure history, a physical examination, and additional medical testing as needed to evaluate whether the individual has a WTC-related health condition or health condition medically associated to a certified WTC-related health condition and is eligible for treatment under the WTC Health Program. See 42 CFR 88.1.

Monitoring means periodic physical and mental health assessment of a WTC responder or certified-eligible survivor in relation to exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, terrorist attacks and which includes a medical and exposure history, a physical examination and additional medical testing as needed for surveillance or to evaluate symptom(s) to determine whether the individual has a WTC-related health condition. See 42 CFR 88.1.

Nationwide Provider Network (NPN): A nationwide network of health care providers throughout the United States administered by a central entity under contract with the Program to provide WTC-related health care, including initial health evaluation, monitoring, and treatment, for Program members who live outside the NY Metropolitan Area. See 42 CFR 88.1.

Outreach and Education: A service provided by the contractor to ensure prospective members have information they need about the WTC Health Program and how to apply.

Pentagon/Shanksville Responders: Active and retired members of fire and police departments (fire or emergency personnel), employees of recovery or cleanup contractors, volunteers who performed rescue, recovery, demolition, debris cleanup, or other related services at the Pentagon site in Arlington, VA, or the crash site near Shanksville, PA. See 42 CFR 88.1.

Personally Identifiable Information (PII): Information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual. Office of Management and Budget Circular No. A-130 (July 27, 2016).

Prior Authorization (PA): PA is required for certain services that required to meet specific eligibility criteria before they are eligible for coverage by the WTC Health Program. The NPN contractor shall maintain multiple, closed treatment plans in their benefit plan system, allowing each separate treatment plan to have unique PA criteria for the same service. Reasons that services or items require a PA are multi-use/certification specific services, high cost, high fraud/waste/abuse potential, or off-label use. PA approval may be granted on a per-service basis for a member after PA criteria are met. See the WTC Health Program codebook and Administrative manual for more information.

Protected Health Information (PHI): Individually identifiable health information (health information, including demographic information, collected from an individual and created or received by a health care provider, health plan, employer, or health care clearinghouse that relates to the individual’s past, present, or future mental or physical health condition, provision of health care, or payment for care and which identifies the individual or is reasonably believed to make the individual identifiable) that is transmitted by electronic media, maintained in electronic media, or transmitted or maintained in any other form or medium. PHI excludes individually identifiable health information in certain education records, certain student medical records, employment records held by a covered entity in its role as employer, and records regarding a person who has been deceased for more than 50 years. 45 CFR 160.103.

Responder: Certain workers or volunteers who provided rescue, recovery, debris cleanup, or related support services on or in the aftermath of the September 11, 2001, terrorist attacks for specified amounts of time between September 11, 2001 and July 31, 2002. There are three groups of responders in the WTC Health Program: FDNY Responders (and surviving FDNY family members); WTC General Responders (including NYPD); and Pentagon and Shanksville, PA Responders. See 42 CFR 88.1.

Retention: A service provided by the contractor to maintain contact and promote continued participation with current NPN members and encourage inactive members to participate in the Program.

Screening-eligible survivor: An individual who is not a WTC responder, claims symptoms of a WTC-related health condition, and meets the eligibility criteria for a survivor specified in § 88.8 of the Regulations (https://www.cdc.gov/wtc/regulations2.html). See 42 CFR 88.1.

Survivors: Certain persons who claim symptoms and who were in the dust or dust cloud on 9/11; lived, worked, or attended school, childcare, or adult daycare in the New York City Disaster Area during specified timeframes;; performed non-responder 9/11 cleanup or maintenance work; were eligible for a Lower Manhattan Development Corporation Residential Grant; or whose employers were eligible for certain incentive grants. See 42 CFR 88.1, 88.7, 88.8, 88.10.

Technical Guidance Document (TGD): A technical guidance document (TGD) is an official communication from the WTC Health Program Contracting Officer Representative (COR) and the WTC Health Program. TGDs are included as part of the WTC Health Program Procedures and will be provided upon award, if not in the Administrative Manual or in the online policies and procedures.

Utilization Management (UM)[footnoteRef:2][footnoteRef:3]: The evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan. [2: Institute of Medicine. 1989. Controlling Costs and Changing Patient Care?: The Role of Utilization Management. Washington, DC: The National Academies Press. https://doi.org/10.17226/1359.] [3: Nursing Beyond the Bedside - Utilization Management and Utilization Review - Case Management Institute]

Utilization Management -- Concurrent Review (CCR): a method of reviewing patient care and services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form of utilization review that tracks the consumption of resources and the progress of patients while being treated. CCR involves review of necessity decisions made while the patient is currently in an acute or post-acute setting (CCR may also be referred to as “Urgent Concurrent”[footnoteRef:4]). [4: See page 66: https://www11.anthem.com/ca/provider/f1/s0/t0/pw_b134117.pdf?refer=provider

Utilization Management -- Continued Stay Review (CSR): type of review used to determine that each day of the hospital stay is necessary, and that care is being rendered at the appropriate level. It takes place during a patient’s hospitalization for care. CSR is conducted concurrently (as is CCR); however, it applies to non-Diagnosis Related Grouping (DRG) facilities in which the status of each day of a hospital stay is addressed separately. DRG facilities may only require an initial review in which the determination would apply to the entire hospital stay.

Utilization Management -- Prospective Review: The review of medical necessity for the performance of services or scheduled procedures before admission.

Utilization Management -- Retrospective Review: Medical necessity review after treatment is provided.

Waste: Failure to control costs or regulated payment associated with federal program funding that results in taxpayers not receiving reasonable value for their money in connection with any government-funded activities due to an inappropriate act or omission by payers with control over or access to government resources. Importantly, waste relates primarily to mismanagement, inappropriate actions, or inadequate oversight (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf).

WTC Health Program: The program established by Title XXXIII of the Public Health Service Act, as amended, 42 U.S.C. 300mm to 300mm-61 (codifying Title I of the James Zadroga 9/11 Health and Compensation Act of 2010 , Pub. L. 111-347, as amended by Pub. L. 114-113 and Pub. L. 116-59), to provide medical monitoring and treatment benefits for eligible responders to the September 11, 2001, terrorist attacks and initial health evaluation, monitoring, and treatment benefits for residents and other building occupants and area workers in New York City who were directly impacted and adversely affected by such attacks. See 42 CFR 88.1.

WTC Health Program member: Any responder, screening-eligible survivor, or certified-eligible survivor enrolled in the WTC Health Program. See 42 CFR 88.1.

WTC-related health condition: An illness or health condition for which exposure to airborne toxins, any other hazard, or any other adverse condition resulting from the September 11, 2001, terrorist attacks, based on an examination by a medical professional with expertise in treating or diagnosing the health conditions in the List of WTC-Related Health Conditions, is substantially likely to be a significant factor in aggravating, contributing to, or causing the illness or health condition, including a mental health condition. Only those conditions on the List of WTC-Related Health Conditions codified in 42 CFR 88.15 may be considered WTC-related health conditions. See 42 CFR 88.1.

SECTION 1.2 – Selected Roles and Business Associates

The following is a non-exclusive list of other WTC Health Program contractors and business associates with which the NPN may be expected to engage while carrying out Program services and functions.

Clinical Center of Excellence (CCE): A NYMA-based medical facility that, in accordance with the Zadroga Act, operates under an individual contractual relationship with the WTC Health Program to provide medical monitoring, diagnosis, and treatment services for members in the NY metropolitan area. Members residing in NYMA or otherwise electing care through a CCE are assigned a CCE which is responsible for coordinating their care under the WTC Health Program. There are currently eight CCEs contracted with the Program: one for the survivor population and six for the responder population. There is also a Short-term Survivor Clinic in the NYMA.

Comprehensive Cost Avoidance, Coordination of Benefits, and Recovery (CCA): A vendor who implements a comprehensive cost avoidance, coordination of benefits, and recovery platform from pre- to post-payment processes to facilitate the ability of the WTC Health Program to improve efficiency and control health care costs without compromising quality of care.

Data Center (DC): One of several centers under contract with the WTC Health Program to support various functions, including receiving data from the CCEs and NPN; developing examination, monitoring, and treatment protocols; establishing provider credentialing criteria; and coordinating outreach activities. See 42 CFR 88.1.

Health Program Support (HPS): A vendor under contract to support various Program functions, including processing member enrollment and certification applications, managing the customer-service call center, managing the provider network, administering benefit plans, processing medical claims, maintaining the member database, and coordinating member communications.

Health Program Evaluation (HPE): A vendor providing consulting services for data analytics to support strategic planning and program evaluation.

Pharmacy Benefits Manager (PBM): A vendor who disseminates the Program’s formulary updates and works closely with the NPN contractor on pharmacy claims adjudication.

Outreach Partner: Vendor who supports needs of recruitment for responders and survivors through culturally and linguistically appropriate educational materials during various outreach efforts.

SECTION 2 - PURPOSE

The purpose of this contract is to serve members living outside of the New York metropolitan area (NYMA) by administering and managing the Nationwide Provider Network (NPN).

The solicitation is intended for a single contract to provide limited health care delivery services that include:

· Contract management

· Member services

· Program Communications

· Establish and maintain NPN provider network

· Administer monitoring and treatment

· Conduct physician determinations and request certifications

· Administer end-to-end medical benefits claim and billing program

· Coordination of benefits with private health insurance for survivors

· Quality Assurance Controls to prevent unauthorized services

· Establish a pilot preferred provider group site or facility

· Case management and care coordination

In supporting the Program, the NPN contractor shall work closely with the WTC Health Program administering agency and its contractors as listed in SECTION 1.2., and other federal and non-federal stakeholders as directed.

The WTC Health Program is a federally funded, limited health benefit program and, therefore, must comply with all federal regulations and requirements, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA) (Pub. L. 104–191; 42 U.S.C. § 1320d), as modified, and the corresponding implementing regulations, including the Privacy, Security, Breach Notification, and Enforcement Rules (45 C.F.R. pts. 160, 162, and 164).

SECTION 3 – SCOPE OF WORK

The scope of work for a NPN is defined by SECTION 3313 of the Zadroga Act and incorporates requirements from other parts including SECTIONs 3301, 3304, 3305, and 3331 and listed in SECTION 4 of this Performance Work Statement (PWS). The NPN contractor shall operationalize a nationwide provider network to ensure eligible members receive monitoring and treatment only for appropriately certified condition(s). The NPN contractor is responsible for an up-to-date understanding of and compliance with the Zadroga Act and the Program’s implementing regulation, including any amendments, as well as the Program’s policies, standard operating procedures, technical and medical guidance documents, and WTC Health Program Administrative Manual. The NPN contractor shall manage the NPN using advanced and continually improved industry standards. The NPN contractor shall provide these services with the goals of minimizing costs to the WTC Health Program, improving member health, and providing superior member services. The NPN contractor shall manage the contract to ensure that subcontracts, staffing, reporting, security, deliverables, repositories, and Quality Assurance (QA) experts and services meet the requirements of the contract.

The NPN contractor shall make every effort to ensure the accuracy, quality, and timeliness of all written communications and deliverables prior to providing the information to the Contracting Officer (CO), Contracting Officer’s Technical Representative (COR), WTC Health Program Units, and other stakeholders.

SECTION 4 – TASKS TO BE PERFORMED

The NPN contractor must possess the knowledge, capability, and resources to effectively provide services to manage the NPN in accordance with all federal, state, and any other applicable laws; regulations; policies; procedures; and WTC Health Program requirements.

The NPN contractor awarded the contract under the associated request for proposals (RFP) shall be responsible for cooperating with the WTC Health Program and the incumbent NPN contractor during an estimated (6) six month transition period to become the NPN contractor responsible for completing all required services.

The NPN contractor shall provide competent and qualified staff to work on the scope of services under the contract. The NPN contractor is responsible for ensuring the accuracy, timeliness, and completion of all tasks assigned under the resulting contract.

At a summary level, these tasks include:

1. Implementation Services

2. Administrative Requirements

3. Member Services

4. Maintain Nationwide Provider Network

5. Administer Health Benefits and Claims

SECTION 4.1 – Implementation

All required services must be successfully implemented for the incoming contractor to begin performance of the contract on the contract start date. The NPN contractor shall develop an Implementation Plan to submit with the draft proposal and submit again for approval within 30 calendar days after the award. Once the plan has been approved, any material changes to the plan must be documented and presented in conjunction with the monthly progress report. (See SECTION 8). The plan shall include:

1. Assignment of dedicated NPN key personnel to lead and manage transition and implementation efforts;

2. Defined project management plans for implementing all tasks and deliverables in accordance with this PWS;

3. Establishment of the staff utilized under the contract, including subcontractors, with clearly defined roles and responsibilities to include the proposed labor mix of personnel who will be responsible for implementing this requirement, including the identification of key personnel and the percentage of their time devoted to the contract; and

4. Transition activities, including testing of system integration and customer service capabilities.

The NPN implementation team shall collaborate with the WTC Health Program, COR, and the incumbent NPN contractor to facilitate the implementation and transfer of all aspects of the NPN and provide the Program the following standard implementation services:

SECTION 4.1.1 - Meeting participation The NPN contractor shall participate in a kick-off meeting either virtually or in-person with WTC Health Program personnel within seven (7) days of award. The NPN contractor must coordinate with the COR and CO to establish dates, location, and agenda for the kickoff meeting. The contractor must take meeting minutes, which must be provided to WTC Health Program five (5) days post kickoff. The NPN contractor shall conduct project implementation status meetings with appropriate WTC Health Program staff thereafter on an agreed-upon schedule (e.g., weekly).

SECTION 4.1.2 – Pre-transition audit

The NPN contractor shall complete an audit to evaluate all processes and systems necessary to operationalize the network and services at least 15 calendar days prior to the “Go-Live” date. Pre-transition audit results shall be shared with the Program as part of the Weekly Service Log and Agenda (SECTION 8).

SECTION 4.1.3 - Training

The NPN contractor shall provide onsite and/or virtual training for new operational processes and systems to the NPN staff and/or WTC Health Program staff if applicable, in accordance with the training section in this document (See SECTION 4.2.3).

SECTION 4.1.4 - Data/File transfers

Implement system programming for data/file transfers including data collection, data mapping, and data from systems listed in SECTION 4.2.8, and file transfers to and from the WTC Health Program and the Program’s contractors. The contractor shall develop and maintain data and file mapping to support its operations and provide meaningful data analytics and reports to demonstrate its status and performance of requirements implementation with capability to transfer the data and files to the Government when requested and at the end of the contract. Data may include service/item claims, eligibility files, prior approval (PA) review files, and member information. All file transfer processes must be tested for accuracy and HIPAA compliance and be in place 30 days before the implementation date. Data formatting shall be indicated by the Program and mutually acceptable by the NPN contractor.

SECTION 4.2 – Administrative and Contractual Requirements

The NPN contractor shall develop and maintain an Operations Manual that is transferrable to the government and contains a complete set of written standard operating procedures and plans with descriptions of all contract-related services, processes, and activities of this PWS. The Operations Manual shall be used to meet the objectives outlined in this PWS and provide the requisite security and process support for the WTC Health Program’s NPN. The Operations Manual shall be aligned with the WTC Health Program policies and procedures and Administrative Manual which can be found at https://www.cdc.gov/wtc/ppm.html. The Operations Manual is due to the WTC Health Program within 60 days of award (See SECTION 8). Unless otherwise specified, all plans are maintained in the Operations Manual and have the same deliverable dates. A Staffing Plan shall be submitted within 30 days of award and provide staffing status report quarterly including dedicated hours for the functions listed in Section 4.2.1.

SECTION 4.2.1 – Key Administrative Functions

Key Personnel:

The NPN contractor shall notify the Program if there is a change in “Key Personnel.” If it becomes necessary to replace someone holding a position listed as “Key Personnel,” the NPN shall provide the Program the resume of another staff person of equal or greater experience for review and approval through the monthly report. The NPN shall provide, at a minimum, the following staff positions:

1. Account Services: a dedicated senior account manager assigned to the WTC Health Program account who:

· Has a minimum of five years of experience in a Government account management role

· Returns all WTC Health Program staff inquiries on the same or next business day

· Attends all weekly, monthly, and semi-annual scheduled client and implementation meetings

· Facilitates and coordinates all requirements related to the account.

2. Medical Director: a dedicated medical director that is assigned to the WTC Health Program account who:

· Possesses the necessary education and experience as a physician, preferably specializing in occupational health

· Has a minimum of five years of relevant clinical experience that enables them to make independent clinical decisions

· Returns all WTC Health Program inquiries on the same or next business day

· Attends all weekly, monthly, and semi-annual scheduled client meetings in which clinical based updates or decisions are required. Attendance at the weekly Medical Forum Call, monthly Responder Steering Committee, and quarterly Pharmacy and Therapeutics (P&T) meeting is required

3. Program Manager:

· Has a minimum of ten years of experience in a Government program management role

· Returns all WTC Health Program staff inquiries on the same or next business day

· Attends all weekly, monthly, and semi-annual scheduled client and implementation meetings

· Facilitates and coordinates all requirements related to the contract

· Support Services (2 individuals):

· Dedicated business analysts assigned to the WTC Health Program account who:

· Each have a minimum of three years of experience in a healthcare business analyst role

· Provide all regular client reporting within required timeframes

· Support program management and operations (i.e., QA, claims issues, program performance)

· Respond to inquiries for ad-hoc reporting on the same or next business day with estimates of the time requirement for the response and associated cost (if any).

4. Case Management Lead: a dedicated nurse case manager that is assigned to the WTC Health Program account who:

· Possesses the necessary education, credentials and experience to make and oversee case management decisions

· Returns all WTC Health Program inquiries on the same or next business day

· Attendance at the case management forums meeting is required

5. Care Coordinator/Social Service Lead:

· Possesses the necessary education, credential and experience to make and oversee care coordination decisions

· Returns all WTC Health Program inquiries on the same or next business day

· Attendance at the case management forums meeting is required

6. Member Services Lead:

· Has at least five years of experience working with public, customers, clients or similar experience

· Oversees issues, changes, and quality around all member services functions. Works directly with the WTC Health Program Health Plan Operations Deputy and Member Services and Enrollment Unit Chief and staff

The NPN shall carry out the following key functions to administer the NPN.

1. Training Coordination: (SECTION 4.2.3)

· Coordinates and tracks all training provided to NPN contractor staff and Network Provider staff and support staff

2. Pharmacy Support: (SECTION 4.6.6)

· Establishes pharmacy program processes, quality assurance, and troubleshoots pharmacy related issues; authorizes medications based on WTC Health Program policy and Administrative Manual.

· Attends all quarterly P&T meetings, mandatory trainings, and other meetings that are related to the pharmacy benefits.

3. Quality Management: (SECTION 4.9)

· Troubleshoots issues, implements new quality initiatives.

· Works continuously to improve quality across NPN contractor services as well as collaborates with the Program and Network Providers to improve quality care.

4. Communications Support: (SECTION 4.4)

· Develops a website and web presence, develops and disseminates communication materials in plain language to members, develops and disseminates outreach materials for potential members, and collaborates with the Communication Unit chief to ensure communication needs are met.

5. Technical Support: (All Sections)

· Possess the skills to troubleshoot technical issues and work directly with the Program technical staff and business associates

6. Medical Claims/Billing Support: (SECTION 4.7)

· Possesses expertise in claims administration and adjudication aligned with managing a limited health care benefit plan.

7. Medical Coding Support: (SECTION 4.7)

· Possesses medical expertise in medical coding for the purposes of billing and determining coverage and the ability to audit and support network providers in understanding authorized treatment and associated coding.

8. Certification Coordination: (SECTION 4.6.3)

· Possesses the medical and technical expertise to assist the Medical Director and Case Management Lead in creating WTC-3 requests for members, submitting them to the program, and in troubleshooting any quality or technical issue associated with WTC-3 requests.

9. HIPAA/Privacy Oversight: (SECTION 9)

· Possess the knowledge and skills to oversee all HIPAA security incidents and works closely with the Program HIPAA Privacy Officer

10. Provider Network Management: (SECTION 4.5)

· Manages provider compliance WTC Health Progarm specific with terms and conditions, provider education, enrollment and disenrollment of providers, and dissemination of benefits updates to providers

The Staffing Plan is due within 30 days of the contract award and a staffing list is due quarterly (See SECTION 8).

SECTION 4.2.2 – Participation in meetings

The NPN contractor shall participate in meetings as requested to ensure collaboration with the WTC Health Program, the CCEs, the DCs, the PBM, and other contractors to the WTC Health Program. The NPN contractor shall require the key personnel, including Medical Director and Program Manager and staff responsible for key functions (See SECTION 4.2.1), to participate in the Responder Steering Committee Meetings, Survivor Steering Committee Meetings, Medical Forum call, Data Center outreach calls, Pharmacy and Therapeutics forum and other forums/meetings as requested.

The NPN contractor shall select qualified staff to participate in WTC Health Program meetings. Travel will be required for some meetings and staff must be available to travel when applicable. Required meetings include:

· Monthly outreach calls organized by the General Responder Data Center

· Weekly Medical Forum Calls

· Responder and Survivor Steering Committee Meetings

· Ad hoc meetings

· Semi-annual or annual report meetings

· Meeting series established by CO, COR, or the Program

SECTION 4.2.3 – Training

The NPN contractor shall establish a training plan to provide comprehensive virtual or in-person training to all appropriate NPN contract staff to ensure cohesive and quality benefits and ensure understanding of the limited-health benefit plan. Training shall be tracked and reported as required in SECTION 8.

1. The NPN contractor shall develop and provide training to all network provider staff on a regular basis, as determined by the NPN contractor Operations Manual. The NPN contractor must implement a security awareness and training program for all members of its workforce at least annually, and must provide HIPAA training to all members of its workforce at least annually and to new members of the workforce within a reasonable time after joining the NPN contractor. The NPN contractor shall work with the Program to review provider education materials for accuracy.

2. The NPN contractor shall require contractor and subcontractor staff to attend (virtually; in person or by recorded video) the WTC Health Program Administrative Overview Training within the following timeframes:

A. All NPN contractor key personnel within 3 months of award B. NPN contractor staff identified as holding key functions within 3 months award C. All NPN contractor clinical staff, call center and other support staff within 6 months of contract award D. All Preferred Provider Group (PPG) staff (clinical and non-clinical) within 3 months of PPG implementation; part-time PPG support staff at the discretion of the NPN contractor

3. All NPN contractor and subcontractor staff shall attend WTC Health Program and Program contractor (PBM etc.,) hosted trainings aligned to their roles and responsibilities.

4. NPN contractor key staff and clinical staff shall remain up to date on research findings and best practices funded by the Program.

5. The NPN must deliver NPN established “provider specific” training and resources for enrolled providers (See SECTION 4.5) to ensure they are familiar with the WTC Health Program’s billing and coverage policies and procedures, through:

A. Orientation training for newly enrolled providers when possible B. Annual trainings for all enrolled providers C. Ad hoc trainings when requested or is otherwise determined to be necessary D. Established training and criteria specific to the “preferred provider group or site”

6. The NPN contractor shall train staff to respond in an emergency, or difficult situation when a conflict or violent event occurs, to ensure the health and safety of staff and members. The NPN contractor shall follow any WTC Health Program policy that deals with such situations.

7. The NPN contractor shall provide HIPAA training to all staff that have access to personally identifiable information (PII) including personally identifiable health information (PHI).

SECTION 4.2.4 – Risk Management

The NPN contractor shall prepare a Risk Management Plan as part of the Operations Manual. Once approved, the NPN contractor shall perform all required services in accordance with their established Risk Management Plan, document their activities, and include reports in the monthly, mid-year, and annual reports, as appropriate (See SECTION 8). The Plan shall include any potential administrative and operational program integrity risks and proposed strategies to reduce/mitigate these risks. The Plan shall be continuously assessed and updated to ensure relevant risks are mitigated appropriately.

SECTION 4.2.5 – Change Request and Control Process

The NPN Contractor shall manage the contract to ensure the required services are being performed and the required contract deliverables are being submitted. As part of this requirement, the NPN contractor shall maintain a WTC Health Program-approved change control process to identify, record, assess, and secure approval for changes to the project. The NPN contractor and the WTC Health Program shall follow this process to classify, prioritize, approve, or reject changes, so that implementation does not negatively impact core mission applications, functions, or live production environments. The Change Request Log shall always address any variance from the baseline plan.

Change requests need to be described clearly, including their cost and schedule implications, to allow the WTC Health Program to make appropriate decisions. The NPN contractor shall require authorization and approval of expenditures by the WTC Health Program before starting any work on changes. The Program requires seven (7) business days to review and provide prior written approval for any change requests submitted by the NPN contractor. Change requests shall be tracked in a Change Request Log (see SECTION 8).

SECTION 4.2.6 – Systems

The NPN contractor shall maintain its operating systems and ensure they are running optimally and in accordance with the HIPAA Privacy, Security, and Breach Notification Rules at 45 CFR pts. 160, 162, and 164, as well as the Federal Information Security Modernization Act of 2014 (Pub. L. 113-283). The NPN contractor must perform comprehensive systems testing and QA audits, with results reported to the WTC Health Program at least 30 calendar days prior to the “Go-Live” date. The systems may be integrated with each other to centralize and streamline access and control for secured data exchanges. These systems shall include:

1. Call center system (see SECTION 4.3.5)

2. Member portal/web-based system (See SECTION 4.3.1)

3. Provider portal/web-based system (See SECTION 4.5.5)

4. Claims adjudication system (See SECTION 4.7)

5. Electronic member record system: System must be able to store in real time Member records such as demographic information, other health insurance (OHI) information, enrollment and certification information, medical records when appropriate, prior authorization records. It must also track appointments/services rendered, document Member interactions, and hold important documents related to the Members care and Program affiliation. The system must be able to generate data reports including individual member reports as well as data reports for the entire cohort (ex: all survivor members).

SECTOIN 4.2.8 – Risk Management

The NPN contractor shall prepare a Risk Management Plan as part of the Operations Manual. Once approved, the NPN contractor shall perform all required services in accordance with their established Risk Management Plan, document their activities, and include reports in the monthly, mid-year, and annual reports, as appropriate (See SECTION 8). The Plan shall include any potential administrative and operational program integrity risks and proposed strategies to reduce/mitigate these risks. The Plan shall be continuously assessed and updated to ensure relevant risks are mitigated appropriately.

SECTION 4.3 - Member Services

The NPN contractor shall establish a comprehensive Member Services program with dedicated representatives to provide support for all aspects of WTC Health Program Member engagement including scheduling appointments, answering member and designated representative questions, benefits counseling, assistance selecting a provider, language services, and retention and outreachservices. See Sections 3303 and 3313(b) of the Zadroga Act; 42 U.S.C. §§ 300mm-2, 300mm-23(b).

SECTION 4.3.1 – Member Portal

The NPN contractor shall establish a web-based self-service portal (See 4.2.7) for members to:

1. schedule provider and case management appointments

2. reach out to the NPN contractor directly for questions and concerns (e.g., chat feature, feedback mechanism, receive a callback)

3. access certification records

4. access benefit information, including prior authorizations, referrals, scheduling, and care plans, and Explanation of Benefits (EOB).

5. find network providers

6. review claims related to their care.

SECTION 4.3.2 – Transfers

The NPN Contractor shall process all transfers in accordance with the WTC Health Program Member Transfer Policy (See solicitation Attachments or to be provided upon award).

SECTION 4.3.3 – Member Disenrollment

If the WTC Health Program determines that a member should be disenrolled from Program, the NPN contractor shall follow the procedures indicated by the Program and outlined in the WTC Health Program member handbook to assist in communicating and transitioning the member’s care to a provider(s) outside of the Program. If the NPN becomes aware of a member whose exposure may require further review or seems inconsistent with Program enrollment policies, the NPN shall notify the Program for further review.

SECTION 4.3.4 – Member Retention

Member retention activities are those performed to maintain contact with members and encourage inactive members to participate in the Program. The NPN shall establish a Member Retention Plan as part of the Implementation Plan and Operations Manual and implement retention activities that align with the retention benchmarks and Program priorities as described in the WTC Health Program Member Retention Standard Operating Procedures.

The previously reported retention rate should not decline:

1. More than 2.0%, in absolute terms, in six (6) months, or

2. More than 0.5%, in absolute terms, in twelve (12) months.

An acceptable retention rate is when at least 65% of eligible members have received a monitoring exam in the previous eighteen (18) months. All records of completed exams during the lookback period must be added to the database before the calculations are made. This rate shall exclude members who:

1. Are deceased,

2. Have stated they do not want to participate in any aspect of the Program and do not want to be contacted again, or

3. Have no valid contact information on file and therefore cannot be reached.

SECTION 4.3.5 – Member Call Center

The NPN contractor shall provide a service center (call center/helpdesk/support) with knowledgeable and accessible representatives that are well trained in the specifics of the WTC Health Program. The call center must provide accurate and timely information to members, prescribers, pharmacies, CCE/NPN staff (when applicable), and the WTC Health Program staff and be able to resolve issues quickly, which is vital to the success of the Program. The NPN shall provide the following call center system and operational features:

1. Furnish a dedicated toll-free number exclusive to WTC Health Program for incoming service calls, including telephone technology for the hearing impaired and multi-lingual support.

2. Ensure call center staff have access to Member records and consent forms (e.g., HIPAA, Designated Representative forms, etc.)

3. Interactive Voice Response (IVR) system messaging that is exclusive to WTC Health Program member services.

4. Service shall be available in multiple time zones and multiple languages (See SECTION 4.3.8 and SECTION 4.3.7).

5. Management of call scripting/messaging; regularly update call scripts that have been reviewed and approved by the Program for accuracy.

6. Service call centers located in more than one geographic region to permit continuous operations in the event of a local disaster or business disruption.

7. On-call emergency messaging for returned calls within 8 hours.

8. Warm transfer call routing capability for members so they do not have to disconnect from the original call to call separate services such as Case Managers, WTC Health Program Main Call Center, Victim’s Compensation Fund Call center etc.

9. Average Speed of Call Answer within 20 seconds or fewer.

10. Call Abandonment rate of fewer than 2% of calls.

11. First Call Resolution Rate of 98%.

12. Written member inquiries shall be answered within ten business days of receipt.

13. Provide service support for claims.

14. Provide translation services for Spanish, Polish, Chinese, and other languages (e.g., Russian).

The NPN contractor shall maintain and make available to the government for audit materials including call logs, call records, notes, documentation, quality controls, and reporting. A call activity and quality control summary shall be provided no less than quarterly to provide trend analysis and outliers. In addition, the NPN contractor shall coordinate quarterly calls with the WTC Health Program to perform a call audit where calls are listened to for quality assurance. The audit shall review for quality, accuracy, and courtesy. Coaching opportunities for Call Center staff shall be identified as well as improvements in language and processes. Upon request, NPN contractor shall provide digital recordings of phone calls within two (2) business days of request. The NPN shall notify the Program when the call center lines are unavailable, assess and mitigate the impact of the call center’s unavailability, and inform the Program when the issue is resolved.

The NPN contractor call center shall be able to handle, at a minimum, the following matters:

1. Answering general questions about Program processes (such as eligibility or condition coverage)

2. Serving as a reference for questions about the medical review process

3. Serving as a liaison between programs to direct points of contact to the right entity (for example, participating in three-way calls between Program and members for complaint resolution)

4. Scheduling monitoring exam and treatment appointments for Program members assigned to the NPN

5. Explaining the member’s rights and responsibilities as a member of the WTC Health Program’s NPN

6. Answering questions regarding the research consent form. The consent form is only needed one time to record the member’s agreement to allow their past and future information to be used for research purposes, and the consent is optional. If a consent form is not signed, the information may still be used for internal analyses for purposes of the WTC Health Program.

7. Explaining the benefits and covered services offered under the WTC Health Program’s NPN, including covered conditions and limitations

8. Providing Program information updates to members and providers (such as newsletters, letters, brochures, emails)

9. Explaining the process for obtaining WTC Health Program NPN services (e.g., eligibility)

10. Providing information on the NPN providers from whom members may obtain services

11. Fielding and responding to member questions and complaints regarding NPN benefits and/or services (i.e., captured from member satisfaction survey, the resource line, or Case Managers)

12. Advising members of the applicable complaint and appeals procedures, and the member’s rights to a fair review as outlined in the Member Handbook and WTC Health Program Administrative Manual

13. Assisting with obtaining medical records, including processing member requests to release protected information

14. Assisting in outreach efforts to locate enrolled members who have been inactive or lost to the Program

15. Assisting in member transfers (See SECTION 4.3.2).

Call Center Staff Training The Call Center staff supporting the NPN contractor’s Call Center shall provide the specific training hours for all call center staff (See also SECTION 4.2.3):

1. A minimum of 40 hours provided by the NPN contractor of training prior to taking live calls; including WTC Health Program Administrative Overview (See SECTION 4.2.3).

2. Receive a minimum of two hours of initial training or re-training per year in the specifics of the WTC Health Program.

3. Receive annual HIPAA training for all workforce members and receive HIPAA…