PERFORMANCE WORK STATEMENT

for

Military Treatment Facilities Third Party Collections Program

Revenue Cycle Management Branch Cost Accounting Division, Financial Operations J-8

Defense Health Agency Department of War

TABLE OF CONTENTS

1. DESCRIPTION OF SERVICES 5

1.1 Background 5

1.2 Scope 5

1.3 Implementation 5

2. GENERAL INFORMATION 5

2.1 Contractor Identification 5

2.2 Contractor Training 6

2.3 Contractor and Government Communication 6

2.4 Place of Performance 7

2.5 Travel Requirements 7

2.6 Mission and Emergency Essential 7

2.7 Duty Hours 7

2.8 Federal Holidays 7

2.9 Conduct of Contractor Personnel 7

2.10 Health Requirements 8

2.11 Access to GBS 9

3. SECURITY 9

3.1 Security Requirements 9

4. CONTRACT REQUIREMENTS 11

4.1 Third Party Collections Services 11

4.2 Cease of Collection Activities 12

4.3 Claim Generation and Submission 12

4.4 Insurance Verification 12

4.5 Preauthorization and Advance Notification 13

4.6 Encounter Coding/Data Review 13

4.7 Payment Adjudication Monitoring 13

4.8 Balance Billing 14

4.9 Follow-Up/Denials Management 14

4.10 Unpaid Claims 14

4.11 Payment Posting and Refund Management 14

5. QUALITY CONTROL PLAN (QCP) 15

5.1 QCP 16

6. POST AWARD AND INITIAL CONTRACT PERFORMANCE 16

6.1. Post Award 16

6.2 Business Process 17

6.3 Human Resource Management Plan 17

6.4 Medical Expense and Performance Reporting System (MEPRS) 17

6.5 Invoices 17

7. TRANSITION/CONTINGENCY PLANS 17

7.1 Phases-in Plan 17

7.2 Phase-out Plan 17

7.3 Contingency Plan 18

8. CONTRACTOR QUALIFICATIONS 18

8.1 Experience and Requirements 18

8.2 Personnel Qualifications 18

8.3 Certification Statement 19

8.4 Government Furnished Training 19

8.5 Continuing Training 19

8.6 Identification of Contractor Employees 19

9. CONTINUITY OF SERVICES 20

9.1 Continuity of Services 20

9.2 Subcontracting 20

10. ADDITIONAL ADMINISTRATVIE CONSIDERATIONS 20

10.1 Contract Management 20

10.2 Inspection and Acceptance 20

11. PII AND PHI 20

11.1 Safeguards 20

11.2 HIPAA 21

11.3 Breach Response 21

11.4 Business Associate Agreement 21

12. PERFORMANCE OBJECTIVES 21

12.1 Services Summary (SS) 21

12.2 Monthly Status Reports 21

12.3 Services Summary Table 22

13. GOVERNMENT FURNISHED PROPERTY AND SERVICES 23

13.1 General 23

14. DELIVERABLES 24

14.1 Aging of Accounts Receivable 24

14.2 DD2570 Report 24

14.3 Monthly Invoice 24

15. APPENDIX A ACRONYMS 25

16. APENDIX B BUSINESS ASSOCIATE AGREEMENT 27

17. APPENDIX C DHA NON-DISCLOSURE AGREEMENT 36

18. APPENDIX D APPLICABLE PUBLICATIONS AND FORMS 37

19. APPENDIX E HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

(HIPAA)

20. APPENDIX F CONTRACTOR FULL TIME EQUIVALENT REPORTING ADDENDUM

21. ATTACHMENT 1– LIST OF MTFs

PERFORMANCE WORK STATEMENT

THIRD PARTY COLLECTIONS PROGRAM

1. DESCRIPTION OF SERVICES

1.1. Background. In accordance with U.S. Code 1095 and 1079b, the Code of Federal Regulations, and Department of War (DoW) directives, the Government is authorized to recover the cost of providing health care services to covered DoW beneficiaries from third party payers under the Third-Party Collections Program (TPCP). Under this program, the Government bills for medical services provided in DoW/Defense Health Agency (DHA) military treatment facilities (MTFs) and professional services rendered by MTF providers at civilian facilities. The Government also bills third party payers for care provided to non-beneficiaries who are authorized care in the facility, foreign nationals, and civilian emergency patients who carry Other Health Insurance (OHI). All patients, excluding active duty, are required to provide information regarding OHI coverage annually or upon a change in coverage status.

1.2. Scope. The purpose of this contract is to centralize OHI billing and collection activities to standardize and optimize revenue within the enterprise using a government provided medical billing program (herein referred to as the Government Billing Solution or “GBS”). Billing and collection activities shall include: identification and verification of OHI provided on the paper and/or electronic DD Form 2569, updating OHI information into the GBS, direct billing of third party payers, ongoing follow-up actions for unpaid claims every 30 days to include denials management processes, posting payments, conducting valid write-offs and referral of delinquent claims by the 120th day delinquency. This contract will not include first party billing to beneficiaries, interagency billing, billing for Elective Cosmetic Surgery procedures, copying charges, or incidental charges (family member rate) for inpatient stays. The contractor shall be required to conduct balance billing for non-beneficiaries only. The successful Offeror shall:

1.2.1. Adhere to all applicable U.S. Codes, the Code of Federal Regulations, DoW Guidance, Centers for Medicare and Medicaid Services guidance, and DHA Policy regarding billing and collection activities (those in effect at the time of contract award and any changes made throughout the contract period of performance).

1.2.2. Adhere to all DoW and DHA published guidance and regulations regarding financial reporting.

1.3. Implementation. This contract shall include all MTFs identified in Attachment 1 – List of Military Treatment Facilities (MTFs).

2. GENERAL INFORMATION

2.1. Contractor Identification. Within 10 calendar days following notification of contract award, the

Contractor shall provide, in writing to the Contracting Officer (CO) and the Contracting Officer’s Representative (COR), the name of the Contractor Representative responsible for coordination and implementation of contract services. Additionally, the representative shall be available telephonically to the CO/COR during normal duty hours to discuss any problems that may arise concerning contractual matters relating to daily operation of the contract.

2.1.1. The Contractor shall notify the CO/COR at least five calendar days in advance of any change or replacement actions concerning the individual selected to be the Contractor

Representative after the contract period of performance begins. Such notification shall be in writing and shall state the name and telephone number of the new Contractor Representative.

2.1.2. The Contractor Representative shall advise the CO/COR 30 calendar days in advance of any foreseeable event that could affect performance of these contract requirements.

Personnel changes, to include scheduled and unscheduled absences of contract personnel, shall be reported to the COR as soon as possible. The Contractor Representative shall also provide a written plan for continued support until the departing Contractor employee is replaced.

2.2. Contractor Training. The contractor is required to complete any Government required Contractor training listed below:

2.2.1. Basic Life Support Certification. At a minimum, any Contractor personnel working within an MTF must maintain either current certification in the American Heart Association Basic Life Support (BLS) or the American Red Cross Heart Saver Course. Initial training must be obtained in the community at no cost to the Government, so the Contractor employees arrive in the position fully qualified. The Government may offer refresher training for contract workers on a space available basis. If training is received within the facility, the time will not be billable to the Government. The Government will not pay for recertification training obtained outside the MTF.

2.2.2. Privacy Act, Health Insurance Portability and Accountability Act

(HIPAA) and Cyber Awareness Training. The Contractor shall ensure that all staff, including sub-contractors and consultants, comply with the training requirements of the Privacy Act of 1974 (5 U.S.C. 552a) and Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191). The Contractor shall ensure annual Privacy Act and HIPAA training is completed by all staff assigned to this contract, including sub-contractors and consultants. All required Privacy Act and HIPAA training will be conducted online through Joint Knowledge Online (JKO) at https://jkodirect.jten.mil or the current Military Health System/DHA learning platform in place to deliver training to meet the above requirements. The Contractor shall ensure all employees and sub-contractors supply a certificate of Privacy Act, HIPAA, and Cyber Awareness training to the COR within 30 days of being assigned to the contract and on an annual basis.

2.2.3. GBS Training. Specific training required for any access to the GBS.

2.2.4. Records Management. When creating and maintaining official Government records, the Contractor shall comply with all federal requirements established by 44 USC, 41 USC, 36 CFR, DoD Administrative Instruction No. 15 (DoD AI-15), “Records Management, Administrative Procedures and Records Disposition Schedules,” and Chapter 2 of the TRICARE Operations Manual.

2.3. Contractor/Government Communication. The Contractor shall designate a focal point to be the single point of contact for all Contractor and Government correspondence. The focal point shall provide clear and consistent written and verbal response to the Government within 12 business hours of Government initiated communication (e.g., return phone calls, emails or other communication).

The Contractor shall communicate via Government email addresses and not company email address.

2.4. Place of Performance. The Contractor shall determine the appropriate staffing and placement of contractor staff necessary to carry out the services under this contract in coordination with the COR.

2.5. Travel Requirements. Travel may be required during the performance period of this contract at the request of the Government and within the Continental United States (CONUS) and Outside Continental United States (OCONUS).

2.6. Mission/Emergency Essential. None of the services listed in this PWS are mission/emergency essential.

2.7. Duty Hours. Normal duty hours are 7:30 am to 4:30 pm, Monday through Friday (excluding Federal Holidays).

2.8. Federal Holidays. Federal offices are closed on federal holidays.

2.9. Conduct of Contractor Personnel. The CO may require the Contractor to remove from the job site Contractor personnel working under this contract. Removal from the job site or dismissal from the premises shall not relieve the Contractor of the contract requirements.

2.9.1. The Contractor shall not employ individuals who are potential threats to health, safety, security, general well-being, or the operational mission of the DoW and its population. This shall include individuals who are a potential threat because of prior felony convictions (reference Automated Information Systems (AIS) III Security Requirements, section 3.1 below). The Government reserves the right to refuse access to Government facilities and/or operations under this contract to any Contractor employee, or prospective employee, who is identified as a potential threat to the health, safety, security, general well-being, or operational mission of the DHA and its population.

2.9.2. The Contractor shall ensure all Government-issued identification badges, keys, and equipment (as appropriate) are returned to the COR or MTF Security Manager when an individual leaves employment under this contract and/or upon expiration of this contract.

2.9.3. English Language Requirement: Contractor employees shall read, understand, speak, and write English fluently.

2.9.4. Contractor personnel shall be required to observe Government facility parking, safety and traffic regulations that apply to all facility employees.

2.9.5. Alcoholic beverages on the job are prohibited.

2.9.6. There shall be no loud, profane or abusive language used on the job.

2.9.7. Contractor personnel shall present a neat well-groomed appearance. Neat, clean, casual business attire clothing shall be worn.

2.10. Health Requirements. All Contractor employees shall follow the methods for controlling and preventing disease as described in the American Public Health Association publication, Control of Communicable Diseases Manual, and the Centers for Disease Control and Prevention (CDC) publication, Morbidity and Mortality Weekly Report (MMWR), and its supplements. Where applicable, the most recent guidelines from these publications are utilized as the standard.

2.10.1. Prior to start of work, Contractor employees working in MTFs shall provide proof of immunization for the following diseases according to CDC guidelines: Hepatitis B, measles, mumps, rubella, varicella, and influenza, and proof of a negative tuberculosis skin test completed within the past 12 months (if positive, proof of negative chest X-ray within the past 12 months is required). After work starts, the Government will provide post bloodborne exposure protocols according to applicable regulations.

2.10.2. In those areas where there is a higher risk of transmission of tuberculosis, Contractor employees may be tested as frequently as directed by the MTF policy. This test will be provided by the MTF at no cost to the Contractor.

2.10.3. Immunization information will be tracked in DoW computer systems for all Contractor employees providing services within the MTF under this contract.

2.10.4. No medical tests, procedures, or immunizations required by the contract will be performed by the MTF (with the exception of tuberculosis testing after start of work and in the event of exposure). Expenses for all required tests and/or procedures shall be borne by the Contractor, not the Government.

2.10.5. Contractor employees working in an MTF are strongly encouraged to be immunized annually with the influenza vaccine. This vaccine will not be provided by the Government to Contractor employees. If the vaccine is obtained at other facilities, the cost will be borne by the Contractor, not the Government.

2.10.6. The Contractor shall immediately inform the Government when Contractor employees working in the MTF become pregnant. The Government will notify the Contractor Representative of any work hazards. For the safety of the Contractor’s employee, if work hazards exist, it will be the Government’s decision whether the worker can continue work in the environment.

2.10.7. Proof of subsequent immunizations required for continued employment at the MTF must be provided on the anniversary of the employee’s hire date or when the option year is executed, whichever comes first.

2.11. Access to the GBS. Access to the GBS will be available to the Contractor remotely (at Government-approved locations) with the use of a government-issued Common Access Card (CAC). The Government does not require third party billing and collection services be performed in an MTF. However, to facilitate billing and collection services that require access to the GBS the Government will provide space in the MTFs in accordance with Attachment 1 – List of MTFs on a space available basis that may change without notice if the Government requires the space. Access to the GBS database for Outside the Continental United States (OCONUS) MTFs will be provided to Contractor employees assigned to Continental United States (CONUS) or other OCONUS MTFs (access to OCONUS GBS databases can typically be provided from any CONUS or OCONUS MTF location). In general, the data within a given GBS database is specific to the MTF location;

however, the servers at the bases listed in Attachment 2 – Consolidated Servers, support multiple MTFs.

2.11.1. The Contractor shall only access the GBS from Government-approved locations. At no time will the Contractor or any contract employee perform services under this contract from their personal residence or other public locations without specific written authorization from the COR. The Contractor’s proposal shall include all locations where they intend to perform services under this contract. The locations must be approved by the Government prior to the contract start date to ensure access to the GBS is authorized for the proposed locations. The Contractor must have a Data Sharing Agreement and Business Associate Agreement on file. Following contract start, any changes to the locations shall be mutually agreed upon by the CO, COR and the Contractor.

2.11.2. If Contract employees are assigned to work within an MTF or any other Government provided space, those employees shall only perform services directly supporting the Government requirements under this contract. If contract employees are assigned to work within an MTF, the employees shall comply with all requirements listed in this Performance Work Statement.

2.11.3. In all cases, the Contractor shall maintain segregation of duties between the employee who generates bills, and the employee who posts the payment for that bill (i.e., the same person that generates the bill cannot be the person to post payment/write- offs).

3. SECURITY

3.1. Security Requirements. Contractor personnel will have access to and/or process information requiring protection under the Privacy Act of 1974 on unclassified Automated Information Systems (AIS) under this contract. Due to this required access, contractor personnel are in non-sensitive public trust positions designated as AIS III (formally ADP) positions IAW DoD Directive 5200.2- R. In compliance with DoD Directive5200.2-R and AFI 31-501, a National Agency Check with Inquiries (NACI) is required for all AIS III positions. The Contractor shall adhere to the provisions in these referenced publications by having all contractor personnel performing under this contract submit the appropriate forms and have a favorable outcome from the NACI investigation.

All contractor personnel will schedule an appointment with the appropriate Government Unit Security Manager at the installation where services are provided and/or through the Contractor Human Resource Manager and DHA Security Manager. The Contractor shall ensure no employee has access to the information or systems required under this contract without meeting the requirements outlined in this contract and the referenced directives, regulations, and instructions.

Contractor personnel shall handle and safeguard any unclassified but sensitive information in accordance with appropriate DoW security regulations. Any security violation shall be reported immediately to the COR. No foreign nationals shall be employed under this contract without prior approval of the Government.

3.1.1. The Contractor shall appoint a Security Officer to be the sole point of contact for NACI/clearance processing with the COR. The Security Officer shall ensure the following forms reach the appropriate Government Security Manager, prior to the employee’s start date for services under this contract:

3.1.2. SF-85P, Questionnaire for Public Trust Positions. An electronic SF-85P form can be accessed and submitted through the U.S. Office of Personnel Management web site at http://www.opm.gov/e-qip/. The Contractor Management Staff is required to provide the Government Unit Security Manager with two printed and signed (original signatures) hardcopies of the SF-85P. To eliminate possible re-submission of the security information, it is highly recommended that contractor personnel maintain a copy of the completed hardcopy of the SF-85P document.

3.1.3. Two (2) sets of FD-258, FBI Fingerprint Cards for each contract employee. In some cases, contractor personnel may also be required to submit a Birth or Naturalization Certificate to the appropriate Security Manager.

3.1.4. The Contractor shall advise contractor personnel that a positive (favorable) NACI report is needed as a condition of employment under this contract. Contractor shall make the appropriate staffing adjustments and plan accordingly for the approval process. While the Government will make every effort to expedite investigations, typical approval from the time all paperwork is received by the Government from a contract employee ranges from 30 to 60 days and may last as long as 180 days.

3.1.5. At the start of the contract and each option year, The COR and/or MTF Uniform Business

Office (UBO) Managers shall provide the names and phone number of the MTF’s Primary Security Manager and Alternate.

3.1.6. The Contractor’s Security Officer shall be responsible for coordinating the initiation of the background investigation for all contract employees prior to performance following MTF and/or DHA Security protocol. They will inform both the COR and the MTF or DHA Security Manager of the new hire.

3.1.7. Authorization for renewal CAC cards shall be obtained through the MTF Security Manager and/or DHA Security protocol for contractor personnel performing services in the MTF and/or remotely. All CAC cards shall be issued at local Real-Time Automated Personnel Identification System (RAPIDS) sites; the Contractor’s Security Officer is responsible for identifying the nearest RAPIDS location for personnel not assigned to an MTF. All costs associated with travel to and from the RAPIDS site shall be borne by the Contractor, not the Government.

3.1.8. The Contractor Representative will provide the COR with a list of current contract http://www.opm.gov/e-qip/ employees, to include last name, first name, SSN, date of birth, work location, date favorable NACI was granted, and date data submitted for new personnel. An updated list will be provided at the start of the contract, at the start of each option year, and every time there is a change in personnel.

3.1.9. All Contractor employees requiring access to the Government unclassified computer network shall have a valid Tier 1 investigation verified through JPAS. No Contractor employee will be provided access to unclassified computer network or its inherent capabilities (i.e., internet access, electronic mail, file and print services) without a valid Tier 1 investigation. The Contractor shall be aware of and abide by all Government regulations concerning the authorized use of the Government’s computer network including the restriction against using the network to recruit Government personnel or advertise job openings.

3.1.10. Disclosure of Information. In the performance of this contract, the Contractor may have access to data and information proprietary to a government agency or to another Government Contractor, or of such nature that its dissemination or use, other than as specified in this contract, would be illegal or otherwise adverse to the interests of the Government or others. The Contractor and its personnel shall not divulge, or release data or information developed or obtained under performance of this contract, except to authorized Government personnel or upon written approval of the CO. The Contractor and its Contractor personnel shall not use, disclose, or reproduce proprietary information bearing a restrictive legend, other than as specified in the contract.

3.1.11. Uses and Safeguarding of Information. Information from the secure web site is proprietary in nature when the contract number and contractor identity are associated with the direct labor hours and direct labor dollars. At no time will any data be released to the public with the Contractor name and contract number associated with the data.

4. CONTRACT REQUIREMENTS

4.1. Third Party Collections Services. The Contractor shall perform billing services in accordance with the DHA Procedures Manual, 6015.01, in its entirety to include future revisions, and all DHA applicable billing guidance (unless otherwise directed by the COR).

The Contractor shall be paid a negotiated percentage of each dollar collected from third party payers and from the balance-billing of non-beneficiaries that is posted prior to the 121st calendar day after the date of delinquency. A debt becomes delinquent on the 31st day after the date billed. Regardless of the location where billing is performed, all data transmission fees, outside of Government locations and established communication lines, will remain the sole responsibility of the contractor (i.e., any services in support of this requirement performed outside of an MTF). To facilitate and support the TPC contract, the Contractor shall provide all personnel, supervision, training, and services necessary to perform all duties.

4.1.1. The Contractor will be required to ensure all services billable to third party payers are identified, billed, and collected or appropriately written off in accordance with DHA guidance. The Contractor shall provide the MTF with all written documentation received on claims by scanning all hard-copy documents into Portable Document Format (PDF) format and uploading those documents to the GBS. The required documentation includes, but is not limited to copies of checks, verification of electronic payments, explanations of benefits (EOBs), demand letters, non-payment documentation, legal determinations, proof of preauthorization, pre-certifications, notes of phone conversations with insurance company personnel (including the name of the insurance representative, date/time of the phone call, and a brief summary of the discussion), and any other relevant information. Most billing data will automatically flow from other DoW automated information systems to the GBS. The contractor will contact the MTF and/or COR to seek correct billing codes from civilian, military or contracted employees (coding is performed under a separate contract) for all encounter data that does not automatically flow to the GBS. The billing contractor is not responsible for coding encounters. The Contractor shall collect all required data that did not automatically flow into GBS. For newly identified OHI, the Contractor will back-bill encounters, to the extent allowable and specified in each insurance contract or according to the Centers for Medicare and Medicaid Services (CMS) guidelines, within 30 calendar days of OHI discovery. The Contractor will be expected to request authorizations, after the fact, for care provided before back billing is performed.

4.2. Cease of Collection Activities. The Contractor shall cease collection activity on claims that are more than 120 days delinquent. Delinquent claims MUST be transferred back to the Government by the 120th day of delinquency. All delinquent, ignored, erroneously denied, and/or grossly underpaid claims from insurance companies must be transferred to the Office of General Counsel (OGC) no later than the 120th day of delinquency. The Contractor shall abide by DHA guidelines pertaining to delinquent debt balances, including the appropriate write off procedures. If payment on the delinquent amount is received prior to the 121st day of delinquency, the Contractor shall be compensated the negotiated rate per the contract. However, the Contractor shall not be compensated for any payment received after 10 business days from the time the debt was transferred back to the Government and/or OGC for debt collection. This stipulation is necessary to ensure the DHA maintains full compliance with laws and regulations pertaining to delinquent debt.

4.3. Claim Generation and Submission. The Contractor is required to work within the work item queues daily and ensure errors are resolved within 10 business days. Work item queues and/or errors must not sit unworked past 10 business days. The Contractor shall prepare and send inpatient claims to the third-party payers within 10 business days following completion of the medical record and coding. The Contractor shall prepare and transmit/send outpatient claims within 10 business days following completion of the medical record and coding. For OHI policies discovered after care was rendered, the Contractor shall back bill the insurance companies within 30 calendar days of OHI discovery for all billable encounters that fall within the coverage timeframe. The Contractor shall collect all data necessary to manually bill. The Contractor must review additional reports and system notifications in the GBS to stay abreast of any necessary billing/collection actions.

4.4. Insurance Verification. The Contractor is required to manage the paper and/or electronic DD Form 2569, Third Party Collection Program - Record of Other Health Insurance. The Contractor is required to update the GBS to reflect the collected OHI (to include updating OHI fields, scanning, and uploading any/all versions of the DD 2569) and update GBS OHI data elements. Entries may include, but not be limited to, updates to family members covered, annual deductibles, copayments, plan restrictions, plan type, medical versus pharmacy or dental carrier, and claim submission instructions. The Contractor shall perform OHI discovery using any means necessary or available to identify any information required to bill a third-party payer that was not captured on the DD 2569. When new OHI is found via receipt of an updated DD 2569 or other means of OHI discovery, this coverage shall be validated as active and billable by the Contractor (to include contacting the insurance company and determining which family members are included in the coverage) and all required data shall be entered into the GBS within 5 business days of discovery. The DD2569 shall be scanned and uploaded into the GBS with the proper boxes checked and date added into the registration component of the GBS. The Contractor shall retrieve the necessary encounter data, ensure encounters are reviewed by a certified coder employed by the Government as a civilian, military or contracted employee (coding is performed under a separate contract), and submit these documents for back billing. All OHI shall be verified annually before the anniversary of when it was first found (even if a new DD 2569 was not completed by the patient).

4.5. Preauthorization and Advance Notification. Preauthorization for care, as required by insurance companies, shall be identified and requested by the Contractor. The Contractor shall request the assistance of a Government employed civilian, military, or contract nurse assigned to the MTF when required, to provide diagnosis and treatment information. If care was provided on a non-duty day, the Contractor shall be required to request authorization, after the fact, to include sending copies of treatment notes to the insurance company. Although the Contractor may not receive advance notification when a high- dollar drug (or a drug requiring precertification) is initially dispensed, they are required to request authorization for all refills dispensed. The billing and denial of the initial dispensing will be considered a valid write-off, but all subsequent claims denied for lack of preauthorization will not be considered valid write-offs.

4.6. Encounter Coding/Data Review. Ensure all encounters are billable to OHI by a certified coder employed by the Government as a civilian, military or contracted employee (coding is performed under a separate contract) prior to sending the bill to the payer. The Contractor shall review coding for encounters rejected due to errors or outpatient visits using the CPT-4 (or later versions, as applicable) for procedures and ICD-10 (or later versions, as applicable) for diagnoses and Evaluation & Management (E&M) codes for the office portion during the normal course of billing. The Contractor shall contact the MTF certified coder to correct the errors and either resubmit or cancel the bill, as appropriate.

4.6.1. The Contractor shall collect all data required for billing that does not automatically flow into the GBS. This shall include, but is not limited to, creating bills for inpatient professional charges associated with External Resource Sharing hospital care and the examples listed in paragraph 4.1.1. All billing, to include outpatient visits and ancillary services, inpatient admissions, trauma care and civilian emergencies, shall be accomplished in the GBS.

4.7. Payment Adjudication Monitoring. Claims previously billed for patients and subsequently found to have no valid OHI shall be cancelled within 3 business days of receipt of notification to remove the accounts receivable data from the GBS. The Contractor shall immediately contact the insurance company to determine if payments received for service provided after the cancellation date need to be refunded. If a draft refund is required, the Contractor shall process the draft refund within 30 days of notification of cancelled coverage or receipt of the refund request in accordance with COR guidance. Processing refunds include, but are not limited to, the preparation of all documentation required by the Defense Finance and Accounting Services (DFAS) and the subsequent submission of that documentation to the MTF for review and validation;

however, only Government personnel (military or civilian) will transmit the documentation to DFAS. If a refund is not required, the Contractor shall add a note to each claim in the GBS to indicate a payment was received after the cancellation date, but a refund was not required.

4.8. Balance Billing. The Contractor shall not balance bill eligible DoW beneficiaries. For non-beneficiaries with OHI, the Contractor shall pursue all payments due from third party payers and the patient up to 120 calendar days after the date of delinquency.

4.9. Follow-Up/Denials Management. The Contractor shall perform active and aggressive follow-up actions for all unpaid, ignored, erroneously denied and/or grossly underpaid claims no less than every 30 calendar days and work in tandem with any future automated and/or artificial intelligence enhancement within the GBS. The Contractor must annotate all follow-up efforts within the GBS using the standardized notes in accordance with DHA policies. The Contractor is required to transfer all delinquent, ignored, erroneously denied, and/or grossly underpaid claims from insurance companies to OGC no later than the 120th day of delinquency with some denials requiring earlier transfer per DHA UBO policies. Any delinquent debt from the balance billing of non-beneficiaries MUST be transferred back to the Government by the 120th day of delinquency.

The Contractor shall abide by DHA guidelines pertaining to delinquent debt balances, including the appropriate write off procedures. The Contractor shall perform denials management for all claims, regardless of amount, to ensure compliance with the timelines referenced in this PWS. To effectively manage this process, the Contractor shall utilize the Government’s key performance indicators and metrics based on industry standards in denials management and report performance metrics to the COR on monthly basis. The Contractor shall identify industry ratios/indicators they intend to utilize for this contract beyond those outlined within this PWS and shall include this information in their proposal.

4.10. Unpaid Claims. The Contractor shall complete and close all valid bills no later than the 120th day of delinquency. Any amounts that remain open from insurance companies due to being ignored, erroneously denied, and/or grossly underpaid must be transferred to OGC no later than the 120th days of delinquency.

All open claims from the balance billing of non-beneficiaries MUST be transferred back to the Government by the 120th day of delinquency.

4.11. Payment Posting and Refund Management. The Contractor shall post TPC payments and valid write-offs in the GBS. All forms of payment shall only be handled by MTF Government personnel. Typically, all payments and EOBs will be received by Government personnel;

however, the Contractor shall retrieve all EOBs that are not mailed to the MTF and any missing EOBs. Government personnel will provide a copy of all checks and EOBs received to the Contractor. The Contractor shall then discern the account information associated with the EOB, annotate that account information or patient identification information on the EOB, and post payments and/or valid write-offs in the GBS within 24 hours of receipt or by close of business the next business day. When the posting of a batch is started, it must be completed on the same business day. The Contractor shall reconcile with insurance companies those payments for which no claim could be found within the GBS. The Contractor shall dispute invalid denials with the insurance company to arrive at a resolution. Partial or reduced payments shall be posted in the GBS, and the Contractor shall continue collection efforts to recover the full amount due in accordance with insurance policy coverage. Any remaining balances shall be turned over to the Government in accordance with paragraph 4.9.

4.11.1. Payments that are posted electronically (i.e., Electronic Remittance Advice) shall be verified to ensure claims are paid properly.

4.11.2. MTF Government personnel will maintain responsibility and accountability for the deposit of collections received. Payments will be deposited no later than the next business day after postings are verified, usually by the next business day.

4.11.3. The Contractor shall verify refund requests are valid and process the draft refund transaction in the GBS within 30 days of notification of cancelled coverage or receipt of the refund request. Unless otherwise directed by the COR, after the refund is processed in the GBS, electronically transmit all pertinent documents that support the refund and contain the information necessary to disburse the refund (such as payee, amount, reason for refund, EOB, etc.) to DHA MTFs personnel via GBS for processing through DFAS.

4.11.4. Program Support. Market the TPC program to patients and train MTF staff quarterly on their responsibilities in support of the TPC program; Contractor must provide COR, a summary report on the Contractor’s requirement to train TPC program responsibilities to appropriate MTF.

All billing and collection information shall remain the property of the U.S.

Government. The Government shall retain unlimited use and ownership of all billing information, data, and data/technical rights for any upgrades and/or modifications to Government systems, upon completion and/or termination of this contract. All tools developed by the Contractor in support of this requirement, (i.e.

GBS ad hoc reports, Microsoft Word, Access, Excel, PowerPoint, or other software developed databases) shall become and remain the property of the Government and shall have no effect or impact on monies owed to the Contractor by the Government.

Access to the GBS will be available to the Contractor with the use of a government issued CAC – reference paragraph 3.1. The Contractor shall collaborate with the COR and any other required personnel (i.e., MTF Systems and Security Officers) to obtain access to the GBS and any other Government applications (such as required existing legacy systems still in place during the period of performance) as required to execute this contract.

4.11.5. Audit/Compliance. The Government shall have the right to audit any data produced or any function performed by the Contractor at any time and shall have access to any Contractor owned, managed, or otherwise operated facilities where services are performed under this contract without advance notice.

The Contractor may be asked to participate in meetings to facilitate discussions providing input as billing and collection subject matter experts on behalf of the DHA.

5. QUALITY CONTROL PLAN (QCP)

5.1. QCP. The Contractor shall establish and maintain a complete Quality Control Plan. The COR shall review the Quality Control Plan annually. The plan shall include procedures to implement all requirements of the contract to include the in-processing submittals for all contract personnel and the following:

5.1.1. A compliance plan for TPC in accordance with DHA UBO guidelines.

5.1.2. An inspection system covering all the services required under this contract. The Contractor shall specify the areas to be inspected on either a scheduled or unscheduled basis, how often inspection shall be accomplished and documented, and identify the title of the individual(s) who shall perform the inspection. The Contractor shall maintain a record of all inspections conducted by the Contractor and corrective actions taken. This documentation shall be made available to the Contracting Officer (CO)/COR upon request during the term of the contract. The methods of identifying and preventing defects in the quality of services performed before the level of performance becomes unacceptable.

5.1.3. Written standards (developed by the Contractor) for documentation and fraud prevention for third party collections.

5.1.4. The policy and procedures to ensure all contractor personnel have the required TPC skills and training initially and annually. The plan should also identify the individual(s) performing the assessment.

5.1.5. The Contractor shall establish and maintain an internal policy and procedures checklist for conducting TPC quality control checks to ensure work is free of grammatical, typographical, punctuation, and spelling errors and is properly formatted prior to delivery of products.

5.1.6. Customer Satisfaction. The Contractor shall have a customer satisfaction system outlining internal controls and procedures to measure DHA customer satisfaction. The process shall outline methods and frequency of customer interactions, reporting processes, and problem resolution procedures. A satisfaction measurement of patient satisfaction is not required or authorized.

6. POST AWARD AND INITIAL CONTRACT PERFORMANCE

6.1. Post Award. The Government will host a post award meeting with the Contractor within

10 business days after contract award. The CO shall contact the COR and the Contractor to schedule this meeting. Telecon/teleconference is permissible for the post-award meeting. The purpose of the post-award meeting is to introduce the Contractor to the Government representatives (COR) and go over the contract. Takeaways from the meeting should be an exchange of contact information; a timeline of when direct support will start, if not yet started; and an understanding by all parties of all the requirements to be met by the Contractor and the support the Government will provide for the Contractor to perform the requirements safely and efficiently.

6.2. Business Process. The Contractor shall provide their business process with their proposal to include an organizational management structure and specific business approach to the requirements listed throughout this PWS. The proposal shall clearly define roles, responsibilities, subcontractors and/or business partners to ensure effective and efficient TPC services. In addition, the Contractor shall demonstrate a comprehensive process for revenue cycle management that specifically details their approach to the medical claims processing continuum. The Contractor shall notify the COR of any significant changes to their business process during the contract. All contractor instruction given to MTFs that change level of effort required of MTF staff to facilitate execution of the requirements of this PWS shall go through COR for process review.

6.3. Human Resource Management Plan. The Contractor shall have in place a Human Resource Management Plan to ensure qualified candidates are identified, screened, placed, monitored, trained, and retained to fulfill service requirements and minimize personnel turnover under this contract. The Contractor shall accomplish the assigned work by employing and utilizing qualified personnel with appropriate combinations of education experience, knowledge, training, abilities and skills. The plan shall include quality assurance and productivity measurements that demonstrate internal controls for workload management that directly support attainment of acceptable output standards and the efficient allocation of resources for performance in accordance with this PWS. These systems and controls for recording and monitoring workload shall be capable of providing historical and in- process workload data.

6.4. Medical Expense and Performance Reporting System (MEPRS). MEPRS is the DoD accounting system for financial, personnel, and workload data within MTFs. The Defense Medical Human Resources System-internet (DMHRSi) is the interface used to report hours worked in the MTF. Per DHA-PM 6010.13, Medical Expense and Performance Reporting System for Fixed Military Medical and Dental Treatment Facilities, when working within an MTF, the Contractor is required to submit hours worked bi-weekly through DMHRSi to their assigned MTF.

6.5. Invoices. A monthly invoice listing the total collections per MTF and the amount due the Contractor, shall be submitted on a Microsoft Excel spreadsheet on 5th business day the following month (editable version). The invoice will be processed for payment after billed amounts are verified by the COR.

7. TRANSITION/CONTINGENCY PLANS

7.1. Phase-in Plan. The Contractor shall include a Phase-in Plan as part of their proposal that describes in detail what actions the Contractor will take to ensure their employees are prepared to begin performance for all services required under this PWS and the process to minimize disruption in services throughout the transition. The Contractor shall attend a post award orientation meeting within 10 business days after contract award to review requirements and implementation of the Contractor’s transition plan.

7.2. Phase-out Plan. The Contractor shall include a phase-out plan as part of their proposal that describes in detail what actions the Contractor will take to ensure a smooth and successful transition of operations between this contract and the next contract provider.

Assistance shall include but is not limited to detailing current requirements, suggesting milestones and suggesting necessary actions for the last 30 business days of the contract;

this may include formal coordination with Government staff or contractor successor staff as needed. The plan should illustrate a process that would allow the Contractor to “turn over Government claims data” within 30 calendar days (in a mutually agreed upon format) whereby the Government could continue uninterrupted billing and collections services. It shall also include providing any information pertinent to the daily activities as outlined in the PWS such as duties, responsibilities, data, metrics, or requirements that are critical for ensuring continued operations.

7.3. Contingency Plan. The Contractor shall maintain a contingency plan to ensure continuity of operations for all services required under this PWS. In the event of staffing shortages, equipment or communication failures, or other delays associated with the performance of TPC services under this contract, on the part of the Contractor, a contingency plan shall be implemented to continue collection and billing services at the MTF. It shall describe how the Contractor will continue to meet production standards during the repair or replacement of faulty equipment. If the contingency plan fails during an actual failure of operations, the Government will require the contractor to modify the plan within 5 business days, in addition to any other re-performance associated with the failure of the plan.

8. CONTRACTOR QUALIFICATIONS

8.1. Experience and Requirements. The Contractor shall have a demonstrated, in-depth knowledge of best practices associated with Government healthcare and the health insurance industry as they relate to the performance of all services described in this PWS at multiple MTFs in a Government or commercial setting. The Contractor shall have experience performing revenue cycle back-end functions for claims submissions, insurance identification and verification, accounts receivables management, denials and appeals management, and collections follow-up within the healthcare industry. In addition, the Contractor shall have a working knowledge of Ambulatory Procedure Groupings (APGs), Diagnosis Related Groupings (DRGs), International Classification of Diseases- Version 11(ICD-11) coding, electronic billing and collection procedures (to include future versions as appropriate) and itemized Revenue Cycle billing. In addition, the Contractor shall have legal assistance, a Registered Nurse, and Registered Information Health Care Administrators on staff or immediately available to facilitate and expedite collection processes.

8.2. Personnel Qualifications. The Contractor shall employ a staff able to read and interpret medical documentation and understand medical terminology to correctly bill both outpatient and inpatient services. In addition, the Contractor shall employ a staff with at least two years of experience in the operation of personal computers and familiarity with common office software to include, but not limited to, Microsoft Excel, Microsoft Word, Microsoft PowerPoint, Microsoft Access, and electronic mail systems.

8.2.1. At a minimum, at any location where services are performed under this contract (MTF and/or external location), there shall be one or more contractor employees who possess either two years of experience in medical billing and collections or have completed a medical biller certification program. The Government considers experience acceptable if it was performed within the DoW or in a commercial healthcare organization; however, it must be specific to medical billing and collection services. At a minimum, the Contractor’s management team shall include the following key personnel who meet the requisite experience requirements as identified below:

Contractor Representative – The Contractor Representative shall have a minimum of five (5) years’ experience performing all services described in this PWS at multiple MTFs in a Government or commercial setting.

Billing and Collection Manager – The Billing and Collection Manager shall have a minimum of five years’ experience supervising medical billers and support staff at multiple locations. This individual shall also have a minimum of five years’ experience simultaneously dealing with medical insurance companies across multiple markets and the practical application of laws and regulations governing medical billing and collection practices nationwide.

Human Resource Manager – The Human Resource Manager shall possess a…