ESBD_392672_1737756684283_HHS Open Enrollment for IRO Contract - Final Approved.docx

Medicaid and CHIP Services Medical and UR Appeals – Independent Review Organization Services OE Number: HHS0015818

TEXAS HEALTH AND HUMAN SERVICES COMMISSION

OPEN ENROLLMENT (OE)

for Independent Review Organization Services Medicaid and CHIP Services Medical and UR Appeals

OE No. #HHS0015818

NIGP Class/Item Nos: 948-07, 969-44 tABLE OF cONTENTS

SECTION 1: SCHEDULE OF EVENTS

Enrollment Period Opens (Posted to HHS OE Opportunities webpage) February 01, 2025

Enrollment Period Closes (Final date for RECEIPT of Applications) January 31, 2028

Applications must be received by HHSC prior to the closing date as indicated in this Schedule of Events or as changed via an Addendum posted to the HHS OE Opportunities webpage.

Every Applicant is solely responsible for ensuring its Application is received before the submission period closes. HHSC is not responsible for lost, misdirected or late applications.

The dates in the Schedule of Events are tentative. HHSC reserves the right to modify these dates at any time by posting an Addendum to the HHS OE Opportunities webpage.

By submitting an Application, the Applicant represents and warrants that any individual submitting the Application and any related documents on behalf of the Applicant is authorized to do so and to bind the Applicant under any resulting contract.

Withdrawal of Application:

Applications may be withdrawn from consideration or amended at any time prior to the “Enrollment Period Closes” date by emailing a request to the Point of Contact, listed under that section. The e-mail subject line must contain OE number and title of this OE as indicated on the cover page. The Applicant is solely responsible for ensuring requests are received timely by HHSC. HHSC is not responsible for lost, misdirected or late emails.

SECTION 2: OVERVIEW

2.1 Introduction

The Texas Health and Human Services Commission (HHSC) is an agency within the Texas Health and Human Services (HHS) system.

HHSC is seeking Applications to establish Contracts for Independent Review Organizations (IROs) to assist HHSC Medical and UR Appeals (M&URA) and HHSC Operations Management (OM) Provider Resolution and Administrative Appeals (PRAA) with conducting appeal reviews.

To be considered for award, Applicants must submit a comprehensive Application which meets all the requirements of this OE and includes all requested documentation.

2.2 Legal Authority

HHSC is authorized to enter into this Contract pursuant to Texas Government Code section 531.024164. HHSC is posting this OE pursuant to 1 TAC § 391.103(a) and 1 TAC § 391.601.2.3

2.3 No Guarantee of Volume, Usage or Compensation

HHSC does not guarantee any volume, usage, or compensation to be paid to any Contractor under any Contract resulting from this Open Enrollment. Additionally, all contracts resulting from this Open Enrollment are subject to appropriations, the availability of funds, and termination.

SECTION 3: DEFINITIONS AND ACRONYMS

Unless the context clearly indicates otherwise, throughout this OE, the definition given to a term below applies whenever the term appears in this OE, in any Application submitted in response to this OE, and in any Contract awarded as a result of this OE. All other terms have their ordinary and common meaning.

Term

Definition

A conflict of interest would include circumstances in which a party’s personal, professional, or financial interests or obligations may directly or indirectly: 1) Make it difficult or impossible to fulfill its contractual obligations to HHSC in a manner that is consistent with the best interests of the State of Texas, and/or 2) Impair, diminish, or interfere with that party’s ability to render impartial or objective assistance or advice to HHSC; and/or 3) Provide the party with an unfair competitive advantage in this HHSC OE.

Conflicts may include, but are not limited to reviewers having:

Any prior involvement related to the claim under appeal review, including but not limited to, treatment, claims submission, retrospective review and determination processes, appeal submission processes, or the appeal review processes.

Any professional, personal, or financial affiliations with any parties that had any prior involvement related to the claim under appeal review, including but not limited to, treatment, claims submission, retrospective review and determination processes, the appeal submission processes, or the appeal review processes. Examples of parties with a Conflict of Interest include the RAC, the appellant, other IROs, or other third-party vendors involved in the Appeal process.

Emergency Medicaid Eligibility

Texas Medicaid provides that certain undocumented aliens and legalized aliens who require treatment of an emergency medical condition or emergency behavioral health condition are eligible to receive that treatment. After the emergency condition requiring care is stabilized and is no longer an emergency, the coverage ends. If the alien continues to receive ongoing treatment after the emergency ceases, the ongoing treatment is not a benefit.

Certification for emergency Medicaid occurs after the services have been provided. The coverage is retroactive and limited to the specific dates that the client was treated for the emergency medical condition.

https://apps.hhs.texas.gov/pcs/openenrollment.cfm

Cost Outlier

A payment adjustment for a claim with extraordinarily high costs above a fixed-loss cost threshold amount. Payment methodology as described in 1TAC 15 RULE §355.8052 Inpatient Hospital Reimbursement.

SECTION 4: GENERAL INFORMATION

4.1 Sole Point of Contact

All questions, requests for clarification, or other communication about this OE shall be made in writing only to the HHSC Sole Point of Contact listed below.

Attempts to ask questions by phone or in person will not be allowed or recognized as valid.

Marticia Lee Contract Manager (CM) Email: Marticia.Lee@hhs.texas.gov

To be considered for contract award, applications must only be submitted to this email address. See Section 14 for submission requirements.

Do not contact other HHS Agency personnel regarding this OE.

This restriction, as to only communicating in writing with the HHSC Sole Point of Contact identified above, does not preclude discussions between Applicant and agency personnel for the purposes of conducting business unrelated to this OE.

Failure of an Applicant or its representatives to comply with these requirements may result in disqualification of the submitted Application.

4.2 Changes, Modifications and Cancellation

HHSC reserves the right to change, amend, modify, or cancel this OE at any time.

All Applications, including those submitted after cancellation of the OE, become the property of HHSC upon receipt.

4.2.1 Advertisement of Changes, Modifications or Cancellation If HHSC determines the OE needs to be changed or modified, either an Addendum will be posted on the HHS OE Opportunities webpage, or the OE will be canceled. The action to be taken will be determined at the sole discretion of HHSC. Furthermore, if the OE will be canceled, HHSC will determine, in its sole discretion, if a new OE will be posted.

No HHS Agency will be responsible or liable in any regard for the failure of any individual or entity to receive notification of any posting to the HHS OE Opportunities webpage.

It is the responsibility of each Applicant to monitor the HHS OE Opportunities webpage for any Addenda or additional information regarding this OE. Failure to monitor the HHS OE Opportunities webpage will in no way release or relieve any Applicant or Contractor of its obligations to fulfill the requirements as posted.

4.3 Offer Period

By submitting an Application in response to this OE, Applicant agrees that its Application will remain a firm and binding offer to enter into a Contract under all terms and conditions of this OE for at least 240 days from the date applications are due, unless withdrawn by the Applicant before the Enrollment Period closes.

An Applicant may extend the time for which its Application will be honored by including the extended period in the Application.

4.4 Costs Incurred

HHSC accepts no obligations for costs incurred in preparing, submitting, and screening an Application, including, but not limited to, costs or expenses related to contract execution.

Applicants understand that issuance of this OE or retention of Applications in no way constitute a commitment by HHSC and convey no legal rights upon the applicant.

All Applications shall be prepared simply and economically, providing a straightforward, concise delineation of the Applicant’s capabilities to satisfy the requirements of this OE, and submitted at the sole expense of the Applicant.

Responses to questions and requests for clarification will not be posted. However, if HHSC determines, based on a question, request for clarification, or any other factor, including, but not limited to notices of ambiguity, conflict, or discrepancy as referenced in Section 4.5.3, below, that the OE needs to be amended or clarified, either an Addendum will be posted on the OE Opportunities webpage, or the OE will be canceled. The action to be taken will be determined at the sole discretion of HHSC. Furthermore, if the OE will be canceled, HHSC will determine, in its sole discretion, if a new OE will be posted.

4.5.2 Question and Clarification Format

Questions and requests for clarification must include the following information:

a. The OE Number.

b. The question or request for clarification, providing the following information:

· OE language, topic, and section heading.

· Section, Paragraph and Page number(s) or Exhibit/Attachment.

The requestor must provide the following contact information:

· Company Name

· Company Representative Name

· Phone Number

· E-Mail address

4.5.3 Ambiguity, Conflict, Discrepancy

Applicants must notify the Sole Point of Contact, Section 4.1, of any ambiguity, conflict, discrepancy, exclusionary specification, omission, or other error in the OE. Notices must be submitted in the same manner as for submitting questions.

Each Applicant submits its Application at its own risk.

If an Applicant fails to properly and timely notify the Sole Point of Contact, Section 4.1, of any ambiguity, conflict, discrepancy, exclusionary specification, omission or other error in the OE, the Applicant, whether awarded a contract or not:

a. Shall have waived any claim of error or ambiguity in the OE and any resulting contract,

b. Shall not contest the interpretation by HHSC of such provision(s).

c. Shall not be entitled to additional compensation, relief, or time by reason of ambiguity, conflict, discrepancy, exclusionary specification, omission, or other error or its later correction.

SECTION 5. HUB SUBCONTRACTING PLAN (HSP) REQUIREMENTS

It is the policy of HHS to promote and encourage contracting and subcontracting opportunities for State of Texas-certified Historically Underutilized Businesses (HUBs) in all contracts in compliance with Chapter 2161 of the Texas Government Code and Title 34, Part 1, Chapter 20, Subchapter D, Division 1 of the Texas Administrative Code.

Applicants who may be eligible are encouraged to become HUB certified and may access more information including the State of Texas HUB Application at the CPA website at: https://comptroller.texas.gov/purchasing/vendor/hub/.

HHS has determined subcontracting opportunities are not probable under this OE; therefore, an HSP is not required to be submitted with the Application.

SECTION 6. CONTRACT TERM

6.1 Term of Contract

HHSC may award one or more Contracts under this OE.

Any Contract resulting from this OE will be effective on the signature date of the latter of the Parties to sign the agreement and will expire 3 years after the effective date, unless terminated earlier pursuant to the terms and conditions of the Contract.

6.2 Extension Option

HHSC, at its sole option and subject to availability of funding, may extend the Contract beyond the initial term for up to one year as necessary to ensure continuity of service, to process a new OE to award new contract(s), for purposes of transition, or as otherwise determined to serve the best interest of the State of Texas.

SECTION 7. MINIMUM QUALIFICATIONS

To be eligible to apply for a Contract and receive an award, Applicant(s), must be eligible, qualified, and meet all requirements of this OE. Applicant requirements apply with equal force to Contractors and Providers awarded contracts under this OE.

7.1 Required Experience

To be considered for contract under this OE, an Applicant shall have a minimum of 2 years of relevant experience performing the services as outlined in this OE or similar services.

All personnel assigned to perform the services must be fully trained and have a minimum of 3 years of postgraduate direct patient care experience in the United States.

References: Applicants must provide a minimum of 3 references reflecting positive performance for current or previous contracts for similar or same services during the two 2-year period immediately preceding submission of the Application.

For each reference, the Applicant shall provide the following documentation with Application:

7.2 Licensure and Accreditation

Applicant and all personnel assigned to provide services under the Contract must have all permits, licenses, and certifications required by applicable law.

Any contracting IRO and its subcontractors, if any, must be licensed in Texas. Any professional personnel, including physicians or nurses, directly involved in or supervising the appeal review process, who, by law, require a professional license or certification, must maintain current, valid, and applicable Texas licensure or certification in good standing.

Contractor is responsible for ensuring compliance with these requirements and shall provide updated required permits, licenses, and certifications at HHSC’s request.

7.3 Additional Minimum Qualifications for Contractor and Personnel Applicant must provide a description of the Applicant’s knowledge base and experience performing appeal reviews in Texas or in other states, including types of cases, healthcare entities, and payers involved. Topics addressed must include at least:

SECTION 8. STATEMENT OF WORK.

The Statement of Work (SOW) is attached as Exhibit C.

8.1 Project Overview

An overview of the project is detailed in Exhibit C, Statement of Work.

8.2 HHSC Responsibilities

HHSC responsibilities are detailed in Exhibit C, Statement of Work.

8.3 Statement of Services to be Provided

A detailed description of services to be provided is included in Exhibit C, Statement of Work.

8.4 Performance Criteria

HHSC will look solely to the Contractor(s) for the performance of all contractual obligations resulting from an award based on this OE.

No Contractor will be relieved of its obligations for any nonperformance by its subcontractors. Contractor must ensure that its subcontractors abide by all requirements, terms, and conditions of this Contract. Unless the context clearly indicates otherwise, every requirement and every prohibition set forth in this OE and any resulting contract that applies to a Contractor applies with equal force to its employees, agents, representatives, and subcontractors.

A detailed description of performance standards and reporting requirements is included in Exhibit C, Statement of Work.

8.5 Contractor Personnel Performance

Contractor shall not employ or contract with or permit the employment of unfit or unqualified persons or persons not skilled in the tasks assigned to them.

The Contractor shall at all times employ sufficient personnel to carry out functions and services in the manner and time prescribed by the Contract.

The Contractor shall be responsible for the acts and omissions of the Contractor’s employees, agents (including, but not limited to, lobbyists) and subcontractors and shall enforce strict discipline among the Contractor’s employees, agents (including, but not limited to, lobbyists) and subcontractors performing the services under the Contract.

HHSC, at its sole discretion, may request in writing the immediate removal of any Contractor personnel or subcontractor personnel from the services being provided under the Contract. Upon such request, Contractor shall immediately remove the subject personnel and submit in writing to HHSC within 10 calendar days of HHSC’s request for removal, confirmation of the removal and assurance of continued, compliant Contract performance.

8.6 Notice of Criminal Activity

At the time of submission, Applicants shall provide confirmation that Applicant, any person with ownership or controlling interest in Applicant, and Applicant’s agents, employees, subcontractors, and volunteers who will be providing the required services:

This is a continuing disclosure requirement; prior to Contract award, if any, Applicants must notify the HHSC Sole Point of Contact within five days of the date Applicant learns of actions set forth in subsections (a) and (b) above. Additionally, this is a continuing disclosure requirement for each Contractor, during the term of the Contract, to immediately report, in writing, to the HHSC contract manager when Contractor learns of or has any reason to believe it or any person with ownership or controlling interest in Contractor, or any of Contractor’s agents, employees, subcontractors or volunteers has: engaged in any activity that does or could constitute a criminal offense equal to or greater than a Class A misdemeanor or grounds for disciplinary action by a state or federal regulatory authority; or been placed on community supervision, received deferred adjudication, or been indicted for or convicted of a criminal offense relating to the involvement in any financial matter, federal or state program, or sex crime.

Contractor shall not permit any person who engaged, or was alleged to have engaged, in any activity subject to reporting under this section to perform direct client services or have direct contact with clients, unless otherwise directed in writing by the HHSC contract manager.

Personnel with sex offender, child or adult abuse, or fraud offenses shall not be allowed to provide Contract services and shall not be allowed access to HHS Agency property, facilities, or documents.

Key personnel with misdemeanor offenses must receive prior approval by the HHS Agency before being allowed to work under this contract.

HHSC, at its sole discretion, may terminate any Contract if Contractor, its agents, employees, subcontractors, or volunteers are arrested, indicted, or convicted of any criminal activity.

8.7 Notice of Insolvency or Indebtedness

At the time of submission, Applicants shall provide with the Application detailed written descriptions of any insolvency, incapacity, and outstanding unpaid obligations of Applicant owed to the Internal Revenue Service (IRS) or the State of Texas, or any agency or political subdivision of the State of Texas.

This is a continuing disclosure requirement; prior to Contract award, if any, Applicants must notify the HHSC Sole Point of Contact within five days of the date Applicant learns of such financial circumstances after submission of the Application.

Additionally, Contractors are under a continuing obligation to notify the HHSC contract manager, as applicable, within 5 days of the date Contractor learns of such financial circumstances after Contract award.

8.8 Background Checks For Personnel

The Contractor will conduct or will retain an independent third party to perform comprehensive, statewide Texas Department of Public Safety (DPS) criminal and sex offender background checks on all Contractor personnel, including permanent and temporary personnel and Subcontractor and Subcontractor personnel who will be assigned as key personnel to perform services under the Contract. The Contractor is responsible for all background check expenses.

The background checks must be completed prior to any Contractor personnel arriving on state property, if applicable, and/or beginning the required Contract services.

Supporting documentation for the background checks is subject to review upon request by HHSC. Failure to produce the requested documentation, as with any violation of the Contract, may constitute grounds for termination of the Contract and/or Purchase Order for cause.

The background checks shall include, but not be limited to:

Exhibit C, Statement of Work details the IRO reporting requirements.

Contractor shall submit to HHSC detailed and accurate invoice(s) which include the information below. Each invoice must be submitted by e-mail, in the format prescribed by HHSC, not later than 45 calendar days after completion of [service].

The e-mail address for submitting an invoice is:

HHSC_AP@HHSC.STATE.TX.US AND MARTICIA.LEE@HHS.TEXAS.GOV

The invoice shall include, at a minimum:

· Contractor’s Name.

· Remit to Address.

· Federal ID or Texas CPA Payee ID.

· Accounts Receivable telephone number.

· Contract and/or Purchase Order Number.

· Service date(s).

· Identification and itemization of services provided, with Claim Numbers (ICNs) listed and subtotaled by review type and by agency area.

· Other relevant information supporting and explaining the payment requested, such as reviewer name, date of service, due date, specialty, and Appealing provider name.

· Supporting Documentation.

No payment will be made under this Contract without submission of detailed, accurate invoices submitted as outlined.

8.10.2 Payment

Contracts issued under this OE will be paid in accordance with Exhibit F, Fee Schedule.

No reimbursement for travel or meal expenses is permitted under any Contract resulting from this OE.

8.11 Data Use Agreement (DUA)

By submitting an Application, and if applicable, signing a contract resulting from this OE, Applicant agrees to the terms of the Data Use Agreement, Exhibit E. The Applicant must complete, sign, and return with its Application Exhibit E, Texas HHS System – Data Use Agreement – Attachment 2, Security and Privacy Initial Inquiry (SPI).

8.12 Terms and Conditions

Submission of an Application in response to this OE constitutes acceptance of all Terms and Conditions attached to, referenced, or set forth in the OE. Applicant shall not submit additional or different terms and conditions.

Any term, condition, or other part of an Application that has been rejected by HHSC, that is not accepted in writing by HHSC, or that conflicts with applicable law, this OE, any resulting Contract, or applicable terms and conditions will not constitute part of the Contract.

8.13 Standards of Conduct for Vendors

Pursuant to 1 TAC 391.405(a), contractors, respondents, and vendors interested in working with HHS are required to implement standards of conduct to apply to all matters involving, or related to, those solicitations and contract(s) between themselves and HHS. These standards must adhere to ethics requirements adopted in rule, in addition to any ethics policy, or code of ethics approved by the HHSC Executive Commissioner and must be at least as restrictive as those applicable to HHS personnel in the applicable ethics law and policy provisions.

The standards of conduct must include the ten standards of ethical conduct set forth in Section I of the HHS Ethics Policy and requirements to comply with ethical standards set forth in federal and state law (including, but not limited to, 1 TAC Chapter 391, Subchapter D).

The standards of conduct, together with the responsibilities and restrictions incorporated herein, also apply to subcontractors of contractors, respondents, and vendors.

Standards of conduct of any contractor, respondent or vendor may be reviewed and/or audited by the State Auditor and HHSC. Additionally, pursuant to 1 TAC 391.405(a), HHS may examine a respondent’s standards of conduct in the evaluation of a bid, offer, proposal, quote, or other applicable expression of interest in a proposed purchase of goods or services.

Any vendor or contractor that violates a provision of 1 TAC Chapter 391, Subchapter D may be barred from receiving future contracts or have an existing contract canceled. Additionally, HHSC may report the vendor’s actions to the Comptroller of Public Accounts for statewide debarment, or law enforcement.

SECTION 9. HHSC CONTRACT ADMINISTRATION

HHSC will designate a Contract Manager (Sole Point of Contact) and provide the manager’s contact information to the Contractor.

After award of any Contract resulting from this OE, all communications related to the Contract will be processed through the designated Contract Manager. Additional requirements apply to legal notices which must be provided to the HHS Chief Counsel as well as the Contract Manager.

SECTION 10. INSURANCE REQUIREMENTS

10.1 Insurance Coverage

For the duration of any Contract resulting from this OE, Applicant shall acquire insurance with financially sound and reputable independent insurers, in the type and amount customarily carried within the industry. Failure to maintain insurance coverage or acceptable alternative methods of insurance shall be deemed a breach of Contract.

Contractor shall maintain the required insurance in the types and amounts during the initial term and any renewal or extension period exercised. The insurance shall be evidenced by delivery to HHSC of certificates of insurance executed by the insurer or its authorized agent stating coverages, limits, expiration dates and compliance with all applicable required provisions. Upon request, HHSC, and/or its agents, shall be entitled to receive without expense, copies of the policies and all endorsements.

Contractor shall update all expired policies prior to submission for monthly payment. Failure to update policies shall be reason for withholding of payment until renewal is provided to HHSC.

Contractor shall provide and maintain all insurance coverage with the minimum amounts described throughout the life of the Contract.

Failure to maintain insurance coverage, as required, may be grounds for suspension of work for cause.

Contractor shall deliver to HHSC true and complete copies of certificates and corresponding policy endorsements upon award.

Failure of HHSC to demand such certificates or other evidence of Contractor’s full compliance with these insurance requirements or failure of HHSC to identify a deficiency in compliance from the evidence provided shall not be construed as a waiver of Contractor’s obligation to maintain such insurance.

The insurance and insurance limits required herein shall not be deemed as a limitation on Contractor’s liability under the indemnities granted to HHSC in the Contract.

The insurance coverage and limits established below shall not be interpreted as any representation or warranty that the insurance coverage and limits necessarily will be adequate to protect Contractor.

Coverage shall be written on an occurrence basis by companies authorized and admitted to do business in the State of Texas and rated A or better by A.M. Best Company or similar rating company or otherwise acceptable to HHSC.

10.2 Required Policy Clauses and Other Requirements

This insurance shall not be canceled, materially changed, or non-renewed except after thirty (30) days written notice has been given to HHSC.

It is agreed that Contractor’s insurance shall be deemed primary with respect to any insurance or self-insurance carried by HHSC for liability arising out of operations under the Contract with HHSC. The Texas Health and Human Services Commission, its officials, directors, employees, representatives, and volunteers are added as additional insureds as respects operations and activities of, or on behalf of the named insured performed under Contract with HHSC. The additional insured status must cover completed operations as well. This is not applicable to workers’ compensation policies.

A waiver of subrogation in favor of the Texas Health and Human Services Commission shall be provided in all policies.

Without limiting any of the other obligations or liabilities of Contractor, Contractor shall require each Subcontractor performing work under the Contract, at Subcontractor’s own expense, to maintain during the term of the Contract, the same stipulated minimum insurance including the required provisions and additional policy conditions as shown above.

As an alternative, Contractor may include its Subcontractors as additional insureds on its own coverage as prescribed under these requirements. Contractor’s certificate of insurance shall note in such event that Subcontractors are included as additional insureds and that Contractor agrees to provide workers’ compensation for Subcontractors and their employees. Contractor shall obtain and monitor the certificates of insurance from each Subcontractor in order to assure compliance with the insurance requirements.

Contractor must retain the certificates of insurance for the duration of the Contract plus seven (7) years and shall have the responsibility of enforcing these insurance requirements among its Subcontractors.