ESBD_392672_1738969238102_Scope of Work_Medical-UR Appeals 2024_1220 Waiver Work Removed_rev.docx
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- Attached to
- Open Enrollment for Independent Review Organization Services, Medicaid & CHIP Services, Medical & UR Appeals
- Solicitation number
- HHS0015818
- Issued by
- Texas
About this file
This is a Statement of Work document from the Texas Health and Human Services Commission (HHSC) detailing requirements for Independent Review Organizations (IROs) to assist with Medical and Utilization Review Appeals and Provider Resolution and Administrative Appeals (PRAA). The IROs will conduct independent clinical reviews of provider appeals related to adverse decisions from fee-for-service and managed care claims, including Hospital Utilization Reviews and Recovery Audit Contractor reviews. The scope includes reviewing medical documentation, billing practices, and determining appropriateness of services according to Texas Medicaid requirements. Reviews must be completed within 20 business days for standard cases and 5 business days for expedited reviews. IROs must employ qualified professional reviewers including physicians and nurses, maintain quality control measures, and submit detailed monthly reports on appeal activities.
The document does not specify pricing terms or set-asides, but requires IROs to submit detailed monthly invoices by the 15th day of the following month. No reimbursement is provided for travel or meal expenses. The IRO must maintain all contract-related documents for seven years after contract termination. Case assignments are made on a rotating basis, with no guaranteed minimum volume. The IRO must carry appropriate insurance coverage and implement robust data security measures to protect sensitive healthcare information. Quality evaluations will be conducted periodically, and corrective action plans may be required for identified deficiencies, with potential withholding of case assignments until issues are resolved.
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Exhibit C Statement of Work Project Overview HHSC Medical and Utilization Review (UR) Appeals conducts independent clinical reviews of provider Appeals related to adverse decisions resulting from certain retrospective reviews of fee-for-service and managed care claims by the Health and Human Services (HHS) Office of Inspector General (OIG), including Hospital Utilization Reviews (HUR) and Recovery Audit Contractor (RAC) complex reviews.
HHSC Operations Management (OM) Provider Resolution and Administrative Appeals (PRAA) performs independent, non-clinical (also referred to as “administrative”) Appeals for retrospective payment reviews of fee-for-service and managed care claims resulting from adverse determinations related to OIG’s Acute Care Surveillance (ACS) reviews, Targeted Query (TQ) reviews, and RAC automated reviews. HHSC OM PRAA considers the Appeals to determine administrative accuracy of original findings and any new information submitted by the provider before deciding to deny, uphold, or overturn the original review decision.
HHSC seeks to contract with Independent Review Organizations (IROs) to assist HHSC Medical and UR Appeals and PRAA with conducting these Appeal reviews. The IROs will review provider medical and billing documentation, original findings, and first-level review details to determine if the provider billed and was reimbursed appropriately according to Texas Medicaid requirements and policies effective at the time of service. For Medical and UR Appeals, this includes validating medical necessity at the level of care billed and for assigned Diagnosis Related Group (DRG) coding, as well as identifying any other clinical or quality-of-care issues. This may include policies for emergency Medicaid, outpatient or day surgery, and observation services. More detailed information about HHSC Medical and UR Appeals and its processes can be found at:
https://www.hhs.texas.gov/services/health/medicaid-chip/provider-information/provider-Appeals-hhsc-medical-ur-Appeals IRO Responsibilities
1.1 The IRO must perform independent Appeal reviews of:
1.1.1 OIG HUR decisions, which typically include, but are not limited to:
| a. | Denial of inpatient hospital admission; |
| b. | DRG coding revision, quality of care; |
| c. | Readmission; |
| d. | Day outlier; |
| e. | Cost outlier; and |
| f. | Other instances of non-compliance with Texas Medicaid policy. |
| 2.1.2 | Decisions resulting from OIG ACS, TQ, and RAC retrospective reviews, which typically include, but are not limited to reviews of: |
| a. | Outpatient services; |
| b. | Physician services; |
| c. | Dental services; |
| d. | Durable medical equipment; and |
| e. | School Related and Health Services (SHARS). |
These Appeals require reviewing the provider’s billing practices in comparison with Texas Medicaid policy (and other associated laws, regulations, policies, and medical billing and coding guidelines) for both fee-for-service (FFS) claims and Managed Care Organization (MCO) encounter data. For ACS and complex RAC scenarios, these Appeals also typically include a review of medical records submitted by the provider to validate the appropriateness of services rendered in accordance with Texas Medicaid requirements.
| 2.2 | The IRO must evaluate Appeals by considering the information (including medical records) used in arriving at the original adverse decision, along with other supporting information or documents submitted by providers as part of the Appeal process. However, the IRO may not allow nor accept the submission of any new medical records during the Appeal process. |
| 2.3 | The IRO must employ, contract with, or otherwise make available qualified professional reviewers (e.g., physicians, nurses working under the supervision of a physician, and medical billing and coding specialists) to perform Appeal reviews. |
| 2.3.1 | These reviewers must represent the spectrum of expertise and specialties needed to accept and process Appeals concerning the full range of services that may be covered or sought to be covered by Texas Medicaid. |
| 2.3.2 | Each reviewer must be licensed, certified, or credentialed in good standing, as applicable, by the State of Texas licensing, certifying, or credentialing body for their respective specialty or area of practice that would generally provide the type of treatment that is the subject of the assigned review. |
| 2.3.3 | As part of the required reporting described in section 2.26, the IRO must include a quarterly report with an updated list of reviewers with their credentials with effective dates, as well as professional affiliations with any health care facility (including admitting privileges), health plan, insurer, RAC vender, or other IRO. |
| a. | The IRO must notify HHSC in writing within 5 Business Days of any change in key personnel, including but not limited to, designated points of contact, the IRO’s chief executive officer or equivalent, medical director, or director of operations or equivalent. |
| b. | The IRO must ensure reviewers immediately disclose to the IRO any action taken by a licensing, certification or credentialing body, health care facility or health plan to condition, suspend or revoke the Reviewer’s license, certification, privileges, or credentials. When such notification is received, the IRO must immediately exclude that Reviewer from all Texas Appeal reviews. |
| c. | The IRO must ensure reviewers immediately disclose to the IRO any change in affiliation status that may represent a conflict of interest in performing reviews. If notification is received, the IRO must immediately exclude that reviewer from any Appeal reviews with potential conflict of interest. |
| 2.3.4 | The IRO must have a process in place, approved by HHSC, to ensure reviewers are in good standing with their credentialling bodies. The process must also ensure: | |
| a. | Reviewers immediately disclose to the IRO any action taken by a licensing, certification or credentialing body, health care facility or health plan. | |
| b. | When such notification is received, the IRO must promptly respond in accordance with its process, including notifying HHSC of the circumstances and any action taken; and | |
| c. | Reinstatement of any reviewer excluded from assigned Appeal reviews requires prior HHSC written permission. | |
| 2.4 | The IRO must have ongoing quality control measures in place, including Inter-Reviewer Reliability (IRR) Evaluations conducted according to an HHSC-approved process and must submit a quarterly report related to these activities. | |
| 2.5 | The IRO must submit a monthly report to HHSC detailing all contract-related activities for the preceding month and cumulative for the fiscal year. The report must contain at least the following elements: | |
| 2.5.1 | Number of Appeals received. | |
| 2.5.2 | Number of Appeals pending by Business Day range: 0-5, 5-10, 10-20, 20-30, and 30+. | |
| 2.5.3 | Number of Appeals pending by type (HUR, ACS, TQ, RAC complex, and RAC | automated). |
| 2.5.4 | Number of Appeal reviews completed categorized by: | |
| a. | Number of DRG and non-DRG Appeals. | |
| b. | Number and percent of Upholds, Partial Upholds, and Overturns, categorized by total and by DRG and non-DRG cases. | |
| c. | Number of Appeal reviews completed by type (HUR, ACS, TQ, RAC complex, and RAC automated). | |
| d. | Number and percent of Upholds, Partial Upholds, and overturns by type (HUR, ACS, TQ, RAC complex, and RAC automated). | |
| e. | Number and percent of clinical review determinations (Upholds, Partial Upholds, and Overturns), based on the original review and the underlying rationale for its adverse determination. | |
| f. | Number and percent of clinical review determinations (Upholds, Partial Upholds, and Overturns), based on factors other than the original review and the underlying rationale for its adverse determination, as in section 2.12. In consultation with and agreed upon by HHSC, these may be reported by category. | |
| 2.5.5 | Number of Business Days taken to complete Appeal reviews, including: | |
| a. | Average number of Business Days to complete Appeal reviews, both total and categorized by type (HUR, ACS, TQ, RAC complex, and RAC automated). | |
| b. | Number completed by day range: 0-5, 5-10, 10 to 20, 20 to 30, 30+, both total and by type (HUR, ACS, TQ, RAC complex, and RAC automated). | |
| 2.5.6 | Number of Appeals reviewed by IRO professional reviewers, categorized by specialty. | |
| 2.5.7 | Dollar amount charged per month and cumulative for fiscal year. | |
| 2.5.8 | Summary of reasons for overturning HMS recommendations, categorized by type (HUR, ACS, TQ, RAC complex, and RAC automated). | |
| 2.5.9 | Responses to: | |
| a. | New concerns raised by HHSC during report month. Responses will be required by the 21st Calendar Day after the HHSC concern is communicated in writing to the IRO. | |
| b. | Follow up regarding concerns previously raised but not resolved. | |
| 2.5.10 | Any feedback by the IRO to HHSC, including but not limited to: | |
| a. | Quality of initial or subsequent decision letters from HHSC or its contractors. | |
| b. | Patterns or problems noted for specific providers. | |
| c. | Suggested areas for improved interaction and processes between IRO and HHSC. | |
| 2.5.11 | Number and type of Fraud, Waste, or Abuse referrals submitted to OIG, as well as reference numbers, if requested. | |
| 2.6 | The IRO must refer suspected cases of Fraud, Waste, or Abuse to HHSC OIG within 15 Calendar Days of becoming aware of the Fraud, Waste, or Abuse. | |
| 2.7 | The IRO must abide by all provisions of the attached Data Use Agreement. | |
| 2.8 | The IRO must review case assignments and determine if there are any potential Conflicts of Interest. |
2.8.1 Conflict of Interests may include, but are not limited to reviewers having:
a. 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 Appeal review processes.
b. 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, Appeal submission processes, or 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.
| 2.8.2 | If a Conflict of Interest is identified, the assignment must be returned to HHSC to complete or for reassignment to another IRO, no later than 5 Business Days after assignment. |
| 2.9 | The IRO must perform these Appeal reviews and render a decision within 20 Business Days from the date of assignment for regular reviews and within 5 Business Days for expedited reviews. |
| 2.10 | The IRO must submit Appeal decisions in a secure electronic manner by the deadline, as specified by HHSC for each type of Appeal. |
| 2.11 | If the capability develops that Appeal reviews can be conducted by the IRO within a secure internet portal, IRO reviewers responsible for reviews must obtain portal access from the portal administrator and abide by all associated requirements. |
| 2.12 | In conducting Appeal reviews, the IRO must apply and cite any applicable: |
| 2.12.1 | HHSC policies, including: |
| a. | HHSC OIG policies; |
| b. | Texas Medicaid policies; |
| c. | HHSC Medical and UR Appeals; and |
| d | PRAA policies and procedures. |
| 2.12.2 | Federal laws and regulations, including HIPAA (federal regulations are in the Code of Federal Regulations). |
| 2.12.3 | State laws and Texas Administrative Code of Regulations. Links to certain applicable policies, laws, rules, and further information on HHSC Medical and UR Appeals processes are located at: |
https://www.hhs.texas.gov/sites/default/files/documents/pa-05-hhsc-medical-and-ur-Appeals-review-process.pdf
| 2.12.4 | All final reviews, reports, and resulting text in letters must be personally and thoroughly reviewed in detail and individually signed by a qualified and licensed physician. |
| 2.13 | For Appeal review responses, reports, and other communications, the IRO must employ templates provided or pre-approved by HHSC. |
| 2.14 | For certain types of reviews, the scope of the IRO Appeal review may not be limited solely to the original review and the rational for its adverse determination. These will be defined and listed by HHSC from time to time and provided to the IRO. These reviews may include determinations based on denial of inpatient hospital admission, DRG coding revision, quality of care, readmission, day outlier, cost outlier, and other instances of non-compliance with Texas Medicaid policy. |
| 2.15 | For clients with limited Emergency Medicaid benefits, the IRO must evaluate appropriateness of billing for initial and ongoing care. |
| 2.16 | The IRO must use medical records and documentation submitted on Appeal, clinical judgment, and the provider’s compliance with Texas Medicaid policy and rules to make its determination. The IRO must not rely on third-party clinical guidelines as the sole basis for determining inpatient medical necessity. |
| 2.17 | After completion of the review, the IRO professional reviewer must recommend a final determination for the case. The IRO may recommend upholding, overturning, or partially overturning the adverse decision. The IRO may also recommend additional recoupment or DRG coding modification, as appropriate. |
| 2.19 | IRO reviewers must write appropriate, explanatory Appeal decision analyses. As specified or requested by HHSC, IRO Appeals may be subject to final review and adoption by HHSC. The IRO must respond within five business days to any request by HHSC for a more detailed explanation or modification of their recommendation. |
| 2.20 | For certain types of Appeals, providers may request an educational conference as prescribed by HHSC. If an educational conference is scheduled by HHSC, the IRO must attend the conference along with members of HHSC Medical and UR Appeals to present their recommendations. Any time and effort required for this on the part of the IRO is included in the predetermined payment rate. These conferences are generally scheduled for 50 minutes. |
| 2.21 | The IRO must retain all contract-related documents and correspondence, including Appeal documentation and decisions, for a minimum 7 years following contract termination, in accordance with HHSC requirements. |
| 2.22 | The IRO, including all reviewers, must attend training as required by HHSC prior to conducting reviews on behalf of HHSC and as specified thereafter. |
| 2.23 | IRO will submit detailed and accurate invoice(s) in a format acceptable by HHSC no later than the 15th day of the month for all services performed during the previous month. |
| 2.23.1 | Invoices must be submitted by email to the HHSC Contract Manager/Sole Point of Contact listed in Section 4.1 of the OE document, or to any subsequent Sole Point of Contact and email address designated by HHSC. |
| 2.23.2 | Invoices must include, at a minimum, the information below: |
| a. | Contracting IRO’s Name; |
| b. | Remit to Address; |
| c. | Federal ID, Texas Identification Number (TIN), or Texas CPA Payee ID; |
| d. | IRO Accounts Receivable telephone number; |
| e. | Contract and/or Purchase Order Number; |
| f. | Service date(s); |
| g. | Identification and itemization of services provided, with Claim Numbers (ICNs) listed and subtotaled by review type and by agency area; and |
| h. | Other relevant information supporting and explaining the payment requested, such as reviewer name, date of service, due date, specialty, and Appealing provider name. |
| 2.24 | HHSC Medical and UR Appeals and PRAA will periodically select a representative sample of IRO Appeal reviews for a given period to evaluate for quality and accuracy. For any issues identified, the IRO must respond to HHSC with a Corrective Action Plan within 10 Business Days of notification providing details as to how the IRO will remedy identified issues or deficiencies. HHSC will provide the IRO with a format for the Corrective Action Plan. |
| 2.25 | If the IRO fails to correct identified deficiencies within the cure period specified in the approved Corrective Action Plan, HHSC may elect to withhold assignment of further cases to the IRO until the deficiencies have been corrected. |
| 2.26 | Reports |
| 2.26.1 | Except where otherwise specified, all periodic reports described in this document must be submitted by the 15th Business Day of the month following the end of the month, quarter, or other period covered by the report. |
| 2.26.2 | Each report must be submitted to the Medical and UR Appeals IRO mailbox: |
| Utilization_Appeals@hhsc.state.tx.us. | |
| 2.26.3 | The format, contents, data collection, and general process for each report must be approved in advance by HHSC. |
| 2.26.4 | If any report is delinquent, not in an approved format, or is not created using approved processes, no additional review cases will be assigned to the IRO until the report has been received by HHSC and reviewed as satisfactory. |
| 2.26.5 | Reassignment of cases for failure to meet standards: If the IRO falls below standards for timeliness or other metrics of HHSC’s determination, HHSC may at its discretion reassign cases to another IRO or perform the reviews in-house. The IRO will not be paid for reassigned Appeal cases. |
HHSC Responsibilities.
| 3.1 | HHSC will assign cases to contracted IROs. |
| 3.1.1 | HHSC may, assign a case to a specific IRO if, in it’s judgement a particular IRO may have experience, specialists, or capabilities better suited to a particular case. |
| 3.1.2 | Assignment of cases is otherwise on a rotating basis, based on date of contract execution. |
| 3.1.3 | Assignment of a specific case to an IRO will not affect that IRO’s position in the rotation. |
| 3.1.4 | Exclusion from case assignment for failure to meet standards: |
| a. | If the IRO falls below standards for timeliness or other metrics, HHSC may exclude the IRO from case assignments until such time as the IRO has successfully completed a Corrective Action Plan. Any Corrective Action Plan shall be determined by HHSC and may require a variety of elements, including requiring the IRO to increase its number of staff or specialty staff to handle caseloads. |
| b. | HHSC may at its discretion remove cases from assignment to that IRO and place them back in rotation for assignment to other IROs, or HHSC may perform the reviews in-house. |
| c. | If and when the IRO takes corrective action and fixes any problems to the satisfaction of HHSC, the IRO will, at HHSC’s discretion, resume its normal place in the case assignment rotation. |
| 3.2 | After HHSC Medical and UR Appeals has assigned cases to the IRO for review HHSC will provide access to Appeal documentation in a secure manner to the IRO within 3 Business Days of assignment for regular Appeal reviews and the same day for expedited reviews. |
| 3.3 | HHSC will administer any contract awarded. |
| 3.4 | HHSC will assign cases for review and make documentation available by agreed-upon means. If necessary, HHSC will facilitate access to the RAC contractor’s electronic portal. |
| 3.5 | HHSC will periodically review the IRO’s work product and provide feedback as needed. |
| 3.6 | HHSC will review reports submitted by the IRO and provide feedback, as needed. |
| 3.7 | HHSC will respond to IRO’s questions in a timely manner and provide guidance. |
| 3.8 | HHSC will liaison with the RAC contractor, providers, other stakeholders, and the IRO as needed. |
3.9 HHSC with reimburse the IRO in accordance with the Fee Schedule, Exhibit F.
3.9.1 No payment will be made under the Contract without submission of timely, detailed, accurate invoices submitted as outlined in this section.
3.9.2 No reimbursement for travel or meal expenses is permitted.
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