ESBD_File_328573_Addendum 2_Attachment 1_Revised RFQ.pdf

PCS 550 HHS RFQ Template, RFQ No. HHS0013244 Page 1 of 65 Version 1.0 (10/11/2022)

Cecile E. Young, Executive Commissioner

Request for Qualifications (RFQ) for

Recovery Audit Contractor Services

RFQ No. HHS0013244

Date of Release: July 20, 2023 See Section 3.1 for Schedule of Events

208-10 *Accounting /Financial: Bookkeeping, Billing and Invoicing, Budgeting, Payroll, Taxes, etc., Microcomputer

208-21 *Business Intelligence Software, Microcomputer

208-36 *Data Processing Software, Microcomputer

208-60 *Medical Software, All Types, Microcomputer

208-82 *Scientific, Statistical, Engineering, Mathematical, and Mapping Software, Including Photogrammetry, Microcomputer

918-04 Accounting, Auditing, Budget Consulting

918-78 Medical Consulting

946-11 Accounting Services (Not Otherwise Classified)

946-20 Audit Services

948-07 Administration Services, Health

948-47 Health Care Center Services

948-48 Health Care Services (Not Otherwise Classified)

948-74 Professional Medical Services: Physicians, Pharmacists, and All Specialties

952-59 Human Services (Not Otherwise Classified)

PCS 550 HHS RFQ Template, RFQ No. HHS0013244 Page 2 of 65

Table of Contents Article I. Introduction, Definitions, and Authority

1.1 Introduction

1.2 Definitions

1.3 Authority

Article II. Scope of Work

2.1 Description of Services

2.1.1 Identify Potential Improper Payments

2.1.2 Coordinate Recovery of Improper Payments

2.1.3 Rebuttals and Appeals

2.2 Contractor Requirements

2.2.1 General Requirements

2.2.2 Communication Requirements

2.2.3 Reporting Requirements

2.3 Required Qualifications

2.3.1 Organizational Requirements

2.3.2 Key Personnel and Staffing

2.4 Technical Web Requirements

2.4.1 Online Portal

2.4.2 Data Sharing and Security

2.5 Agency Requirements

2.6 Deliverables

2.7 Contract Turnover Requirements

2.8 Liquidated Damages

2.8.1 Performance Measures with Liquidated Damage Amounts

2.9 Payments and Invoices

2.9.1 Invoices

2.9.2 Final Payment

2.10 Contract Award, Term, and Historical Compensation

2.10.1 Contract Award and Reservation of Rights

2.10.2 Contract Term

2.10.3 Historical Compensation

2.11 No Guarantee of Volume, Usage, or Compensation

2.12 Data Use Agreement and Security Privacy Inquiry

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2.13 Texas Risk and Authorization Management Plan

Article III. Administrative Information

3.1 Schedule of Events

3.2 Ambiguity, Conflict, or Discrepancy

3.3 Inquiries

3.3.1 Sole Point of Contact

3.3.2 Exceptions to Sole Point of Contact

3.3.3 Prohibited Communication

3.3.4 Solicitation Questions

3.4 Pre-proposal Conference

3.4.1 Attendance

3.4.2 Pre-proposal Conference Logistical Information

3.4.3 Questions During Pre-proposal Conference

3.5 Solicitation Response Composition

3.5.1 General Information

3.5.2 Page Limit and Supporting Documentation

3.5.3 Discrepancies

3.5.4 Exceptions

3.5.5 Assumptions

3.5.6 Binding Offer

3.6 Solicitation Response Submission and Delivery

3.6.1 Deadline

3.6.2 Delivery

3.6.3 Submission Checklist

3.6.4 Modifications and Withdrawals of Solicitation Response

3.6.5 Retention of Solicitation Responses

Article IV. Solicitation Response Evaluation and Award Process

4.1 Conformance with State Law

4.2 Best Value Determination

4.2.1 Selection Methodology

4.2.2 Minimum Qualifications

4.2.3 Initial Compliance Screening

4.2.4 Written Solicitation Response Evaluation

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4.2.5 Written Response Evaluation Criteria

4.2.6 Final Written Response Score

4.2.7 Additional Selection Considerations

4.2.8 Summary of Best Value Determination

4.3 Questions or Requests for Clarification

Article V. Statement of Qualifications

5.1 Executive Summary

5.2 Minimum Qualification Documentation

5.3 Proposed Work/Project Work Plan

5.4 Qualifications (Key Personnel and Staffing)

5.5 Performance and Experience

5.6 Technical Web Qualifications (Online Portal)

Article VI. Required Respondent Information

6.1 Company Information

6.1.1 Company Narrative

6.1.2 Company Profile

6.2 Authorization to Conduct Business in Texas

6.3 References

6.4 Affirmations and Certifications

6.5 Corporate Guarantee

6.6 Major Subcontractor Information

Article VII. HSP Requirement

7.1 HSP Submission Instructions

Article VIII. General Terms and Conditions

8.1 General Conditions

8.1.1 Changes, Modifications, and Cancellation of the Solicitation

8.1.2 Offer Period

8.1.3 Costs Incurred

8.1.4 Contract Responsibility

8.1.5 Public Information Act - Respondent Requirements Regarding Disclosure

8.1.6 Respondent Waiver – Intellectual Property

8.1.7 Standards of Conduct for Vendors

8.1.8 Disclosure of Interested Parties

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8.2 Insurance

8.2.1 Required Coverage

8.2.2 Alternative Insurance

8.3 Protest

Article IX. List of Exhibits

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ARTICLE I. INTRODUCTION, DEFINITIONS, AND AUTHORITY

1.1 INTRODUCTION

The Texas Health and Human Services (HHS) Office of Inspector General (OIG) is seeking a qualified Contractor to perform all recovery audit services as described in 42 U.S.C. § 1396(a)(42)(B), 42 CFR §§ 455.500-455.518, Texas Government Code Section 531.117, and 1 TAC § 354.1451, which require states to Contract with a Recovery Audit Contractor (RAC) for the purpose of identifying Medicaid Underpayments and Overpayments (also referred to as “Improper Payments”) under the Medicaid state plan and any waiver of the Medicaid state plan.

The Health and Human Services Commission (HHSC) oversees operations of the entire Health and Human Services System in Texas. The HHS System is comprised of two state agencies:

HHSC and the Department of State Health Services (DSHS). Information regarding HHSC and its programs is available online and can currently be accessed at https://www.hhs.texas.gov.

The mission of the HHS OIG, as prescribed by statute, is the "prevention, detection, audit, inspection, review, and investigation of fraud, waste, and abuse in the provision and delivery of all health and human services in the state, including services through any state-administered health or human services program that is wholly or partly federally funded, and the enforcement of state law relating to the provision of these services." Information regarding HHS OIG can be found online at https://oig.hhs.texas.gov.

HHSC PCS will administer the procurement process for this Solicitation and will manage Respondent communications as well as the receipt of Solicitation Responses for review and evaluation.

1.2 DEFINITIONS

As used in this Solicitation, unless a different definition is specified or the context clearly indicates otherwise, the terms and conditions have the meanings assigned below. Refer to Exhibit B, Health and Human Services (HHS) Uniform Terms and Conditions – Vendor, Version 3.3., for additional definitions (e.g., Contract, Contractor, Deliverable, Effective Date, HUB, Services, Solicitation Response, Subcontractor, System Agency, Work, and Work Order).

“Addendum” means a written clarification or revision to this Solicitation posted on the ESBD.

https://www.govinfo.gov/content/pkg/USCODE-2010-title42/html/USCODE-2010-title42-chap7-subchapXIX.htm https://www.govinfo.gov/content/pkg/USCODE-2010-title42/html/USCODE-2010-title42-chap7-subchapXIX.htm https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-F?toc=1 https://statutes.capitol.texas.gov/Docs/GV/htm/GV.531.htm https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1451 https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1451 https://www.hhs.texas.gov/ https://oig.hhs.texas.gov/

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“Advancement Criteria” means the published criteria for Respondent to advance to the next phase of evaluation if multiple evaluation methods are utilized.

“Automated Scenarios” are scenarios where the RAC reviews reimbursement data and does not examine medical documentation to determine the existence of an improper payment.

“Award Consideration (AC) Documents” means documents Respondent must submit as part of the Solicitation Response to be considered for negotiations or award.

“Business Day” refers to any day in which normal business operations of HHSC are conducted.

“Calendar Day” refers to a calendar day, and includes Saturday, Sunday, a skeleton crew day, and national, state, and optional holidays.

“Contract Term” means the duration of the Contract, including any exercised extensions or renewals, commencing on the Effective Date and ending when the Contract expires in accordance with its terms, or when it has been terminated.

“Complex Scenarios” are scenarios where the RAC examines medical documentation to determine the existence of an improper payment

“ESBD” means the Electronic State Business Daily, an online directory where State of Texas solicitations over $25,000 are posted. The ESBD may currently be accessed at http://www.txsmartbuy.com/esbd.

“Final Written Response Score” refers to the final scoring of the written response as documented in the Solicitation.

“HHSC” means the Texas Health and Human Services Commission.

“HHSC PCS” means the Procurement and Contracting Services division of HHSC. HHSC PCS provides purchasing support services to DSHS and the Department of Family and Protective Services pursuant to Section 531.00553 of the Texas Government Code.

“Holiday” refers to a Texas State or Federal holiday. The list of observed holidays by state fiscal year can be found here: https://hr.sao.texas.gov/Holidays/.

“HUB Subcontracting Plan” or “HSP” means the written documentation regarding the use of Subcontractors that is required by Section 2161.252 of the Texas Government Code for a purchase with an expected value of $100,000 or more when the state agency has determined subcontracting opportunities are probable. The HSP subsequently becomes a provision of the Contract and Contractor’s compliance with the HSP will be monitored during the Contract Term.

http://www.txsmartbuy.com/esbd https://hr.sao.texas.gov/Holidays/

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“Improper Payment” is an Overpayment or an Underpayment, per 1 TAC § 354.1451.

“Overpayment” is the amount paid by HHSC or an HHS agency to a provider that is in excess of the amount that is allowable for services furnished under §1902 of the Social Security Act and its implementing regulations and policies, as defined by the Centers for Medicare & Medicaid Services (CMS), and that is required to be refunded under §1903 of the Social Security Act, per

1 TAC § 354.1451.

“Recovery Audit Contractor (RAC)” is an eligible company or consultant contracted with HHSC to perform recovery audit services, per 1 TAC § 354.1451.

“Respondent” means the individual or entity responding to this Solicitation.

“Review Scenario” means a particular violation of Medicaid or other healthcare policy and the associated improper payment detection methodology used to identify the Improper Payments through data and/or medical record reviews.

“Software-as-a-Service” or “SaaS” means the service model described by the National Institute of Standards and Technology (NIST) in Special Publication No. 800-145 (https://csrc.nist.gov/pubs/sp/800/145/final)to be the capability provided to the consumer to use the provider’s applications running on a cloud infrastructure. The applications are accessibly from various client devices through a thin client interface such as a web browser (e.g., web-based e-mail). The consumer does not manage or control the underlying cloud infrastructure including network, servicers, operating systems, storage or even individual application capabilities, with possible exception of limited User-specific application configuration settings.

“Solicitation” means this RFQ including all Exhibits and Addenda.

“Solicitation Consideration (SC) Documents” means documents that must be submitted by Respondent with the Solicitation Response in order to be considered for evaluation and cannot be resubmitted or have errors remedied after the submission due date and time in the Schedule of Events has passed.

“State” means the State of Texas and its instrumentalities, including HHSC, as well as any other state agency, its officers, employees, or authorized agents.

“Statement of Qualifications” means the portion of the Solicitation Response that comprises a Respondent’s qualifications and skills as set out in Article V of the Solicitation.

“TX RAMP” means the Texas Risk and Authorization Plan established by DIR that provides a standardized approach for security assessment, authorization, and continuous monitoring of cloud computer services that process the data of a state agency. To become TX-RAMP certified, entities https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1451 https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1451 https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1451 https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1451 https://csrc.nist.gov/pubs/sp/800/145/final

PCS 550 HHS RFQ Template, RFQ No. HHS0013244 Page 9 of 65 must submit prescribed documentation to DIR. Information regarding TX-RAMP is currently located at https://dir.texas.gov/information-security/texas-risk-and-authorization-management-program-tx-ramp.

“Underpayment” is an amount paid by HHSC or an HHS agency to a provider at a lesser amount due and payable for items or services furnished under §1902 of the Social Security Act and its implementing regulations and policies, as defined by CMS, per 1 TAC § 354.1451.

“VPTS” means the Vendor Performance Tracking System maintained by the Texas Comptroller of Public Accounts. The VPTS may be currently accessed at https://comptroller.texas.gov/purchasing/programs/vendor-performance-tracking/.

1.3 AUTHORITY

The System Agency is soliciting the services listed herein under Title 10, Subtitle F of the Texas Government Code Section 2254, Subchapter A, Professional Services.

ARTICLE II. SCOPE OF WORK

2.1 DESCRIPTION OF SERVICES

The Contractor will perform Recovery Audit Contractor (RAC) services as described in 42 CFR §§ 455.500-455.518 and 1 TAC § 374.1451, and conduct RAC activities in accordance with HHS OIG’s directives and guidelines.

RAC services are federally required activities that involve the detection and identification of Improper Payments for goods and services delivered under the Medicaid State Plan or a waiver of the Medicaid State Plan. The Contractor will be required to perform the following:

A. Identifying potential Medicaid Improper Payments across the spectrum of provider types and services delivered under the Texas Medicaid State Plan;

B. Coordinating recovery efforts for identified Improper Payments; and

C. Conducting rebuttal reviews and facilitating appeals.

https://dir.texas.gov/information-security/texas-risk-and-authorization-management-program-tx-ramp https://dir.texas.gov/information-security/texas-risk-and-authorization-management-program-tx-ramp https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1451 https://comptroller.texas.gov/purchasing/programs/vendor-performance-tracking/ https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-F?toc=1 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-F?toc=1 https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1451

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2.1.1 Identify Potential Improper Payments

A. Contractor must thoroughly evaluate and interpret federal and state Medicaid laws, rules, policies, processes, manuals, contracts, payment schedules, and medical coding and billing practices, including requirements specific to Texas Medicaid and associated waiver programs (hereafter referred to as “Medicaid requirements”).

B. Contractor must develop Improper Payment detection Review Scenarios based on potential Medicaid violations observed in claims or other Medicaid information and data.

Review Scenarios must represent the range of provider types and services delivered within Texas Medicaid and associated waiver programs.

C. Contractor must submit and present Improper Payment Review Scenarios to HHS OIG and other assigned stakeholders, as directed by HHS OIG, for approval.

D. Contractor must obtain approval from HHS OIG before pursuing identification of Improper Payments.

E. Contractor must categorize Review Scenario submissions as either Automated or Complex.

F. Contractor must submit Review Scenarios to HHS OIG with the following:

1. Definitions and descriptions of the Improper Payment scenario;

2. The policy or requirements that support the potential violations;

3. The process, criteria, and logic used to identify and calculate potential Improper Payments;

4. Examples of potential Improper Payments based on claims or other data; and

5. An impact analysis regarding the scenario (e.g., projected number of providers, claims, and potential recoveries).

6. Contractor must analyze associated Review Scenario data and other relevant information to determine if services were provided and/or reimbursed in accordance with the Medicaid requirements effective on the date that the service was rendered or the claim was adjudicated, as applicable, for each approved Review Scenario. An Analysis may include review of medical charts, documentation, and records to determine if services were medically necessary, appropriate, or authorized.

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G. Contractor must coordinate with HHS OIG or its designee(s) to identify and exclude from review and/or recovery any claim details that have already been reviewed and/or recovered by another entity, that are currently under review by another entity, or that are expected to be reviewed by another entity to prevent duplication of review and recovery efforts.

H. Contractor must restrict reviews to the service dates, program types, provider types, claim types, and other relevant parameters determined and approved by HHS OIG for a given scenario. Contractor must not review claims older than five (5) years from the date the claim was submitted unless a written exception is granted by HHS OIG.

I. Contractor must identify claims with Improper Payments resulting from approved RAC Scenarios and provide identified claim details to HHS OIG and/or its designee(s) to facilitate recoupment of Improper Payments.

J. Contractor must adhere to limitations established by HHS OIG regarding the number and frequency of medical records to be reviewed for a given scenario, provider type, provider, or other defined parameter, unless a written exception is granted by HHS OIG.

K. Contractor must perform reviews of individual claims upon request by HHS OIG, regardless of otherwise established deadlines.

L. Contractor must recommend process or system changes to prevent future Improper Payments based on observed Improper Payment trends.

2.1.2 Coordinate Recovery of Improper Payments

A. Contractor must submit a file containing identified Improper Payments (referred to as the offset file) to HHS OIG and/or its designee(s) on a periodic basis as determined by HHS OIG and/or its designee(s). HHS OIG and/or its designee will then provide Contractor with a file that includes all claims that have been successfully scheduled for recovery and those that resulted in an error (referred to as the return offset file).

B. Contractor must resolve any errors included on the return offset file and submit the results to HHS OIG and/or its designee, once resolved. The process of resolution involves coordinating with HHS OIG and/or its designee to research and address the conditions that resulted in the error.

C. HHS OIG or its designee will send the Contractor a file summarizing successful recovery information from the previous stat financial month (referred to as the collection file, currently sent on the first (1st) Saturday of each month).

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D. Contractor must reconcile the collection file with the resolved offset file. The process of reconciliation involves:

1. Comparing the Contractor’s record of identified Improper Payments with the collection file prepared by HHSC and/or its designee, using matching data elements (e.g., Claim Numbers);

2. Coordinating with HHS OIG and/or its designee to research claims that are not represented in both data sets; and

3. Ensuring that claims match between the final iteration of the Contractor’s record of identified Improper Payments (the resolved offset file) and the collection file for a given time period (usually a stat financial month), and that any unmatched claims are appropriately documented, addressed, and shared with HHS OIG.

2.1.3 Rebuttals and Appeals

A. Providers who are subject to an Improper Payment finding as the result of a RAC review are entitled to two levels of due process.

1. The first is a rebuttal review by the Contractor to determine whether the original finding is valid based on the original review parameters plus any additional information supplied by the provider within allowed parameters.

2. The second level of due process is an appeal, which is an independent review by HHSC or its designee that considers the original finding, the rebuttal decision and associated information, and any other information supplied by the provider within allowed parameters.

B. Contractor must conduct and adjudicate rebuttal reviews for both Automated and Complex Scenarios within 45 Calendar Days of receiving a rebuttal request or the date that all rebuttal request deficiencies are resolved, if applicable.

C. Contractor must thoroughly and objectively review rebuttals and associated documentation to determine whether to uphold or overturn the initial finding in accordance with Medicaid requirements.

D. Contractor must utilize individuals who possess the subject matter expertise required to assess a particular scenario to conduct rebuttal reviews. Individuals conducting rebuttal reviews must independently and objectively review each rebuttal, and individuals conducting rebuttal reviews may not be the same individuals who initially identified the Improper Payments.

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E. Contractor must facilitate communication and information exchange regarding appeals between providers and HHS OIG and/or its designee(s).

F. Contractor must develop, maintain, and use an online portal, as described in Section 2.4, (Technical Web Requirements), for receiving, processing, and tracking rebuttal and appeal requests, documents, and time frames. The portal must allow providers to:

1. Register to submit rebuttals and appeal requests electronically;

2. Receive notifications and status updates regarding rebuttals and appeal requests;

3. Upload rebuttal and appeal request documents (identified as such); and

4. Confirm the total number of pages uploaded.

G. If a provider chooses to dispute the initial Improper Payment finding by filing a rebuttal, complete the rebuttal review, and notify the provider or their designated agent of the rebuttal decision within 45 Calendar Days. The notification must include the result of the rebuttal review, the reason for the result, and, if the initial Improper Payment finding is upheld, information regarding the requirements and process for submitting an appeal.

H. If a provider elects to appeal the Improper Payment rebuttal decision, notify the assigned appeal reviewer, as designated by HHS OIG, that the record for a pending appeal is complete and ready for review within five (5) Business Days of receiving the appeal request. Additionally, Contractor must perform the services below:

1. Contractor must provide appeal reviewers with access to all materials submitted regarding the appeal request, as well as the original documents and correspondence related to the Improper Payment, rebuttal request, and associated decision.

2. Once an appeal has been adjudicated, Contractor will receive the decision from the appeal reviewers and shall notify the provider of the appeal decision within seven (7) Calendar Days of receipt. Mailed letters may be sent in batches on a weekly basis.

Copies of letters should be placed in the provider’s online portal account.

I. Contractor must create and maintain the official records for rebuttals and appeals in the Contractor’s online portal application and ensure that HHS OIG and designated appeal reviewers can access appeal records on demand.

J. Contractor must accept documents via mail (U.S. Postal Service or other shipping service such as UPS or FedEx), facsimile, or other secure transmission method(s) approved by HHS OIG for providers who do not register to access the Contractor’s online portal. HHS OIG may define document categories and issue specific guidelines for each.

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K. Contractor must provide HHS OIG with copies of all documentation on file for any rebuttal or appeal received within ten (10) Calendar Days of the date requested by HHS

OIG.

2.2 CONTRACTOR REQUIREMENTS

2.2.1 General Requirements

A. Contractor must maintain a strong understanding of Medicaid program integrity requirements and Texas Medicaid services.

B. Contractor must follow all applicable federal and state laws, rules, policies, processes, manuals, contracts, and payment schedules and comply with any required changes, as directed by HHS OIG.

C. Contractor must be proficient in:

1. Interpreting Texas Medicaid policy and billing requirements;

2. Performing program integrity risk assessments;

3. Developing logic and algorithms to analyze large data sets and produce meaningful outcomes;

4. Utilizing efficient methods to detect fraud, waste, abuse, and Improper Payments;

5. Handing, analyzing, storing, and transmitting large volumes of confidential data;

6. Understanding control systems and weaknesses; and

7. Conducting project administration and management.

D. Contractor must coordinate with HHS OIG to implement a governance process for the Texas RAC program that includes holding project and status update meetings on a schedule to be determined, as well as other routine or ad hoc meetings as requested by

HHS OIG.

E. Contractor must work closely and collaboratively with HHS OIG and its designee(s), to effectively implement the Texas RAC program.

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F. Contractor must consult with HHS OIG, as appropriate, to effectively and efficiently carry out the daily administrative, technical, and programmatic requirements of the Texas RAC program.

G. Contractor must furnish all personnel, material, labor, computers, software, equipment, technology, supplies, travel costs, and other direct or indirect expenses necessary to perform required services. HHS OIG will not pay for incidental or administrative expenses related to RAC services.

H. Contractor must maintain a secure, electronic portal for the exchange of medical records and other relevant documents submitted by Medicaid providers and State staff or their designees.

I. Contractor must provide HHS OIG with permissions to all provider access points, including, but not limited to, the Contractor’s electronic portal.

J. Contractor must honor HHS OIG’s explicit right of access to Contractor working papers (including copies of documentation collected from the provider and all chain of custody and authenticating affidavits related to the working papers and all underlying records and documents).

K. Contractor must collect evidence (including expert opinions) in accordance with Texas law, including the Texas Rules of Evidence (https://www.txcourts.gov/rules-forms/rules-standards/).

L. Contractor must not remove original records from State offices, Contractor offices, or provider locations.

M. Contractor must participate in formal hearings/appeals and provide expert testimony related to RAC activities, as needed, and be available to review testimony and evidence with HHSC legal counsel at least two (2) Business Days in advance of any scheduled testimony.

2.2.2 Communication Requirements

2.2.2.1 Contractor Communication with HHS OIG

A. Contractor must respond to requests from HHS OIG within 48 hours, excluding weekends and Holidays.

B. Contractor must notify HHS OIG when providers or other external stakeholders raise concerns or inquiries that Contractor is not reasonably or satisfactorily able to respond to, https://www.txcourts.gov/rules-forms/rules-standards/

PCS 550 HHS RFQ Template, RFQ No. HHS0013244 Page 16 of 65 that remain unresolved after the associated resolution timeframe, or that indicate a pattern or trend that may require additional exploration or intervention.

C. Contractor must obtain HHS OIG approval regarding the content, format, and transmission method for provider and other published or external communications.

D. Contractor must escalate all inquiries or outreach related to the Texas RAC program received from members of the media; legislative members, bodies, or related agents;

other federal, state, or local agencies; or other similar sources to HHS OIG for direction prior to responding.

E. Contractor must deliver trend analysis and performance reports to HHS OIG and/or its designee(s) in the agreed upon manner and timeframes.

F. Contractor must request advance HHS OIG approval for extensions to timelines described within this Solicitation, the resulting Contract, or defined in subsequent written direction from HHS OIG.

G. Contractor must provide HHS OIG with electronic copies of provider correspondence (letters and notices) monthly in an agreed-upon manner and format.

H. Contractor must proactively discuss contractual requirements, performance, amendments, billing and invoicing, or other related matters with HHS OIG, as needed.

2.2.2.2 Contractor Communication with Providers

A. Contractor must obtain advance HHS OIG approval regarding the content, format, and transmission method for provider communications related to the Texas RAC program.

All published content, educational materials, and letter and correspondence templates must be approved by HHS OIG prior to being used or distributed and when any changes are made.

B. Contractor must create and maintain a website, in accordance with Section 2.4 (Technical Web Requirements), specific to the Texas RAC program that includes information for providers regarding functions performed under this Contract. Provide the website link for inclusion on HHS OIG and other State websites, as appropriate.

C. Contractor must establish a toll-free number and mailing address for provider inquiries and customer support, to be included on all provider correspondence. Additional customer service support contact methods, such as email or chat options, may also be considered.

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1. Toll-free numbers and other customer service contact methods must be accessible and staffed during normal business hours, 8:00 a.m. to 4:30 p.m., in time zones applicable to Texas provider locations (Central Time and Mountain Time).

2. Customer service support representatives must be knowledgeable about the RAC process and able to satisfactorily address provider inquiries regarding the review process and status, medical record requests and receipt verification, appeal processes, and requests for copies of provider correspondence.

D. For Complex Scenarios, once the Contractor has identified a claim with a potential Improper Payment, the Contractor will contact the provider in writing to request the medical documentation or other evidence necessary to determine the appropriateness of the claim reimbursement and will grant providers the response timeframe allowed by HHS OIG. Contractor must accept medical records and documentation via:

1. Upload to the Contractor’s secure, online portal,

2. U.S. Postal Service and other similar mail/package carriers, and

3. CD/DVD or facsimile, upon provider’s request.

E. For Complex Scenarios, the Contractor will send reminder letters and make follow up phone calls for medical documentation requests in a frequency and timeframe determined by HHS OIG.

F. Contractor must notify providers in writing of potential Improper Payments within 60 Calendar Days of observation. Notification should be completed either by uploading a letter to the Contractor’s portal with associated alert to the provider contact on record, mailing a letter to the provider, or otherwise sending written correspondence to the provider via the provider’s preferred method of contact - either the designated contact preference selected by the provider within the Contractor’s online portal or the default contact method if no preference has been designated. Notices to providers must include a description of the review scenario, the reason for the potential Improper Payment, information regarding the provider’s appeal rights, and the process for submitting a rebuttal, as defined by HHS OIG.

G. For mailed correspondence, Contractor must apply a standard, distinct colored border on envelopes to easily distinguish RAC mail and inform the provider community about using the markings to recognize important RAC correspondence. Contractor will be allowed a 90-Calendar Day grace period following the Effective Date of the executed Contract to develop and implement this requirement.

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H. For mailed correspondence, Contractor must utilize the address of record on the master provider file (supplied by HHS OIG or its designee), unless the provider has designated a RAC-specific contact preference in the online RAC portal. If the portal includes an updated contact preference or information, the information in the portal takes precedence.

I. When correspondence is received by mail or any transmission method other than the Contractor’s online portal, Contractor must enter the information into the online portal (or associated database) for tracking, retention, and reporting.

J. Contract must establish Business Day due dates for provider requirements. If the original due date falls on a weekend or Holiday, update the due date to the following Business Day and recalculate subsequent timeframes accordingly.

K. Contractor must respond to provider inquiries within 48 hours of receipt, excluding weekends and Holidays. Resolve issues included within an inquiry within seven (7) Calendar Days, unless HHS OIG grants an extension based on the complexity, volume, or other factors involved.

2.2.2.3 Provider Education and Outreach Program

A. Contractor must develop and implement an education and outreach program for providers and stakeholders regarding RAC policies, protocols, and improper payment findings.

1. Examples of education and outreach efforts may include sending correspondence to providers, attending provider association and stakeholder meetings, creating virtual training presentations or videos, and providing technical assistance.

2. Examples of education and outreach content may include education on how Improper Payments are detected, explaining specific Review Scenarios and how to prevent Improper Payments, or reducing technical denials by responding to records requests (a “technical denial” is a potential Improper Payment detected through a Complex Scenario that is identified as an Improper Payments and recovered based on a provider’s failure to supply medical records or documentation upon request.).

B. Education and outreach materials must be approved by HHS OIG prior to use, presentation, or distribution.

2.2.3 Reporting Requirements

A. Contractor must respond to requests from HHS OIG staff for information and reports related to the Contract within 48 hours, excluding weekends and Holidays, unless HHS OIG agrees to an extension based on the complexity, volume, or other factors involved.

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B. Contractor must develop and deliver reports in a manner and schedule agreed upon by HHS OIG that enable HHS OIG to assess Contractor, program performance, and conduct RAC trend analysis. Examples of reports include:

1. Statistics regarding Automated and Complex Scenarios.

2. Scenario reports, such as the number and dollar value of claim details reviewed, the number of claim details that resulted in findings associated with the scenario, and the recoveries identified and collected (by provider, provider type, and in total).

3. Reports identifying providers that may benefit from education.

4. The number of letters sent to providers.

5. The number of medical records requested and received (by scenario, provider, provider type, and total).

6. The number and types of technical denials for each Complex Scenario.

7. Rebuttal and appeal trends (requested, completed, outcomes).

8. Customer service inquiries, including number of inquiries and response timeliness.

9. Call volume, answer rates, and hold times for the toll-free phone number.

10. Technical performance, including system availability, downtime, and performance.

11. Other reports as requested by HHS OIG to assess Contract and program performance.

C. Contractor must refer suspected cases of fraud, waste, or abuse to HHS OIG.

2.3 REQUIRED QUALIFICATIONS

2.3.1 Organizational Requirements

Contractor must maintain the qualifications described in 42 CFR § 455.508, which includes the technical capability to perform RAC services as described in 42 U.S.C. § 1396(a)(42)(B), 42 CFR §§ 455.500-455.518, Texas Government Code Section 531.117, 1 TAC § 354.1451, and the requirements detailed in Article V of this solicitation.

2.3.2 Key Personnel and Staffing

To prevent any real or perceived key personnel conflict of interest, Contractor will ensure that key personnel and reviewers (or those consulted during a review) do not participate in RAC activities, such as reviews or rebuttals, involving medical facilities, business entities, or https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-F/section-455.508 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-F?toc=1 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455/subpart-F?toc=1 https://statutes.capitol.texas.gov/Docs/GV/htm/GV.531.htm https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=1&pt=15&ch=354&rl=1451

PCS 550 HHS RFQ Template, RFQ No. HHS0013244 Page 20 of 65 individuals with which they are employed, contracted, or affiliated, either indirectly or directly, or with which they have been employed, contracted, or affiliated in the preceding 12 months.

2.3.2.1 Key Personnel and Required Credentials

A. Project Director: At least five (5) years of relevant experience in managing a complex system or project, ideally performing RAC or similar government or public health review activities, is preferred.

B. A minimum of one Medical Director or a Panel of Physicians to evaluate RAC scenarios and participate in reviews that involve services relevant to their area of medical expertise.

(Note: This is subject to change. Texas HHSC currently has an approved State Plan Amendment that allows the RAC Contractor to use a panel of physicians in lieu of a Medical Director). HHS OIG prefers Contractor provide both a Medical Director and a panel of medical professionals, as described below.

1. Medical Director: A physician with relevant Medicaid experience licensed to practice medicine in the State of Texas. The Medical Director must be a Doctor of Medicine or Doctor of Osteopathy actively licensed and in good standing with relevant State of Texas licensing authorities and must possess associated medical credentials from an accredited medical school.

2. Panel of Physicians: A panel of physicians and other medical professionals with a variety of specialties (Medical specialists may include, but not be limited to, pharmacists, radiologists, therapists and registered nurses) to review and assess the range of providers and services within Texas Medicaid. All individuals on the review panel must possess appropriate medical credentials for their specialty and must be actively licensed and in good standing with the relevant licensing authority (preferably Texas) for their area of medical specialization. If Contractor elects to provide a panel of physicians in lieu of or in addition to a Medical Director, the Medical Director is exempt from being licensed in Texas.

C. Certified Coder(s): Individuals certified and experienced in medical coding requirements, including processes and practices and who maintain active and ongoing continuing education to remain abreast of changes to medical coding guidelines. Certified coders are responsible for rendering coding determinations associated with Review Scenarios and the identification of Improper Payments.

D. Review Manager: Must have relevant experience in Medicaid policies, regulations, and claims reimbursement, as well as experience with compliance reviews or audit techniques and procedures. Certification as a Fraud Examiner, Fraud Investigator, or similar credentials are preferred.

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E. Medical Review/Utilization Manager: Must possess recent and relevant supervisory experience in medical utilization review.

F. Technical Point of Contact: Individual with relevant IT experience who is responsible for maintaining and overseeing Contractor’s technological infrastructure, including the online portal and telecommunication services. This position will coordinate with HHS OIG or its designee(s) regarding Contractor’s technology, telecommunication, and information security services.

G. Data Analytics Point of Contact: Individual with relevant data analysis or data science expertise who will coordinate with HHS OIG or its designee(s) regarding the Contractor’s data analytics services, including the logic and techniques associated with developing and maintaining RAC scenarios, comparing data sets, and reporting.

2.3.2.2 Key Personnel Maintenance

A. Contractor must provide and maintain key personnel and staffing at all times. HHS OIG reserves the right to add or modify positions as necessary for appropriate performance of the RAC program.

B. Contractor must provide HHS OIG with the list of all key personnel within ten (10) Calendar Days of awarded Contract execution.

C. Contractor must also provide HHS OIG with an updated list within ten (10) Calendar Days of any changes to key personnel.

D. Contractor must maintain and, upon request, provide HHS OIG with documentation regarding the credentials, employment history, or affiliations of individuals involved with review or rebuttal determinations, as well as other clinical, professional, or administrative staff.

2.4 TECHNICAL WEB REQUIREMENTS

2.4.1 Online Portal

A. Contractor must develop and maintain a secure online portal application accessible by HHS OIG, providers, and other stakeholders for:

1. Providers to designate and update their points of contact for RAC activities;

2. Electronic information exchange, including provider correspondence;

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3. Secure upload and storage of medical records and other documents related to RAC reviews; and

4. Tracking timeframes and displaying status updates related to RAC review activities (e.g., outstanding, received, review underway, review complete).

B. The portal must:

1. Be accessible via standard web browsers, such as Microsoft Edge, Google Chrome, and Mozilla Firefox;

2. Allow providers and other stakeholders to register for a portal account with a secure login and authentication process;

3. Include role-based security provisioning that conditions the levels of access available to different categories of users;

4. Be enabled to allow view-only access to all portal functionality, accounts information, and download/edit access to certain information. HHS OIG must approve roles for State users;

5. Include functionality for providers to designate one or more points of contact and associated demographics (e.g., name, title, phone number, email address, mailing address, fax number) for receiving RAC correspondence and coordinating rebuttals and appeals;

6. Allow upload of large documents or sets of documents (e.g., medical records), including the ability for document uploads to be named/labeled and categorized by predetermined labels;

7. Include a method to alert provider contacts when correspondence is added to their account or when a workflow status or activity changes;

8. Include capabilities to support appeal policies and procedures as defined by HHSC;

9. Include a method to communicate systemic information to all users (e.g., banner messages or similar functionality);

10. Be accessible 24/7, with the exception of standard downtime for enhancements and maintenance or unscheduled outages;

11. Publish notifications regarding scheduled maintenance on the login page at least 48 hours in advance of the planned downtime; and

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12. Serve as the official source of record for rebuttals and appeals.

13. Meet the compliance standards of TX-RAMP Level Two. See Section 1.2 Definitions, Section 2.13, Texas Risk and Authorization Management Plan, Exhibit M, HHSC Information Security Controls, Exhibit N, Insurance Security Assessment External Entities, and Exhibit O, HHS Information Security and Privacy Requirements.

C. The Contractor must report unscheduled outages to HHS OIG no later than 24 hours after Contractor becomes aware of an outage.

D. If Contractor does not have an online portal that meets the criteria in Subsection 2.4.1, (Online Portal), A and B, the Contractor must provide an alternative, interim option(s) to meet the communication requirements detailed herein, as well as a proposed timeframe for developing an online portal that meets these requirements.

1. If the alternative is a SaaS, Contractor must meet the National Institute of Standards and Technology (NIST) standard definition of SaaS. Refer to NIST Definition of Cloud Computing SP 800-145.

E. If the online portal initially proposed by the Contractor does not meet the necessary criteria, in Subsection 2.4.1, (Online Portal), A and B, HHS OIG may request the Contractor provide an interim solution and a timeframe for amending its online portal to meet HHS OIG’s requirements.

2.4.2 Data Sharing and Security

A. Contractor must ensure that all data transmission, exchange, and storage processes meet the technical specifications and information security standards applicable to the content of information being exchanged, which includes confidential data such as Personally Identifiable Information (PII) and Personal Health Information (PHI).

B. Contractor must ensure all data exchange and storage processes are secure and compliant with the Health Insurance Portability and Accountability Act (HIPAA) and all provisions of Exhibit D, HHS Data Use Agreement (DUA).

C. As Review Scenarios are developed, Contractor must consult with HHS OIG and/or its designee(s) to determine and document a complete list of the required data fields, with descriptions and associated parameters, that will be used for the detection and validation of Improper Payments.

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D. Contractor must coordinate with HHS OIG and its designee(s) to implement a data/file exchange solution that aligns with the existing infrastructure (e.g., file layouts, file types, secure data exchange methods) of the Medicaid Enterprise System (MES) or other systems from which data is collected and exchanged, with minimal impact to existing systems.

E. Contractor must document the agreed-upon data flow and information exchange in a diagram that details the data exchange processes, transmission methods or systems, and file layouts associated with RAC activities. Maintain and update these documents as necessary throughout the duration of the awarded Contract and submit updated iterations to HHS OIG as changes occur.

F. Contractor must respond to additional data exchange documentation requests from HHS OIG in the manner, format, and timeframe requested. For example, HHS OIG may request Contractor’s assistance in updating the RAC data exchange processes in HHSC’s Joint Interface Plan (JIP).

G. Upon request, Contractor must demonstrate, explain, or provide to HHS OIG the Contractor’s process(es) for comparing data sets and identifying inconsistencies in data provided by HHS OIG or other entities.

H. Contractor must receive and send all data in a format and timeline designated by HHS

OIG.

2.5 AGENCY REQUIREMENTS

HHS OIG (or its designee(s)) will:

A. Arrange a kick-off meeting with Contractor upon Contract execution;

B. Assist Contractor with development and facilitation of the RAC governance process;

C. Review and approve Contractor’s publications, correspondence templates, and other communications as necessary;

D. Coordinate with Contractor to define specific business processes and associated timelines;

E. Provide direction and technical assistance to the Contractor to support the fulfillment of the duties outlined in Article II, Scope of Work;

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F. Review and render approval decisions regarding Improper Payment Review Scenarios submitted by the Contractor. HHS OIG will establish a Scenario Review process to obtain input from other HHSC stakeholders or designee(s), as appropriate;

G. Provide Contractor with data sets applicable to a given review;

H. Identify claims or populations that should be excluded from a given review;

I. Coordinate recovery or recoupment of Improper Payments and…