F1681310284_AHCAITN00321.22AddendumNo.1.pdf

RON DESANTIS

GOVERNOR

SIMONE MARSTILLER

SECRETARY

Facebook .com/AHCAFlo r ida Youtube.com/AHCAFlor i da

Twi t te r . com/AHCA_FL S l ideShare.net /AHCAFlo r ida

2727 Mahan Dr ive • Mai l S top #15 Ta l lahassee, FL 32308 AHCA.MyFlor i da.com

December 1, 2021

Prospective Vendor(s):

Subject: Solicitation Number: ITN 003-21/22

Title: FX Claims and Encounters Processing (Core) Module

Addendum No. 1

The enclosed information has been provided for consideration in the preparation of your response to the above referenced solicitation.

All other terms and conditions of the solicitation remain in effect.

Section 120.57(3)(b), Florida Statutes and Section 28-110.003, Florida Administrative Code, require that a Notice of Protest of the solicitation documents shall be made within seventy-two hours after the posting of the solicitation. Failure to file a protest within the time prescribed in section 120.57(3), Florida Statutes, or failure to post the bond or other security required by law within the time allowed for filing a bond shall constitute a waiver of proceedings under chapter 120, Florida Statutes.

Sincerely, Ashley Balkcom Issuing Officer, Purchasing Manager Bureau of Support Services

Enclosures: Addendum No. 1 (3 Pages)

Exhibit A-4-a, Submission Requirements and Evaluation Criteria Components (Technical Response) - (42 Pages)

Exhibit B-1, Scope of Services (57 Pages) Exhibit B-1-a, Deliverables and Performance Standards (22 Pages)

Exhibit B-2-b, Service Level Metrics (10 Pages) Exhibit B-3-a, Requirements Matrix (94 Pages) Exhibit A-3-a, Required Certifications and Statements (6 Pages) Questions and Answers (11 Pages)

ITN 003-21/22

ADDENDUM NO. 1

ITN 003-21/22, Addendum No. 1, Page 1 of 3

Item #1

Attachment A, Instructions and Special Conditions, Section A.1, Instructions, Subsection D., Response Evaluation, Negotiations and Contract Award, Item 5., Scored Requirements – Evaluation Criteria, Table 3: Core ITN Evaluation Score Sheet, is hereby deleted in its entirety and replaced with the following:

Max Raw Score

Weight Factor Max Points

Possible

SRC# 1 Table of Contents SRC# 2 Executive Summary SRC# 3 Organizational Structure and History

SRC# 4 Respondent Qualifications 25 X

2.00 =

50.00 SRC #5 Customer Experience

SRC# 6 Sanctions 10 X

1.00 =

10.00

SRC# 7 Security Rating Score 5 X

4.00 =

20.00

SRC # 8 Project Management and Service Delivery Approach 25 X

1.42 =

35.50

SRC #9 Disaster Recovery and Business Continuity 30 X

1.00 =

30.00

SRC #10 Core Platform Solution (Technology) 15 X

17.00 =

255.00

SRC #11 Core Services Solution - Claims and Encounters 70 X

1.10 =

77.00

SRC #12 Core Services Solution - Capitation Process 55 X

1.40 =

77.00

SRC #13 Core Services Solution - Financial Management 50 X

1.50 =

75.00

SRC #14 Core Services Solution - Federal and Financial Reporting 35 X

1.50 =

52.50

SRC #15 Core Services Solution - Recipient Management 30 X

2.50 =

75.00

SRC #16 Performance Standards and Reporting 20 X

2.00 =

40.00

SRC #17 Security 20 X

1.50 =

30.00

ITN 003-21/22, Addendum No. 1, Page 2 of 3

Max Raw Score

Weight Factor Max Points

Possible

SRC #18 Deliverable Approach SRC #19 Optional Additional Innovation Opportunities SRC #20 Vendor Staffing

SRC #21 Facilities and Service Location(s) 15 X

1.00 =

15.00 SRC #22 Turnover Planning

SRC #23 Operations and Maintenance 35 X

2.30 =

80.50

SRC #24 Implementation and Transition Approach 20 X

2.00 =

40.00

SRC #25 General Core Product Demo 15 X

2.50 =

37.50

Total 475 1,000.00

Item #2

Attachment A, Instructions and Special Conditions, Exhibit A-4, Submission Requirements and Evaluation Criteria Components (Technical Response), is hereby deleted in its entirety and replaced with Exhibit A-4-a, Submission Requirements and Evaluation Criteria Components (Technical Response), attached hereto, and made a part of the ITN. All references in the ITN to Exhibit A-4 shall hereinafter refer to Exhibit A- 4-a.

Item #3

Attachment B, Scope of Services, is hereby deleted in its entirety and replaced with Attachment B-1, Scope of Services, attached hereto, and made a part of the ITN. All references in the ITN to Attachment B shall hereinafter refer to Attachment B-1.

ITN 003-21/22, Addendum No. 1, Page 3 of 3

Item #4

Attachment B-1, Scope of Services, Exhibit B-1, Deliverables and Performance Standards, is hereby deleted in its entirety and replaced with Exhibit B-1-a, Deliverables and Performance Standards, attached hereto, and made a part of the ITN. All references in the ITN to Exhibit B-1 shall hereinafter refer to Exhibit B-1-a.

Item #5

Attachment B, Scope of Services, Exhibit B-2-a, Service Level Metrics, is hereby deleted in its entirety and replaced with Exhibit B-2-b, Service Level Metrics, attached hereto, and made a part of the ITN. All references in the ITN to Exhibit B-2-a shall hereinafter refer to Exhibit B-2-b.

Item #6

Attachment B, Scope of Services, Exhibit B-3, Requirements Matrix, is hereby deleted in its entirety and replaced with Exhibit B-3-a, Requirements Matrix, attached hereto, and made a part of the ITN. All references in the ITN to Exhibit B-3 shall hereinafter refer to Exhibit B- 3-a.

Item #7

Attachment A, Instructions and Special Conditions, Exhibit A-3, Required Certifications and Statements, is hereby deleted in its entirety and replaced with Exhibit A-3-a, Required Certifications and Statements, attached hereto, and made a part of the ITN. All references in the ITN to Exhibit A-3 shall hereinafter refer to Exhibit A-3-a.

REMAINDER OF PAGE INTENTIONALLY LEFT BLANK

EXHIBIT A-4-a

SUBMISSION REQUIREMENTS AND EVALUATION CRITERIA

COMPONENTS (TECHNICAL RESPONSE)

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 1 of 42

Instructions to Respondents for the Completion of Exhibit A-4-a, Components (Technical Response):

The Agency is seeking information to determine the ability of Respondents to provide a Core module solution as described in this ITN, to include development and ongoing operations and maintenance services.

All Respondents to this ITN shall utilize Exhibit A-4-a, Submission Requirements and Evaluation Criteria Components (Technical Response), for submission of its response and shall adhere to the instructions below for each Submission Requirement Component (SRC).

Respondents shall not include website links, embedded links and/or cross-references between SRCs unless otherwise instructed within a particular SRC.

Each SRC contains form fields. Population of the form fields with text will allow the form field to expand and cross pages. There is no character limit.

Attachments are acceptable for any SRC but must be referenced in the form field for the respective SRC and located behind each respective SRC response. Respondents shall name and label attachments to refer to respective SRCs by the SRC identifier number.

Agency evaluators will be instructed to evaluate the responses based on the narrative contained in the SRC form fields and the associated attachment(s), if applicable.

Each SRC response will be independently evaluated and awarded points based on the criteria and points scale using the Standard Evaluation Criteria Scale, below, unless otherwise identified in each SRC contained within Exhibit A-4-a, Submission Requirements and Evaluation Criteria Components (Technical Response).

STANDARD EVALUATION CRITERIA SCALE

Point Score Evaluation

0 The component was not addressed anywhere in the response submission.

1 The component contained significant deficiencies and omissions and lacked meaningful detail.

2 The component is below average. It met some of the minimum requirements but did not address all elements requested.

3 The component is average and met the minimum requirements with minimum detail.

4 The component is above average. It exceeded the minimum requirements and provided good detail.

5 The component is excellent. It exceeded the minimum requirements and contained exceptional content and detail.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 2 of 42

The SRCs in Exhibit A-4-a, Submission Requirements and Evaluation Criteria Components (Technical Response), may not be retyped and/or modified and must be submitted in the original format.

Failure to submit SRC responses via Exhibit A-4-a, Submission Requirements and Evaluation Criteria Components (Technical Response), may result in the rejection of the response.

Exhibit A-4-a, Submission Requirements and Evaluation Criteria Components (Technical Response), is available for Respondents to download at:

http://ahca.myflorida.com/procurements/index.shtml.

http://ahca.myflorida.com/Procurements/index.shtml

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 3 of 42

Respondent Name:

SRC #1 – TABLE OF CONTENTS

The Respondent shall include a Table of Contents in its response. The Table of Contents shall contain section headings and subheadings along with corresponding page numbers. The Table of Contents page(s) shall be provided as the first page(s) of the Respondent’s Technical Response.

Response:

Score: No points will be awarded for the Table of Contents.

SRC #2 – EXECUTIVE SUMMARY

The Respondent shall include an Executive Summary, which demonstrates its overall understanding of the services described in this ITN and describes the prominent features of its Technical Response.

Score: No points will be awarded for the Executive Summary.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 4 of 42

SRC #3 – ORGANIZATIONAL STRUCTURE AND HISTORY

The Respondent shall demonstrate its capability to provide the services specified in this ITN by describing its organizational structure and history. For responses including the use of proposed subcontractors, the same descriptions of organizational structure and history shall be provided for each subcontractor, including the organizational structure connecting the Respondent and each proposed subcontractor. At a minimum, the description shall include:

1. The Respondent's, and its proposed subcontractor’s, organizational structure, ownership, affiliations, and location(s)

2. The Respondent's, and its proposed subcontractor’s, corporate organizational chart, and a depiction of where the Core Solution services described in this ITN falls within the organizational structure

3. Background information on the Respondent’s corporation, and on its proposed subcontractor’s corporation(s), the size, and resources, to include:

a. Name of Respondent and any subcontractor(s)

b. Date established

c. Ownership (public company, partnership, subsidiary, etc.)

d. Corporation's Federal Employer Identification Number (FEIN) and Florida Corporate

Charter Number

e. Corporation's primary line of business

f. Total number of employees

Attachments are limited to the following:

• Organizational chart of the Respondent and its subcontractor(s)

• List of the Respondent’s, and its proposed subcontractor’s, physical location(s)

Score: No points will be awarded for Organizational Structure and History.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 5 of 42

SRC #4 – RESPONDENT QUALIFICATIONS

The Respondent shall demonstrate its capability to provide the services specified in Attachment B-1, Scope of Services, by describing its relevant experience with large healthcare systems, qualifications, and length of experience in providing technology and services similar in nature to those described in this ITN. The description shall include how these experiences will be applied to move the Agency forward, based on its own current Strategic Plan. Details of corporate experience (including any subcontractor experience and capabilities) shall include a list of all contracts related to services similar in nature to those described in this ITN within the last five (5) years, and shall include, at a minimum:

1. Relevant experience with designing, developing, implementing, hosting, and maintaining information technology and business solutions including claims and encounters processing, financial management (including capitation payments), and recipient data management.

2. Relevant experience with developing and implementing technology services and support, business operations for large healthcare systems including project and program management, business requirements elicitation and development, system testing, and system implementation.

3. Capability to work in parallel on multiple projects, with multiple vendors, and maintain timelines while effectively working as a single, distributed team to meet State and federal requirements.

4. How the Respondent’s, and any subcontractor’s, qualifications and experience prepare the Respondent to move the Agency forward based on the goals, objectives, and guiding principles specified within the Agency’s Strategic Plan.

5. Any relevant experience the Respondent has with obtaining CMS certification for overall operations.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 6 of 42

SRC #4 Evaluation Criteria:

1. The adequacy of the Respondent’s capability and approach to meet the requirements described in this ITN, based on the relative experience in the performance of current or previous contracts for which it is/was the lead vendor on any projects similar in size, scope, and complexity to the Core Project in the past five (5) years.

2. The adequacy of the Respondent's relevant experience with large healthcare systems.

3. The adequacy of the Respondent’s experience and demonstrated capability to work in parallel to perform project and program management, business requirements elicitation and development, systems testing, and systems implementation.

4. The adequacy of the Respondent’s and any subcontractor’s qualifications and experience to move the Agency forward based on the goals, objectives, and guiding principles as described within the Agency’s Strategic Plan and to limit the potential for vendor lock-in and conflict of interest for future Agency acquisitions.

5. The adequacy of the Respondent's relevant experience with obtaining CMS certification.

Score: This section is worth a maximum of 25 raw points with each of the above criteria being worth a maximum of 5 points each.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 7 of 42

SRC #5 – CUSTOMER EXPERIENCE

The Respondent shall demonstrate its capability to integrate its proposed Core Solution with other Agency and vendor systems where the end-user has a consistent and unified digital user experience across all modules. In addition, the Respondent shall demonstrate its capability to continuously improve the experience of customers, including recipients, providers, and other Stakeholders. The Respondent shall provide an overview of its experience in improving customer experience and using tools (i.e., customer experience blueprint, customer journey maps) to continuously improve the customer experience.

Score: No points will be awarded for Customer Experience. The response will be reviewed by the Agency and may be addressed with the respondent in the negotiation phase of the ITN, at the Agency’s discretion.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 8 of 42

SRC #6 – SANCTIONS

The Respondent shall list and describe any sanctions levied against the Respondent, its affiliates, its subsidiaries, its parent company, the affiliates and subsidiaries of its parent company, its affiliate’s subsidiaries and subcontractors (handling subcontracts related to consultant services when the subcontracts are for $250,000.00 or more annually), within the five (5) years preceding the date of its response to this ITN. Sanctions shall include those imposed by a state or federal entity in relation to a contract under which the Respondent provided health care system implementation and operations services or government services contracts in excess of one million dollars ($1,000,000.00). Sanctions shall include financial consequences, damages, liquidated damages, or other amounts paid by the Respondent in a settlement of a contract dispute.

Information requested for each sanction shall be provided by the Respondent for administrative and non-administrative sanctions. An administrative sanction means the issue pertains to timeliness or the use of an incorrect format (i.e., report, deliverable, or another required item submitted late or submitted in the wrong format). A non-administrative sanction means the issue pertains to performance in accordance with the contract scope of services (i.e., incomplete, or inaccurate deliverable or services).

SRC #6 Evaluation Criteria:

1. The extent to which sanctions were due to issues with performance (non-administrative) in accordance with the contract scope of services, versus administrative issues.

2. The severity of the sanction(s) from minor (dollar amounts less than $10,000.00 or resolution time less than 90 calendar days) to significant ((dollar amounts above $10,000.00 or resolution time longer than 90 calendar days or numerous sanctions (more than one sanction among two or more contracts)).

Score: This section is worth a maximum of 10 raw points with each of the above criteria

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 9 of 42

For Item 1:

a. 5 points if no sanctions.

b. 4 points if sanction(s) were related only to administrative issues.

c. 3 points if non-administrative sanction(s) were all minor and there were fewer than four (4) incidents.

d. 2 points if non-administrative sanctions were all minor but four (4) or more incidents.

e. 1 point if any significant administrative sanction.

f. 0 points if any significant non-administrative sanction.

For Item 2:

a. 5 points if no sanctions.

b. 4 points if sanction(s) were minor and there were fewer than four (4) incidents.

c. 3 points if sanctions were all minor but four (4) or more incidents.

d. 2 points if up to two (2) significant sanction(s); or more than two (2) contracts with multiple sanctions.

e. 1 point if more than two (2) significant sanctions but fewer than five (5); or more than two (2) but fewer than five (5) contracts with multiple sanctions.

f. 0 points if performance falls below the above limits.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 10 of 42

SRC #7: SECURITY RISK RATING SCORE SCAN

In accordance with Attachment B-1, Scope of Services, Section E., Special Provisions, subsection 7, Information Technology, Item 7.1, Development Requirements, sub-item ee., the Agency will conduct an initial IT security risk rating score scan on the Respondent through an IT security risk rating service, at the Agency's expense, to enable the Agency to effectively measure and mitigate the successful Respondent’s security risks. The Respondent shall work with the Agency’s security risk rating service provider to define the relevant Respondent assets providing Agency services.

SRC #7 Evaluation Criteria:

The adequacy of the Respondent’s IT security risk rating score by determining whether the Respondent has received:

a. A score in the top 90-100% of the scan recommendations.

b. A score in the top 80-89% of the scan recommendations.

c. A score in the top 70-79% of the scan recommendations.

d. A score in the top 60-69% of the scan recommendations.

e. A score in the top 50-59% of the scan recommendations.

f. A score in the lower 0-49% of the scan recommendations.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 11 of 42

Score: This Section is worth a maximum of 5 raw points as outlined below:

a. 5 points for a score in the top 90-100% of the scan recommendations.

b. 4 points for a score in the top 80-89% of the scan recommendations.

c. 3 points for a score in the top 70-79% of the scan recommendations.

d. 2 points for a score in the top 60-69% of the scan recommendations.

e. 1 point for a score in the top 50-59% of the scan recommendations.

f. 0 points for a score in the lower 0-49% of the scan recommendations.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 12 of 42

SRC #8 – PROJECT MANAGEMENT AND SERVICE DELIVERY

APPROACH

The Respondent shall present its project management and service delivery approach and explain how it reflects industry best practices in service delivery excellence. The Respondent shall demonstrate its capabilities in working with third-party organizational standards by developing an approach that complies with the Agency's FX Project Management Standards included in the Core Proposal Library.

The Respondent shall describe its proposed approach to PD-1: Project Management Plan (includes the Core Vendor Resource Management Plan) and provide a draft PD-2: Project Schedule, as described in Attachment B-1, Scope of Services, Exhibit B-1-a, Deliverables and Performance Standards.

The proposed draft Project Schedule should show the Respondent’s thorough understanding of the services required in this ITN, and the capability to successfully complete each deliverable.

The draft Project Schedule shall include a high-level project timeline for successful management and completion of the project, as well as identify major project phases with consideration to Attachment B-1, Scope of Services, Section B., Manner of Services Provisions, subsection 8, Transition/Design, Development, and Implementation (DDI), Item 8.2., Implementation Plan, and any applicable requirements specified in Exhibit B-3-a, Requirements Matrix. The draft Project Schedule must include timeframes and durations for key milestones and deliverables.

The Respondent shall demonstrate the following:

1. Approach to following project management best practices to ensure adherence to the P-2: FX

Project Management Standards, including, but not limited to:

a. Communications management

b. Risk and issue management

c. Change management

d. Scope management

e. Schedule management

f. Requirements management

g. Quality management

h. Status reporting

i. Human resource management

2. Experience following third party standards (such as the FX Program standards included in the

Core Proposal Library).

3. Experience implementing the System Development Life Cycle (SDLC) for multi-component configurable and customizable technology platforms.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 13 of 42

4. Experience in, and approach to, successful delivery of services and solutions in a multi-vendor and multi-agency environment.

5. Ability to effectively manage multiple teams that would include the Respondent, subcontractor(s), and Agency Core staff.

6. Ability to implement and provide services and solutions to be adapted to accomplish the Core

Objectives and FX Guiding Principles outlined in Attachment B-1, Scope of Services, Section A., Services to be Provided, subsection 3, General Overview, Items 3.2, Overview of the FX Transformation and 3.5, Core Module Objectives.

SRC #8 Evaluation Criteria:

1. The adequacy of the Respondent’s proposed approach to project management and service delivery, and its alignment with FX Project Management Standards, including demonstrated understanding and approach to the System Development Life Cycle (SDLC) for a multi-component configurable and customizable technology platform.

2. The adequacy of the Respondent’s draft Project Schedule to demonstrate a high-level project timeline for successful management and capability to successfully complete each deliverable.

3. The adequacy of the Respondent's experience following third party standards (such as the

FX Program standards included in the Core Proposal Library).

4. The adequacy of the Respondent’s experience and demonstrated ability to successfully deliver in a multi-vendor and multi-agency environment.

5. The demonstrated ability of the Respondent to effectively manage multiple teams including Core Vendor, subcontractor and Agency staff.

Score: This Section is worth a maximum of 25 raw points with each of the above criteria

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 14 of 42

SRC #9 – DISASTER RECOVERY AND BUSINESS CONTINUITY

1. The Respondent shall demonstrate its capability and approach to meeting the disaster recovery and business continuity requirements described in the referenced subsections, below, of Attachment B-1, Scope of Services, Section B., Manner of Services Provisions, and Exhibit B-3-a, Requirements Matrix.

a. Subsection 9.3, Disaster Recovery and Business Continuity

b. Subsection 11.1, Operations and Maintenance Phase Requirements

c. Subsection 15, Facilities and Service Location(s)

SRC #9 Evaluation Criteria:

For both technology and services, the adequacy of the Respondent’s ability to:

1. Maintain and annually test a Contingency Plan (for Disaster Recovery and Business continuity) for the Core Solution with the FX Technical Management Strategy.

2. Support the Agency’s Enterprise Contingency Plan and coordination of related activities.

3. Provide backup procedures, hot sites, redundancy, and support to prevent and accommodate the disruption of systems and communications.

4. Minimize downtime and disruption of services.

5. Provide timely failover.

6. Create effective policies and procedures to implement a recovery, as well as business continuation services.

Score: This Section is worth a maximum of 30 raw points with each of the above criteria

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 15 of 42

SRC #10 – CORE PLATFORM SOLUTION (TECHNOLOGY)

The Respondent shall demonstrate its capability and approach to meeting the requirements described in Attachment B-1, Scope of Services, Section B., Manner of Services Provisions, subsection 9, Core Platform Solution (Technology), and any applicable requirements specified in Exhibit B-3-a, Requirements Matrix, including, but not limited to, ensuring its Core Solution provides all the required technology components and specified options, and all components are integrated into one common solution. In addition, the Respondent shall complete and submit with its response to this SRC, Attachment B-1, Exhibit B-4, Core Technology Matrix, to provide its proposed solution components.

SRC #10 Evaluation Criteria:

The adequacy of the Respondent's demonstrated ability to:

1. Provide hosting services to meet the Agency’s requirements and support optimal performance of the Core Solution.

2. Provide a Core solution that includes adequate quality management capabilities.

3. Provide a Core solution with relevant business operations technologies.

Score: This Section is worth a maximum of 15 raw points with each of the above criteria

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 16 of 42

SRC #11 – CORE SERVICES SOLUTION (CLAIMS AND ENCOUNTERS)

The Respondent shall demonstrate its proposed approach to providing a Core Services Solution addressing all requirements specified in Attachment B-1, Scope of Services, Section B., Manner of Services Provisions, subsections 10.1 through 10.6. and 10.11. At a minimum, the Respondent shall demonstrate its experience and proposed approach to:

1. Providing a Core Services Solution that will adjudicate fee-for-service (FFS) claims for Medicaid reimbursement, including the following services:

a. Electronic Data Interchange (EDI) and web portal claims submission and outbound transactions using HIPAA mandated X12 standards.

b. Configurable business rules to manage edit and audit disposition criteria and status.

c. Plan match, coverage, reimbursement rules and methodologies associated with claim pricing.

d. Calculating the allowed amount and application of payment deductions and cost sharing requirements, based on client, and claim criteria.

e. Responding to submitter on claim disposition through an electronic Explanation of Benefits

(EOB) or other applicable X12 transactions.

f. Transaction adjustment processes with automated and ad-hoc functions to support retroactive rate changes, procedure or diagnosis code revisions, benefit plan updates, audit activities.

g. Functionality to interface with the Agency’s Utilization Management Vendor for service authorizations and referrals and the outsourced TPL Vendor for cost avoidance and recoupment activities.

h. Manage reference information that supports the core business areas for processing claims.

2. Providing a Core Services Solution that will process managed care encounters, including the following services:

a. EDI submission and outbound transactions using HIPAA mandated X12 standards.

b. Configurable business rules separate from claims processing to manage criteria.

c. Plan match, coverage, reimbursement rules and methodologies associated with encounter shadow pricing.

d. Shadow price calculation based on recipient and claim criteria, allowed amount and application of payment deductions and cost sharing requirements, including the capture of actual plan paid amount.

e. Responding to submitter on encounter disposition through an electronic Explanation of Benefits (EOB) or other applicable X12 transactions.

f. Functionality to interface the Agency’s Pharmacy Benefit Management Vendor to accept and process pharmacy encounters.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 17 of 42

SRC #11 Evaluation Criteria:

The adequacy of the Respondent’s relevant experience with and proposed approach to:

a. Designing, developing, implementing, and maintaining a claims processing and adjudication solution that can process a large volume of transactions.

b. Designing, developing, implementing, and maintaining an EDI and web-portal claims submission and outbound transaction service.

c. Designing configurable business rules to manage edit and audit disposition criteria.

d. Claim pricing methodologies, reimbursement rules, and plan and coverage match criteria.

e. Calculating the allowed amount and application of payment deductions and cost sharing requirements.

f. An electronic Explanation of Benefits (EOB) or other applicable X12 transactions responding to submitters on claim and encounter disposition.

g. Transaction adjustment processes with automated and ad-hoc functions to support retroactive rate changes, procedure or diagnosis code revisions, benefit plan updates, audit activities.

h. Developing, implementing, and maintaining an interface with the Agency’s Utilization Management Vendor for service authorizations and referrals and the outsourced Third-Party Liability (TPL) Vendor for cost avoidance and recoupment activities.

i. Managing reference information that supports the core business areas for processing claims.

j. Designing, developing, implementing, and maintaining an encounter processing solution that can process a large volume of transactions.

k. Designing, developing, implementing, and maintaining an EDI for encounter submission and outbound transaction service.

l. Designing configurable business rules specific to encounters.

m. Shadow pricing methodologies and calculation.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 18 of 42

n. Developing, implementing, and maintaining, an interface the Agency’s Pharmacy Benefit Management Vendor to accept and process pharmacy encounters

Score: This Section is worth a maximum of 70 raw points with each of the above criteria

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 19 of 42

SRC #12 – CORE SERVICES SOLUTION (CAPITATION PROCESS)

The Respondent shall demonstrate its proposed approach to providing a Core Services Solution addressing all requirements specified in Attachment B-1, Scope of Services, Section B., Manner of Services Provisions, subsection 10.10, Capitation Payments. At a minimum, the Respondent shall demonstrate its experience and proposed approach to:

1. Providing a Core Services Solution that will support the capitation process (currently known as the “monthly magic” process), including:

a. Maintaining and updating capitation rates for each rate cell. Capitation rate determination based upon pre-defined rate tables with beginning and ending effective dates.

b. Maintenance of a rate structure hierarchy, including the ability for special conditions to trigger a specialized capitation rate.

c. Capitation payment based on the rate cell that the recipient falls into (based on but not limited to, date, age, gender, aid category).

d. Configurable business rules to apply capitation recoupments during the capitation cycle.

e. Automatic generation of a capitation or capitation adjustment based on updated enrollment or recipient demographics.

f. Process for performing capitation rate reprocessing.

g. Process to report capitation payment on ASC X12N 820 as required by HIPAA.

h. Generating enrollment rosters for each managed care plan in a HIPAA (834) format that reconciles with each plan’s 820 file.

i. Generating monthly capitation payments (e.g., prospective, retro-active, manual, real-time, etc.) on a defined frequency.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 20 of 42

SRC #12 Evaluation Criteria:

The adequacy of the Respondent’s relevant experience with and proposed approach to:

1. Processing large volumes of capitation payment transactions.

2. Maintaining and updating capitation rates for each rate cell.

3. Determining capitation rates based upon pre-defined rate tables.

4. Maintaining rate structure hierarchy, including the ability for special conditions to trigger a specialized capitation rate.

5. Generation of a capitation payment based on the rate cell that the recipient falls.

6. Configuring business rules to apply capitation recoupments during the capitation cycle.

7. Generating capitation or capitation adjustments based on updated enrollment or recipient demographics.

8. Capitation rate reprocessing.

9. Reporting capitation payment on ASC X12N 820.

10. Generating enrollment rosters for each managed care plan in a HIPAA (834) format that reconciles with each plan’s 820 file

11. Generating monthly capitation payments (e.g., prospective, retro-active, manual, real-time, etc.) on a defined frequency.

Score: This Section is worth a maximum of 55 raw points with each of the above criteria

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 21 of 42

SRC #13 – CORE SERVICES SOLUTION (FINANCIAL MANAGEMENT)

The Respondent shall demonstrate its proposed approach to providing a Core Services Solution addressing all requirements specified in Attachment B-1, Scope of Services, Section B., Manner of Services Provisions, subsections 10.7, Fiscal Management and 10.10, Capitation Payments. At a minimum, the Respondent shall demonstrate its experience and proposed approach to:

1. Providing a Core Services Solution that will support all Medicaid financial activity including, but not limited to, capitation payments and FFS claims, including the following services:

a. Financial payment activity to ensure accurate calculation and disbursement of various capitation payments (health and dental plans, Provider Service Network (PSN), Capitation Non-Emergency Transaction (CNET) and Dual Special Needs Plan (DSNP), Incentive Payments, Premium Payments, and No Emergency Transport Payments)).

b. Process to managing the payment of claims in a financial cycle.

c. Generating detailed remittance advice (e.g., paid claims, denied claims, reason, and remark codes) for each payee that reflects all financial activity in a payment cycle.

d. Process and controls to manage associated financial activities (e.g., accounts payable, accounts receivable, cash receipts, bank reconciliations).

e. Producing accurate annual 1099 forms in accordance with IRS specifications for all providers and vendors that reflect all payments and adjustments made through the financial system (e.g., claims, adjustments, voids, and any other financial transactions).

f. Managing the payment processes for Medicare programs (e.g., buy-in, claw back, Part D) related to Agency Healthcare Program.

g. Processes to suspend, terminate, withhold, or continue processing payments to providers under investigation.

h. Interfacing with the Agency’s financial systems and banking vendor to report and reconcile financial activities.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 22 of 42

SRC #13 Evaluation Criteria:

The adequacy of the Respondent’s relevant experience with and proposed approach to:

1. Processing large volumes of financial transactions.

2. Generally accepted accounting principles and controls related to all financial activities.

3. Managing the payment of claims in a financial cycle.

4. Generating detailed remittance advice (e.g., paid claims, denied claims, reason, and remark codes) for each Payee that reflects all financial activity in a payment cycle.

5. Financial payment activity to ensure accurate calculation and disbursement of various capitation payments.

6. Process and controls to manage associated financial activities (e.g., Accounts Payable, Accounts Receivable, Cash Receipts, Bank Reconciliations).

7. Producing annual 1099 forms in accordance with IRS specifications for all providers and vendors that reflect all payments and adjustments made through the financial systems.

8. Managing the payment processes for Medicare programs.

9. Suspending, terminating, withholding, or continuing processing payments to providers under investigation.

10. Developing, implementing, and maintaining an interface with the Agency’s financial systems and banking vendor to report and reconcile financial activities.

Score: This Section is worth a maximum of 50 raw points with each of the above criteria

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 23 of 42

SRC #14 – CORE SERVICES SOLUTION (FEDERAL AND FINANCIAL

REPORTING)

The Respondent shall demonstrate its proposed approach to providing a Core Services Solution addressing all requirements in Attachment B-1, Scope of Services, Section B., Manner of Services Provisions, subsections 10.8, Federal Reporting and 10.9, Financial Reporting. At a minimum, the Respondent shall demonstrate its experience and proposed approach to:

1. Providing a Core Services Solutions reporting capabilities in coordination with the EDW

Vendor to comply with federal reporting requirements, including the following services:

a. Collecting and grouping required data to facilitate the execution of federally mandated reports.

b. Interfacing with the EDW Vendor to store the required data in the EDW Vendor’s

Operational Data Store (ODS).

c. Supplying the accurate and necessary data to the EDW Vendor for Transformed Medicaid

Statistical Information (TMSIS), Management and Administrative Reporting (MAR) and Surveillance and Utilization Review (SUR) reports.

d. Processing to ensure the quality of data submitted and remediation activities for corrections.

2. Providing a Core Services Solutions reporting capabilities throughout the adjudication process for claims and encounters, reimbursement, and financial management, including the following services:

a. Collecting required data for each process associated with claim and encounter adjudication.

b. Interfacing with the EDW Vendor to store the required data in the EDW Vendor’s

Operational Data Store (ODS).

c. Producing standard financial management reports including of provider payments by expenditure categories, provider receivables, and bank reconciliation.

d. Process to ensure the quality of data submitted and remediation activities for corrections.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 24 of 42

SRC #14 Evaluation Criteria:

The adequacy of the Respondent’s relevant experience with and proposed approach to:

1. Collecting and grouping required data to facilitate the execution of federally mandated reports.

2. Developing, implementing, and maintaining an interface with the EDW Vendor to store required data in the EDW Vendor’s Operational Data Store (ODS).

3. Financial payment activity to ensure accurate calculation and disbursement of various capitation payments.

4. Process and controls to supply accurate and necessary data to the EDW Vendor for

Transformed Medicaid Statistical Information (TMSIS), Management and Administrative Reporting (MAR) and Surveillance and Utilization Review (SUR) reports.

5. Ensuring the quality of data submitted and remediation activities.

6. Collecting required data for each process associated with claim and encounter adjudication.

7. Producing standard financial management reports including of provider payments by expenditure categories, provider receivables, and bank reconciliation.

Score: This Section is worth a maximum of 35 raw points with each of the above criteria

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 25 of 42

SRC #15 – CORE SERVICES SOLUTION (RECIPIENT MANAGEMENT)

The Respondent shall demonstrate its proposed approach to providing a Core Services Solution addressing all requirements in Attachment B-1, Scope of Services, Section B., Manner of Services Provisions, subsection 10.11, Recipient Management. At a minimum, the Respondent shall demonstrate its experience and proposed approach to:

1. Providing a Core Services Solution that will receive, maintain, and reconcile recipient eligibility and enrollment information to support Core and other enterprise business functions, including the following services:

a. Interfacing with partner agencies (e.g., DCF, SSA, CMS, FHKC, etc.) to receive eligibility information on recipients.

b. Process to maintain eligibility files for benefit plan assignment, to support claims and encounter processing, eligibility inquiries, calculate provider and plan reimbursement, cost sharing, managed care plan assignment, and to facilitate utilization review and analysis.

c. Process to ensure that Medicaid recipients entitled to Medicare Buy-in receive their benefits.

d. Reconciliation processes to ensure the integrity of the data and to support other Core business functions that utilize recipient data.

e. Assignment algorithms for mandatory managed care enrollment.

f. Coordination with the UOC Vendor to provide recipient eligibility and enrollment support services.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 26 of 42

SRC #15 Evaluation Criteria:

The adequacy of the Respondent’s relevant experience with and proposed approach to:

1. Developing, implementing, and maintaining interfaces with partner agencies to receive eligibility information on recipients.

2. Maintaining eligibility files that support benefit plan assignment, claims and encounter processing, eligibility inquiries, calculate provider and plan reimbursement, cost sharing, managed care plan assignment, and to facilitate utilization review and analysis.

3. Ensuring that Medicaid recipients entitled to Medicare Buy-in receive their benefits.

4. Reconciliation processes to ensure the integrity of the data and to support other Core business functions that utilize recipient data.

5. Developing, implementing, maintaining, and assigning algorithms for mandatory managed care enrollment.

6. Coordination with the UOC Vendor to provide recipient business services and support of eligibility and enrollment activities.

Score: This Section is worth a maximum of 30 raw points with each of the above criteria

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 27 of 42

SRC #16 – PERFORMANCE STANDARDS AND REPORTING

1. The Respondent shall demonstrate its experience, understanding and ability to provide an automated method or system/operations tools to provide reports of the quality measurements and performance monitoring dashboards for the post-implementation Core Solution services as specified in Attachment B-1, Scope of Services, Section B., Manner of Services Provisions, subsection 12, Reporting and Exhibit B-2, Operations and Maintenance Service Level Agreement, and any applicable requirements specified in Exhibit B-3-a, Requirements Matrix. This shall include, at a minimum, the following:

a. Providing a Core performance reporting dashboard system and resulting generated reports to the Agency’s Contract Manager.

b. Providing real-time performance reporting dashboards for contracted performance standards and Service Level Metrics described in Attachment B-1, Scope of Services, Exhibit B-2-b, Operations and Maintenance Service Level Metrics.

c. Storing and reporting relevant data for ongoing and ad hoc reporting, including methods for conducting quality control.

Adhering to and reporting on Service Level Metrics provided in Attachment B-1, Scope of Services, Exhibit B-2-b, Operations and Maintenance Service Level Metrics.

2. The Respondent shall submit, with its response, samples of the following types of dashboard report exports:

a. Staffing Report

b. Executive Level Dashboard Report

c. Contract Compliance / Service Level Metrics Dashboard

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 28 of 42

SRC #16 Evaluation Criteria:

1. The adequacy of the Respondent’s relevant experience with and proposed approach to providing web-based reporting dashboard solutions and tools for performance reporting.

2. The adequacy of the Respondent's proposed approach and demonstrated ability to meet the Service Level Metrics.

3. The adequacy of the Respondent’s relevant experience and proposed approach to developing standard report dashboard extracts and ad hoc queries for the Core Solution.

4. The adequacy of the Respondent’s sample dashboard reports to demonstrate a successful performance and status reporting approach (storing, data reporting, quality control, etc.) for the Core Solution.

Score: This Section is worth a maximum of 20 raw points with each of the above criteria

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 29 of 42

SRC #17 – SECURITY

1. The Respondent shall demonstrate its experience, capability, approach and proposed solution for the Security Life Cycle to include activities defined in certification and accreditation, risk assessment, and system security plan phases and to address the requirements in Attachment B-1, Scope of Services, Section B., Manner of Services Provisions, subsection 9.7, Security, to:

a. Coordinate with stakeholders to develop and execute a Systems Security Plan, security controls, security assessments, and risk assessments, in compliance with all State and federal enterprise information security policies, standards, security initiatives, and regulations.

b. Develop and execute a Security Controls Test Plan that includes objectives, scope, misuse cases, testing type, entrance and exit criteria, schedule, testers, software tools, and test results.

c. Develop and execute a Security Test Plan for all shared infrastructure, connectivity and communications between the EDW Solution, the Integration Platform and the modules.

d. Conduct periodic Security Control Assessments to monitor ongoing effectiveness of implemented security controls and remediate those issues as determined by the Agency.

2. The Respondent shall describe its proposed plan and approach to resolving security breaches in relation to the Core Solution. The Respondent shall also describe any security breaches that have occurred within the last five (5) years and the remedies used for those breaches, if applicable. The described security breach(s) may pertain to more than one (1) system.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 30 of 42

SRC #17 Evaluation Criteria:

1. The adequacy of the Respondent’s proposed approach and demonstrated ability to meet all federal, state, and Agency security requirements.

2. The adequacy of the Respondent’s proposed Core Solution in terms of including all security/vulnerability testing as outlined in T-8: Enterprise Data Security Plan, in the Core Proposal Library.

3. The demonstrated ability of the Respondent to provide a hosting environment that is FEDRAMP compliant.

4. The demonstrated capability of the Respondent to resolve security breach incidents.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 31 of 42

SRC #18 – DELIVERABLE APPROACH

1. The Respondent shall describe its relevant experience, proposed approach, and representative content, relative to the Core deliverables described in Attachment B-1, Scope of Services, Exhibit B-1-a, Deliverables and Performance Standards. Where proposed approaches and content for a deliverable are addressed by the Respondent in another SRC, the Respondent shall refer to the other SRC(s) within its response to SRC #18.

a. PD-1 Project Management Plan (Includes Vendor Resource Management Plan)

b. PD-2 Project Schedule

c. PD-3 High-Level Technical Design

d. PD-4 System Security Plan

e. PD-5 Requirements Management Plan

f. PD-6 Bill of Materials

g. PD-7 Completed Requirements Traceability Matrix

h. PD-8 System Design Document (Architecture Specifications)

i. PD-9 Implementation Plan/Software Release Plan

j. PD-10 Contingency Plan (for Disaster Recovery and Business Continuity)

k. PD-11 Test Plan

l. PD-12 Customer Experience Blueprint Integration

m. PD-13 Organizational Change Management Plan

n. PD-14 Training Approach and Plan

o. PD-15 Training Materials

p. PD-16 Training Delivery

q. PD-17 Operations and Maintenance Manual

r. PD-18 Production Readiness Review

s. PD-19 Post Implementation Report

t. PD-20 Warranty Completion Report

u. PD-21 Annual Operational Analysis (AOA)

v. PD-22 Vendor Turnover Plan

Score: No points will be awarded for Deliverable Approach. The response will be reviewed by the Agency and may be addressed with the respondent in the negotiation phase of the ITN, at the Agency’s discretion.

AHCA ITN No. 003-21/22, Attachment A, Exhibit A-4-a, Page 32 of 42

SRC #19 - OPTIONAL ADDITIONAL INNOVATION OPPORTUNITIES

1. General Opportunities – The Respondent may include any additional innovations offered to the Agency that are not included in Attachment B-1, Scope of Services. The requirements described in Attachment B-1, Scope of Services are not intended to limit innovations, cost effective solutions, or creativity in preparing a response, which provides the Agency the best solution. Innovative ideas, product offerings, and new concepts other than those presented in this ITN can be considered by the Respondent. Responses to this SRC will not be scored and may, at the Agency’s discretion, be included in the Negotiations phase of this ITN.

The market for operations and business services is constantly changing, offering new or modified service delivery methods and technologies. The Agency is seeking a Core vendor that will utilize Agency-approved innovative methods and technologies to meet Core objectives and demonstrate tangible benefits.

Following are examples of areas where potential innovations may be of benefit:

a. Self service capabilities

b. 100% paperless service delivery

c.