HMO_Attachment B - Technical.xlsx

XLSX spreadsheet 262 KB Posted Aug 2, 2022

Attached to: TPA Services for HMO
Solicitation number: ITN-02183
Issued by: Leon County, Florida

About this file

Written by GovTribe AI · Jul 30, 2024

This document is an Invitation to Negotiate (ITN) issued by the State of Florida, Department of Management Services (Department) to establish a contract for Third Party Administrative (TPA) Services for Health Maintenance Organization (HMO) coverage. The ITN requests Replies from interested Respondents that include technical and cost information for the provision of HMO TPA services. Key details include the availability of an HMO Standard plan and an HMO High Deductible Health Plan (HDHP), as well as the requirement for Respondents to provide separate technical and cost replies. Respondents must also provide details on network access, medical and pharmacy network management, clinical and quality care programs, wellness program capabilities, services and administration, ongoing services, and renewals. The contract term is not specified, but the ITN indicates the Department may renew the contract.

The ITN provides detailed instructions for pricing, including requirements for Respondents to break out various administrative fees and medical and pharmacy management fees. It also notes that the Department may consider set-asides for certain vendors. The current incumbent provider is not identified. Funding for the contract will come from the Department, but specific amounts or sources are not provided. Respondents must submit their Replies by the stated due date to be considered.

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Other files

File	Type	Posted
Addendum No. 4.pdf	PDF	Aug 2, 2022
DMS-2223-072 HMO ITN.pdf	PDF	Aug 2, 2022
Revised Forms 5b and 6b.pdf	PDF	Aug 2, 2022
HMO_Attachment E -Draft Contract.pdf	PDF	Aug 2, 2022
HMO_Attachment G - Benefits Doc_HMOSPD_2022.pdf	PDF	Aug 2, 2022
HMO_Attachment H - Data Use Agreement.pdf	PDF	Aug 2, 2022
Revised Attachment E -Draft Contract.pdf	PDF	Aug 2, 2022
DMS-2223-072_Addendum No. 1.pdf	PDF	Aug 2, 2022
HMO Addendum No. 2.pdf	PDF	Aug 2, 2022
HMO_Attachment A - Administrative Requirements_07.27.2022.xlsx	XLSX spreadsheet	Aug 2, 2022
HMO_Attachment D - Cost_09.12.2022.xlsx	XLSX spreadsheet	Aug 2, 2022
Revised Attachment A - Administrative Requirements_9.9.22.xlsx	XLSX spreadsheet	Aug 2, 2022
Revised Attachment B - Technical_9.9.22.xlsx	XLSX spreadsheet	Aug 2, 2022
Addendum No. 3.pdf	PDF	Aug 2, 2022
Attachment H2 - Data Use Agreement.pdf	PDF	Aug 2, 2022
HMO_Attachment C - Network.xlsx	XLSX spreadsheet	Aug 2, 2022
HMO_Attachment D - Cost.xlsx	XLSX spreadsheet	Aug 2, 2022
HMO_Attachment F - BAA.pdf	PDF	Aug 2, 2022
Questions and Answers HMO.pdf	PDF	Aug 2, 2022

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Tech Q

Invitation to Negotiate (ITN) for the State of Florida, Department of Management Services (Department)

HMO Medical

Technical Questionnaire

Respondent Name:

[Insert Respondent Name Here]

Indicate Carve-in / Carve-out

[Indicate Carved-in / Carved-out]

Instructions: Enter the answer to each question using the "Reply" column. Use the "Explanation" column to provide an explanation, if applicable. Written Replies and Explanations within this excel Attachment must be limited to 400 characters or less. Written Replies and Explanations beyond 400 characters will not be evaluated.

The questions indicated with a “¥” will not be scored by the Evaluators, as described in section 4.3 of this ITN.

		SECTION I.
		NETWORK ACCESS/MEDICAL NETWORK MANAGEMENT	Answer Format	Reply	Explanation
		Employees' Access to Providers
1		Describe the national and regional networks that would be available for use with this ITN.	text
2		Does Respondent maintain executed contracts with all providers participating in the network?	drop down box
3		Confirm that Respondent's provider contracts do not provide for any type of remuneration to Respondent's firm, such as commission, finder's fee, rebate, or other financial benefit.	drop down box
4		Please describe how Respondent's claim processing system accommodates and accurately processes claims utilizing any/all combination of multi-tiered networks, customized financial controls, and/or special contracts negotiated by a Client.	text
5		Does Respondent have clients who currently have direct contracts with healthcare entities and providers? If awarded, would the Respondent be willing to amend the awarded contract to use pricing contracts that Department is able to negotiate outside of the Respondent's organization (use Explanation column to respond)?	drop down box
6		In the state of Florida overall, what has been the Respondent's average network turnover rate within the last twenty-four (24) months for each of the following categories of providers:
	a.	PCP (Family/General Practitioner/Internist/OB/GYN/ Pediatrics)	text
	b.	Specialists	text
	c.	Hospitals	text
7		Describe how Respondent plans to notify Department and/or participants if a network physician terminates his/her contract during the plan year.	text
8		Confirm that, if requested, Respondent is willing and able to add medical providers to Respondent's medical networks.	drop down box
9		Explain the process of adding medical providers to Respondent's medical networks.	text
10		If Respondent uses leased networks to service this account, will the leased discounts be loaded into Respondent's claims system?	drop down box
11		How often is the online provider directory updated?	text
12		When viewing the provider directory online, how does a member know if a provider is not accepting new patients?	text
13		Are there quality indicators on Respondent's online provider directory? If yes, please describe in the "Explanation" column.	drop down box
14		Confirm that Respondent will provide encounter data for services covered under Respondent's capitation arrangement. List the contracted services where capitation fees will apply.	drop down box
15		How are network provider cases selected for review?	text
16		Are pay-for-performance or other treatment incentives offered in Respondent's network? Please explain.	drop down box
17		Across Respondent's Florida provider networks only - what has been Respondent's average percent increase in provider reimbursement for calendar years 2019, 2020, and 2021? What are you projecting for 2022? Break these figures out by product type as indicated below.
	a.	Broadest Provider Network : 2019	percent,1
	b.	Broadest Provider Network : 2020	percent,1
	c.	Broadest Provider Network : 2021	percent,1
	d.	Broadest Provider Network : 2022	percent,1
	e.	Hospital : 2019	percent,1
	f.	Hospital : 2020	percent,1
	g.	Hospital : 2021	percent,1
	h.	Hospital : 2022	percent,1
	i.	Primary Care Physician : 2019	percent,1
	j.	Primary Care Physician : 2020	percent,1
	k.	Primary Care Physician : 2021	percent,1
	l.	Primary Care Physician : 2022	percent,1
	m.	Specialist : 2019	percent,1
	n.	Specialist : 2020	percent,1
	o.	Specialist : 2021	percent,1
	p.	Specialist : 2022	percent,1
		Credentialing and Recredentialing	Answer Format	Reply	Explanation
18		How does Respondent determine quality measures and performance issues with respect to behavioral health?	text
19		Is Respondent's doctor credentialing program certified by NCQA?	drop down box
20		At the time of credentialing, does Respondent verify at least the following information from primary sources:
	a	A current, valid license to practice as a physician or independent behavioral healthcare practitioner at the highest level certified or approved by the state.	drop down box
	b	Clinical privileges in good standing at the institution designated by the behavioral healthcare practitioner as the primary admitting facility, as applicable.	drop down box
	c	A valid DEA or CDS certificate, as applicable.	drop down box
	d	Graduation from an accredited professional school and/or highest training program applicable to the academic degree, discipline, and licensure of the practitioner.	drop down box
	e	Board certification if the practitioner states that he/she is board-certified on the application.	drop down box
	f	Work history for the past ten years.	drop down box
	g	Current, adequate malpractice insurance according to the Respondent's policy.	drop down box
	h	History of professional liability claims which resulted in settlements or judgments paid by or on behalf of the practitioner.	drop down box
	i	Query all entities where practitioners have held privileges.	drop down box
	j	Ever had placement issues post discharge	drop down box
	k	Ever had transfer acceptance issues intra or post discharge	drop down box
21		Does Respondent formally recredential its practitioners at least every two years, during which it verifies at least the following information from primary sources:
	a.	A valid state license to practice	drop down box
	b.	The status of clinical privileges at the institution designated by the practitioner as the primary admitting facility as applicable	drop down box
	c.	A valid DEA or CDS certificate, as applicable (a copy is sufficient)	drop down box
	d.	Board certification (only if the practitioner was due to be recertified)	drop down box
	e.	Current, adequate malpractice insurance according to the Respondent's policy	drop down box
22		Describe any networks that Respondent may currently have in place for clients driven by quality, cost-effectiveness and evidence-based outcomes.	text
23		Describe any specialized networks that Respondent may have in place relative to high quality, evidence-based behavioral health?	text
24		Describe the programs and the technology that Respondent has in place to measure performance and quality variations between medical providers (hospitals and physicians)	text
	a.	Provide a description of the source of that information.	text
	b.	Explain how the information will be used to develop high-quality/high-performance networks for clients.	text
25		Explain how Respondent obtains provider outcomes and how it uses that information to establish network provider performance standards.	text
26		How does Respondent's provider contracts reduce unwarranted price and quality variations?	text
27		Provide any evidence that Respondent may have that links payment reform and adherence to clinical guidelines that results in meaningful improvement in "value" and clinical outcomes.	text
28		What percentages of Respondent's aggregate net payments to providers will be tied to value or efficiency in the next 5 years?	text
29		Is Respondent currently evaluating, piloting, or fully participating in any value-based contracting initiatives, including Patient Centered Medical Homes (PCMH) or Accountable Care Organizations (ACO)?	text
	a	If yes, provide a detailed overview of the initiative(s), including markets offered, validated results achieved to date, applicable fee structure/attribution model, etc.	text
	b	What Client markets currently have or are targeted for medical homes, HPNs, ACOs or similar initiatives?	text
		High Performance Network - Address for Florida Networks Only	Answer Format	Reply	Explanation
30		Does Respondent offer a high performance network in Florida?	drop down box
31		Describe Respondent's high performance or high quality network in Florida. What types of providers are included and how are specific providers/facilities identified for inclusion? How is it developed and what expectations are there for modifications in the near future?	text
32		Does Respondent have the ability to include two levels of copayments with lower copayments for network physicians in a high performance network?	drop down box
33		How is ongoing provider performance measured and how is this performance evaluation communicated back to providers?	text
34		What percentage of the Respondent's standard PPO/HMO is included in the High Performance Network?	Percent,0
35		Describe any mechanisms in place to communicate quality and performance information to plan participants, such as health advocates, nurse advice lines, participants directly, etc.	text
36		Provide a listing of the markets where Respondent's high performance/high quality network is currently available, including the provider specialties for each market and plans for future expansion. Highlight the specialties in the Florida Market. Name the file: [Respondent's Name]_High Performance Network Market.	drop down box
37		How is a particular geographic market selected as an appropriate service area to support a high-performance network?	text
38		Explain any programs in place to help navigate or guide participants to high performance/high quality providers and to avoid care from under-performing providers.	text
39		Will Respondent recruit and add "high performing" non-participating physicians in areas where access is limited in order to meet Department employees' needs?	drop down box
40		What is the value/percentage of dollars saved due to offering a high performance network?	text
41		Provide a detailed description and a map by Center and condition of your Centers of Excellence Network and future strategy for this network. Indicate any limitations that may exist in Respondent's contracting that would limit Department from steering care to these facilities. Name the file: [Respondent's Name]_COE.	drop down box
42		Describe any quality and cost driven provider segmentation to identify/steer members to preferred providers producing cost savings while maintaining or enhancing medical quality.	text
		Fraud	Answer Format	Reply	Explanation
43		What actions are taken to stop or eliminate fraud activity at the point it is first discovered in-network? Out-of-Network?	text
44		What claims edits, claims limits, systematic procedures and systematic controls are in place prior to prevent and detect fraud in-network?	text
45		What is the dollar amount claim threshold, number of claims per member per day or per condition in network that would automatically pend or deny an in-network claim?	number
46		Do clients have the ability to input or customize claims system edits for in-network claims?	drop down box
47		Do clients have the ability to input or customize claims system edits for out-of-network claims?	drop down box
48		Does the Respondent check and verify all providers’ licenses before out-of-network claims are paid? Please explain.	drop down box
49		If a wrap or supplemental network is utilized out-of-network, are the providers credentialed by the wrap or supplemental network? Use Explanation tab for details.	drop down box
50		Briefly describe if Respondent has policies and procedures in place for identification and investigation of potential and/or actual fraud, waste and abuse for the following areas: underwriting operations, financial operations, electronic data gateways, eligibility, claims processing, network provider credentialing?	text
51		Does the Respondent's provider application ask about any health care facility or healthcare business arrangements in which the provider may have full or partial ownership or own shares? If Respondent have such procedures, please explain what actions the Respondent take if any convictions or conflicts of interest are identified.	drop down box
52		Is Fraud, Waste, and Abuse management managed in a specific unit or group?	drop down box
	a.	If yes, describe the organizational structure, responsibilities and staffing of the Fraud, Waste, and Abuse operations.	text
53		Under what circumstances is an employer made aware of fraud, waste or abuse on their account? Under what circumstances is an employer made whole before recovery is accomplished?	text
54		What does the Respondent do to recoup funds paid in error for services not rendered in-network? Out of Network?	text
55		What does Respondent do to recoup funds paid in error to fraudulent providers in-network? Out of Network?	text
56		What analytic methods and tools does the Respondent use to monitor referral patterns and the associated volume by individual provider or provider practices?	text
57		In the situations involving health care provider fraud, waste, or abuse, describe how action and recovery proceed for contracted versus non-contracted providers.
	a	Does Respondent engage law enforcement agencies to criminally prosecute?	drop down box
	b	Does Respondent employ or retain legal counsel with expertise in fraud, waste and abuse?	drop down box
	c	Under what circumstances is criminal prosecution initiated?	text
	d	What means are employed for recovery in confirmed cases of provider fraud?	text
	e	At what threshold is recovery pursued?	text
58		Have Respondent had a data security breach? if yes, how many in the past 24 months and how many lives has it affected? Use "Explanation" box.	drop down box
59		If Respondent have had a data security breach, what corrective action has been taken to prevent it from happening again?	text
60		In the event of a security breach, what services and communication does Respondent provide to the members?	text
61		Does Respondent carry cyber liability insurance?	drop down box

		Section II.
		CLINICAL AND QUALITY CARE PROGRAMS/HEALTH IMPROVEMENT SERVICES	Answer Format	Reply	Explanation
		Accreditations
1		NCQA Accreditation Status:
	a	Managed Care firm Accreditation ¥	drop down box
	b	Preferred Provider Accreditation ¥	drop down box
2		NCQA Accreditation Expiration Dates:
	a	Managed Care firm Accreditation ¥	Month Day, Year
	b	Preferred Provider Accreditation ¥	Month Day, Year
3		URAC Accreditation Status:				List,Accreditation	List,Precertification	List,Frequency
	a	Health Plan Accreditation ¥	drop down box			Full Accreditation	Pre-Certification Always Required	Weekly
	b	Health Utilization Management Accreditation ¥	drop down box			Conditional Accreditation	Pre-Certification Sometimes Required	Monthly
	c	Case Management Accreditation ¥	drop down box			Provisional Accreditation	Pre-Certification Not Required	Quarterly
4		URAC Accreditation Expiration Dates:				Accreditation Not Requested	See Explanation	Annually
	a	Health Plan Accreditation ¥	Month Day, Year			Accreditation Denied	Not Applicable - See Explanation
	b	Health Utilization Management Accreditation ¥	Month Day, Year			Accreditation In-Process
	c	Case Management Accreditation ¥	Month Day, Year			Request Voluntarily Withdrawn
5		JCAHO Accreditation ¥	drop down box
6		Provide Respondent's latest copy of its triennial JCAHO survey report. Name the file: [Respondent's Name]_JCAHO. ¥	drop down box
7		What is Respondent's best practice with respect to Medical Consultation? Provide a listing of surgeries/services that require pre-certification, if any.	text
8		How do utilization management and care management interact with other areas (i.e. disease management, claims, clinicians, etc.)?	text
9		How do members access care from Centers of Excellence (COEs) and what support programs are provided for family members, if any?	text
10		Please provide details on any updates or initiatives Respondent is implementing relative to Centers of Excellence for Behavioral Health?	text
11		Does the Respondent's offer include an integrated approach for the clinical/care management programs? Please include those charges in the "Other" section of Attachment D - Cost, ASO HMO Fees tab. Please DO NOT include those charges in this tab.	drop down box
12		Describe Respondent's process to assess and identify member clinical risk.	text
13		Describe if Respondent has a predictive modeling program in place (early warning system that notifies physicians if there is a gap in care) and that it is possible to "turn off" these notifications if requested.	text
14		Provide the following information on Respondent's next generation bundled payments or episodes of care programs:
	a	a. For which procedure and/or condition categories and in which locations are offered today?	text
	b	b. What services are included in the bundle/episode of care?	text
	c	c. What is the timeframe covered by the bundle? E.g. From first outreach by the member to 90 days post-discharge?	text
	d	d. If a client implements Respondent's bundled payment/episode of care program, how are members made aware of the availability of the program? Is it mandatory they access these providers?	text
	e	e. Does Respondent offer patient concierge/navigation specifically for this program?	drop down box
	f	f. What support do Respondent provide members?	text
	g	g. Does Respondent offer an assessment only bundle for surgical avoidance?	drop down box
	h	h. Does Respondent offer a warranty on complications/readmissions?	drop down box
	i	i. What procedures and/or conditions by location are planned on Respondent's roadmap?	text
15		Does Respondent's network utilize Centers of Excellence for high intensity procedures and experimental or clinical protocols (i.e., transplants, cardiac bypass surgery, high morbidity or "complicated" cancer surgery, major trauma, major burns, etc.) that do not fall under the bundled pay/episodes of care above?	drop down box
16		For which conditions, treatment, etc., are COEs utilized?	text
17		Clearly identify components that are included for the Respondent's physician reimbursement or bonus formula: HEDIS Effectiveness of Care and Access measures, Patient satisfaction surveys (physician-specific), Member complaints and grievances, Ambulatory/inpatient utilization, and/or Administrative (chart review, site visit, coding accuracy); describe using %'s equaling 100%, if possible.	text
18		Describe Respondent's contracting strategy as it relates to the rebalancing of payments between primary care and specialty care. (e.g. Do you have a strategy to control specialty costs, in an effort to reduce the high costs? Or is there a redesigning the specialty fee schedule?) This could include - medical homes, accountable care organizations.	text
19		Describe the Respondent's unique contracting arrangements that might be in place with your organization a Client could take advantage of to gain further savings. (e.g. Centers of Excellence/COE description)	text
20		Include a concise description of how Respondent covers transition of care conditions, such as pregnancy, chemotherapy, case management, scheduled surgeries, chronic illnesses, terminal illnesses, behavioral health illnesses, etc., if a new member is receiving treatment from a non-participating provider as of December 31, 2023. Name the file: [Respondent's Name]_Transition of Care.	drop down box
21		What type of follow-up post discharge programs does Respondent have? What integration does Respondent have with local providers in this effort?	text
		Program Design Services	Answer Format	Reply	Explanation
22		What programs does Respondent have in place to emphasize appropriate utilization by members? Specifically, what programs does Respondent have to address inappropriate use of the emergency room and educate members on the most appropriate utilization settings?	text
		Case Management	Answer Format	Reply	Explanation
23		Please explain Respondent's approach with respect to case management and disease management.	text
24		Provide a description of Respondent's case management services and what differentiates Respondent's UM services.	text
25		Indicate which of the following triggers are used to identify potential case management cases:
	a	Utilization (e.g. multiple admissions, readmissions, length of stay)	drop down box
	b	Diagnosis	drop down box
	c	Procedure (e.g. transplants, hemodialysis, etc.)	drop down box
	d	Alternate level of care (e.g. rehab, LTAC, SNF)	drop down box
	e	High-cost services (inpatient/outpatient)	drop down box
	f	High-cost threshold > $100,000 incurred on a rolling 12 months (if threshold is different, please indicate).	drop down box
	g	Situational triggers (e.g. caregiver, psychosocial factors)	drop down box
	h	Predictive technology	drop down box
	i	Other	text
26		Case management referrals are accepted from:
	a	Nurse advice/health information line	drop down box
	b	Disease Management	drop down box
	c	Discharge Planner	drop down box
	d	Utilization management staff	drop down box
	e	Member self-referral	drop down box
	f	Practitioner referral	drop down box
	g	Medical Director	drop down box
	h	Outreach staff	drop down box
	i	Other	text
27		Please provide the average caseload for the case managers that would be servicing members, expressed as "x cases/mgr".	text
28		On average during the previous 12 months, what percent of members were for high-risk outreach? Please define high-risk outreach in the "Explanation" column.	percent,1
29		On average during the previous 12 months, what percent of members were referred to episodic/short-term case management? Please define episodic in the "Explanation" column.	percent,1
30		On average what percent of members referred were accepted to episodic/short-term case management?	percent,1
31		On average during the previous 12 months, what percent of members were referred to complex case management? Please define complex case management in the "Explanation" column.	percent,1
32		Does Respondent have emergency room usage management programs? What tools and methods are used to prevent hospital emergency room usage and hospital readmissions? What are the ER visits results from 2018, 2019 and 2020? Use "Explanation".	drop down box
		Wellness	Answer Format	Reply	Explanation
33		Can Respondent offer well-care centers/employee clinics to Client's employees, if requested.	drop down box
34		If requested, Respondent has the ability to implement a formal wellness incentive program to encourage completion of Health Risk Assessments (HRAs), biometric screenings, wellness/coaching programs, etc. Please provide a suggested five-year wellness plan. Name the File: [Respondent's Name]_Wellness Plan	drop down box
35		Describe the services and resources within Respondent's firm and embedded within your medical program that drive overall employee wellbeing, adaption of health behaviors, and improvements in employee health (e.g. online resources for preventive care and other health information, podcasts, best practices, etc.)	text
36		Will Respondent allow the Client to select which health and wellness programs to offer its employees, using Respondent's proposed wellness dollars, other than programs offered by Respondent?	drop down box
37		Will Respondent offer an annual wellness credit for the Client to select which health and wellness programs they would like to offer its employees or to purchase a program from another provider. Please explain any restrictions on these funds in the "Explanation" column here and confirm if the Client may use these funds for both resources and support within Respondent's firm as well as independent resources and support outside Respondent's firm. Provide the credit in your Cost reply.	drop down box
38		Are there any discounts for wellness services or fitness clubs?	drop down box
39		Please describe the online wellness tools that Respondent offers.	text
40		Does Respondent's proposed Wellness Program offer the following Products/Services at no additional charge? Indicate Yes or No and if yes, please explain.
	a	Health risk assessment	drop down box
	b	Onsite biometric screenings	drop down box
	c	Well-baby	drop down box
	d	Onsite clinical immunizations	drop down box
	e	Nutritionist/Nutrition education	drop down box
	f	Weight management	drop down box
	g	Obesity management	drop down box
	h	Lactation consultation	drop down box
	i	Smoking cessation	drop down box
	j	Stress management / stress reduction	drop down box
	k	Nearsite fitness center partnerships (e.g. YMCA)	drop down box
	l	Tracking from other gym attendance online?	drop down box
	m	Personal training / wellness & fitness coaching	drop down box
	n	Ergonomics / back care / injury prevention	drop down box
	o	Pedometers/activity tracking devices	drop down box
	p	Sleep management	drop down box
	q	Team-based corporate challenges	drop down box
	r	Activity tracking devices downloadable via mobile applications	drop down box
	s	Partnership with retailer(s) for healthy food or other healthy products initiatives	drop down box
	t	Coordination with community / local health programs	drop down box
	u	Incentive management	drop down box
	v	Promotional awareness campaigns	drop down box
		Managed Behavioral Health	Answer Format	Reply	Explanation
41		Describe Respondent's behavioral health triage system in place. Is it operational 24-hours/7-days a week and staffed by behavioral health professionals with at least a master's degree, to direct members to appropriate levels of mental health or substance abuse care?	text
42		Describe if and how health plan members have access to a range of alternative behavioral health services; including, residential treatment, partial hospitalization, halfway houses, intensive outpatient care, and home therapy.	text
43		Describe if Respondent's network has a multidisciplinary mixture of board-certified psychiatrists, independently licensed doctoral psychologists, and master's-level clinicians?	text
44		Describe if Respondent's network has a multidisciplinary mixture of board-certified psychiatrists, independently licensed doctoral psychologists, and master's-level clinicians that are pediatric specific?	text
45		Does Respondent have established standards for the timeliness of routine and urgent care, behavioral healthcare appointments, and access to after-hours care?	drop down box
46		Does Respondent have protocols in place to handle emergency calls? Please provide your procedures in the "Explanation" column.	drop down box
47		Does Respondent update primary care physicians (PCPs) on diagnosis, treatment, and referral of behavioral healthcare disorders commonly seen in primary care?	drop down box
48		Describe how Respondent is addressing the burgeoning use of “luxury” behavioral health treatment facilities, which are out of area and/or out of network.	text
49		Describe in detail the information required for processing and approving a provider treatment plan.	text
50		Describe in detail Respondent's pre-admission and continued hospital stay certification process for inpatient care, including the nature and timing of the contact with the provider(s) and the patient.	text
51		How are the specifications of approved treatment formally communicated to the provider, the treatment facility and to the patient?	text
52		How do the certification and notification processes differ between in-network, out-of-network and out-of-area providers? Provide examples.	text
53		How is an emergency inpatient admission defined and how is it certified (during regular hours and during weekends or after hours)? Please include any differences between certifying an admission to in-network and out-of-network facilities.	text
54		Briefly describe the criteria used to guide case manager decisions regarding approval of acute inpatient hospital admissions, emergency inpatient, intensive outpatient, partial day inpatient, individual/group outpatient treatment for adults, adolescents and children. Provide specific Diagnostic and Statistical Manual (DSM) diagnostic categories that would be excluded from any particular level of care. Do the criteria vary geographically? if yes, how?	text
55		What are the standard number of inpatient days and number of outpatient treatment sessions that are approved for a patient's initial treatment in the following conditions?
	a	Drug/ Alcohol standard # inpatient days	number
	b	Mental Health standard # inpatient days	number
	e	How frequently is the approved care (inpatient and outpatient) reviewed?	text
	d	Describe the procedures for how an initial request for hospitalization is denied, a request for additional hospitalization is denied, and a request for additional outpatient visits is denied	text
56		Describe what follow-up action is taken by Respondent when patients drop out of treatment against medical advice.	text
57		Explain Respondent's standard procedures for coordinating utilization review with the Client's EAP and Medical-Surgical plans, including a description of the responsibilities and authority of those plans.	text
		Telemedicine Program	Answer Format	Reply	Explanation
58		Does Respondent offer a telemedicine program?	drop down box
	a.	If yes, who provides this service? Is it outsourced? If yes, to whom?	text
	b.	Number of members with access to Telemedicine	number
	c.	Number of consult visits via phone in calendar year 2020	number
	d.	Number of consult visits via video in calendar 2020	number
	e.	Number of prescriptions issued in calendar year 2020	number
	f.	How does the member access the telemedicine program?	text
59		What resources does Respondent have to help promote the telemedicine solution?	text
60		What percent of telemedicine consultations result in: a) Resolution, b) visit to the Emergency Room, c) visit to other health care provider.	percent,1
61		Design and Reporting
	a	What flexibility in plan design options are available (e.g.. Copayments)?	text
	b	What services are available through telemedicine? Please provide any additional costs in the cost reply.	text
	c	What reporting details are available on a monthly basis?	text
	d	Does Respondent provide monthly claims experience reporting on the 15th calendar day for the prior month?	drop down box
	e	What communication tools and resources are available to the Client and what educational materials are available to the Client's employees at no additional cost? Are there any buy-up options?	text
	f	How is a telemedicine visit reported to a member's primary care physician?	text
	g	Please list all benefits available through this method (e.g. Mental Health, Pediatrics, PCP, Physical Therapy, etc.)	text
62		Does Respondent track satisfaction rates for telemedicine services? If yes, provide latest results showing percent of members satisfied or highly satisfied.	drop down box
63		Are there services that can be done virtually where Respondent believes the quality is inferior to in-person?	drop down box
64		What guidance is being provided to providers to bill the appropriate level of coding for virtual care?	text
65		What is Respondent's policy on how frequently a virtual visit can be billed? (e.g., a provider can only bill once every 24 hours or bill e/m code once every 7 days)	text
66		Detail the presence of any spread pricing that you or your telemedicine vendor may retain for all telehealth consultations in addition to any fees you may charge for the service. Please confirm whether this service is included in the Administration Fee.	text
67		Does Respondent provide both direct pay (employee pays) and plan sponsored (run through the medical plan)?	drop down box
68		Is a guaranteed wait time is offered?	drop down box
69		Please provide an implementation timeline. Name the file: [Respondent's Name]_Telemedicine Implem.	drop down box

		SECTION III.
		SERVICES & ADMINISTRATION	Answer Format	Reply	Explanation
		Reporting
1		Attach a sample management and utilization report(s) that would be prepared for a Client's population. Name the file: [Respondent's Name]_ MgmtRptgPkg.	drop down box
		Customer Service/Claims Processing	Answer Format	Reply	Explanation
2		List the location(s) of call centers that service members and the corresponding geographic areas/service areas covered by the respective location. Use the "Explanation" column if you need more space.
	a.	Call Center 1
		Location 1 ¥	text
		Service Area(s) Covered 1 ¥	text
	b.	Call Center 2
		Location 2 ¥	text
		Service Area(s) Covered 2 ¥	text
3		List the location(s) of Respondent's claims processing centers that service members and the corresponding geographic areas/service areas covered by the respective location. Use the "Explanation" column if you need more space.
	a.	Claims Processing Center 1
		Location 1 ¥	text
		Service Area(s) Covered 1 ¥	text
	b.	Claims Processing Center 2
		Location 2 ¥	text
		Service Area(s) Covered 2 ¥	text
4		What is Respondent's staffing approach? Provide information on the background and training of representatives, the overall caseload of representatives, turnover rates, etc.	text
5		From the date of service, what is the average length of time until a the Client's participant can view a claim online?	text
6		Do customer service representatives also process claims and have the ability to make eligibility updates and claim adjustments?	drop down box
7		Please describe Respondent's multi-lingual capabilities.	text
		Member Website Capabilities	Answer Format	Reply	Explanation
8		Provide complete details of Respondent's cost transparency tool, including, but not limited to: strategy and tactics to change behavior of a member; name of third party vendor utilized and length of relationship (if applicable); frequency/schedule of tool update; strategy and tactics used to audit control to verify accuracy of data communicated; strategy and tactics used for member communications; school district clients' average utilization; and, effectiveness of program/savings/ROI.	text
	a	Please provide a demo user name and password to test Respondent's cost transparency tool. ¥	text
9		Describe if members can access information through your website or customer service function regarding hospital quality? Please include the information available and the ways in which it can be accessed.	text
10		Describe if members can access information through Respondent's website or customer service function regarding the cost of a particular service from a particular hospital? Please include the information available and the ways in which it can be accessed.	text
11		Describe if members can access information through Respondent's website or customer service function regarding physician quality? Please include the information available and the ways in which it can be accessed.	text
12		What is the average timeframe for the EOBs to post on-line?	text
		Claims Administration	Answer Format	Reply	Explanation
13		Describe how many different systems and platforms would be used for the Client and how they will be integrated.	text
14		Describe the process for updating claims system (e.g., real time or batch)? If batch, how often is the system updated? Please highlight both the process and timing for manual updates of all systems.	text
15		Please describe any changes Respondent anticipates making to the claim payment system or implementing a new system before/after implementation date.	text
16		For any service where coinsurance or copays apply, is the discount calculated before or after the reduction for the copay/coinsurance?	text
17		How long is claim history maintained online?	text
18		Please describe Respondent's claims coordination capabilities and procedures with other payers.	text
19		Please confirm that all covered services incurred by covered members during an inpatient admission into a participating hospital will be covered as a participating, in-network service, regardless of the participating status of the attending provider (i.e. anesthesiologist, radiologist).	drop down box
20		To the extent permitted under state law please confirm no fault auto insurance, governmental plans coordination, and negligent third party subrogation claims will be administered.	drop down box
21		Describe how Respondent incorporates pharmacy data into the utilization management program.	text
22		For all plans, are participants required to submit claim forms and bills:
	a.	In-Network	drop down box
	b.	Out-of-Network	drop down box
	c.	Out-of-Area	drop down box
		Communications	Answer Format	Reply	Explanation
23		Is the timeline to receive non-English communication materials different than receiving communications in English?	drop down box
24		Does Respondent provide an allowance for member communications?	drop down box
25		Please provide a sample ID Card and description of the elements that may be customized. Name the file: [Respondent's Name]_IDCard.	drop down box
26		Will Respondent pay for production, printing and mailing costs for:
	a.	ID Cards (mailed to members)	drop down box
	b.	Booklets (electronically)	drop down box
	c.	Certificates (electronically)	drop down box
	d.	SBCs (electronically)	drop down box
	e.	SPDs (electronically)	drop down box
27		Please provide Respondent's latest member survey results about members' health care experiences.	text
		ID Cards	Answer Format	Reply	Explanation
28		If related to errors caused by Respondent, will Respondent be responsible for the cost to reproduce ID cards (including priority shipping).	drop down box
		Account Management
29		Please describe the experience for each the Executive Sponsor, Strategic Account Executive, Day-to-Day Account Manager, Customer Service Representative, Customer/Claims Advocate for Escalated Claims, Implementation Manager, Communication Liaison and any other Key Personnel who would be assigned to service a new client. Please attached biographies and Name the file: [Respondent's Name]_Biographies	drop down box
30		Describe Respondent's detailed plan for managing the account, including periodic reviews of cost and utilization and recommendations for plan design changes from Client's representatives. Name the file: Respondent's Name]_Account Management Plan.	drop down box
31		Is Respondent able to provide multilingual plan representative support for open enrollment meetings? Please list other languages in the "Explanation" column.	drop down box
		Banking	Answer Format	Reply	Explanation
		The requested banking arrangements for the self-insured medical plans are described below. Indicate Respondent's ability to comply with these standards.
32		Are there any fees associated with Respondent owning the bank accounts? Use "Explanation" box to describe fees.	drop down box
33		Can Respondent receive electronic transfers at no additional cost?	drop down box
34		Confirm Respondent's willingness to be self-billed for ASO fees, if requested.	drop down box
	a	Percent	percent
	b	Calculation Description	text
35		Please provide a copy of Respondent's ASO/Fully Insured Billing Description. Name the file: [Respondent's Name]_Billing Descriptions.	drop down box
		Administrator and Member User Security
36		Is there the ability to set roles and assign security levels to a role? (i.e. can Respondent's application support or delegate administrator access for the benefits office to go in and review changes?)	drop down box
37		Upon contract termination, for how long would a member be able to access his/her claims information on the member website?	text
38		What are Respondent's protocols on purging data beyond the agreed upon retention period? Does Respondent provide a certificate upon completion of data destruction?	text
39		What happens if the database server is unavailable?	text
40		Describe Respondent's back-up and off-site storage procedures. a) How often is the database backed up? b) How accessible are archived records? c) What is your record retention policy? d) Does Respondent have any plans to improve or enhance this system?	text
41		Describe Respondent's process in place for identifying member fraudulent activities, specifically what is the member identification process for providers? How do providers confirm that the member is actually the person who possesses the ID card?	text
		Eligibility	Answer Format	Reply	Explanation
42		Describe how Respondent's system handles eligibility and enrollment history and retroactive coverage changes.	text
43		Confirm Respondent will capture the 9-digit SSN, Department employee ID, and Medicare HICN (if applicable) in its eligibility system.	drop down box
44		Based on the eligibility files you receive, will Respondent:
	a.	Add coverage for members who have joined the plan within 72 hours of receipt of eligibility data.	drop down box
	b.	Update member information (e.g., address changes) within 24 hours of receipt of eligibility data.	drop down box
	c.	Notify appropriate party of eligibility issues within 24 hours of receipt of eligibility data.	drop down box
		Integration	Answer Format	Reply	Explanation
45		How does Respondent make changes to correct problems as a result of a quality improvement review, such as an audit, etc.?	text
		Please provide information concerning implemented and planned changes related to Respondent as follows:
46		Does Respondent offer warm transfers to other programs such as EAP or behavioral health?	drop down box
47		Does Respondent accept inbound warm transfers from other vendors?	drop down box
48		Will Respondent accept inbound referrals via fax, secure email or shared database and provide outreach to members based on the referral.	drop down box
49		Describe if all of Respondent's internal systems are integrated? (e.g., claims payment, eligibility, enrollment, customer service, utilization management, case management, pharmacy, behavioral health, and disease management)	text
50		Describe how Respondent interfaces with (e.g., sending to and/or receiving from) all claims files including biometric screenings, prescription drug, wellness initiatives, Data Analytics vendor, COBRA administrator, FSA/HSA administrator, Dental vendor, Vision vendor, bundled surgical vendor, and transparency vendor.	text
		Legal/Contractual Considerations	Answer Format	Reply	Explanation
51		At the time of a contract termination, does Respondent's serving Account Manager continue to provide dedicated support for up to one year after the term of the contract to facilitate run-out issues, claims payments, reconciliation, member transition, or any other issues that may arise from the termination of a contract?	drop down box
52		Please describe any judgment or settlement during the past three years or pending litigation that could result in judgments or settlements in excess of $100,000 in the "Explanation" column.	text
		Compliance, Privacy and Confidentiality	Answer Format	Reply	Explanation
53		Does Respondent make internal practices, books, and records relating to the use and disclosure of PHI received from, or created, or received by your firm available to the Secretary of the Department of Health and Human Services for purposes of the Secretary of the Department of Health and Human Services determining firm’s compliance with the privacy rules?	drop down box
54		Does Respondent adopt and implement written confidentiality policies and procedures in accordance with applicable law to ensure the confidentiality of member information used for any purpose?	drop down box
55		Is Respondent fully compliant with the Genetic Information Nondiscrimination Act (GINA)?	drop down box
56		Does the Respondent assist with the compliance of the provisions of the Affordable Care Act (ACA) and the associated fees related to ACA as necessary?	drop down box

	SECTION IV.
	ONGGOING SERVICES, RENEWAL	Answer Format	Reply	Explanation
1	Confirm Respondent will provide routine underwriting and actuarial related contract services. Please describe these services using "Explanation" column.	drop down box

&"Arial Narrow,Regular"

Request for Medical and RX Proposal

Disease Mgmt

Invitation to Negotiate (ITN) for the State of Florida, Department of Management Services (Department)

HMO Medical

Disease Management

Respondent Name:

[Insert Respondent Name Here]

Indicate Carve-in / Carve-out

[Indicate Carved-in / Carved-out]

Instructions: Enter the answer to each question in the space provided. Do not change the formatting of this worksheet including adding or deleting rows and/or columns. Be as brief as possible. We are looking for clear, concise answers. Written Replies and Explanations within this excel Attachment must be limited to 400 characters or less. Written Replies and Explanations beyond 400 characters will not be evaluated.

Program Component -

Complete the table for each health management program to the right:

Asthma

Diabetes

CAD

COPD

Heart Failure

Chronic Low Back Pain

Osteoarthritis

Cerebrovascular/Peripheral Artery Disease

Behavioral

Low Back Pain

Other (Specify)

Using your BOB results, for each condition list the % of high risk members

High:

Using your BOB results, for each condition indicate the average participation/% of high risk members that are successfully contacted and actively participate in the telephonic condition management program.

High:

What is the target age range of members for pediatric programs, if available.

Indicate whether the following are provided for members as a standard part of the program (specify if provided only for certain risk levels, i.e. biometric monitors for high risk CHF only):

Welcome Letter sent to each identified potential participant

Outbound calls

Accept inbound calls

Condition specific assessment

Depression screening

Functional assessment

Condition specific educational materials

Reminder program for routine preventive screenings, gaps, errors and omissions in care

Co-morbid condition management

Routine mail/telephone contact with attending physician

Biometric monitoring/ telehealth devices

Access to on-line condition specific information and health related tracking tools

Onsite services such as condition tracking, health coaching, etc. (Describe onsite services provided)

Other interventions/resources/tools - describe:

	Please respond to the following questions regarding Respondent's Disease Management
			Reply	Explanation
5	Describe Respondent's bundled (all disease states) approach to disease management?	text
6	If Respondent offers a bundled approach, are you able to "turn off" certain disease states, if requested?	drop down box
7	Please list any additional disease states that Respondent would recommend be integrated into this contract.	text
8	Are you able to have one nurse manage all of the member's conditions in your disease management program?	drop down box
9	Is your enrollment model opt-in or opt-out?	text
10	How do you define active participation/engagement in your program (opt-in versus opt-out) Please be specific (e.g. individuals with identified condition vs. receiving ongoing telephonic nurse interventions).	text
11	How do you define graduation from a disease management program?	text
12	How will disease management coordinate with other health care management programs (e.g., utilization management, pharmacy management, behavioral health, case management)?	text
13	Describe your methodologies for calculating and reporting cost savings related to disease management.	text
14	What Return on Investment (ROI) have you experienced with your disease management programs? Describe the specific programs and exactly how you calculate the ROI.	text
15	Indicate the electronic avenues used/available to communicate with participants (e.g. email, text messaging, secure chat capability with nurse coach, other).	text
16	Do you notify and communicate/engage with the PCP/treating physician for a patient enrolled in a disease management or wellness program?	drop down box
17	Are any of your disease management services subcontracted?	drop down box
17a	If yes, list each outsourced service, corresponding partner and length of time providing each outsourced service.	text
18	If biometric monitoring/telehealth devices are used, describe how members that decline or are unable to use them are managed.	text
19	What is Respondent's approach for management of members with co-morbid conditions?	text
20	What data elements are used to identify/stratify members for condition management? How frequently are the identification/stratification algorithms refreshed?	text
21	Briefly describe program outreach staff including their qualifications and role. Does the program use a primary nurse/coach model?	text
22	What is the role of the medical director in the disease management program?	text
23	Does Respondent's disease management program integrate pharmacy information from carve out vendors?	drop down box

This is the start of the file's text. The full file is on GovTribe.

File details come from the government source that posted it. Updated Jul 30, 2024.