Attach 12_Optional Line for Medical SOW.pdf

HSCEDM-11-R-00002

ATTACHMENT 12

STATEMENT OF WORK

MEDICAL SERVICES

DENVER METROPOLITAN DETENTION CENTER

A. The Contractor shall ensure that all health care service providers used for ICE detainees hold current licenses, certifications, and/or registrations with the State and/or City where they are practicing. The Contractor shall have a registered nurse on staff to provide health care and sick call coverage 24 hours 7 days per week.

B. The Contractor shall be responsible for the provision of medical, dental and mental health care services for ICE detainees at the facility including: on-site sick call, Over the Counter (OTC) and prescription medications, and medical / dental supplies.

C. The Contractor shall be responsible for the provision of health care services for ICE detainees at the facility in accordance with ICE Performance Based National Detention Standards, National Commission on Correctional Health Care and American Correctional Association Standards.

D. The Contractor shall ensure that onsite medical and health care coverage as defined below is available for all ICE detainees at the facility for twenty-four (24) hours per day, seven (7) days per week. The Contractor shall ensure it has a procedure in place to solicit each detainee for health complaints daily.

E. The Contractor shall not charge any ICE detainee a fee or co-payment for medical services or treatment provided.

F. The Contractor’s onsite health care personnel shall perform an initial medical, dental and mental health screening within twelve (12) hours of arrival to the facility, sick call coverage, provision of OTC medications, treatment of minor injuries, treatment of special needs and mental health assessments using the ICE Health Service Corps (IHSC) In processing Health Screening form 795A or approved equivalent. Arrival screening shall include, at a minimum, Tuberculosis (TB) symptom screening, planting of the TB skin test (PPD), or chest x-ray, and recording the history of past and present illnesses (mental and physical, pregnancy status, history of substance abuse). A medical and mental health classification level will be assigned to each detainee in a timely manner.

G. Contractor shall perform a full health assessment to include a history and hands on physical examination within the first 14 days of detainee arrival.

H. Detainees with chronic medical and/or mental health conditions shall receive prescribed treatment and follow-up care. There shall be evidence of the following:

Appropriate follow-up provided

Appropriate treatment plan provided

Monitoring of laboratory values, as indicated

Pain assessment

I. The Contractor shall notify the IHSC of detainees with serious illnesses including, but not limited to, cancer, those on dialysis, etc. Notifications shall be submitted using the Medical

Payment Authorization Request system (MedPAR) to IHSC website at www.icehealth.org .

Notification shall be submitted via e-mail to: IHSC.managedcare@dhs.gov .

J. The Contractor shall ensure staff is trained annually in hunger strikes, suicide prevention, and the Prison Rape Elimination Act (PREA). Custody staff shall be included to receive this training. Custody staff shall also receive training in completion of the In Processing Health Screening Form 794 or approved equivalent.

K. The Contractor shall notify the ICE HQ Epidemiology Unit of any pandemic flu (eg: H1N1) cases among ICE detainees and of any ICE detainees exposed to pandemic flu. The Contractor shall follow the most current Centers for Disease Control and Prevention Guidelines for pandemic flu. Guidelines may be found by going to the website http://www.cdc.gov/h1n1flu/guidance/ . TB and other infectious diseases shall be reported to the appropriate agency including ICE Headquarters Epidemiology Unit State and local Health Departments within the one day timeframe.

L. If the Contractor determines that an ICE detainee has a medical condition which renders that person unacceptable for detention under this contract, (for example, contagious disease, condition needing life support, uncontrollable violence); the Contractor shall notify the Contracting Officer Technical Representative (COTR) and IHSC Managed Care Coordinator immediately. Upon such notification, the Contractor shall allow ICE reasonable time to make the proper arrangements for further disposition of that detainee.

M. The IHSC acts as the agent and final health authority for ICE on all off-site detainee medical and health related matters. The Contractor shall release any and all medical information for ICE detainees to the IHSC representatives upon request, except where prohibited by federal or state law or regulation. The Contractor shall submit a Medical Payment Authorization Request (MedPAR) to IHSC for payment approval before proceeding with non-emergency, off-site medical care (e.g. off site lab testing, eyeglasses, cosmetic dental, prosthetics, and dental care for cosmetic purposes).

N. In an emergency, the Contractor shall obtain all medical treatment required. The Contractor shall have access to an off site emergency medical provider at all times. The Contractor’s Health Administrator shall notify the organization listed below as soon as possible, and in no case more than seventy-two (72) hours after detainee receipt of such care. The Contractor’s Health Administrator shall submit a MedPAR via the IHSC website at www.icehealth.org within one business day, and will obtain pre-authorization for payment from the IHSC Managed Care Coordinator for service(s) beyond the initial emergency situation.

ICE Health Service Corps VA Financial Services Center PO Box 149345 Austin, TX 78714-9345 800-479-0523 http://www.icehealth.org/ManagedCare/Providers.shtm

O. Serious illness, injury or the death of a detainee must be immediately reported to the local Officer in Charge (OIC), the Facility Administrator, and the ERO Field Office Director (FOD) of the detainee's condition by phone or in person and document the detainee's condition in a memorandum to the Facility Administrator that briefly describes the illness http://www.cdc.gov/h1n1flu/guidance/ http://www.icehealth.org/ManagedCare/TAR.pdf http://www.icehealth.org/ManagedCare/Providers.shtm and prognosis. The IHSC Managed Care Unit must also be notified. The e-mail address is ihsc.managedcare@dhs.gov . It is the responsibility of ICE to notify local authorities and any family members of serious illness, injury or the death of a detainee as outlined in the policy.

The medical staff shall NOT speak to family members unless authorized by ICE.

P. Wills and Advanced Directives. The Contractor shall use the Colorado State Advanced Directive form for implementing Living Wills and Advanced Directives. The guidelines include instructions for those who wish to have a Living Will when a detainee requests a Living Will other than the generic form the facility provides, the opportunity to have an attorney prepare the documents (at the detainee’s expense) shall be facilitated.

Q. When it is determined that the terms and conditions of the detainee's advanced directive should be implemented, the Contractor will notify the IHSC Managed Care Coordinator and the ERO Field Office Director of the name and basic circumstances.

R. The Contractor shall allow IHSC Managed Care Coordinators and IHSC medical records personnel complete access to its facility and medical records of detainees for the purpose of liaison activities with the Contractor’s Health Administrator and associated Contractor departments. In addition to medical documentation, nursing notes, medication administration records, treatment plans, doctor’s order, etc, health records shall contain evidence of the following:

Medical Consent - Medical consent shall be obtained from ALL detainees who report to the medical facility for health care prior to rendering the care. The content of the form must be explained to the detainee and be properly signed and dated. Completion of this form provides consent to health care: initial health screening, physical examination, diagnostic procedures, medical, dental, or mental health treatment (including administration of medication), and the collection of patient information for state and federal reporting purposes.

Refusal Form - For each occurrence for which a detainee refuses any type of medical, dental or mental health treatment, including administration of any medication, the refusal will be documented and maintained as a permanent part of the medical record. After the staff member has completed the refusal form, the detainee will be requested to sign the form. At least one other person must witness the refusal and then document the form by signature. If the detainee refuses to sign the form, the staff member will document the refusal to sign the form, both on the form and in the progress note (“Detainee has refused treatment and has refused to sign the form” must be written.) If a detainee refuses tuberculosis screening (either PPD or chest x-ray), the Contractor’s Health Administrator will recommend to the detention facility administrator that the detainee be segregated from the general population. By refusing any treatment at a particular time, the detainee does not waive the right to subsequent processing.

Medical/Psychiatric Alert – This includes, but is not limited to:

o A medical escort o "Pill line" or directly observed therapy o Medical care requiring ongoing therapy such as:

1. Active TB

2. All chronic conditions

3. Other infectious diseases

4. Ongoing physical therapy o Mental health care requiring ongoing therapy such as:

1. Suicide risk

2. Potential for violent behavior o Short-stay unit care o Notification of pregnant females o Allergies documented

TABLE OF CONTENTS

I. ................................................................................................................................... 2 PREAMBLE

II. .................................................................................... 2 SCOPE OF COVERAGE PROVISIONS

III. .................... 3 MEDICAL PAYMENT AUTHORIZATION REQUEST SYSTEM (MEDPAR)

IV.

ROLE OF IHSC FIELD CASE MANAGERS, REGIONAL MANAGED CARE

COORDINATORS

V.

REFERENCE MATERIAL, SYSTEM UPDATES AND EDUCATIONAL

INFORMATION

VI. ...................................................................................................................... 4 APPEAL PROCESS

A. ........................................................................................4 Level I – Provider Claims B. ............................................................................4 Level II – Denied Authorizations

VII. .................................................................................................................... 5 DENIED PAYMENTS

VIII. .................................................................................... 5 IT TECHNICAL SUPPORT SERVICES

IX. .................................................................................................................................... 5 CONTACTS

X. ............................................................................................ 6 ELIGIBILITY DETERMINATION

XI. ........................................................................................... 6 VERIFICATION OF ELIGIBILITY

XII. ............................................................................................ 6 REIMBURSEMENT AUTHORITY

XIII. ............................................ 6 PAYMENT AUTHORIZATION COVERAGE INFORMATION

A. ..........................................................................................6 When Coverage Begins B. ............................................................................................7 When Coverage Ends

XIV. ..................................................................................................................... 7 CLAIMS PAYMENT

A. ............................................7 Claims Submission, Review, Analysis, and Pricing B. .................................................................7 Patient Deductibles and Co-Payments

XV. ......................................................................................... 7 NO PRIVATE RIGHT STATEMENT

GLOSSARY OF TERMS

I. PREAMBLE

This guide is intended for use by providers, hospitals, other health care facilities, detention facilities, legal representatives and other parties involved in the delivery of medical, mental health, dental and other health care and services to individuals in U.S. Immigration and Customs Enforcement’s (ICE) or U.S. Customs and Borders Protection (CBP) custody.

The ICE Health Service Corps (IHSC) serves as ICE’s medical authority relating to health care provided to those in ICE custody. As a component within ICE’s Office of Enforcement and Removal Operations (ERO), IHSC performs two important functions affecting the provision of medical care to ICE detainees. First, IHSC provides direct patient care to, and is consequently the direct medical authority, for detainees who are generally housed at either ICE-owned detention facilities, otherwise known as Service Processing Centers (SPCs), or designated Contract Detention Facilities (CDFs) across the country. Second, IHSC is responsible for coordinating (or facilitating) medical services provided to ICE detainees at facilities not staffed by IHSC such as Intergovernmental Service Agreement (IGSA) facilities. At these IGSA facilities, the local health authority provides, directs and is responsible for assuring access to medical care for ICE detainees.

ICE, through IHSC and other medical providers, must provide medically appropriate treatment to ICE detainees who have identified any serious medical needs. A given medical condition could qualify as a “serious medical need” if, when left untreated, it could result in further significant injury or the unnecessary infliction of pain. Serious medical needs include conditions that affect daily activities or which cause chronic and substantial pain. This duty applies with equal force, notwithstanding the expected timing of a detainee's release or removal, except that a physician may consider the timing of a detainee's removal or release from custody for purposes of recommending an overall treatment plan to be included in the continuity of care plan that is provided to a detainee upon his/her release or removal. Medical care, including for critically ill cases, will be provided until removal unless beginning treatment is deemed medically detrimental to the detainee.

A medical professional treating an ICE detainee must exercise that degree of care and skill that a reasonable medical professional of the same medical specialty would exercise under similar circumstances.

II. SCOPE OF COVERAGE PROVISIONS

The Medical Payment Authorization Request system (MedPAR), which replaces the Treatment Authorization Request (TAR) system, is a web-based application designed to issue payment authorization for billable medical, mental health, dental, specialty services and durable medical equipment and supplies in the treatment and provision of health care to individuals in ICE custody. Authorization for payment will be denied for services to non-detainees or where eligibility cannot be established because they were not in ICE or CBP custody at the time of treatment.

Payment will be denied for services for cosmetic procedures that are not required to treat a serious medical need, and for procedures, services, and supplies that are experimental or investigational in nature, and/or that are not approved by the Food and Drug Administration.

The detainee's medical provider(s) is responsible for determining what treatment(s) is medically necessary for a serious medical need.

IHSC intends to release clinical guidelines in the near future which will be provided to all facilities housing ICE detainees and their respective Health Authorities. The purpose of these clinical guidelines is to ensure access to timely, necessary and appropriate medical, mental health and dental care that meet the legal standards for the provision of treatment.

III. MEDICAL PAYMENT AUTHORIZATION REQUEST SYSTEM (MedPAR)

Authorized requestors of MedPAR will be limited to physicians and other personnel in the medical units of these facilities. A minimum of two (2) employees at each ICE designated facility or IGSA will be identified as authorized requestors; as such, they will be authorized access to MedPAR. The facility’s designated authorized requestors will be trained before receiving password-protected access to MedPAR.

The authorized requestor, i.e., physician or their designee will log on to MedPAR and complete the required data fields in MedPAR. The detainee’s provider will also be required to certify in MedPAR that the service(s) requested are medically appropriate and necessary in response to serious medical needs.

IV. ROLE OF IHSC FIELD CASE MANAGERS, REGIONAL MANAGED CARE

COORDINATORS

Field Case Managers (FCM) and Regional Managed Care Coordinators (RMCC) will provide technical assistance for MedPAR. The FCMs and RMCCs will also coordinate services with qualified medical personnel in facilities housing ICE or CBP detainees and provide assistance with the appeal process for denied payment or services with system.

FCMs and RMCCs will conduct inpatient utilization review and discharge planning on all hospitalizations. In the course of providing utilization management, the FCM or RMCC may deem it necessary for the detainee to be transferred to an alternate facility or level of care, based on the medical care needed and other considerations. FCMs and RMCCs will coordinate their recommended medical and mental health services.

V. REFERENCE MATERIAL, SYSTEM UPDATES AND EDUCATIONAL

INFORMATION

IHSC maintains a web site, www.icehealth.org that will serve as the vehicle for communicating any changes to the MedPAR and provide materials to share detainee and provider-specific educational materials, news, and other online services. The MedPAR User Guide will also be posted at this IHSC web site, along with all required billing forms and key IHSC personnel contact information. All users should continue to monitor this web site for updates and new instructions as future changes and enhancements are made to the MedPAR system.

VI. APPEAL PROCESS

A. Level I – Provider Claims

The Veterans Administration Financial Service Center (VA FSC) has a Service Level Agreement with ICE to provide medical claims payment processing, claims payments, and accounting, and hosting, support and maintenance of MedPAR. Providers to whom the VA FSC has denied payment for a claim may appeal that denial by completing the following Level I appeals procedures.

Prior to submitting a claims appeal, providers should review the Explanation of Benefits (EOB) received from the VA FSC in response to the submission of their request for payment. After reviewing the EOB, if the provider still believes the denial is unwarranted, s/he should submit in writing and within 90 days of receipt of the initial determination supporting documentation to overturn the denial. Included within the appeal, the provider should offer a full explanation of the basis for the appeal, along with a copy of the EOB, a copy of the original medical invoice, and a copy of the corrected invoice, if applicable.

Level I appeals should be submitted to:

VA FSC

ATTN: DIHS Appeals – Level I 1615 Woodward Street Austin, TX 78772

B. Level II – Denied Authorizations

The Level II appeals process permits any ICE detainee, his/her legally-appointed advocate (e.g.

attorney, legal guardian) or other detainee-designated individual or organization, to request, in writing, that [PARTY] reconsider a denial of authorization of payment for a service.

The letter submitted to IHSC for this purpose should clearly identify the patient by name, ICE or CBP assigned tracking number, facility name and address, date of denial, description of denied service(s), and explain why the original decision to deny payment for a specific service(s) should be http://www.icehealth.org/ overturned. Upon receipt of the appeal, the IHSC Medical Director’s Office will review the case and may consult specialty providers or any other decision support resources deemed necessary as part of the appeal review process. The IHSC Medical Director's office will review the detainee's medical records and decide to either uphold the decision of denial, overturn and approve the request for payment, or seek further information or a second opinion from a consultant within 10 (ten) business days of receipt of the appeal. IHSC will pay for an outside consultant if a second opinion is required to make a decision regarding the appeal. The outcome of the appeal review process will be a decision to authorize for payment and is not to be construed as to subordinate the clinical judgment or practice of a medical professional. Additional options are available that, dependent on the medical seriousness of the denied service, may involve recommendations up to and including transferring the detainee to another facility.

Level II appeals should be submitted to:

ICE Heath Service Corps Attn: Appeals-Level II 500 12th ST SW 2nd Floor, Mailstop 5202 Washington, D.C. 20536 Fax: 866-808-8154

For questions related to managed care, clinical services, case management, placement assistance, and appeal process, contact IHSC at (202) 732-4600.

VII. DENIED PAYMENTS

Again, the VA FSC may deny payment for a given medical service because the individual is not in ICE or CBP custody; however, providers do have an opportunity to re-submit their medical invoices with additional information to assist VA FSC in confirming the ICE or CBP custody status of individuals.

VIII. IT TECHNICAL SUPPORT SERVICES

Technical IT support for accessing MedPAR, obtaining passwords, and requestor authorization can be obtained through IHSC.

The IHSC Managed Care Unit is available to provide information and instruction on the use of the MedPAR and address concerns about referrals, services and case management. Additionally, the IHSC Medical Director, FCMs, RMCCs, Regional Clinical Directors, Regional Dental Officers, and Regional Psychiatrists are available to consult with local medical providers as needed.

IX. CONTACTS

For questions related to IT technical issues of the MedPAR such as user training, user access and password support, contact IHSC at (202) 732 – 4600.

X. ELIGIBILITY DETERMINATION

To be eligible for payment for detainee health care, the following must apply:

The individual requiring care must be in ICE or CBP custody as indicated by a valid tracking number assigned by ICE or CBP in the ENFORCE case tracking database. This assigned tracking number is a unique detainee identifier that can be correlated to a particular detainee and the facility or Sector/Station that has custody of the detainee.

XI. VERIFICATION OF ELIGIBILITY

VA FSC will verify ICE custody status through ENFORCE before releasing payments on a medical invoice. If the patient is not eligible, according to ENFORCE, VA FSC will deny the invoice. The facility/provider will receive an Explanation of Benefits (EOB) stating that no documentation to support eligibility of the patient was found for the date(s) of service listed for that specific patient as contained in their invoice. The provider has the opportunity to re-submit their invoice with the appropriate documentation which verifies the patient's status as a detainee of ICE or CBP.

XII. REIMBURSEMENT AUTHORITY

As per 18 U.S.C. § 4006, Subsistence for Prisoners:

(a) In General. The Attorney General or the Secretary of Homeland Security, as applicable, shall allow and pay only the reasonable and actual cost of the subsistence of prisoners in the custody of any marshal of the United States, and shall prescribe such regulations for the government of the marshals as will enable him to determine the actual and reasonable expenses incurred.

(b) Health Care Items and Services. -

(1) In general. - Payment for costs incurred for the provision of health care items and services for individuals in the custody of the United States Marshals Service, the Federal Bureau of Investigation and the Department of Homeland Security shall be the amount billed, not to exceed the amount that would be paid for the provision of similar health care items and services under the Medicare program under title XVIII of the Social Security Act.

(2) Full and final payment. - Any payment for a health care item or service made pursuant to this subsection shall be deemed to be full and final payment.

XIII. PAYMENT AUTHORIZATION COVERAGE INFORMATION

A. When Coverage Begins

Coverage is effective on the first day that an individual is placed in ICE or CBP custody.

B. When Coverage Ends

Coverage ends on the day that ICE or CBP releases the individual from custody.

XIV. CLAIMS PAYMENT

A. Claims Submission, Review, Analysis, and Pricing

The VA FSC has a Service Level Agreement with ICE to provide medical claims payment processing, claims payments and accounting services, and hosting, support and maintenance of MedPAR.

ICE requires that the physician, clinic or hospital submit their claim on approved Center for Medicare & Medicaid Services (CMS) and the American Dental Association approved claim forms. Invoices are to be submitted to the VA FSC located in Austin, Texas, for claims adjudication, pricing and payment issuance. The completion of all pertinent medical information will be the same as for any other claims submitted.

The VA FSC will price the medical claims according to negotiated contract rates and/or established for Medicare. The United States Treasury will mail the payment along with an Explanation of Benefits (EOB) to the payee.

B. Patient Deductibles and Co-Payments

Authorized medically necessary and appropriate medical, dental, mental health services and durable medical equipment and supplies are provided at government expense. The detainee has no responsibility for payment, deductible or co-payment. There is no requirement for Coordination of Benefits (COB) for detainees. All payments made by the VA FSC represent payment in full.

XV. NO PRIVATE RIGHT STATEMENT

This Directive is an internal policy statement of ICE. It is not intended to, and does not create any rights, privileges, or benefits, substantive or procedural, enforceable by any party against the United States; its departments, agencies, or other entities; its officers or employees; contractors or any other person.

GLOSSARY OF TERMS

Case Management A collaborative process which assesses, plans, implements, coordinates monitors and evaluates the options and services to meet an individual's health care needs using resources available to provide quality and cost-effective outcomes. Case management is not restricted to catastrophic illnesses and injuries.

Claims Processor The VA FSC processes all authorized medical claims for care received by individuals in custody of ICE and CBP for payment.

Clean Claim/Invoice A claim/invoice that complies with the billing guidelines and requirements of the claims processor has no defect or impropriety, includes substantiating documentation and all required data elements, and does not require special processing that would prevent timely payment.

Durable Medical Equipment (DME), Prostheses and Orthotics DME is reusable medical equipment. Prostheses serve as an artificial replacement of missing body parts, to replace or augment the performance of a natural body function. Orthotics are mechanical devices used to correct or prevent musculoskeletal deformities.

Explanation of Benefits A statement sent to the provider that shows who provided the care, the kind of covered service or supply received, the allowable charge and amount billed, and the amount paid.

It also gives the reason for denying a claim.

Provider A government or civilian doctor, hospital, clinic, health care professional or group of health care professionals that provide medical, mental health and dental services and/or supplies.

12/2010

Attachment 12a

Attachment 12a

IHSC Poster.v4_back

Attach 12a_Medical Statistics 2009 2010