ICS - compressed.pdf

SPB Form 22 | RFP Template | Effective 07192024

Per Nebraska’s Transparency in Government Procurement Act, Neb. Rev Stat § 73-603, DAS is required to collect statistical information regarding the number of contracts awarded to Nebraska Vendors. This information is for statistical purposes only and will not be considered for contract award purposes.

_____ NEBRASKA VENDOR AFFIDAVIT: Bidder hereby attests that bidder is a Nebraska Vendor.

“Nebraska Vendor” shall mean any bidder who has maintained a bona fide place of business and at least one employee within this state for at least the six (6) months immediately preceding the posting date of this Solicitation. All vendors who are not a Nebraska Vendor are considered Foreign Vendors under Neb. Rev Stat § 73-603 (c).

_____ I hereby certify that I am a Resident disabled veteran or business located in a designated enterprise zone in accordance with Neb. Rev. Stat. § 73-107 and wish to have preference, if applicable, considered in the award of this contract.

CONTRACTUAL AGREEMENT FORM

By signing this Contractual Agreement Form, the bidder guarantees compliance with the provisions stated in this solicitation and agrees to the terms and conditions unless otherwise indicated in writing and certifies that bidder is not owned by the Chinese Communist Party.

FORM MUST BE SIGNED MANUALLY IN INK OR BY DOCUSIGN

BIDDER:

COMPLETE ADDRESS:

TELEPHONE NUMBER:

FAX NUMBER:

DATE:

SIGNATURE:

TYPED NAME & TITLE OF

SIGNER:

BIDDER MUST COMPLETE THE FOLLOWING

_____ I hereby certify that I am a blind person licensed by the Commission for the Blind & Visually Impaired in accordance with Neb. Rev. Stat. § 71-8611 and wish to have preference considered in the award of this contract.

Innovative Claims Strategies LLC

30 Knightsbridge Road, Suite 525, Piscataway, NJ 08854

800-427-0047

01/22/2025

Carlos M. Navarro, Chief Operating Officer

SPB Form 22 | RFP Template | Effective 07192024

NEBRASKA DEPARTMENT OF CORRECTIONAL SERVICES

SUPPLEMENTAL INFORMATION

SOLICITATION NUMBER 120174 O3

The Nebraska Department of Correctional Services (NDCS) is committed to the open and fair process for selection of contractual services; additionally, we are committed to upholding the laws of the State of Nebraska, the NDCS Code of Ethics and Conduct, and internal recommendations for improving best business practices.

Please complete the questions below and submit with your bid documents. Responding “yes” to any question will not disqualify you from consideration but may necessitate a follow-up information request.

Company Name:

PO Box Address:

Physical Address:

City/State/Zip:

Phone Number:

Name/Title of Contact:

YES NO

1. To your knowledge do you have any relatives, employees, contractors, sub-contractors, or a personal relationship with anyone who is currently employed by the Nebraska Department of Correctional Services?

If yes, who?

2. Has an employee of the Department of Correctional Services performed work for you under your current contract with the NDCS?

If yes, who, how long, and in what capacity?

3. Does an employee of the Department of Correctional Services (past or present) hold any corporate position in your company?

If yes, who and what position?

4. Incorporated companies, please provide the following information:

Name of Corporate Entity: ______________________________________________

Principle Office Address: ______________________________________________

Registered Agent and Office Address: _____________________________________

5. Non-Incorporated Companies please provide the following information:

Owner: _____________________________________

By my signature below, I attest that neither I, nor my company, nor any primary officer or employee in my company has a known conflict of interest with the Nebraska Department of Correctional Services.

Company President Signature Date

Innovative Claims Strategies LLC

30 Knightsbridge Road, Suite 525 Piscataway, NJ 08854

732-425-1066 Carlos M. Navarro, Chief Operating Officer

Innovative Claims Strategies LLC

30 Knightsbridge Road, Suite 525, Piscataway, NJ 08854

Kay R. Estes, President & CEO

01/22/2024

REVISED ATTACHMENT A, BIDDER QUESTIONNAIRE

RFP 120174 O3

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) healthcare services.

Bidder Name: Innovative Claims Strategies LLC

It is preferred that the bidder uses this template. Bidder must describe in detail solutions on how their response meets and/or exceed the requirements as outlined in the RFP. Bidder should use the RESPONSE box below for the detailed solution being proposed.

If the bidder choses to provide additional documents outside this template to aid in their response, for evaluation purposes, bidder must cross-reference which question in Attachment A the supplemental documents support.

Business Requirements

C.1

No correspondence of any type is to be sent to the incarcerated individual(s). This includes, but is not limited to, explanation of benefits (EOB), checks, letters, brochures, billings, etc.

Describe what methods are in place to ensure that communication is not sent to the incarcerated individual directly.

RESPONSE:

ICS will not send any correspondence directly to the incarcerated individual.

Our staff is hired and trained to provide excellent communication and customer service across the board that builds relationships between your staff and healthcare providers. All ICS team members have extensive training on the program, inclusive of all program components. Training will include modules that test program knowledge, service level agreement, and other aspects that align with their ability to effectively interact with NDCS. Ongoing training and communication will be part of the process as any changes are made to the operational workflow supporting the program. While there will be a specific process manual, the key is for the ICS staff to “know” the program and not always page through a document.

During the Implementation and Go Live Roundtable Meetings, ICS would create a NDCS specific operational workflow inclusive of process and procedures tied to a Gatekeeping function for claims review and reimbursement.

C.2

Rates for Medical/Dental Claims submitted: Nebraska Medicaid Rates or the negotiated PPO.

Incarcerated Individuals and/or NDCS are not responsible for remaining balance due after Medicaid/PPO rates have been applied.

a. Contractor is responsible for notifying member providers on remittance statements.

No balance will be due after Medicaid or PPO rates are applied.

Rates for Medical/Dental Claims submitted: Nebraska Medicare Rates unless the negotiated PPO rate is lower. Incarcerated Individuals and/or NDCS are not responsible for remaining balance due after Medicare/PPO rates have been applied. Contractor is responsible for notifying member providers on remittance statements, no balance will be due after Medicare or PPO rates are applied.

Describe the process of how the contractor will notify member providers on remittance statements ensuring no balance will be due after Medicare Medicaid or PPO rates are applied.

The Medicare UCR database can be used for repricing codes that do not have a value in the fee schedule. SmartAdvisor applies the Medicare Physician Fee Schedule, Clinical Laboratory, DMEPOS, Ambulance and ASP drugs. The Medicare Physician Fee Schedule (MPFS) is used by Medicare to determine payment amounts for physicians. It is based on the fee schedule developed and maintained by the Centers for Medicare and Medicaid Services (CMS). The Medicare Physician Fee Schedule is

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) commonly referred to as the Resource Based Relative Value Schedule (RBRVS). The RBRVS lists the commonly billed CPT and HCPCS procedure codes and assigns a unit value to each. The unit value is then adjusted by the geographic practice cost indices (GPCI) based on the physical location of where the services were provided.

Codes listed in the MPFS are assigned a status code, which indicates whether the code is in the fee schedule and whether it is separately payable if the service is covered. Certain services may be non-payable under Medicare policy; however, SmartAdvisor applies the RVU data that is supplied in the RBRVS, when available, to calculate an allowance.

C.3 Bidder understands and acknowledges Nebraska Medicaid eligibility as defined by Nebraska Department of Health and Human Services (DHHS).

Will comply

Will not comply

RESPONSE: Based on our understanding of what NDCS is looking for, we feel leveraging ICS’ Online Web Portal Approval Module would be aligned to ensure this requirement is met.

X

C.4 Bidder understands that deductible, coinsurance, and/or copays do not apply.

Will comply

Will not comply

C.5 Bidder understands that the awarded contractor will accept claims as timely if filed within two (2) years of date of service pursuant to the State Contract Claims Act, see Neb. Rev. Stat. § 81-8,306.

Will comply

Will not comply

C.6 Bidder understands Claims maximums such as day, dollar, and lifetime maximums do not apply.

Will comply

Will not comply

C.7 Bidder understands that preauthorization is not applicable for emergency services or inpatient services. For out-patient services, NDCS will provide a prior authorization number.

Will comply

Will not comply

RESPONSE: Our bill review software identifies the difference between inpatient versus outpatient services and for outpatient if it meets our capstone criteria. We can provide reporting that meets NDCS’ needs plus an electronic dashboard showing real time data for inpatient/ outpatient visits.

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

C.8

The services below should not be paid by contractor. Describe what processes will be in place to ensure these services are not paid.

a. Claims billed by out-of-network providers. These claims should be sent to NDCS for consideration.

b. Medications for use after leaving medical provider.

c. Prosthetics/ Orthotics except for those off-site items issued at the time of surgery.

i. Prosthetics/orthotics deemed necessary will need to be pre-approved by NDCS Medical

Director or designee and billed directly to NDCS.

d. Services covered by Medicaid.

e. Newborn or childcare.

f. Abortion.

g. Caffeine-related disorders.

h. Chiropractic care.

i. Dental implants.

j. Dentures/Dental Laboratory Services,

i. Claims deemed necessary will need to be pre-approved by NDCS Medical Director or designee and billed directly to NDCS.

k. Elective procedures.

l. Erectile dysfunction.

m. Factitious disorder.

n. Learning disorder.

o. Nicotine-related disorders.

p. Other conditions/disorders/issues/procedures as determined by the Medical Director or designee for NDCS Health Services.

RESPONSE:

ICS will not pay the above listed items. Using our robust Online Medical Bill Review Web Portal will ensure this these services will not be paid. ICS initially receives the bills and after we process the fee schedule, it is pended for review. Stakeholders can identify the services that they do not want us to pay.

In addition to the online approval process, we can customize capstone rules to identify the services that need to be pended for further review and/or automatically deny or pend for further review by the ICS nurse or NDCS. We have provided sample workflow models in our Proposal Solicitation Requirements Response.

C.9

In-State and Out-of-State Services: Only those services approved by the NDCS should be submitted to contractor for payment. If billed, the following services should be paid by contractor:

a. Claims billed by out-of-network providers. These claims should be sent to NDCS for consideration.

b. Prosthetics/ Orthotics except for those off-site items issued at the time of surgery.

i. Prosthetics/orthotics deemed necessary will need to be pre-approved by NDCS Medical Director or designee and billed directly to NDCS.

c. Dentures/Dental Laboratory Services,

i. Claims deemed necessary will need to be pre-approved by NDCS Medical Director or designee and billed directly to NDCS.

RESPONSE:

Capstone rules embedded in our software would be built to identify these types of bills such as Prosthetics/ Orthotics and dentures/dental. Using our Online Medical Bill Review Web Portal would help accomplish this.

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

C.10

Bidder understands that Contractor will not pay Workers’ Compensation /Subrogation claims. The employer’s workers' compensation insurer must cover the incarcerated individuals for all work-related claims.

Will comply

Will not comply

RESPONSE:

We understand this requirement. ICS offers a specialized service – Inmate Medical Cost Saving Program. This program was created to help correctional facilities, County and City jails maximize their annual inmate medical expense budgets by achieving savings using the following Industry Best Practice techniques and approach.

Using our Online Medical Bill Review Web Portal would help accomplish this.

C.11

Billing received for transplant services must be pre-approved by the NDCS Medical Director or designee. Patient must also meet transplant criteria. NDCS will not pay for elective transplant procedures.

Describe what processes will be in place to ensure that pre-approval is received prior to billing.

RESPONSE:

ICS can build capstone rules to identify procedure codes that tie back to transplant services. Once these bills are identified our Nurse contact the NDCS Medical Director to review these bills and determine next steps. In addition, our Online Approval Process will assist in this requirement as stakeholders can look online to determine if transplant services and requirements have been met for payment.

C.12

Bidder understands Medicaid Claims are covered by Medicaid will not be paid by contractor. NDCS will notify contractor of any Medicaid service eligibility changes.

Will comply

Will not comply

RESPONSE: We will identify Medicaid claims with installed capstone rules and in addition, our online portal will support this initiative to ensure the NDCS is managing its Medicaid claims correctly. X

Bidder Requirements

E.7

Contractor network will include service providers for all NDCS facility locations.

Provide listing of in-network providers in a sortable file by each Specialty listed in Lincoln Physicians Directory in following 5 cities in Nebraska: Omaha metro area, Lincoln, York, Tecumseh, and McCook.

Will comply

Will not

RESPONSE:

Our PPO Network will include service providers for all NDCS facility locations including:

1. Community Corrections Center Lincoln (CCCL) Lincoln

2. Community Corrections Center Omaha – (CCCO) Omaha

3. Reception and Treatment Center (RTC)- Lincoln

4. Nebraska Correctional Center for Women (NCCW) York

5. Nebraska Correctional Youth Facility (NCYF) Omaha

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

6. Nebraska State Penitentiary (NSP) Lincoln

7. Omaha Correctional Center (OCC) Omaha

8. Work Ethic Camp (WEC) McCook

9. Tecumseh State Correctional Institution (TSCI) Tecumseh

Please see Exhibit B.

E.8

Describe the processes to ensure provider rates are not paid higher than the Nebraska Medicare rates.

Identify the processes to ensure provider rates are not paid higher than the Nebraska negotiated rates.

What reports are available that compare provider and Medicare Medicaid rates to the corresponding claims paid.

ICS has created client specific network(s) in our bill review software. We would load the directly contracted and/or negotiated rates that NDCS has in place with existing medical care providers. When a bill comes in tied to one of these providers our system will recognize the contracted and/or negotiated rate and pay accordingly this will ensure we are not paying higher than your rates.

Yes, we have reports available. Please see Exhibit C. During implementation meetings, we will discuss NDCS specific reporting needs including KPI Metric results to review where improvements in the program can take place

E.9

Include an outline of compliance management for claims processing in accordance with the RFP Scope of Work.

Describe the proposed utilization management of claims process. Including the ability and process to customize the utilization management of claims.

RESPONSE:

Please reference our proposed workflows that depict the compliance management for claims processing for NDCS. Specifically, as referenced in the Scope of Work are listed below.

1. Healthcare providers will bill contractor directly for NDCS incarcerated individuals’ healthcare provided off-site or on-site of a NDCS facility. NDCS will notify contractor if services are to be billed as an exception to the contract, i.e., Medicaid, NDCS direct billing; such claim exceptions will not be processed and will be rejected by the contractor.

Our compliance management to meet this is to educate the provider community to submit their bills correctly to ICS. We would explore the opportunity leveraging our clearing house for the NDCS to have the providers submit their bills electronically to ICS. Fo all other “exception management” such as Medicaid, NDCS direct billing, etc., our online bill approval portal is the preferred compliance management tool to meet this scope of work.

2. Individuals on parole or individuals in the custody of NDCS on behalf of a county jail will not be factored into the average daily population (ADP) and at this time are considered outside the scope of services.

Some examples of our compliance management tool to assist and manage this type of scope of work include receiving a claim eligibility file. If ICS receives a medical bill for an individual that falls under this criteria that we can identify that bill that falls outside of this scope of services.

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

3. Pay networked provider claims in accordance with contractor’s internal network provider agreement.

Leveraging the ICS direct PPO Bridge, all medical bills are repriced directly by the PPO network ensuring that contractor rates are paid directly.

4. NDCS approved dental services.

Our compliance management to meet this would be to incorporate the specific approved dental services that NDCS wants paid by the contractor. In addition, our online bill review portal is also a preferred compliance management tool to manage this scope of work.

5. Pregnancy care: This will include prenatal and postnatal care for the mother only not covered by

Medicaid.

We would leverage the online medical bill review web portal in conjunction with our proprietary capstone rules.

6. Prosthetics/Orthotics when placed at the time of surgery.

7. Other Specialty Out-Patient Services.

E.11

Provide a list of all network providers with response to the RFP.

ICS’ core philosophy is to offer our clients access to a dynamic grid of providers and hospitals at the national, regional and market‐by‐market level. We have developed our “best of breed’ network offering to deliver to our clients the highest level of PPO penetration and savings for each jurisdiction and client utilizing a combination of national, regional, and local PPO networks. Following our philosophy of offering programs and not commodities, we have branded this service as ICING, or Integrated Coordination Increasing Network Growth.

Our strategy is to organize and contract providers for specific product lines and for specific client needs.

All providers that meet our standards and pass credentialing can participate. Our contracting systems will operate to manage and administer the contracting process from initial conversation to credentialing the providers. This process allows providers to be evaluated for appropriateness, verified for correctness of data, and solicited by initial call from the contracting team, e‐mail, fax or standard mail.

This is a true customization and verification process at the network level.

All providers are formally credentialed which adheres to URAC and NCQA standards. Our process will ensure the correct history, education, malpractice, licensure, insurance are in place before presenting the provider to our credentialing committee. Not all providers pass this through this process of analysis.

As a result of this process, we are confident that the accepted providers are of the highest quality for

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) treating our members.

ICS has direct contracts with all our PPO partners, inclusive of the specialty networks such as Physical Therapy and Diagnostic to National and Regional PPO Networks. In addition, ICS can also load and manage any networks that a client may have an existing contractual arrangement. These provider records will be designated as part of a client’s EPO that would guarantee any savings below Fee Schedule that the client has contracted directly remain outside of the traditional PPO Savings amount subject to Access Fees.

Please see Exhibit B for a list of all network providers.

Contractor Requirements – General

F.1.a

Contractor’s network will include services for all NDCS facility locations

RESPONSE: ICS will comply with this requirement.

F.1.b Describe how valid patient care claims for State incarcerated individual(s) committed to NDCS will be processed.

RESPONSE:

ICS has created numerous interfaces that applies the data received from a claims feed to identify appropriate relationship of the medical bill review service to the compensable injury. Based on our understanding the RFP, we feel in the workflow model described in our SUMMARY OF BIDDER’S PROPOSED PERSONNEL/MANAGEMENT APPROACH (Proposal Solicitation Requirements Narrative

- page 8) will achieve savings and ensure the most appropriate medical is being rendered to an inmate.

ICS will create and send to a new client our comprehensive Inmate Medical Bill Review ID Cards as shown below. The ID Card can be used by the Jail when transporting an inmate to a medical facility and providing the medical facility with all the information they would need to submit their medical bills with supporting medical documentation for review and payment. In addition, we would work with our PPO Network Partner to create an insurance card that would expedite the identification of a NDCS inmate and ensure the correct medical care is rendered following any NDCS specific protocols as well as ensuring the medical provider understands the billing workflow and payment process.

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

Our workflow supports the review of bills by medical coding experts and nurse specialists as well as the proper application of fee schedule reimbursement rates. The Code Review process systematically identifies improperly up‐coded bills, unbundled/bundled procedures, and employs other clinical considerations that result in significant savings beyond fee schedule savings.

Leveraging our Capstone Rules Decision Manager, ICS would create a workflow modeler for identifying incoming medical bills that have a telemedicine service component and establish customized User Work Queues to pend these bills for further or specialized review by our Coders and Nurse Auditors, as well as the NDCS. SmartReports will then be customized to generate any kind of output report NDCS is needing to understand and manage inmates that receive telemedicine services and the impact on their claim and resolution.

We can accept both computerized and manual eligibility updates. We would prefer building out an electronic eligibility interface with the NDCS of which ICS would not charge for this integration. For all our other Jail clients, client eligibility is confirmed upon an inmate being transferred to an outside medical facility.

Methods to Identify Improper Billing

ICS leverages system edits and flags within SmartAdvisor that promote quality assurance tied to bill adjudication. SmartAdvisor detects inappropriate billing and anomalies on several levels. The first level of measurement is against the state fee schedule. SmartAdvisor contains all rules associated with the fee schedule and automatically applies them against bills as they are processed. The system also

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) contains National Correct Coding Initiative (NCCI) edits, Component Code Edits (CCE), Mutually Exclusive Edits (MUE), and American Medical Association (AMA) medical edits designed to detect inappropriate coding schemes and automatically disallow these services. NCCI edits are pairs of CPT or HCPCS Level II codes that are not separately payable except under certain circumstances. These edits are applied to services billed by the same provider for the same claimant on the same date of service.

All claims are processed against the NCCI tables. These provide additional standard billing rules within the system for circumstances that are not covered by the fee schedule.

Using NCCI data tables, SmartAdvisor can apply logic to billed procedures defining the national correct coding methodologies based on coding conventions defined in the American Medical Associations Current Procedural Terminology (CPT) Manual. The coding methodologies are based on current standards of medical and surgical coding practice with input from specialty societies and analysis of current coding practice, the system unbundles/bundles and deny inappropriately billed procedures.

Rarity edits including ICD and CPT, are also embedded allowing the client to determine bills that contain codes that are rarely seen. Bills that fail this tolerance level test may be automatically adjusted or sent to a specialized user for review. The software allows interfaces with Utilization Review systems that recognize billed treatment that is outside of the treatment plan for a specific claim. These bills may be automatically reduced or pended to a user for review. With SmartAdvisor there is an option to turn on the “Apply Bill Review Rarity Edits. This edit manages the relationship between diagnosis and procedure by allowing the end user to select a percentile from the drop‐down list.

Another feature within SmartAdvisor that is used to assist with the identification of improper billing is the Medical Alert module. Medical Alert is one of the most implemented system alerts. Medical Alert is a component that is available during bill entry and provides the user with statistics on medical treatment activity for a specific claim and provider. Medical Alert advises the end user during bill entry when a claim has exceeded its predetermined limits (Medical Treatment Guidelines parameters). Additionally, other fields set up on the client record define the information that displays on the Medical Alert window, including Days since Date of Injury/Loss, Maximum Allowance, Maximum Number of Visits, and Warning Number of Visits. The Medical Alert window can be set to “Auto‐display” whenever bill header information is entered, and the Lines tab is clicked.

Once a medical bill has reached its final adjudication destination within the SmartAdvisor application, automated scripts generate a Medical Payment File containing the information necessary to import the paid data into its Claims System used as the basis for creating the provider reimbursement. In addition to the paid data, ICS typically sends a corresponding EOR File that allows our clients to sync the payment with the EOR. Questionable claims are identified within the fee schedule reimbursement rate application as well as a review by medical coding experts and nurse specialists. For a “clean” medical bill that does not hit any front end Capstone Rules suspending a medical bill or an Out of Network Signed Agreement on the back end, ICS’ turnaround time from receipt of the medical bill to sending the completed EOR/Medical Payment File to the NDCS is 4‐5 business days.

We would leverage any one of a variety of repricing schedules to meet the NDCS’ needs, inclusive of Medicare, Fair Health Usual, Customary, and Reasonable (UCR), and other jurisdictional fee schedules.

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

F.1.c Describe how the contractor will ensure claims are paid properly and what measurements are in place to ensure Nebraska Medicare rates are do not exceed the negotiated rate.

ICS leverages the software technology SmartAdvisor, for Medical Bill Review/PPO services.

SmartAdvisor deploys powerful technology to help claims organizations process medical bills using accurate and up-to-date fee schedules and other benchmarks. The proprietary platform integrates end-to-end with your claims system, provider and specialty networks, clinical services and IME systems, electronic billing and payment technologies and more to provide you the information you need exactly when you need it—helping you to see the full picture of the claim.

SmartAdvisor provides a review of all medical bills including inpatient, outpatient, diagnostic testing, prescription medicine, skilled nursing, home health. Fee schedules are utilized in all states where required. ICS also uses DRG grouping software and surgical coding edits. In non-fee schedule states, ICS utilizes Fair Health for usual and customary pricing. System edits include:

• Billing anomalies against state fee schedule

• Inappropriate billing and coding identification against NCCI Data Tables

• Inappropriate billing and coding identification against AMA Medical Edit Guidelines

• System driven bundling/unbundling of codes and services

• Rarity Edit Rule-base - selection of tolerance levels to determine codes that are rarely seen in bills.

• Medical Alert Module –advises when claims exceed their predetermined limits (UR parameters).

• Integrated UR module that recognizes billed treatment outside of the treatment plan for a specific claim. These bills may be automatically reduced or pended to a user for review.

Fee schedules are utilized in all states where required. ICS also uses DRG grouping software and surgical coding edits. In non-fee schedule states, ICS utilizes Fair Health for usual and customary pricing.

ICS’ core philosophy is to offer our clients access to a dynamic grid of providers and hospitals at the national, regional and market‐by‐market level. ICS has direct contracts with all our PPO partners, inclusive of the specialty networks such as Physical Therapy and Diagnostic to National and Regional PPO Networks. ICS has negotiated contracts with each PPO network in a manner that allows us to perform initial and ongoing detailed data analysis for each client and select the best primary/secondary network solution City by City, State by State, or even by zip code.

F.1.d Claims to be paid by Nebraska Medicaid are to be denied. Describe what methodology is used to ensure this requirement will be met.

RESPONSE:

Based on our understanding of what NDCS is looking for, we feel leveraging ICS’ Online Web Portal Approval Module would be aligned to ensure this requirement is met.

F.1.e Describe the ability to have the provider directory available via an electronic site. Including the process on how the directory is maintained by contractor to ensure accurate information.

RESPONSE:

Electronic provider directories are supported on either ICS or our provider vendor partners site. Provider directories are an important tool to select and contact physicians and other contracted providers who deliver medical care.

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

Contractor Requirements - Reporting

F.2.a Contractor will provide NDCS Accounting with an automated denial report monthly (minimum).

Will comply

Will not comply

F.2.b

Provide an example of reporting that meets electronic reports requirements. Bidder may provide a narrative response expanding on reporting along with the samples.

Provide the following electronic reports, upon request by NDCS, at no charge:

Include a listing (title or topic) and provide a sample printout of all reports that are considered standard and included at no additional charge.

Special reports of health care paid for an incarcerated individual within two (2) business days.

Rejected claims and rationale for rejection.

Breakout by specialty, i.e. physical therapy, dental, psychiatry, maternity, etc.

Report of charges of $20,000 or above per incarcerated individual, per diagnosis, and per off-site hospitalization per occurrence, or as requested.

Leveraging our comprehensive and customizable SmartReports reporting engine, ICS will create the customized detail claims reports NDCS is requiring and incorporate that into the customized Key Performance Indicator Report and Dashboard ICS would create and manage for NDCS.

ICS can provide claims analysis ad hoc as requested by NDCS to meet your specific needs. In addition, SmartReports allows users to create customized ad hoc reports, and perform desktop analysis on SmartAdvisor data. SmartReports produce reports in a web-based environment using SmartAdvisor data. There is no additional cost for reports. During the Implementation and Go Live Meetings reporting metrics that will be needed to support the Program will be discussed. We have flexibility to dynamically change the Reporting Metrics as the Program matures or new metrics are identified.

SmartAdvisor incorporates SmartReports as one of the key components. SmartReports allows users to access current standard reports, create customized ad hoc reports, and perform desktop analysis on the SmartAdvisor data. The SmartReports tool allows users to produce reports in a web-based environment using SmartAdvisor data. Shown on the following page is a small sample of the various types of reports that can be generated by SmartReports

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

Customized reports are created using the ad hoc query tool, Report Builder 3.0. Report Builder is a tool developed by Microsoft that allows users to create and design custom reports generated from the published data in the reporting database (also known as the Online Analytical Processing exported (OLAP) database). This allows clients to design reports that meet their business needs using an easy-to-use drag-and-drop functionality that produces reports in various formats. These reports are run using published data pulled from the reporting database, which is refreshed nightly.

We urge the NDCS to leverage our web-based technology platforms, ReviewStat Browser, CEP, and SmartReports that will provide 24/7 access to all data, images, and the ability to leverage over 100 canned reports as well as creating their own ad hoc reports. These programs allow complete up to the minute access to its claims, the ability to interact electronically with ICS staff, and to set next steps etc.

ICS can customize our systems to accommodate any client specific data elements, inclusive of type and cause codes, and type of payment. There is no additional charge for providing this type of customization, as we feel this is part of the process that makes ICS unique in the industry.

Sample reports have been provided in Exhibit C.

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

F.2.c

Bidder should provide an example of reporting that meets these requirements. Bidder may provide a narrative response expanding on reporting along with the samples.

Contractor will provide a monthly listing in Excel format of all claims paid per incarcerated individual, identifying:

Incarcerated individual committed name.

NDCS Incarcerated individual identification number.

Incarcerated individual age/ date of birth.

Date of service (beginning and ending).

Medical provider name and location.

Place of service codes.

Detailed billing including ALL diagnosis code(s) and each procedure code(s) (ICD10, CPT, modifiers, units, and NDCS number(s)).

APR-DRG (Diagnose Related Group) + SOI (Severity of Illness) level determines reimbursement level.

Prospective Payment System detail showing weight and rate of each APR-DRG for different clinics/hospitals/surgical centers.

Total Gross charged amount.

Total Net paid amount.

Dates of claim submission to contractor.

Dates of payment to providers.

Sample reports have been provided in Exhibit C.

F.2.d Provide an example of the Service Organizational Control Report (SOC2) and provide the Service

Organizational Control Type 2 certification if applicable.

ICS is a Service Organization Controls (SOC) Type II certified organization. Being a SOC certified organization, our clients feel confident that ICS is operating in an ethical and compliant manner. Please see Exhibit D for ICS’ Standard Type II Audit Report.

Contractor Requirements – Electronic Dashboard

E.10

F.3.a

Provide an example of an electronic dashboard meeting the RFP requirements.

Describe what methodology will be used to establish an electronic dashboard meeting the minimum requirements as described in the RFP.

hboard must provide a minimum of the following. Most expensive patients.

Top diagnoses.

Frequency of diagnoses.

Year to date. Month to month.

Specialists/category.

Itemized billings for all patients.

Files be protected to meet confidentiality standards. Prefer to have the capability to print off

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) the file at NDCS.

Contractor shall provide menu listing of industry standard services including Certification and Concurrent Review Requirements with applicable cost and bullet point Return on Investment (ROI) as options for NDCS to consider using:

Pre-payment auditing cost. Concurrent review cost.

Complex medical review cost.

ICS can directly receive computerized and manual claims from any community providers used by a NDCS facility. ICS strives to break down the barriers that often prevent clients and their vendors from reaching mutual goals. These barriers often result from disconnected systems, conflicting workflows, and financial incentives that separate the two parties from aggressively pursuing these goals. We have built many system interfaces with TPAs to ensure that all communication is electronic in nature, inclusive of the exchange of clinical notes, treatment plan, disability duration, expected return to work milestones, medical bills, medical payment information, medical records, and EORs.

ICS pledges to ensure the highest standards of performance; integrity, customer service and fiscal accountability in managing the cost containment portion of our clients’ needs. We consider the evaluation of its services to be an integral part of any program we implement. Performance is evaluated in a manner that meets the needs and requirements of each of our clients while adhering to any methodological, data or system constraints. Our strength is to analyze outcomes, trends, goals, and recommend program enhancements.

ICS provides Key Performance Indicator Metrics for our clients to review where improvements in the program can take place and to set the Road Map for the ensuing year. During the Implementation and Go Live Meetings we determine reporting needed to support the Program. ICS has the flexibility to dynamically change the Reporting Metrics as the Program matures or new metrics are identified.

Our software incorporates SmartReports that allows users to access current standard reports, create customized ad hoc reports, and perform desktop analysis on the SmartAdvisor data. The SmartReports tool allows users to produce reports in a web‐based environment using SmartAdvisor data. The SmartReports application produces two report types: Static Reports and Analysis Reports.

F.3.b

Contractor will, to the best of their abilities, include additional analytics on the electronic dashboard as required by the NDCS Medical Director. It is preferred that the data on the electronic dashboard be easily customized to perform analysis.

ICS leverages our SmartAdvisor and Claims Examiner Portal (CEP) real time integration for our medical bill review clients and offer a solution that will greatly improve adjuster efficiency, promote the advent of a “paperless” medical file, and shift the administrative burden of managing a medical bill to all bills and medical records received by ICS will be imported into our document management server.

The NDCS will have online access to CEP. CEP is a powerful, secure web‐based solution for utilization alerts, bill authorization, EOR reprints, bill management, and provider relations. This portal provides a comprehensive web version of the SmartAdvisor application that can be used by examiners, physicians, and other external entities. The CEP gives users an online "window" into the bill‐review

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) process. The two main functions of CEP include:

• History inquiries: Real‐time information exchange with the SmartAdvisor application.

• Examiner approval: Allows examiners to approve and deny bills and to modify editable fields and charges.

Through this web‐based tool, users can get instant information regarding bills that have been submitted for review. In addition, users have access to extensive current and historical information (at the header and detail level) generated by the bill review process including EORs, send backs, and reconsiderations.

Access requires a high‐speed connection to the Internet and an Internet browser application, preferably Google Chrome or Microsoft Edge. Since CEP is web based, it supports an unlimited number of users. ICS does not charge for access to CEP.

Online access is available 24/7.

Contractor Requirements – Claims

F.4.a

When submitting claim inquiries to NDCS, contractor will provide details as described in the RFP.

Incarcerated individual committed name and date of birth.

NDCS five (5) or six (6) digits incarcerated individual identification number. Medical provider name and location and clinic/hospital/surgical center if applicable. Admit and Discharge Date.

Total Charges.

Detailed billing including ALL diagnosis code(s) and each procedure code(s) (ICD10, CPT, modifiers, units, and NDCS number(s)).

APR-DRG (Diagnose Related Group) + SOI (Severity of Illness) level determines reimbursement level.

F.5.a F.5.b

Contractor will attend quarterly meetings and an annual review of SOC2. Will

Will not

Throughout our partnership, ICS will roundtable with NDCA to determine reporting that will be needed to support the Program with a flexibility to dynamically change the Reporting Metrics as the Program matures or new metrics are identified. During implementation and transition kick off meetings, the frequency of claim reviews is discussed. We recommend the following:

• Monthly Claims Conference Calls –review open files to determine next steps and plans of action.

• Quarterly Claims Review Meetings – a face-to-face process focusing on claims

Contractor Requirements –Meetings

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) that have fallen outside of best practice criteria and guidelines and other “high profile claim files.

• Year in Review Stewardship Meetings – a formal face to face with all interested stakeholders to assess the KPI Metric results from the past year, to review where improvements in the program can take place and to set the Road Map for the ensuing year.

PAYMENT SCHEDULE/DELIVERABLES

J.1.a

Invoices shall include detailed itemized billing per patient including ALL diagnosis code(s) and each procedure code(s) (ICD10, CPT, modifiers, units, and NDCS number(s)).

RESPONSE:

In every EOR the provider receives a detailed list of the items audited and a clear analysis of how a line item was adjudicated, including reductions tied to State Fee Schedule, UCR, or Network participation. Any adjustments made to a bill or line service is recorded via the adjustment code, which will provide an explanation of the adjustment. A sample EOR have been provided below.

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

J.2.a If awarded at a fee per incarcerated individual, the formula used to calculate the monthly processing fee shall be “fee per incarcerated individual multiplied by the ADP.”

Will comply

Will not comply

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

In addition to the required Cost Form that has been uploaded as a separate document, we would like to propose an alternative pricing method as shown above for NDCS’ consideration and would be happy to provide additional detail if interested.

J.2.b If awarded at a monthly flat rate, no formula will be required on invoices. Will

Will not comply

J.3 All recoupment requests to NDCS will be processed within 30 calendar days upon agreement.

Will comply

Will not comply

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

OPTIONAL SERVICES (NOT SCORED)

K.1

Prior to claims being paid, a utilization review shall be completed to include but is not limited to reviewing claims for appropriate services, review procedures/documentations related to visit for appropriateness and review hospital stays for appropriate length of stay.

Describe in detail the analytical capabilities and competency of providing a detailed, accurate and comprehensive utilization review.

Our focus is to ensure overall compliance, quality, and reporting that demonstrates cost effective solutions consistent with the client’s standards and expectations. In today’s world where everyone expects quality and compliance, we believe it is necessary to go beyond those basic expectations … so every day we push to ensure clients receive:

• Spot‐on evidence‐based decisions

• Graded decisions with the highest available evidence

• Precise turnaround times meeting individual demands

• Experts to oversee client and jurisdictional requirements

• Treatment focused relevant specialty matching

• Successful peer to peer phone calls conducted by the peer reviewer

Clinical Audit & Code Review

ICS provides Clinical Audit and Code Review on all complex medical bills. This review consists of reviewing all coding and the associated documentation to verify that the billing was submitted correctly and that the submitted documentation supports the services billed. Any bill that is keyed and that bill meets the clinical audit review criteria, that bill is automatically “pended” for Clinical Audit Review prior to the bill going out to the PPO networks

Our experience has shown the following types of bills have historically been ideal candidates for a secondary review, all inpatient hospital bills, all trauma bills, all Ambulatory Surgery Center bills, multiple surgical procedures, EMG testing, ASA (anesthesia) codes billed with CPT codes, high level office visits (over level 3), all unlisted codes, physical therapy and chiropractic bills (based on state guidelines), and ICD9 & CPT codes that are not normally billed for workers’ compensation injuries.

All codes that are changed or down coded by a Clinical Audit Review are confirmed and approved by the provider. This approach eliminates retrospective provider disputes and reduces reconsiderations by resolving the bill issues up front. Clinical Audit Review savings are separately identified on the Explanation of Review (EOR) and in our reporting. Both Fee Schedule/UCR and Clinical Audit Review reductions are always applied prior to any attempt to apply a PPO discount to reduce clients’ PPO expenses.

Treatment Standards and Protocols

ICS leverages the URDM within SmartAdvisor with our Case Management/UR application, ReviewStat, which is fully integrated with SmartAdvisor. On a specific claim, URDM matches UR results against the bills that are received. Through the rarity edits, rarely performed treatment is identified. SmartAdvisor has capability through its Capstone Decision Engine to alert the user to potential mismatches between nature of injury, body part, and treatment performed.

Utilization Review decisions are loaded into SmartAdvisor. As the medical bills pass through the workflow, the system recognizes the overutilization, unnecessary care, and those instances where denied services are billed. The client can define if these are automatically denied or pended for specialized review.

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s)

The SmartAdvisor Capstone Module can help clients recognize mismatches between nature of injury and body part. Through databases that recognize these mismatches, the corresponding bills may be pended to a specialized user for review. SmartAdvisor tracks diagnosis codes that are present and accepted on a claim. Through ICD/CPT matches, the system can identify those treatments that are seemingly unrelated. The client can select to have these automatically denied or pended to a specialized user for review.

During Implementation meetings we would devise the most efficient operational workflow that will create the desired data integration to support the UR Decision/MBR workflow.

K.2 Describe and/or provide examples of any other available analytical services, reports, quality assurance, auditing, tools etc., at no additional cost.

ICS considers the evaluation of its services to be an integral part of any program we implement.

Performance is evaluated in a manner that meets the needs and requirements of each of our clients while adhering to any methodological, data or system constraints. Our strength is to analyze outcomes, trends, goals, and recommend program enhancements. We work hard to identify new areas in which we can further assist in achieving our client’s business objectives and as a result we’ve identified new trends and opportunities for growth and expanded our scope of solutions to meet them.

ICS…