signed_3rd Party Eligibility_SOW_111524.pdf

Department of Health and Human Services Indian Health Service

Claremore Indian Hospital Statement of Work (SOW)

Third Party Eligibility Services

1. PURPOSE OF THE PROJECT

The Claremore Indian Hospital (CIH), Indian Health Services (IHS) has a requirement for third party eligibility monitoring services related to eligibility and enrollment of referred patients to assist patients in obtaining financial aid under federal, state and local programs to pay for medical expenses incurred by patients of the hospital.

2. DETAILED DESCRIPTION OF THE TECHNICAL REQUIREMENTS

The contractor shall provide the following services:

Eligibility Services:

a. The contractor shall provide an on-site representative to screen inpatient, outpatient and Emergency Department referrals.

b. The contractor’s representative shall attempt screening at bedside in the facility. If this does not occur or if the account is a non-inpatient date of service, the contractor’s contact with the patients will include, but are not limited to, phone, mail, and coordination with facility should the patient return for services.

c. The contractor’s representative shall provide comprehensive and in-depth screening for patients to determine eligibility for the following assistance programs:

a. Medicaid

b. Social Security Disability (SSI / SSDI)

c. Health Information Exchange (ACA)

d. ESRD Medicare

e. Crime Victim Compensation Fund

f. Medicaid Secondary Coverage to Medicare

g. Long Term Care

h. COBRA insurance eligibility or other commercial options available to provide payor source.

d. Screening shall confirm all demographic and coverage information. Complete financial/employment questionnaire is completed with the patient to include the patient providing information regarding household members, reason for services received, and historical personal medical information.

e. The contractor shall assist and/or complete the necessary forms/applications for patients deemed eligible for financial assistance and obtain signed release form from patient allowing further assistance.

f. The contractor shall submit application on patient’s behalf to the appropriate agency or institution.

g. The contractor shall assist in scheduling any needed personal interviews with appropriate agencies, as well as appointment verification of those appointments, either arranged for or provided by the contractor at no additional cost to the Hospital.

h. The contractor shall independently determine and gather verifications that are needed to ensure application approval. If any required documentation must be purchased for verification requirements, this will be provided at no cost to the patient or hospital.

i. The contractor shall follow up weekly with the agency or institution responsible for enrollment determination.

j. The contractor shall pursue appeal of unfavorable decision on patient’s behalf, as appropriate.

k. The contractor shall coordinate with the Hospital to assist with needed information in regards to

Coordination of Benefits including the completion of any needed forms to allow for reevaluation of claim for possible payment.

l. The contractor shall update hospital system with current account status information.

m. The contractor shall verify billing information and effective dates before submitting to hospital for coverage of past medical bills.

n. The contractor shall update and correct, as needed, any portion of referred accounts within granted system access parameters.

Batch Filing Services:

a. The contractor shall attempt to find existing Medicaid, Medicare and other insurance coverage through ProfitPal or other contractor electronic batch filing software.

b. Upon notification to the contractor that coverage exists under any insurance program, return such member coverage information to Claremore Indian Hospital for follow-up and billing.

c. The contractor shall provide the hospital with accurate, complete and timely eligibility information within 72 hours of information being obtained.

d. The contractor shall provide the Claremore Indian Hospital with a monthly summary report of all identified member eligibility summarizing inventory account volume in an agreed upon file format.

3. PERIOD OF PERFORMANCE

The Period of Performance will be 10 months from date of award.

4. LEVEL OF EFFORT

a. The contractor shall possess an internal account management system for tracking and reporting of patient accounts and will utilize this system as the main workflow driver.

b. The contractor shall accept account placements and account updates via auto-outsourcing databases or manual file transfer.

c. The contractor shall provide comprehensive notation on assigned accounts demonstrating substantial and meaningful service work.

d. The contractor shall provide experienced service line subject matter experts appropriate to successfully fulfill work requirements complying with requirements as specified in the job description and will demonstrate competency levels of the job.

e. The contractor shall provide staff appropriate training and support to all assigned staff for the execution of the contract.

f. The contractor shall ensure staff has current certifications as needed.

g. The contractor shall ensure all staff activities comply with all applicable Federal, State and local laws and regulations.

h. The contractor shall ensure that all employees assigned to the contract have completed a background check, passed a competency assessment and are not on the HHS-OIVG list of excluded individuals.

i. The contractor shall provide a monthly distribution of proprietary performance reports and make available via secured online client portal and /or printed copies.

j. The contractor shall produce, at the hospital’s request, any custom reports that the hospital may deem as necessary.

k. The contractor shall ensure that the services provided are in accordance with all applicable federal, state and local laws, regulations, and rules governing contracted services; including the Fair Debt Collection Practices Act (FDCPA), PCI Compliance, 501R Compliance (patient notification of credit reporting), and HIPAA.

l. The contractor shall treat all patients, employees, and business partners in accordance with the values and mission of the Hospital.

m. The contractor shall not retain any information related to accounts other than that which is required by law.

n. The contractor shall warrant that it will use best practices in performing all services.

5. SPECIAL REQUIREMENTS

5.1. In accordance with HHSAR 304.1300(b) non-routine contractor employees shall comply with OPDIV

DHHS/SE Region – Human Resources, Security Clearance Guidance – Visitors (3/29/12) policy for contract performance period. Contractor employees will be required to obtain a visitor’s pass upon arrival for services from Facilities Management.

5.2. The US PHS Claremore Indian Hospital is a tobacco/smoke free environment (buildings and grounds). No tobacco/smoking use will be tolerated during service.

5.3. Security Requirements: Contractor personnel will be required to contact the government designated point of contact upon arrival when reporting for service calls or delivery supplies. The contractor shall be responsible for the security of all organizational information. Current rules and regulations applicable to the premises, where the work shall be performed shall apply to the contractor and its employees while working on the premises. These regulations include but are not limited to, escort by Claremore Indian Hospital official, presenting valid identification, smoking restriction and any safety procedures.

5.4. The contractor shall not disclose or cause to disseminate any information concerning operations of

Claremore Indian Hospital. Such action(s) could result in violation of the contract and possible legal actions.

5.4.1. All inquiries, comments, or complaints arising from any matter observed, experienced or learned of as a result of or in connection with the performance of the contract, the resolution of which may require the dissemination of official information, shall be directed to the government’s designated representative.

6. DELIVERABLES AND REPORTING REQUIREMENTS

6.1. Delivery: The contractor will coordinate the delivery, installation and training date with the designated government employee. The government will provide the contractor with dock access and building access for this sole purpose. The designated government employee will work with the pertinent government agency(ies) to secure the needed dock access. No deliveries can be made after 4:15pm. Driver needs a valid ID.

6.2. Contractor Point of Contact: The contractor shall furnish one designated point of contact (POC) to the government’s designated representative for coordination of supplies, delivery, and/or maintenance. The POC will be empowered to make daily decisions to ensure that the contract implementation and day-to-day maintenance meets the terms and conditions of this contract.

6.3. Contractor’s Phone Numbers: The contractor shall provide a toll-free telephone number for service calls, which must be answered during at least eight working hours, between 8:00 am and 4:30 pm, Monday through Friday.

6.4. Personnel Qualifications:

a. Must know eligibility requirements of various third-party resources such as Medicare, Medicare

Part D and C, Medicaid, Social Security Administration, County DHS Office, Tribal Programs and the Affordable Care Act. Knowledge to include other related agency policies/procedures for enrollment in alternate resources and required forms.

b. Has the ability and skill to interview patients in-depth in order to determine eligibility of alternate funding. Ability to communicate to the patient what specific information is needed, the reason for that specific information, and be able to ascertain that it is as accurate as possible. Must possess tactfulness and ability to deal effectively with persons of diverse backgrounds.

c. A thorough knowledge of the Privacy Act of 1974, which mandates that the incumbent shall maintain complete confidentiality of all administrative, medical, and personnel records, and all other pertinent information that comes to his/her attention or knowledge.

d. Must possess the ability to follow directions and absorb quantities of material necessary to the efficient performance of assigned duties and responsibilities.

7. GOVERNMENT FURNISHED PROPERTY, FACILITIES AND SERVICES

a. Claremore Indian Hospital (CIH) shall assign a main point of contact as a contractor liaison.

b. CIH shall provide the contractor with appropriate access to systems for patient account access to perform the contracted services.

8. CONTRACTOR FURNISHED PROPERTY, FACILITIES AND SERVICES

a. Services shall be performed as stated herein.

9. CHANGES TO THE STATEMENT OF WORK (SOW)

Any changes to this SOW shall be authorized and approved only through written correspondence from the Contracting Officer. Costs incurred by the contractor through the actions of parties other than the Contracting Officer shall be borne by the contractor.

10. DELIVERABLES/PERFORMANCE MATRIX

10.1. Properly trained and certified staff to include background investigation: Yes No

10.2. Screening of patients for third party billing: Yes No

10.3. Monthly report of eligible patients for third party billing: Yes No

10.4. Submission of third party billing application for patients: Yes No

Department Supervisor Signature:_________________________

Administrative Officer Signature:_________________________