Luma Event 4.pdf

IDAHO DEPARTMENT OF HEALTH AND WELFARE

RFQ Event 4

Medical Claims Clearinghouse

1. Purpose The Idaho Department of Health and Welfare, Division of Public Health (Department) is requesting quotes for the receipt of provider electronic and paper medical claims and then providing that information electronically to the Department, as further detailed below. Idaho Women’s Health Check is funded by the Centers for Disease Control and Prevention and the National Breast and Cervical Cancer Early Detection Program. Women’s Health Check provides free breast and cervical cancer screening and diagnostic services to eligible women in Idaho.

Women’s Health Check is looking for a Contractor that is capable of receiving medical claims from providers across Idaho and sending the information electronically to the Department. The Contractor must be capable of receiving both electronic and paper medical claims and sending information daily to the Department.

2. Background The Department is seeking a Contractor to receive claims for eligible client services, appropriate documentation of medical claims, the submission of an electronic file to the Department on a regular basis, and to share data electronically for reconciliation of the claims database with the Department’s client databases. The selected Contractor will be compensated on a fee-for-service basis. The target population is Department eligible participants and their health care providers.

The Department provides screening and diagnostic services to approximately eight hundred (800) women per year, through a system of nine (9) Local Coordinators (LCs) who coordinate appropriate services provided by about three hundred fifty (350) health care providers. The LC determines eligibility and enrolls clients.

It is the responsibility of the Contractor to utilize a system that ensures claim receipt and transmission to the Department within ten (10) business days for complete claims that meet basic requirements for the appropriate HIPAA Transaction sets.

The Contractor must be able and willing to exchange client and program data electronically with the Department, and outline safeguards to maintain security of sensitive data. Communication, timely processing of claims and excellent customer service is extremely important to the success of this contract.

For the most recent fiscal year, the current contractor received five thousand one hundred eighty-nine (5,189) claims for eight hundred and twenty-one (821) Department clients who received services from three hundred fifty

(350) health care providers. The claims received in the most recent fiscal year, were lower than in previous years for a similar number of clients served. The Department expects to receive approximately nine thousand (9,000) claims in the first year of this contract and anticipates a five percent (5%) growth per year over the next four (4) years.

It is not required that the successful offeror reside in the state of Idaho, but they and their systems must be located within the United States.

3. Timelines and Submittal

Quotes will be accepted through Luma only. Submit your quote using the Luma Lines and Questions Pages no later than 5:00 p.m. Mountain Time on 08/24/2023.

All questions must be submitted in IPRO using the Q & A Board located within the Tools tab (left-hand side selection list).

4. Scope of Work See Exhibit C

5. Award Basis and Term

Validity of Quote: Your quote must be firm and binding for a minimum of ninety (90) calendar days, or such alternate time as designated in the solicitation document.

Alternate Quotes: Multiple or alternate quotes will not be accepted unless expressly allowed in the solicitation documents.

AWARD: Award will be ALL OR NONE to the Responsive Responsible Vendor with the Lowest Cost as provided in IPRO.

The initial Contract term is anticipated to be 07/01/2023 to 06/30/2024. Upon mutual, written agreement, the Contract may be amended or extended. The total Contract term, including all extensions, is not anticipated to exceed four (4) years.

Services and requirements will include the following:

Exhibit A – Special Terms and Conditions Exhibit B – Riders Exhibit C – Scope of Work Exhibit D – Reports Exhibit E – Cost/Billing Procedure Exhibit F – State Signature Page

The attached documents will become part of the Contract resulting from this Request for Quotation (RFQ). If you wish to provide a quote for these services, please provide your fully loaded rates which must include, but not be limited to, all operating and personnel expenses, such as: overhead, salaries, profit, insurance, supplies, travel, implementation, transition and quality improvement, into the Lines Page in Luma.

Also, vendors must answer the questions on the Luma Questions Page.

Additional Solicitation Instructions:

Standard Terms and Conditions and Solicitation Instructions: The current versions of the “State of Idaho Standard Contract Terms and Conditions” State of Idaho Standard Terms and Conditions and “Solicitation Instructions to Vendors” State of Idaho Solicitation Instructions to Vendors are incorporated by reference into this solicitation, and any resulting Contract, as if set forth in their entirety. Both documents can be downloaded at https://purchasing.idaho.gov/governing-laws-and-policies/; or copies obtained by contacting the Division of Purchasing at 208.327.7465 or purchasing@adm.idaho.gov. Failure by any submitting vendor to obtain a copy of these documents shall in no way constitute or be deemed a waiver by the State of any term, condition or requirement contained in the referenced documents; and no liability will be assumed by the Division of Purchasing or the Department for a submitting vendor's failure to consider the State of Idaho Standard Contract Terms and Conditions and Solicitation Instructions to Vendors in preparing its response to the solicitation.

6. Response

Enter your Total Cost for each line on the Lines Page of this solicitation in Luma, so that it is received at the Department prior to the deadline established above.

Response must be accompanied by a signed State of Idaho Signature Page, which will be found in the Questions Page of this solicitation in Luma.

It is at the Department’s sole discretion whether or not your response meets the specifications of this RFQ. At the sole discretion of the Department, if your response does not meet the requirements of the RFQ the submitting vendor will not be considered for award. Responses to the questions in the IPRO Question Page will determine whether your response meets the requirements of this RFQ.

Exhibit A – Special Terms and Conditions

I. DEFINITIONS. As used in the Contract, the following terms shall have the meanings set forth below:

A. Contract Manager shall mean that person appointed by the Department to administer the Contract on behalf of the Department. "Contract Manager" includes, except as otherwise provided in the Contract, an authorized representative of the Contract Manager acting within the scope of his or her authority. The Department may change the designated Contract Manager from time to time by providing notice to Contractor as provided in the Contract.

B. Department shall mean the State of Idaho, Department of Health and Welfare, its divisions, sections, offices, units, or other subdivisions, and its officers, employees, and agents.

II. CONTRACT EFFECTIVENESS. It is understood that this Contract or any Amendment is effective when it is signed by all parties, or at a later date if specified in the Contract or Amendment. The Contractor shall not render services to the Department until the Contract or Amendment has become effective. The Department will not pay for any services rendered prior to the effective date of the Contract or Amendment.

III. REASSIGNMENT OF CONTRACTOR EMPLOYEES The Department shall have the right, after having consulted with the Contractor, to require the Contractor to reassign or otherwise remove from the contract any Contractor employee or subcontractor found in good faith to be unacceptable to the Department.

IV. RECORDS AND DATA.

A. Records Maintenance The Contractor shall maintain all records and documents relevant to the Contract for three

(3) years from the date of final payment to the Contractor. If an audit, litigation or other action involving records is initiated before the three (3) year period has expired, the Contractor shall preserve and secure records until all issues arising out of such actions are resolved, or until an additional three (3) year period has passed, whichever is later. If the Contract is terminated for convenience, for cause, or by bankruptcy all records and documents related to the Contract in the Contractor’s possession shall at the election of the Department, be immediately delivered to the Contract Monitor or Department designee.

B. Records Review All records and documents relevant to the Contract, shall be subject to inspection, review or audit, and copying by the Department and other personnel duly authorized by the Department, and by federal inspectors or auditors. The Contractor shall make all records relevant to this Contract available to such parties at all reasonable times, at either the Contractor's principal place of business or upon premises designated by the Department.

V. AUDIT EXCEPTIONS. If a federal or state audit indicates that payments made to the Contractor for goods or services that do not comply with the terms of the contract or applicable federal or state laws, rules or regulations, the Contractor shall refund any compensation paid to the Contractor arising from such noncompliance.

VI. COMPLIANCE WITH CERTAIN LAWS, LICENSING, AND CERTIFICATIONS. The Contractor shall comply with ALL requirements of federal, state, and local laws and regulations applicable to the Contractor pursuant to the Contract.

For the duration of the Contract, the Contractor shall maintain in effect and have in its possession all licenses and certifications required by federal, state, and local laws and rules, including but not limited to:

A. HIPAA The Contractor acknowledges that it may have an obligation, independent of this contract, to comply with the Health Insurance Portability and Accountability Act (HIPAA), Sections 262 and 264 of Public Law 104-191, 42 USC Section 1320d, and federal regulations at 45 CFR Parts 160, 162 and 164. If applicable, the Contractor shall comply with all amendments to the law and federal regulations made during the term of the Contract.

B. Lobbying

1. The Contractor certifies that none of the compensation under the Contract has been paid or will be paid by or on behalf of the Contractor to any person for influencing or attempting to influence an officer or employee of any governmental agency, a member, officer or employee of Congress or the Idaho Legislature in connection with the awarding, continuation, renewal, amendment, or modification of any contract, grant, loan, or cooperative agreement.

2. If any funds, other than funds provided by the Contract, have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any governmental agency, a member, officer or employee of Congress or the State Legislature in connection with the Contract, the Contractor shall complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions, and submit a copy of such form to the Department.

3. The Contractor shall require that the language of this certification be included in any subcontract, at all tiers, (including grants, subgrants, loans, and cooperative agreements) entered into as a result of the Contract, and that all sub-recipients shall certify and disclose as provided herein.

4. The Contractor acknowledges that a false certification may be cause for rejection or termination of the Contract, subject the Contractor to a civil penalty, under 31 U.S.C. § 1352, of not less than $10,000.00 and not more than $100,000.00 for each such false statement, and that the Contractor's execution of the Contract is a material representation of fact upon which the Department relied in entering the Contract.

C. Qualification The Contractor certifies to the best of its knowledge and belief that it and its principals:

1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from performing the terms of the Contract by a government entity (federal, state or local);

2. Have not, within a three (3) year period preceding the Contract, been convicted of or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (federal, state, or local) transaction or contract under a public transaction;

violation of federal or state antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property;

3. Are not presently indicted for or otherwise criminally or civilly charged by a government entity (federal, state or local) with commission of any of the offenses enumerated in paragraph 2 of this certification; and

4. Have not within a three (3) year period preceding the Contract had one or more public transactions (federal, state, or local) terminated for cause or default.

5. The Contractor acknowledges that a false statement of this certification may be cause for rejection or termination of the Contract and subject the Contractor, under 18 U.S.C. § 1001, to a fine of up to $10,000.00 or imprisonment for up to five (5) years, or both.

D. Faith-Based Organization If the Contractor is a faith-based organization, the Contractor and all approved subcontractors shall:

1. Serve all participants without regard to religion, religious belief, refusal to hold a religious belief, or refusal to actively participate in a religious practice.

2. Ensure that Department-referred clients' participation in religious activities, including worship, scripture study, prayer or proselytization, is only on a voluntary basis.

3. Notify participants of the religious nature of the organization, their right to be served without religious discrimination, their right not to take part in religious activities, their right to request an alternative provider and the process for doing so.

4. Ensure that contract funds are not expended on inherently religious activities.

5. Comply with applicable terms of 42 CFR Parts 54, 54a, and 45 CFR Parts 260 and 1050.

E. Tribes If the Contractor is a Tribe, the Contractor and Department recognize that services performed pursuant to this Contract by the Contractor and all approved subcontractors within reservation boundaries are subject to applicable laws, ordinances and regulations of the Tribe. Nothing in this Contract should be construed as a waiver of sovereign immunity.

F. Single Audit Act The Contractor acknowledges that it may have an obligation; independent of this contract, to comply with the terms of the "Single Audit Act" of 1984. Funds provided under the Contract may be used to pay for compliance with this act in proportion to other funding sources available to the Contractor for the services provided pursuant to the Contract.

G. Local Contribution To Funding If funding for the Contract is tied to a local contribution or match: (1) The Contractor certifies that none of the local contribution or match funds are federal funds, are derived from or are in lieu of federal funds, and none of said funds have been used, or have been substituted for funds used, to earn other federal funds. (2) The Contractor further certifies that any costs incurred by the Contractor prior to the Contract will not be allowable to or included as a cost of any other state or federally financed program in either the current period or any prior period.

VII. CONFLICT OF INTEREST.

A. Public Official No official or employee of the State of Idaho or the United States government who exercises any functions or responsibilities in the review or approval of the undertaking or carrying out of the Contract shall, prior to the termination of the Contract, voluntarily acquire any personal interest, direct or indirect, in the Contract.

B. Contractor The Contractor and its agents shall have no present or future interest, direct or indirect, that would conflict in any manner or degree with the performance of the services provided pursuant to this Contract.

VIII. REMEDIES.

A. Remedial Action If any of the Contractor’s responsibilities do not conform to Contract requirements, the Department shall consult with the Contractor and may at its sole discretion require any of the following remedial actions, taking into account the nature of the deficiency: (1) require the Contractor to take corrective action to ensure that performance conforms to Contract requirements; (2) reduce payment to reflect the reduced value of services received; (3) require the Contractor to subcontract all or part of the service at no additional cost to the Department; or (4) terminate the Contract.

B. Mutual Termination for Convenience Either party may cancel the Contract at any time, without cause, upon written notice to the other party specifying the date of termination which shall not be less than thirty (30) calendar days; provided however, the Department must approve Contractor's date of termination and shall not exceed a reasonable timeframe to ensure continuity of business upon termination of the Contract.

C. Termination for Cause Either party may terminate the Contract (and/or any order issued pursuant to the Contract) when either party has been provided written notice of default or non-compliance and has failed to cure the default or non-compliance within a reasonable time, not to exceed thirty (30) calendar days. If the Contract is terminated for default or non-compliance by the Department, the Contractor will be responsible for any costs resulting from the Department’s award of a new contract and any damages incurred by the Department. The Department, upon termination for default or non-compliance, reserves the right to take any legal action it may deem necessary including, without limitation, offset of damages against payment due.

D. Effect of Termination Upon termination by either party, the Contractor shall: (a) promptly discontinue all work, unless the termination notice directs otherwise; (b) promptly return to the Department any property provided by the Department pursuant to the Contract; and, (c) deliver or otherwise make available to the Department all data, reports, estimates, summaries and such other information and materials as may have been accumulated by the Contractor in performing the Contract, whether completed or in process.

E. Survival of Terms Any termination, cancellation, or expiration of the Contract notwithstanding, provisions which are intended to survive and continue shall survive and continue, including, but not limited to, the provisions of these Special Terms and Conditions, Sections IV (Records and Data), V (Audit Exceptions), VI (Compliance with Certain Laws, Licensing, and Certifications), and the State of Idaho Standard Contract Terms and Conditions, Sections 9 (Contract Relationship) and 12 (Indemnification).

IX. FORCE MAJEURE. Neither party shall be liable or deemed to be in default for any Force Majeure delay in shipment or performance occasioned by unforeseeable causes beyond the control and without the fault or negligence of either party, including, but not restricted to, acts of God or the public enemy, fires, floods, epidemics, pandemics, quarantine, restrictions, strikes, freight embargoes, or unusually severe weather, provided that in all cases either party shall notify the other party promptly in writing of any cause for delay and the parties concur that any of the delays identified above were beyond their control and without the fault or negligence of either party. The period for the performance shall be extended for a period equivalent to the period of the Force Majeure.

X. MISCELLANEOUS.

A. Disposition of Property At the termination of the Contract, the Contractor shall comply with relevant federal and state laws, rules and regulations and, as applicable, 2 CFR §§ 200.310-316 concerning the disposition of property purchased wholly or in part with funds provided under the Contract.

B. Time of Performance Time is of the essence with respect to the obligations to be performed under the Contract;

therefore, the parties shall strictly comply with all times for performance.

C. Headings The captions and headings contained herein are for convenience and reference and are not intended to define or limit the scope of any provision of the Contract.

Exhibit B – Riders

Insurance

For the term of the Contract and until all services specified in the Contract are completed, the Contractor shall maintain in force, at its own expense, the following insurance.

Commercial General Liability Insurance and, if necessary, Commercial Umbrella Liability Insurance with a limit of not less than one million dollars ($1,000,000) each occurrence. Insurance required by this section shall name the State of Idaho, Department of Health and Welfare as an additional insured.

Professional Liability Insurance with a limit of not less than one million dollars ($1,000,000) each occurrence.

Cyber Liability Insurance covering third-party liability including at least the following expenses: cost of notifying affected parties; cost of providing credit monitoring to affected parties; cost of public relations consultants; regulatory compliance costs; costs to pursue indemnity rights; costs to analyze the insured’s legal response obligations; costs of defending lawsuits, judgments and settlements; regulatory response costs; costs of responding to regulatory investigations; and costs of settling regulatory claims. Cyber Liability coverage must have a limit of not less than one million dollars ($1,000,000) per claim and two million dollars ($2,000,000) aggregate.

Workers' Compensation Insurance which includes Employer Liability Insurance and shall comply with Idaho Statutes regarding Workers' Compensation in the amount of $100,000 per accident; $500,000 disease policy limit; and $100,000 disease, each employee.

If any of the liability insurance required for this contract is arranged on a "claims-made" basis, "tail coverage" will be required at the completion or termination of this contract for a duration of twenty-four (24) months thereafter. Continuous "claims-made" coverage will be acceptable in lieu of "tail-coverage" provided the retroactive date is on or before the effective date of this contract, or twenty-four (24) months "prior acts" coverage is provided. Contractor will be responsible for furnishing certification of "tail coverage" or continuous "claims-made" coverage.

Prior to performing any services, the Contractor shall provide certificates of insurance to the Department. The Contractor is also required to maintain current certificates on file with the Department and to provide updated certificates upon request. Failure to provide the required certificates of insurance shall constitute a default under this Contract and upon such failure the Department may, at its option, terminate the Contract. Insurance required by this section shall be policies or contracts of insurance issued by insurers approved by the Department. Should any of above described policies be cancelled before the expiration date thereof, notice shall be delivered in accordance with the policy provision.

The Contractor shall further ensure that all policies of insurance are endorsed to read that any failure to comply with the reporting provisions of this insurance, except for the potential exhaustion of aggregate limits, shall not affect the coverage(s) provided to the State of Idaho, Department of Health and Welfare.

Send updated certificates to: DHWInsurance@dhw.idaho.gov

Certificate holder should be listed as: Idaho Department of Health and Welfare Contracting & Procurement Services Unit -- 9th Floor 450 West State Street Boise, ID 83702

Exhibit C – Scope of Work

I. General Requirements A. This Contract is funded by the National Breast and Cervical Cancer Early Detection Program awarded June 30, 2022, through the Centers for Disease Control and Prevention.

B. This Contract supports the Idaho Department of Health and Welfare Strategic Plan and the Division of Public Health priorities.

C. The Contractor must provide a point of contact to the Department Contract Monitor. If a change in personnel who perform key operations under the Contract including the point of contact, occurs during the Contract timeframe, the Contractor must notify the Department Contract Monitor of the change.

D. The Contractor must receive prior written approval from the Department for any deviations from the budgeted services/activities. The Contractor must be financially responsible for costs deemed unallowable or unapproved by the Department Contract Monitor.

E. For the general monitoring of this Contract, the Contractor must maintain and have available for review all reporting and evaluation data and information for activities, and financial data as specified in the Records and Data section of the Special Terms and Conditions.

F. The Contractor must adhere to the Federal Office of Management and Budget (OMB) Circular 2 CFR 200: Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, located at https://federalregister.gov/a/2013-30465

G. The Department will provide access to the Department's Secure File Transfer Protocol (SFTP) data site for posting electronic patient data in a secure manner, as required by federal Health Insurance Portability and Accountability Act (HIPAA) regulations.

H. The Contractor must ensure, when applicable, that all entities, users and servers that access the Department information in performance of the Contract are located within the United States. Information must not be shared with offshore/overseas entities, servers or databases.

Remote offshore/overseas access must not be allowed per the restrictions and regulations of the Internal Revenue Service (IRS), Social Security Administration (SSA), National Institute of Standards and Technology (NIST), and Centers for Medicare & Medicaid Service (CMS).

I. Ownership of Information: The Department and the United States Department of Health and Human Services must have unlimited rights to own, possess, use, disclose, transfer, or duplicate all information and data, copyrighted or otherwise, developed, derived, documented or furnished by the Contractor under the Contract.

II. Contract Services and Activities A. Claims Receipt and Electronic Data Interchange (EDI)

1. The Contractor must provide a real-time, electronic system for electronic claims receiving and transmission. The system must:

a. Be capable of receiving multiple concurrent versions if HIPAA transaction sets.

b. Be available twenty-four (24) hours a day, seven (7) days a week.

c. Include a failover EDI system to ensure that the system is available twenty-four (24) hours a day, seven (7) days a week.

d. Receive and transmit all HIPAA mandated electronic transactions from and to covered entities requesting electronic submission.

e. Provide multiple communication methods to support transmission of all EDI transactions, including internet based, dial-up, and batch files.

f. Supply to healthcare provider, at no cost, HIPAA compliant software and documentation that provides electronic transaction submission through Transmission Control Protocol/Internet Protocol (TCP/IP) transactions via File Transfer Protocol (FTP) or through dial-up communications network.

g. Assign a unique control number to each transaction received.

h. Prescreen or edit EDI transactions for HIPAA compliant content prior to submitting data to the Department.

i. Reject transactions that fail initial EDI edits with a standard electronic response, such as 997/999 Acknowledgement and 824 Application Advice that provides for error correction by the submitter.

j. Provide a standard EDI file HIPAA 5010 837P/I file that is sent daily to the Department that includes all received claims since the last file sent.

2. The Contractor must be capable of receiving and transcribing paper claims in multiple formats and transmitting them to the Department. The Contractor must:

a. Receive claims for the Department in the following paper claims formats, Health Care

Finance Administration (HCFA) or UB-40 claim form.

b. Input HCFA and UB-40 claims into clearinghouse database using manual transcription or OCR scanning technology within five (5) business days of receipt.

i. It is the responsibility of the Contractor to utilize a system that ensures claim receipt and transmission to the Department within ten (10) business days for complete claims that meet basic requirements for the appropriate HIPAA Transaction sets.

c. Generate standard EDI file HIPAA 5010 837P/I from paper claims received to meet the data reporting requirements of the Department.

d. Provide a standard EDI file HIPAA 5010 837P/I file that is sent daily to the Department that includes all received claims since the last file sent.

3. The Contractor must maintain an EDI solution that will enable the Department to provide automated capabilities to facilitate the transmission of all received transactions using a variety of media types, including current and future HIPAA transactions. The Contractor must:

a. Maintain a repository of inbound and outbound EDI transactions in a relational database that is accessible to authorized Department personnel.

b. Prevent duplicate submission of EDI transactions to the Department.

c. Maintain enrollment, testing, and certification of trading partners.

d. Assign a unique identifier for each trading partner.

e. Provide a non-production EDI environment to support testing and compliance.

f. Provide access to electronic claims files for reconciliation with Department data.

g. Provide reporting that meets client level data requirements of the Department.

h. Produce and distribute statistical and operational reports automatically or manually in accordance with formats and media specifications to be defined in the implementation phase.

i. Provide the Department with unlimited remote access to a secure and password-protected claims system accessible to the Contractor and the Department.

j. The Contractor must provide training for Department staff on the use of the system.

k. Provide a minimum two (2) week advance notice to Department staff for planned system outage, maintenance, and upgrade activities.

B. Communications/Problem Resolution

1. The Contractor must:

a. Have a Communication and Problem Resolution Plan in place at all times which addresses the method for resolving claim problems. The plan must include, at a minimum, a lead person to contact for problem resolution, a specific timeline of no more than two (2) business days for Contractor response, and data reports on resolutions. The lead person identified by the Contractor must also be responsible for resolving problems with the Department, Local Coordinators (LC), and providers.

b. The Department will assign one (1) contact person for each Department program included in this Contract.

c. Submit electronic or voice communication with the Department to resolve claims or database problems within two (2) business days of the Contractor becoming aware of problem.

d. Submit a final version of the Communication and Problem Resolution Plan to the Department within thirty (30) calendar days of the Contract effective date for review and approval by the Department.

C. Technical Assistance/Customer Support

1. The Contractor must:

a. Document and retain records of all inquiries received and the resolution provided.

The Department may request access to the documentation at any time.

b. Maintain current contact information on Department staff.

c. Maintain a help desk and toll-free number that provides technical assistance for claims submission.

i. The help desk must be adequately staffed to provide coverage during staff transition times and must provide knowledgeable, trained staff who are available daily Monday through Friday, between the hours of 8:00 a.m. and 6:00 p.m. Mountain Time, during normal Department business days to answer calls, emails, etc. from Department staff clinicians, and third-party medical billers. Department holidays can be found at https://www.idaho.gov/government/state-holidays/.

D. Meetings

1. The Contractor must:

a. Schedule, organize, and conduct, at least quarterly, or at the request of the Department, a conference call with the Department to discuss programmatic issues that occurred during the previous quarter. The Contractor must submit a written summary of each call to the Department within ten (10) business days of the call.

b. Participate in relevant Department meetings, as requested by the Department.

E. Client Confidentiality

a. Ensure confidentiality is maintained for all client information such as, but not limited to: a client's health and risk-related information, a client's personal identifier, and any other information provided to the Contractor.

b. Ensure the use of any client information, even in the aggregate, will not be allowed without Department review and prior written permission from the Department.

c. Safeguard all records with client's name and information in accordance with Department requirements. Requirements can be found at:

https://idhw.sharepoint.com/sites/DO-HR/SitePages/privacy.aspx

F. Security, Storage, Backup, Recovery and Business Continuity

1. The Contractor must provide:

a. Data encryption across the Internet;

b. Application and data recovery in the event of a hardware or database failure;

c. Business continuity in the event of the loss of the Contractor's primary data site;

and

d. Problem resolution for security, backup, recovery, and business continuity within a twenty-four (24) hour timeframe.

G. Fraud and Abuse Prevention

a. Comply with all federal and state statutes and regulations regarding fraud and abuse.

b. Have internal controls and policies and procedures in place that are designed to prevent, detect, and report known or suspected fraud and abuse activities.

c. Have methods for identification, investigation, and referral of suspected fraud cases.

d. Investigate all incidents of suspected and/or confirmed fraud and abuse.

e. Provide adequate staffing and resources to investigate detected offenses;

and for the development and implementation of corrective action plans relating to the contracted services.

f. Report all tips and confirmed or suspected fraud and abuse to the Department within twenty-four (24) hours.

H. Technology Standards and System Requirements

1. The Contractor must:

a. Ensure the Service and hosting facilities comply with all federal, state and local laws and regulations governing the privacy and protection of Personally Identifiable Information ("PII") and Protected Health Information ("PHI").

b. Ensure the Service and hosting facilities comply with information security regulations and security controls as defined by the following:

i. National Institute of Standards and Technology ("NIST") -Contractor must follow the information technology security standards and controls defined in the NIST Special Publication 800-53 (latest version)- Security and Privacy Controls for Information Systems and Organizations and refer to the NIST guidance for security customer data and to implement security controls including encryption of data at rest and data in transit.

Data encryption must utilize FIPS 140-2 certified algorithms.

ii. Security Posture Assessments: The Contractor must ensure that information technology security posture assessments conducted by independent third-party assessment organizations (3PAOs) accredited by the Federal Risk and Authorization Management Program (FedRAMP) are completed annually. Executive summaries of the audit findings must be made available to state of Idaho designated personnel upon request.

iii. Idaho Technology Authority ("ITA"): The Contractor must comply with the ITA Policies and Procedures as applicable to the services and solutions proposed.

ITA Policies and Procedures are available at https://ita.idaho.gov/resources/

iv. Cyber Security Incident Reporting and Management: The Contractor must provide proper and prompt notification to designated state of Idaho personnel in the event of a cyber security incident as required by the ITA: ITA Policy P4510 - Cybersecurity Incident Reporting -https://ita.idaho.gov/psg/p4510.pdf; ITA Policy P4580 - Cybersecurity Incident Management - https://ita.idaho.gov/psg/p4580.pdf; ITA Policy

P4560 - Cybersecurity Breach Management -https://ita.idaho.gov/psg/p4560.pdf

c. Provide the locations for the primary and backup locations of the data centers being used to provide the Contract services (the locations must be in the continental US);

d. Provide a Service-level Agreement ("SLA") that addresses service uptime, technical support coverage days and hours, technical support response timeframes, problem resolution procedures, and related service information which meets or exceeds the following requirements:

i. Uptime of ninety-nine percent (99%);

ii. Technical support via telephone during business hours. Business hours are 8:00a.m. through 6:00p.m. Mountain Time, excluding holidays https://www.idaho.gov/government/state-holidays/ and weekends. In addition, the Contractor must provide an internet-based support system available twenty-four (24) hours a day, seven (7) days a week, each day of the year.

iii. Updated versions of the Service as they are released.

iv. Providing and maintaining a process to provide support for the contracted services, such as a ticketing system.

v. Diagnosis of contracted service problems and performance deficiencies and resolution of those problems and performance deficiencies of the contracted services.

vi. A maintenance plan containing information which addresses: Maintenance windows; maintenance communication plan; change management plan;

and problem escalation plan.

III. Records and Documentation A. The Contractor must provide information as directed by the Department to support the development and submission of Department reporting requirements.

IV. Quality Assurance A. The Contractor must:

1. Be subject to an external review of a minimum of ten percent (10%) of all claims files on an annual basis, to be conducted by the Department.

2. Maintain a Quality Assurance Plan that includes, at a minimum, a plan to internally review five percent (5%) of all active claim records on a quarterly basis.

For each of the claim records reviewed, the Contractor must verify the accuracy of information in the data file provided to the Contractor such as:

a. Number of claims received by the clearinghouse.

b. Number of claims submitted to the Department for processing.

3. Work with the Department to develop a final Quality Assurance Plan within thirty

(30) calendar days after the Contract effective date.

B. The Department will notify the Contractor within two (2) business days from the receipt of the daily claims files of any identified questions/problems. The Contractor must place those particular provider claims that have been identified on hold and not submit them on the daily claim file until the questions/problems have been addressed.

V. Contract Transition Plan

A. The Contractor must provide the Department with a Transition Plan prior to completion of the implementation period to ensure the smooth transition of the contracted services and transfer of materials, documentation, and data either back to the Department or to another contractor upon termination or expiration of the contract. A final Transition Plan must be negotiated with the Department upon Contract termination or one hundred twenty (120) calendar days prior to expiration of Contract, whichever comes first. The Department reserves the right to request an updated Transition Plan during the effective dates of the Contract. The Transition Plan must include how the Contractor will:

1. Ensure claims received after the Contract expiration are forwarded to the new contractor;

2. Notify providers and medical billers that services will be terminated; and

3. Return program files to the Department or to a new contractor, as directed by the Department.

Exhibit D – Reports

Report Description:

Inventory Report – The Inventory Report is a monthly report that outlines the number of claims received electronically, number of paper claims received, number of claims rejected for failing to meet EDI standards, and number of claims sent electronically to the Department.

Report Format:

To be mutually agreed upon between the Department and the Contractor.

Report Due:

Submitted monthly with invoice.

Exhibit E – Cost/Billing Procedure

INTERESTED VENDOR: ENTER YOUR TOTAL COST INTO THE LINES PAGE OF THIS

SOLICITATION IN LUMA. THE BILLING INFORMATION ON THIS PAGE IS FOR YOUR

REFERENCE.

The Contract resulting from this RFQ will be a FIRM FIXED RATE, INDEFINITE QUANTITY Contract. The Department will pay up to the total amount quoted for services successfully delivered in compliance with the terms of the resulting Contract.

The Department may consider rate changes upon renewal. The Contractor must request potential rate changes at least ninety (90) calendar days prior to the Contract renewal date and provide written justification for the request for a rate change.

The "Estimated Number of Units" shown in the Items Page on IPRO are the Department's best estimate of units that may be experienced during the 1st year of the Contract. Estimated quantities are not binding by the Department but are intended to provide an equal and equitable opportunity for quoting purposes.

Billing Procedure:

The Contractor must provide a signed monthly invoice within ten (10) business days after the end of each month. Required reports must be submitted to the SFTP site prior to submission of the monthly invoice. No invoice will be accepted or paid without receipt of required reports.

The invoice must include, but not be limited to:

1. All Contractor services delivered during the billing period, identified by each item in the cost matrix divided into Department programs.

2. Total amount billed for the billing period, including units billed, cost per unit, and total of invoice divided into Department programs.

3. Contract number

4. Invoice date

5. Invoice number

6. Dates of services

7. Contractor name, address, phone number, and email address

Invoices are to be submitted to:

Will be filled in upon award

Reports are to be submitted electronically to the SFTP site.

Final invoices and reports must be submitted to the Contract Monitor no later than thirty (30) calendar days following the Contract expiration date. Invoices received without the required report(s)/documentation will be returned to the Contractor for their resubmission with the final report(s)/documentation.