N00189-19-R-Z095_-_00001.docx

N0018919RZ095

SECTION SF 30 BLOCK 14 CONTINUATION PAGE

SUMMARY OF CHANGES

SECTION SF 30 - BLOCK 14 CONTINUATION PAGE

The following have been added by full text:

AMENDMENT 01

Amendment 01 is hereby issued to answer the following questions and to revise the RFP:

Q1: Is there an incumbent in this effort? If so, could the government provide the name of the incumbent, contract number, and value of the awarded contract?

A1: Yes, the incumbent is Paragon Benefits, Inc. Contract # N00189-15-C-Z006, awarded at a total value of $19,254,886.00.

Q2: Please confirm that a Preferred Provider Organization (PPO) is a requirement of this contract.

A2: The PPO is established by the contractor. However, RSNF sponsors do not have to use the PPO. See Paragraph III.2 of the PWS.

Q3: Can the government elaborate on the expectations to be satisfied in response to an Extraordinary Inclusion letter?

A3: Students who are here for 60 days or less for training will not be given medical cards. If needed, NETSAFA will provide those names to the Contract Administrator. This is a very rare practice.

Q4: About how many dependents are expected to be covered if the Service Member number is 800?

A4: The 800 is inclusive of dependents.

Q5: Where is the “Additional GFI List- Attachments 1-10” referenced on page 13?

A5: It is an attachment to the RFQ.

Q6: Please confirm the requirement for bi-lingual (Arabic-speaking, reading, writing) personnel.

A6: See PWS Section IV Contractor Furnished Items or Responsibilities, Task 1.b.

Q7: Does this requirement apply to all personnel?

A7: Not all, but adequate staff should be supplied during regular customer service hours. See #25 below.

Q8: Are vendors’ costs for printing of ID cards, Prescription Cards, and reproduction of Summary Plan Descriptions, along with expenses for directed express delivery, covered as an ODC or otherwise reimbursable to the vendor?

A8: This should be included in your firm fixed price.

Q9: What portion of this work must be accomplished in Canada (mentioned in Synopsis)?

A9: No performance in Canada. All training done within the U.S. See revised PWS. This plan covers medical and dental services for the sponsor and accompanying family members only within the United States and Canada.

Q10: It is stated that Providers may appeal reimbursement determinations and that appeals are outside this contract – how are appeals handled?

A10: Appeals should be handled between the contractor and the medical provider.

Q11: Can the government be more specific in its requirement on pg 15: “A local area network of personal computers with Internet access and electronic mail capability for key personnel is required for communication with the COR.” For instance numbers of machines, types, requirements for other than MS Access software, NMCI interface (i.e. CAC reader), PKI, Screens, Ingest equipment (e.g. Scanners, OCR, other issues) or location requirements?

A11: See Revised PWS.

Q12: Para B.3 on pg 16 asserts “RSNF approval of report formats is required prior to issuance of the initial reports after contract implementation.” What assurances do we, as vendors have that such approval can be secured within the stated timeline, given that they must be secured from a component of a foreign government?

A12: This will be handled by the COR at NETSAFA.

Q13: On pg 35, 52.217-9(c) a 3 year duration is mentioned. Throughout the rest of the solicitation, the engagement period is stipulated as 5 yrs (i.e. Base + 4 Option Years). Can the government clarify?

A13: See revised RFP.

Q14: CLIN 0002/1002/ 2002 / 3002 / 4002 references PWS Section V Paragraph 10 – this is the required working capital ($445,000) – should bidder populate the CLIN with the working capital plus the applicable burden, working capital only or the $5,340,000 plus the applicable burden?

A14: $5,340,000 plus the applicable burden

Q15: Can the Government please provide a breakdown for the past 3 fiscal years the number of vision, dental, pharmacy and medical claims processed through the program?

A15: Data cannot be provided.

Q16: Can the Government please provide the aggregate medical spend by year for the past three fiscal years?

A16: Incurred costs for medical claim expenses cannot be provided however the alotted amount for the past three years was $3,800,000.00 per year.

Q17: Can the Government please provide the amount per year for the past three fiscal years related to claims were deemed overpayments and not reimbursed to the incumbent?

A17: Information is not available.

Q18: Would the Government allow the administrator to lease provider networks to improve discounts as compared to UCR? If so, can we modify the ID card to include the network lease partner’s logo so the provider knows the agreed upon discount?

A18: There should be no information on the card outside of the contract administrator who is responsible for the contract.

Q19: Does the Government have a preferred means to have the contractor establish a PPO / improved discounts?

A19: No preferred means as long as the PPO is in accordance with the PWS and the solicitation terms and conditions.

Q20: In Para II, 13 cities are named yet reference is made to the top 15 geographic locations in the country, what are the names of the other two locations? Can the government stipulate populations of covered Service Members outside Pensacola?

A20: Mayport, FL and Washington DC. See Revised PWS.

Q21: In reviewing ID cards, if the card is plastic, or pre-laminated card stock, how will the government or service member, or the vendor enter data required on such cards as are required to be delivered to the government in advance each year, assuming these are un-filled cards?

A21: Cards are filled out by the Contract Administrator and then provided to the Government. How this is accomplished is up to the Contract Administrator. No requirement for pre-laminated cards. Historically, cards have been plastic with screen print.

Q22: In reviewing the back of the ID card, If a charge occurs in the last year of the vendor’s contract and in the next year a new contract, with a new vendor is selected and a Service Member or Medical Provider delays presentation of a bill from the first vendor’s last year into the second vendor’s first year, how will these bills be paid? What are the first vendor’s responsibilities in this case?

A22: The date in which medical services occurs and whatever contract is current at that time should be billed. Billing will be paid by same contract period/Contractor in which services were intially incurred (not billed). Funding will remain on the specific contract for the specific contract period.

Q23: In reviewing the Prescription ID card, what are the numbers appearing on its face? (i.e. 3400 and 9740022)? What is the entity “Paid Prescriptions”? “The use of this card is governed by the rules, regulations and procedures provided under an agreement between PAID PRESCRIPTIONS and the insuring organization and the group policy issued.” Are there such pre-existing agreements? Can their details be made available to prospective bidders? Is there a specific meaning to the term “TELEPAID”?

A23: This could be the group number with the insurance vendor and policy number or a designation number to route the bills to the Contract Administrator. See current ID card as a sample, not required template.

Q24: What is the expected annual workload of the calls made to the Arabic speaking call center representative(s)? What historical call volumes have been experienced?

A24: We do not have or collect this type of historical data.

Q25: What are hours of coverage for telephone response to incoming calls?

A25: Contract Administrator should decide and provide best customer service hours to cover at least 12 hours per day to allow for service from Eastern to Pacific Time zone. Check industry standards.

Q26: Is it required the contract administrator provide other travel/medical assistance for the RSNF and dependents? Such as medical repatriation assistance if required to return home due to a medical incident.

A26: No.

Q27: Please indicate what involvement is required to validate medical need and appropriateness for hospital stays? Is it required that a nurse case management review each pre-authorization and inpatient stay?

A27: This should follow industry standard. Providers will determine the need for hospitalization and Contract Administrator/staff will verify.

Q28: Please indicate how many routine and non-routine calls are received by the contractor today? Are fluent Arabic individuals required 24/7? If not, please specify the hours. How many individuals currently take these calls?

A28: We do not have or collect this type of data. Hours should be established by the Contract Administrator to meet industry standards.

Q29: Do they have any data we can use to accurately calculate the utilization of the network and also the membership base?

A29: No. Refer to PWS Section II; Background.

Q30: Are there specific provider coverage specifications: X Primary Care Physicians within 10 Miles, etc. If so, will we be receiving an eligibility file to run geo-access reports?

A30: This should follow industry standards and the requirements under Section II of the PWS.

Q31: The SPD includes a sample ID card. Who will be producing the card and is it possible to include a PPO network logo?

A31: The contractor will be producing the ID cards. No logos for PPO on the cards.

Q32: Should the printing and delivery of the identifications cards be included in the overall pricing or is this an external pricing that can be submitted separately?

A32: Should be included under FFP CLIN.

Q33: Who will be maintaining eligibility files and how frequently will these be updated? What format would the file be in?

A33: NETSAFA representative. Historically, we have used Microsoft access. Excel is another acceptable format. Updated on an as needed basis.

Q34: Will the vendor also be responsible for coordinating pharmacy services?

A34: Yes.

Q35: Many programs compensate the services of a PPO network through charging the client a percentage of savings (discount) – is there a restriction to this methodology? If so, what is the recommended structure? i.e. PMPM, Per case etc.

A35: Members covered under this medical contract WILL NOT be charged. Any charges to the government should be submitted with initial solicitation.

SECTION B - SUPPLIES OR SERVICES AND PRICES

CLIN 0001

The MILSTRIP N6887019RC82048 has been added.

CLIN 0002

CLIN 0003

SECTION C - DESCRIPTIONS AND SPECIFICATIONS

The following have been modified:

PWS

PERFORMANCE WORK STATEMENT

Medical Third Party Administration (TPA) Services

GENERAL

I. Introduction: The contractor shall provide all personnel, equipment, supplies, facilities, transportation, tools, materials, supervision, and other items necessary to perform medical third party administration services for Naval Education and Training Security Assistance Field Activity (NETSAFA), Pensacola, FL in support of Royal Saudi Naval Forces (RSNF) as defined in this Performance Work Statement (PWS).

II. Background: The Naval Education and Training Security Assistance Field Activity (NETSAFA), Pensacola, FL has a requirement to provide health care administration services for Royal Saudi Naval Forces (RSNF) personnel assigned for periods longer than 60 days to training and training supervisory and support duties in the United States and Canada and their authorized dependents. Typically, the majority of RSNF personnel are located for training at U.S. Navy or other U.S. Department of Defense installations in the continental U.S. The contractor shall provide medical administration services to approximately 800 RSNF personnel and their authorized dependents annually through the duration of the contract. This group is usually distributed in about 15 geographic locations across the U.S with the largest single area of concentration occurring in the Pensacola, FL area where approximately 50% of the group is located. RSNF personnel are usually assigned to training sequences in the U.S. ranging from 6 to 36 months and may change individual training sites several times during this period. Historically, the top 15 geographic locations in terms of RSNF personnel attending training courses are Pensacola FL, Charleston SC, Monterey CA, Jacksonville FL, Mechanicsburg PA, Newport RI, San Diego CA, Corpus Christi TX, Great Lakes IL, Norfolk VA, San Antonio TX, Ft Walton Beach FL, Mayport, FL, Washington D.C. and Biloxi MS. The administration of health care services provided by military facilities is not included in the scope of the services solicited herein. (RSNF Personnel are referred to as RSNF Sponsors from hereafter.)

III. Objective:

1. It is desired to provide a broad selection of high quality health care services to the RSNF sponsors and their authorized dependents. Ideally, these services will be available to RSNF sponsors without the necessity that the services be paid for at the time of delivery or that the sponsor be required to file the claim for payment. The claim system will require the health care provider to perform the necessary claim completion and submission to the contract Administrator who, in turn, will screen the claim to determine coverage under the benefit plan and the conformance of charges to what’s reasonable and customary as defined by a recognized national data base of prevailing fees which is routinely updated, and promptly pay the providers accordingly.

2. The PPO (Preferred Provider Organization) is established by the contractor. However, the RSNF will not mandate the use of the Preferred Provider Organization (PPO) physicians by RSNF sponsors. When a RSNF sponsors chooses to use a physician who is not a PPO members, the contract Administrator shall deal directly with the provider for payment, whenever possible. The RSNF will restrict hospital usage to members of a qualified PPO, when available. The PPO should negotiate reduced fees with health care providers for group plans within limited geographic areas. Health care providers reduce their fees in expectation of increased business from the PPO membership. Enrollment of the group in PPO's will be individually (by geographic area) as recommended by the contract Administrator and approved by NETSAFA.

IV. Scope:

1. Non-Personal Services Contract (NPSC). Under this contract, the contractor shall provide strictly non-personal services and shall work as an independent contractor not subject to the supervision of the government. The Contractor shall be required to work in a collaborative effort with the Royal Saudi Naval Forces (RSNF) Country Program Manager (CPM) at NETSAFA. The RSNF CPM will provide technical assistance on specific provisions and will coordinate with the contractor.

2. Performance Period: The period of performance shall be for one (1) Base Year and four (4) one year options commencing on the contract award date.

3. Place of Performance. The work under this contract will be performed 100% at Contractor’s site.

4. Quality Control: Quality Control Plan (QCP). The contractor shall develop and maintain an effective quality control program to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor’s Quality Control Program (QCP) is the means by which he assures himself that his work complies with the requirement of the contract. At a minimum, the contractor shall develop quality control procedures that address the areas identified in Technical Exhibit 1, “Performance Matrix Summary”. The contractor shall deliver a complete QCP within 30 days after contract award and three copies of a comprehensive written QCP shall be submitted to the KO and COR within 5 working days when changes are made thereafter. After acceptance of the Quality Control Plan, the contractor must receive the contracting officer’s acceptance in writing of any proposed change to his QC system.

5. Quality Assurance. The government shall evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan is primarily focused on what the Government must do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s).

6. Performance Matrix Summary: The government shall evaluate the contractor’s performance under this contract in accordance with the Performance Matrix Summary provided in the QASP Technical Exhibit 1. This plan is primarily focused on what the government must do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s). The government reserves the right to change the performance measures and/or performance targets throughout the contract performance period. The government will provide the contractor with a 30-day notice of any changes to the stated performance measures or targets.

7. Periodic Progress Meetings: The contracting officer, Contracting Officer’s Representative (COR), and other Government personnel, as appropriate, may meet periodically (telephone or site) with the contractor to discuss and review the contractor's performance. At these meetings the contracting officer will apprise the contractor of how the government reviews the contractor's performance and the contractor will apprise the Government of problems, if any, being experienced. Appropriate corrective action shall be taken to resolve outstanding issues or action items.

ACRONYMS AND DEFINITIONS

1. Definitions:

CONTRACT ADMINISTRATOR. This is the contractor personnel responsible for administering the Royal Saudi Naval Forces Medical Plan.

ALTERNATE CONTRACTING OFFICER'S REPRESENTATIVE (ACOR). An employee of the U.S. Government appointed by the contracting officer to administer the contract, in the COR’s absence. This individual does NOT have authority to change the terms and conditions of the contract.

CONTRACTOR. A supplier or vendor awarded a contract to provide specific supplies or service to the government. The term used in this contract refers to the prime.

CONTRACTING OFFICER (KO). A person with authority to enter into, administer, and or terminate contracts, and make related determinations and findings on behalf of the government. Note: The only individual who can legally bind the government.

CONTRACTING OFFICER'S REPRESENTATIVE (COR). An employee of the U.S. Government appointed by the contracting officer to administer the contract. Such appointment shall be in writing and shall state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as that direction is within the scope of the contract, does not constitute a change, and has no funding implications. This individual does NOT have authority to change the terms and conditions of the contract.

COUNTRY PROGRAM MANAGER (CPM). U.S. Government that provides technical guidance and approval to the contractor on the requirements as set forth in the PWS. Reviews contractor invoices and approve for payment. Conducts inspections and acceptance of contract deliverables. Systematically monitors the contractor's efforts to ensure the technical requirements and intent of the PWS are on schedule. Promptly rejects, in writing, all work that does not comply with the PWS requirements. Authorize the contractor to travel, if allowed by the referenced PWS. This individual does NOT have authority to change the terms and conditions of the contract.

DELIVERABLE. Anything that can be physically delivered, but may include non-manufactured things such as meeting minutes or reports.

PREFERRED PROVIDER ORGANIZATION (PPO). This is a comprehensive health-care plan offered to employees that allows them to choose their own physicians and hospitals within certain limits.

QUALITY ASSURANCE. The government procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

QUALITY ASSURANCE SURVEILLANCE PLAN (QASP). An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance.

QUALITY CONTROL PLAN. All necessary measures taken by the Contractor to assure that the quality of an end product or service shall meet contract requirements.

RSNF SPONSOR- This is the RSNF military personnel assigned for training.

WORK WEEK. Monday through Friday, unless specified otherwise.

2. ACRONYMS:

GOVERNMENT FURNISHED ITEMS (GFI) OR SERVICES

1. NETSAFA’s Program Office will be responsible for maintaining the group membership list in coordination with the Assistant Defense Attaché for Naval Affairs (ADANA), Washington, DC. Within thirty (30) days prior to the contract effective date, NETSAFA will provide the Contract Administrator the RSNF membership list in MS ACCESS and a master of the Summary Plan Description.

2. Subsequent to issuance of the initial RSNF membership list, NETSAFA will provide the Contract Administrator with add/drop/change reports as required.

3. NETSAFA will provide a copy of the Extraordinary Inclusion letter to the Contract Administrator in order to incorporate the designated RSNF sponsor and dependent(s) under this contract.

4. **Additional GFI List- Attachments 1-10

CONTRACTOR FURNISHED ITEMS OR RESPONSIBILITIES

1. General. The Contractor shall furnish all labor, supplies, equipment, facilities and services required to perform work under objectives of this PWS.

TASKS

General Duties. The contractor shall provide Medical Third Party Administration (TPA) services for Naval Education and Training Security Assistance Field Activity (NETSAFA), Pensacola, FL in support of Royal Saudi Naval Forces (RSNF) as defined in this Performance Work Statement (PWS). In performance of these duties, the contractor and its employees shall adhere to industry, DOD and NAVY procedures and provisions.

1. Start Up. The Contractor shall recognize the importance to a successful start of contract services of the timely recruitment of qualified personnel in sufficient numbers to meet all contract requirements. The Contractor shall perform all start up activities required by this section within 30 days of award effective date (1Dec19).

a. Technical Requirements. The Contractor shall provide qualified and professional personnel required in order to adequately perform the requirements of this PWS.

b. Bilingual Requirement: The contractor shall provide appropriate employees who are fluent in Arabic (reading, writing and speaking) to handle routine and non-routine calls.

c. All associated Contractor personnel shall sign a non-disclosure statement relative to sensitive information.

V. Specific Tasks

1. In areas where a paperless (to group members) claim system is not possible, it is required that a simplified claim system be developed which, insofar as possible, will permit authorized RSNF sponsors to receive health care services without the requirement to pay at the time of delivery (Attachment 1 is an example of a RSNF Medical Reimbursement Claim Form.) Whether payment is subsequently due the provider or the RSNF sponsor as a reimbursement, the requirement for the Contract Administrator services stated above is for screening and prompt payments pertains.

2. Covered group medical, dental, prescription, and vision care benefits of this plan are detailed in Attachment 4-Summary Plan Description (SPD)-Schedule of Benefits. Payment will be authorized on behalf of RSNF sponsor for every covered charge up to the 95th percentile of what is defined as reasonable and customary and is within plan limits. Payments will be charged against the pertinent Foreign Military Sales (FMS) case as identified in the resultant contract. NETSAFA will provide lines of accounting for all pertinent FMS cases to the COR for incorporation into the contract. The Contract Administrator will be responsible for managing each line of accounting/FMS case and for notifying the COR when funds expended reach the 75th percentile within a line of accounting/FMS Case.

3. Except in emergency situations, RSNF sponsors will be required to secure hospital pre-admission certification and surgical second opinions (when applicable) for hospital in-patient care. The Contract Administrator will validate medical need, second opinion concurrence, the appropriateness of the planned length of hospital stay, and hospital membership in a Preferred Provider Organization (PPO) or its willingness to negotiate rates as conditions for certifying admission. In cases where admission is denied a member, the Contract Administrator will notify the RSNF sponsor of denial of admission and provide a list of alternatives.

4. Individual case management beyond utilization review will be undertaken on a case-by-case basis when recommended by the Contract Administrator and approved by the COR. Payment for these additional services will be accomplished on a cost reimbursable basis against designated line items.

5. For the purpose of initiating a recommendation by the Contract Administrator to implement "Large Case Management" procedures, a "Large Case" is defined as one carrying a projected total cost in excess of $10,000.

6. Group membership includes the RSNF sponsor together with dependents designated by the sponsor and listed in the Invitational Travel Order.

7. Within thirty (30) days prior to the contract effective date, the Contract Administrator will provide a draft RSNF Health Plan Identification Card to NETSAFA for COR approval.

a. Upon receipt of the COR's approval, the Contract Administrator will then provide RSNF Health Plan Identification Cards and Prescription Identification Cards to arrive at NETSAFA for distribution to members at least three weeks prior to the contract effective date. Upon receipt of the master for the Summary Plan Description (SPD), the Administrator will have 700 copies printed and delivered to NETSAFA at least three weeks prior to the contract effective date. RSNF Health Plan Identification Card and Prescription Identification Card requirements for option years will be identified by the COR one month prior to the end of the existing contract year. SPD requirements for option years will be identified by the COR at least two months prior to the end of the existing contract year. (Attachments 2, 3 and 4 are examples of the RSNF Health Plan Identification Card, Prescription Identification Card and Summary Plan Description.)

b. The Contract Administrator will provide RSNF Health Plan Identification Cards and Prescription Identification Cards to arrive at NETSAFA for distribution to RSNF Sponsors within one week of receipt of notice of their joining the group, unless directed by NETSAFA to use overnight delivery..

8. All RSNF Health Plan cards will carry the sponsor's full name (first, middle initial, and last), the sponsor's full name and Work Control Number (WCN), Case Number, the Contract Administrator's full name, toll-free telephone number for verification and hospital precertification (if different), billing address and instructions, an expiration date of the last date of assignment or the last day of the current plan year, whichever date occurs first, and costs and billing/payment disclaimers. Cards will carry a requirement that membership be first-time validated to providers by a photo identification card such as a U.S. DOD ID card, passport, or a driver's license. RSNF Health Plan, Prescription Identification Cards and plan summaries are required to be reissued on an annual basis at the beginning of each plan year. A plan year will be one calendar year in length commencing on the effective date of the contract between the U.S. Navy and the Contract Administrator.

a. RSNF Health Plan and Prescription Identification Cards will be reissued when a previously reported expiration date is extended for more than thirty (30) days and sixty (60) days respectively, by NETSAFA. Upon notification of a training extension, which requires identification card reissuance, the Contract Administrator will provide reissued RSNF Health Plan and Prescription Identification Cards to arrive at NETSAFA for distribution to members within two weeks.

b. Upon notification, the Contract Administrator shall replace ANY lost or damaged cards within two weeks.

c. RSNF Health Plan Identification cards can be either plastic or laminated with 10mil plastic on each side and printed on colored (color determined by the RSNF) paper from a laser printer.

9. RSNF personnel assigned for periods of sixty days or less will be designated as sponsors by Extraordinary Inclusion letter (Attachment 5) appointment to NETSAFA from ADANA.

a. RSNF Health Plan and Prescription Identification Cards will not be issued to Extraordinary Inclusion participants. A copy of the Extraordinary Inclusion letter along with a photo identification card by which a sponsor can validate his/her identity will suffice for obtaining medical provider services.

b. In order to obtain prescription drugs, an Extraordinary Inclusion participant will purchase drugs and submit a RSNF Medical Reimbursement Claim Form to the Contract Administrator, who will reimburse the sponsor by check. Payment for medical, dental, prescription and vision costs will be accomplished on a cost reimbursable basis against specific Line items.

c. Extraordinary inclusion sponsor fees will be invoiced against specified line items for the months following the effective date of inclusion. Normally RSNF personnel will be included for periods of 30 days or less.

10. The contractor is responsible for establishing a working fund of $445,000 for the payment of sponsor’s medical claims which the contractor will be reimbursed under specific line items identified in contract section B. It is required that at least 95% of all valid, complete provider billing statements and sponsor claims be screened and paid by the Administrator within 15 working days of receipt, to the limit of the Administrator’s working fund of $445,000. The balance (5%) must be paid within 30 days of receipt, to the limit of the Contract Administrator’s working fund.

11. The Contract Administrator is responsible for promptly submitting his vouchers to the Government for reimbursement at least monthly, so that his working fund is maintained as near to maximum as possible.

12. Each invoice must contain a Public Voucher Form, Certificate of Performance Form, costs broken out by FMS Case and supporting documentation, such as a listing of all claims paid by the Contractor with each WCN listed by dollar amount paid and Case Number. (Attachments 6 and 7 are Public Voucher and Certificate of Performance Forms.)

13. The Contract Administrator shall adhere to policies and procedures for monthly invoicing purposes and certify performance efforts under this contract.

14. If claims are not paid in full, the Providers will be provided a full explanation by the Contract Administrator and advised of appeal procedures. The appeal process is outside the contract. If care is not listed as one of the approved services within this Performance Work Statement, the sponsor will appeal via their RSNF chain of command. Originals of billing statements will be maintained by the Contract Administrator for the life of the contract after which time they will be disposed of as determined and directed by the COR.

15. A local area network of personal computers with Internet access and electronic mail capability for key personnel is required for communication with the COR. Contractor must be able to communicate remotely with the COR via electronic means. MS ACCESS software (latest version) is required for production of RSNF Health Plan Identification Cards.

VI. Covered Services:

See “Schedule of Benefits” in SPD (Attachment 4).

VII. Reports A. Monthly Program Reports

1. The contractor will provide the below listed monthly program summary reports (as of the close of business on the last calendar day of the month) to the COR to be received not later than the 10th calendar day of the following month. RSNF approval of report formats is required prior to issuance of the initial reports after contract implementation.

a.) Paid Claims Report

1. Transactions by FMS case in sequence by payment date, listing:

2. Date of payment

3. Sponsor Work Control Number (WCN)

4. Patient Last Name, First, M.I.

5. Relationship to sponsor

6. Date(s) of service

7. Provider

8. Amount billed

9. Check number

10. Amount paid b.) Eligibility Report

1. List of authorized participants by FMS Case

2. Patient Last Name, First, M.I.

3. Sponsor WCN

4. Date of Birth (DOB)

5. Age

6. Sex

7. Effective Date

8. Termination Date c.) Turnaround Time Report by FMS Case

1. Claims received by day

2. Claims processed by day

3. Total Number of claims received and processed for the month

4. Total Number of claims (not processed) in arrears from prior month

5. Percent of claims processed by day

6. Cumulative percent of claims processed by day

7. Percent of claims processed per month

2. See the following attachments for report examples.

Attachments 8-10:

8. Paid Claims Report

9. Eligibility Report

10. Turnaround Time Report

B. Quarterly Program Reports

1. The Administrator will produce a quarterly report to the COR that outlines the medical service fees that have been negotiated on the part of the customer. The report will display consolidated medical charges that were evaluated for fair reimbursement by comparing charges to industry standards and subsequently negotiated by the provider to reflect a fair and reasonable fee.

2. The report shall summarize all monthly reports and include ALL unresolved issues from prior month or quarter with plan of action for resolutions (anticipated date).

3. Report shall be submitted no later than 15th calendar day of the following quarter. RSNF approval of report formats is required prior to issuance of the initial reports after contract implementation.

VIII. Service Groups:

M0 - Equipment Rental/Purchase S1 - Radiography & Laboratory M1 - Hospital Inpatient S2 - Chiropractic M2 - Surgeon Inpatient P1 - Prescriptions M3 - Doctor(s) Inpatient D1 - Dental M4 - RAD & AMES Inpatient D2 - Orthodontics M5 - Emergency Room V1 - Vision Care/Services M6 - Surgery Outpatient V2 - Vision Care/Supplies M7 - Doctor Outpatient M8 - Medical Record, PPO Payment and Negotiated Discount Fees, and Related Fees as approved by the COR M9 - Total Psychiatric M10 - Non-Medical

IX. QASP PERFORMANCE METRICS/CDRLS

1. QASP Attachment 1/Technical Exhibit 1 – Performance Requirements Summary

2. QASP Attachment 2/Technical Exhibit 2 – Deliverables Schedule

3. CDRLS (DD1423) Exhibit A

SECTION I - CONTRACT CLAUSES

The following have been modified:

52.217-9 OPTION TO EXTEND THE TERM OF THE CONTRACT (MAR 2000)

(a) The Government may extend the term of this contract by written notice to the Contractor within 30 days; provided that the Government gives the Contractor a preliminary written notice of its intent to extend at least 30 days before the contract expires. The preliminary notice does not commit the Government to an extension.

(b) If the Government exercises this option, the extended contract shall be considered to include this option clause.

(c) The total duration of this contract, including the exercise of any options under this clause, shall not exceed 5 years.

(End of clause)

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