Attachment 1 - Statement of Work.pdf

Attachment 1 – Statement of Work for RFP OPEO-SOL-NDMS-2012

Statement of Work

D.1 Statement of Need The purpose of this contract is to provide a mechanism for reimbursing Definitive Medical Care provided to patients who were victims of a specified disaster or public health emergency and managed within the National Disaster Medical System (NDMS). The contractor shall independently, and not as an agent of the government, furnish all the necessary services, qualified personnel, material, equipment, and facilities, not otherwise provided by the government, to develop and administer a claim-based reimbursement program for Definitive Medical Care provided by Facilities and Practitioners (as defined in Attachment J.100).

Hereafter, Facilities and Practitioners will be collectively referred to as “Providers.” “Providers” actively participate in Medicare and Medicaid in accordance with the NDMS Coverage Guidelines (See Attachment J.102). The reimbursement program shall cover ONLY claims resulting from the activation of the NDMS.

Reimbursement, under the guidelines of the NDMS, will be made to Providers providing medical services to patients that participate in the NDMS. Current NDMS reimbursement guidelines are predominantly based on Medicare policies and reimbursement rates and thus require active Medicare participation by providers. However, there are some institutional providers and licensed practitioners who either do not actively participate in Medicare or whose services are not reimbursable under Medicare. In these situations, NDMS will reimburse the providers using their State’s Medicaid policies and reimbursement rates. NDMS seeks a contractor to process any reimbursement claims from qualifying institutional providers and licensed practitioners using Medicare policies and reimbursement rates for services covered under Medicare Part A or Part B and using a State’s Medicaid guidelines for services that are not reimbursable under Medicare but are reimbursable under Medicaid in the State where the patient was treated.

Background information regarding any current disasters or public health emergencies may be found at http://www.phe.gov/emergency/pages/default.aspx.

D.2 Definitions

NDMS definitions are in attachment J.100.

D.3 Authority

The NDMS program is authorized by statute at 42 U.S.C. 300hh-11 and is operated by the Assistant Secretary for Preparedness and Response (ASPR) within the Department of Health and Human Services (HHS).

D.4 Past Experience

HHS will activate the NDMS during certain public health emergencies. Past activations include the responses to Hurricanes Katrina, Rita, Ike, and Gustav, as well as for the Haitian Earthquake response. In public health emergencies that require relocation of patients to hospitals and other facilities for Definitive Medical Care, the NDMS may authorize its Definitive Medical Care component as appropriate for the specific public health emergency. Past experience indicates that, based on the uniqueness of each emergency event, there may be great variation in the source http://www.phe.gov/emergency/pages/default.aspx� of Providers for that event. For example, we have found that for one domestic emergency response, 35% of the claims received by the contractor were from Practitioners while 65% were from Facilities. However, in a more recent response, approximately 90% of the claims received were from Practitioners while 10% were from Facilities. As a rough order of magnitude estimate, the Contractor should expect on average to process 2,500 Medicare format claims and 1,000 Medicaid format claims from six states each year.

D.5 Non-NDMS Activation Tasks

D.5.1. Project Management Plan and Schedule

a. After contract award, the contractor shall submit to the COR a draft project management plan within 25 business days after contract award and prior to any issuance of a task order for the specified disaster or public health emergency. The COR will approve the draft project management plan or inform the contractor of changes/additions/deletions within 10 business days. If changes/additions/deletions are requested by the COR, the contractor shall submit a final project management plan for the COR’s approval within 5 business days of the COR’s response to the draft project management plan. The plan shall be submitted to the COR in an electronic form, in a format agreed upon with the COR.

The project management plan shall include the methods and details for overall project management, staffing, staff training, subcontracting, Provider outreach and training methodology, data management, and data security. The project management plan shall also describe the contractor’s methods for monitoring and managing project cost, project schedule, project performance and quality, project communications, and project risk. In this latter regard, the plan shall briefly but specifically identify the most significant risks, in the contractor’s estimation, to the achievement of the goals of the project, and the contractor’s approach to mitigating these risks.

Under this schedule, the contractor shall be capable of receiving claims either through its website or in hard copy no later than 30 calendar days after contract award. The contractor shall propose a cut-off date for submission and payment of NDMS claims in accordance with each task order.

The project schedule shall clearly identify o Major project tasks;

o Project milestones;

o Dates on which any ASPR/OPEO deliverables are due.

The contractor shall update and maintain this integrated project schedule for payment activities for each specified disaster or public health emergency, and shall provide a copy of this updated project schedule to the COR with every second project status report (see c. below) and/or upon request.

b. The contractor shall provide electronically a brief status report to the COR which identifies the following: The contractor shall provide a brief project status report the

1st and 15th of the month and continuing through the end of the payment activities.

This report shall identify-

• Major activities conducted during the period;

• Milestones achieved;

• Major activities planned;

• Significant project issues/challenges/concerns.

• Claims statistics report as indicated in section C.6.2;

• Inquiries as indicated in section C.6.2; and

• Dispute receipts as indicated in Section C.6.2.

D.5.2 Maintaining a Medicare Adjudication Platform

The contractor will be required to utilize and maintain a claims processing software application capable of adjudicating Medicare Part A and Part B type claims using Medicare rates and guidelines in effect on the date of service specified on the claim. If the Centers for Medicare & Medicaid Services (CMS) have already provided the contractor access to the Medicare Part A Fiscal Intermediary Standard Shared System (FISS) for hospital claims and the Medicare Part B Multi-Carrier System (MCS) claims systems for the processing of professional claims, the contractor shall obtain permission directly from CMS to utilize a copy of this software to process NDMS claims.

a. The contractor will have no ownership of any applications provided by CMS and no ownership of the data generated by the applications while processing NDMS claims. If the contractor chooses to use their own claims processing software or claims processing software from a third party, the contractor will maintain ownership of the system while ASPR maintains ownership of any data generated by the system. Collectively, the claims processing software used by the contractor and the data used or generated by the software will be referred to as the “NDMS Claims Processing System.”

b. The NDMS Claims Processing System will be maintained by the contractor and shall include the incorporation of subsequent changes in Medicare Part A and Part B policies and rate schedules within 30 days of CMS making such changes publically available.

The contractor must have this system up and running within 30 days of contract award.

D.5.3 Establishing and Maintaining an NDMS Claims Adjudication Website

The contractor will develop a website and system for communicating information and updates about the NDMS Reimbursement Program to NDMS Providers and other stakeholders as necessary, along with a means to receive inquiries. This system will remain in ownership by the government. Any physical property or rights to its use will be relinquished to the government upon completion or termination of the contract. The contractor shall create an NDMS Reimbursement Program e-mail address for general inquiries

The contractor must comply with the standards, policies, and procedures and applicable 508 standards below. In the event of conflicts between the referenced documents and this statement of work (SOW), the SOW or Task Order (TO) shall take precedence.

The Rehabilitation Act, Section 508 Accessibility Standards are as follows:

1. 29 U.S.C. 794d (Rehabilitation Act as amended)

2. 36 CFR 1194 (508 Standards), specifically 36 CFR Part 1194.22 a – j, l – p

36 CFR Part 1194.41 a – c

3. www.access-board.gov/sec508/508standards.htm (508 standards)

4. FAR 39.2 (Section 508)

5. ASPR/HHS Standards, policies and procedures (Section 508)

Regardless of format, all Web content or communications materials produced must conform to applicable Section 508 standards to allow federal employees and members of the public with disabilities to access information that is comparable to information provided to persons without disabilities. All contractors (including subcontractors) or consultants responsible for preparing or posting content must comply with applicable Section 508 accessibility standards, and where applicable, those set forth in the referenced policy or standards documents above. Remediation of any materials that do not comply with the applicable provisions of 36 CFR Part 1194 as set forth in the SOW or TO, shall be the responsibility of the contractor or consultant.

D.5.4 Research and Clinical Review

The Assistant Secretary for Preparedness and Response’s Office of Preparedness and Emergency Operations (OPEO) may conduct studies to evaluate whether or not medical transfer objectives were met for NDMS patients. In order to evaluate the clinical care patients received and the costs associated with caring for evacuated victims, OPEO will review and compare transport logs and medical records and will evaluate billing and payment information. Such information may be similar or different in content and format from that which the Contractor is required to submit to meet the requirement at D.5.3 Storage and Receipt of Claims and will be communicated by the COR.

OPEO’s study would involve the retrospective review of medical records for each patient transported within the NDMS system. Additionally, payment information from the NDMS Claims Processing System will be queried. All records obtained from NDMS and from individual hospitals will be maintained securely in accordance with the Privacy Act.

Data will be abstracted from charts and placed in a standardized Case Report Form (CRF). These data will then be analyzed and aggregate information will be summarized in a report. Preparation of a manuscript for a peer-reviewed refereed medical journal is anticipated. No individual patient information will be contained in reports intended for public dissemination.

To support these potential retrospective studies, the contractor will be expected to complete the following tasks within 90 business days of completing claims processing for a Definitive Medical Care event:

http://www.access-board.gov/sec508/508standards.htm%20(508�

a. The contractor shall contact all hospitals who submitted claims and were reimbursed by NDMS in order to obtain a copy of the medical record for NDMS patients.

b. The contractor shall scan medical records received from NDMS hospitals and submit an electronic copy of these medical records to the COR in PDF document format.

c. The contractor shall make 3 documented requests of the NDMS hospital via correspondence or using the NDMS hospital’s medical records copy request forms and then notify the COR of any NDMS hospital where the contractor was unsuccessful in obtaining a copy of the patient’s medical record.

d. In most cases there will be a fee charged by the hospital for copies of the record.

e. The contractor will provide the original paper copies and a photocopied set of all uniform billing (UB-04) and CMS-1500 claim forms received under the NDMS Reimbursement program for Providers in order to facilitate optical character recognition (OCR) scanning by OPEO.

f. The contractor shall extract and submit an electronic copy of all claims processed and all remittance advices produced in HIPAA 837 and 835 electronic formats from the NDMS Claims Processing System in order to facilitate creation of a database by OPEO. Our assumption is that all claims were received in hard copy format using the OCR-scannable red ink forms from CMS. ASPR would like to have all of the original claim forms so that a database can be built using OCR technology instead of having to re-key all NDMS claims. The contractor should maintain a photocopy of all claims for themselves.

g. The contractor shall extract and submit an electronic copy of all claims processed and all remittance advices produced in an electronic format which can be readily imported into Microsoft Excel or Access. The contractor shall test and submit written instructions for how to import this data into Microsoft Excel, or Microsoft Access, or other agreed upon export format.

D.5.5 Training and Exercises

The Contractor shall participate in any training and mock disaster scenarios required by the government to test and reveal successes and areas for improvement in the NDMS Reimbursement Program. This could include participation no more than twice per year for one (1) day in an exercise such as the National Level Exercise (NLE) to ensure the appropriate mechanisms are in place. All activities related to participation in the exercise would be performed at the contractor’s location and billed to the NDMS. The contractor will provide the COR an electronic copy of lessons learned and plans for system alteration within 30 days of completion of each mock event. Such training exercises would be issued as their own task order separate from the task order initiated in response to a specified public health emergency.

D.5.6 Operational Phase-Down and Close-Out

After each emergency event and also upon termination of the contract the following events shall occur:

a. The contractor shall phase-down its claims production, payment, financial, and customer service operations in an orderly manner. The contractor maintains responsibility beyond the termination date of the contract for producing and mailing 1099s to Providers for any payments made during the last performance period of the contract. The contractor will cooperate with ASPR in the transition of the program to a new contractor if applicable.

b. Within 30 days of expiration of the period of performance of the contract, the contractor will modify the program website with a message developed by the COR noting contractor transition information for the program and hyperlinks to the new contractor’s website if applicable.

c. The contractor shall securely store and/or archive all project documentation and materials in a manner that is compliant with the Privacy Act, the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, HHS record retention requirements, and other Federal information laws and policies, as applicable. The storage and archival technique must be readily accessible (within 3 business days of request) to support the COR and audit agency review. Documentation and materials covered by this requirement include, but are not limited to:

i. The contract and statement of work, and the contractor’s technical and business proposal, including any amendments.

ii. Correspondence to and from the COR (beginning with the date of award), including the Contracting Officer and the COR.

iii. Copies of all project deliverables (official draft, final, and amended, to the extent applicable).

iv. All Provider claims received by the contractor.

v. Transaction records on the disposition of NDMS claims.

vi. Transaction records on all NDMS disbursements.

vii. Correspondence to Providers and other NDMS stakeholders.

viii. Provider training materials.

ix. Documentation on business processes and operating procedures used.

d. The Contractor shall deliver to the COR, in an electronic format, the following items developed under this contract. These include but are not limited to the following system related items: databases, files, records, data dictionary, documentation, reports, copybooks, test case scenarios and other related products not specifically described in this document. In those instances where interaction with a subcontractor/vendor is required, the incumbent Contractor shall assist the new contractor.

e. The contractor shall deliver a copy of all materials referenced in D.8.3 in electronic format and shall maintain the above documentation for their own records under (c) for a period of 6 years and 3 months following the date on which final action was taken on NDMS claims and disbursements under this task.

f. The contractor shall maintain fiscal and accounting records to support its administrative expenditures and invoices under this statement of work in accordance with the terms and conditions of this contract.

g. Lessons Learned Fifteen days after the completion of reimbursement tasks for an emergency event and also fifteen days prior to the completion of this contract, the contractor shall provide a lessons learned document in Microsoft Word format to the COR. The primary focus of the lessons learned document shall be suggestions or recommendations that, if implemented, will improve future administration of mission-specific NDMS Reimbursement Programs.

C.6 NDMS Activation Tasks

During or after a public health emergency which may require reimbursement services, the Government will issue a task order which will define the service levels required from the contractor during the task order period of performance (e.g. days and hours of coverage, response times, and escalation procedures). The tasks required on each Task Order shall be specified, based on the listed tasks below.

D.6.1 Claims Processing

In addition to operating the Medicare Adjudication Platform in task D.5.2, the contractor shall establish a procedure for Medicaid format claims, including demonstrating, and operating a process for the receipt, control, review, and adjudication of claims for NDMS primary and secondary reimbursement in order to facilitate effective and efficient reimbursement for care provided to NDMS patients.

a. In addition to maintaining Medicare Part A and Part B policies and rate schedules for providers nationwide, the contractor shall obtain fee schedules for services not covered under Medicare, but that are covered under Medicaid for states to be defined by ASPR.

The contractor shall not be required to configure claims processing system to process Medicaid format claims until an actual emergency event is declared. With respect to Medicaid format claims, ASPR will designate which states to include for each emergency event as this will be unknown until the NDMS system has been activated.

b. The NDMS Claims Processing System must be fully functional within 30 days of initial contract award and any subsequent update to the CMS Medicare Schedules.

c. The contractor shall establish, demonstrate, and operate, a process for the receipt control, review, and adjudication of claims where NDMS serves as the primary payer or serves as the secondary payer for amounts unreimbursed by other payers in order to facilitate effective and efficient reimbursement for care provided to NDMS patients.

d. The contractor shall document and demonstrate this process within 30 days of contract award or any subsequent IDIQ awards for an emergency event. The contractor shall apply the NDMS Coverage Guidelines (attachment J.102), NDMS Reimbursement Guidelines (attachment J.103), the NDMS Coordination of Benefits Guidelines (attachment J.104), and the NDMS Denial Guidelines (attachment J.105) in reviewing and adjudicating NDMS claims.

e. For qualifying claims received that have no data integrity issues, the contractor shall adjudicate these claims within 30 calendar days of receipt.

D.6.2 Administration

a. The contractor shall provide an initial claims statistics report to the COR on the Monday following the receipt of a task order to begin active claims processing. The contractor shall provide a follow-up claims statistics report to the COR every week thereafter through the end of the project. (This report will be similar to, but more limited than, the Contractor Reporting of Operational Workload Data (CROWD) reports submitted for Medicare purposes).

b. The contractor shall provide these reports on the following basis on a bi-weekly basis:

Facility type, Practitioner type, and total; and, totals by state of Provider. Such report shall provide at least the following statistics on a reporting period basis as well as cumulative “project to date” basis for each specified disaster or public health emergency:

• Frequency of ICD-10 codes.

• Number of claims received;

• Total billed charges for claims received;

• Number of claims in process;

• Number of claims approved for payment;

• Number of claims denied for payment;

• Total dollar amounts approved for payment (total dollars paid); and,

• Total dollar amounts on denied claims (total billed charges denied).

• Total dollar amount unspent to date.

c. The contractor shall provide an initial financial statistics report in Microsoft Word or Excel format to the COR by the 15th of each month following the end of each month in which NDMS payments are issued. These reports will be submitted on the next business day if the 15th falls on a Saturday or Sunday. The contractor shall provide these reports on the following basis: Facility type, Practitioner type, and total; and, totals by state of Provider. Such report shall provide the following statistics for each disbursement cycle:

• Number of disbursement transactions executed;

• Total dollars disbursed;

• Number of checks cleared, the total dollar value, and any exception activity

(e.g., payments returned as undeliverable, stale-dated checks, Provider refunds, bank reconciliation issues, etc.)

d. The contractor shall provide ad-hoc operational reports at the request of the COR.

Record Keeping and Reporting Requirements The contractor shall provide to COR upon request within 25 business days, information required to be maintained, as described below, for each specified disaster or public health emergency event.

Operations

a. For each specified disaster or public health emergency, the contractor shall obtain, record, and maintain any information relating to NDMS Providers that admitted patients from the activation of the NDMS described in section D that is needed to effectively process and reimburse claims from such facilities, such as mailing addresses, tax identification numbers, etc..

b. The contractor shall identify qualified Providers who furnished separately reimbursable medical services to patients for their authorized medical care. The contractor shall obtain, record, and maintain any information relating to such Providers that is needed to effectively process and reimburse claims submitted by them, including mailing addresses, tax identification numbers, etc. for each specified disaster or public health emergency.

c. The contractor shall document all claims processing and payment transaction activity (e.g., incoming claims, claims history, payment registers) in a manner that conforms to general Medicare program standards. The contractor shall apply its experience in meeting Office of Inspector General (OIG) and Government Accountability Office (GAO) audit requirements to this requirement.

d. The contractor shall track and maintain a log of each inquiry it receives, the status of each inquiry, and the ultimate resolution. The contractor shall provide a report of all inquiries received within the previous period and program to date for each specified disaster or public health emergency. The report shall be submitted to the COR by the 15th day following the previous reporting period.

e. The contractor shall track and maintain a log of each dispute (“appeal”) it receives, the subject matter of the dispute, the status of each dispute, and the ultimate resolution. The contractor shall provide a report of all inquiries received within the previous period and program to date for each specified disaster or public health emergency to ASPR/OPEO for further review by an ASPR/OPEO medical review board.

D.6.3 Customer Service at time of NDMS Activation

D.3.6.1 Customer Service Expectations

a. The contractor shall establish a toll free phone number and toll free fax number for

Provider and NDMS staff inquiries regarding the program. During normal operations, inquiries shall be responded to within 48 hours of receipt of inquiry.

Hours shall be from 8AM-8PM ET, Monday through Friday. A log of inquiries shall be provided to the Contracting Officer’s Representative (COR) on the 1st and 15th of each month. Any inquiry that cannot be answered by the contractor shall be forwarded to the COR within 48 hours of receipt.

b. The contractor shall be responsive to any patient served through the NDMS program who requests an explanation of benefits by phone, email, mail, or in person within three business days of receipt of the inquiry, after proper validation of patient identity in accordance with its procedures established for Privacy Act and Health Insurance Portability and Accountability Act (HIPAA) privacy regulation purposes.

c. Maintain up-to-date information that is both advertised to Definitive Medical Care Providers and able to be referenced on the NDMS and NDMS Reimbursement Program websites.

d. Establish a listserv mechanism (to inform Providers and others of important updates).

e. Develop and update NDMS Reimbursement Program reference and instructional materials that can be distributed to NDMS Facilities and Practitioners with details on how to enroll with the program, coverage, and reimbursement offered by the program, and claims submission and claims payment instructions.

f. The contractor shall develop and update NDMS Reimbursement Program reference and instructional materials intended for internal NDMS staff use on the Program website.

g. For those services which are not reimbursable under Medicare but reimbursable under a State’s Medicaid program, the contractor shall contact the State Medicaid office to obtain or validate fee schedules as required.

h. In the past, NDMS has experienced situations where claims that a hospital or practitioner should have sent to NDMS for processing were mistakenly sent to a State Medicaid plan for payment. Months later, this has resulted in Medicaid recouping the mistaken payments from providers. To help prevent such situations from occurring, the contractor shall perform the following outreach tasks to NDMS providers and State Medicaid agencies:

1. NDMS will provide the contractor with access to information on qualified

NDMS patients, transportation data and care coordination data.

2. The contractor shall contact the hospitals or facilities that the patient has been admitted to in order to verify insurance coverage and determine if NDMS will be the primary payer for the patient.

3. When qualifying claims are received from a hospital or facility, the contractor shall write a letter to any rendering or referring providers noted on the claim.

The letter shall inform the provider that the NDMS Reimbursement Program may be able to reimburse their claims.

4. As qualifying claims are received for affected State(s), the contractor shall contact the Medicaid office of the affected State(s) and establish a communication schedule with the Medicaid office to share rosters of patients who qualify for NDMS reimbursement. The Medicaid office may then proactively deny or refer claims for these patients to NDMS or may run retrospective reports to identify any mistaken payments made by Medicaid.

5. The contractor shall contact any providers that Medicaid may have reimbursed by mistake and assist the providers with re-filing their claims with NDMS.

Any system or materials developed for the program will remain in ownership by the government. Any physical property or rights to its use will be relinquished to the government upon completion or termination of the contract.

D.6.3.2 Dissatisfied Claimants (Appeals)

a. The contractor shall work informally with Providers that express dissatisfaction or concern with an NDMS reimbursement determination made by the contractor. The contractor shall clarify:

1. the basis for the concern;

2. the structure of the NDMS Reimbursement Program, in the event of Provider misunderstandings about the structure of the program; and

3. whether there is any basis, within NDMS Reimbursement Program guidelines, for making an adjustment to the claim based on the concerns expressed by the Provider.

b. The contractor shall adjust any claim that is found to have been processed in error.

After receiving approval from the COR for the adjustment and correspondence to be mailed to the Provider, the contractor shall mail the adjusted remittance advice and correspondence to the Provider and make appropriate payment at the next scheduled disbursement cycle.

c. In the event that a Provider argues that a patient has been wrongfully omitted from the NDMS patient roster, the contractor shall refer the Provider to the appropriate Federal Coordinating Center (FCC). If the FCC agrees with the claimant and notifies the COR and the contractor in writing to this effect, then the contractor shall adjust the claim and issue appropriate payment at the next scheduled disbursement cycle.

d. The contractor shall develop and maintain a log to track and trend the subject matter of disputes it receives, the resolution status of each dispute, and ultimate resolution.

The contractor shall deliver a monthly report electronically to the COR on these issues by the first of each month.

e. In the event that a Provider wishes to press its concerns further with ASPR OPEO’s COR or the NDMS Partners, or threatens litigation, or the contractor discovers some other urgent issue in its dispute resolution role, the contractor shall notify the COR within one business day. The contractor will provide all necessary information to assist the medical review board in the resolution of the situation.

D.6.3.3 Fraud and Abuse

The contractor shall report to the COR any Provider billing activity that, based on its knowledge of health care industry, Medicare, and Medicaid program standards, may represent fraudulent or abusive conduct. This reporting will take the form of developing and sending to the COR a memorandum describing the suspected activity within 7 business days of discovery. The COR will review the information provided and determine whether to forward it to a Zone Program Integrity Contractor or federal law enforcement for investigation. Once it has submitted the memorandum, the contractor has no further obligation to act on or further develop the reported situation, other than to provide any requested follow-up information or assistance to the COR or to federal law enforcement.

The contractor shall perform analyses on claims submitted to include but not limited to the following:

a. Analysis of rendering provider data/patterns.

b. Analysis of referring provided data/patterns.

D.6.4 Receipt and Storage of Claims

a. The contractor shall establish an efficient, comprehensive mechanism through which

Providers can submit claims. At a minimum, this will include establishing a toll free fax line, a toll free phone number, a website, and a mailing address for the program.

b. The contractor shall scan copies of all hard copy claims and paper correspondence received from Providers into electronic format that can be shared with the COR on demand.

c. At the end of the performance period or option period, an electronic set of all scanned copies of claims and correspondence as well as the original copies shall be provided to the COR.

D.6.5 Provider Enrollment

a. The contractor will collect the following information from Providers submitting claims to the program:

i. Demographic and contact information for Providers.

ii. Banking and tax information for Providers for the purposes of electronic funds transfers. All banking information shall be collected using the SF

3881 ACH VENDOR/MISCELLANEOUS PAYMENT ENROLLMENT

FORM.

iii. Mailing address and contact information for the mailing of remittance advices and explanation of benefits documents.

b. The contractor will contact the Provider within 48 hours of the patient being received in the facility to inform them of how to bill the NDMS.

c. The contractor will validate and note if the Provider submitting a claim is an active participant in either the Medicare or Medicaid program. This is a minimum requirement for Providers to be eligible for reimbursement from NDMS.

d. The contractor will check to see that the Provider has not been debarred from participating in Medicare, a state’s Medicaid program or in any other Federal Government program.

e. If a Provider fails to meet conditions (b) or (c) above, the contractor will notify the COR and await further instructions.

D.6.6 Claims Payment

Prior to paying providers, the Contractor shall submit a list of all approved claims and denials that the Contractor has reviewed to the COR. Upon approval from the COR, the contractor shall pay the approved claims from the contractor’s source of funds and shall then invoice the government with proof of transaction/receipt of payments by the Providers.

a. When a Definitive Medical Care event is authorized by NDMS, the government will provide a task order for both the adjudication of claims, and a reimbursement amount that the government shall make available for that event. The adjudication dollars shall be based on the pricing schedule proposed by the contractor’s in section B. The contractor will be required to establish a NDMS Reimbursement Limit no less than $1,000,000 although the contractor may choose to propose a higher NDMS Reimbursement Limit if desired. A Contractor who is unable to meet this limit shall be deemed non-responsive, and unable to meet this requirement.

b. By the 1st and the 15th of each month, the Contractor shall submit a remittance advice to the government of the claims determined to be eligible for payment. The government shall then review the proposed payments, and authorize the contractor to pay or not pay the claims they submit for approval by the government within 5 business days.

c. For those remittance advices approved by the government, the contractor shall provide a remittance advice to the NDMS Provider that documents the services and charges billed, dates of service, claims control number, dates of claims receipt and processing, and the program payment level (if any) by the following first or 15th of the month. The remittance advice must be mailed to the NDMS Provider prior to payment being made if payment is being made electronically as preferred.

d. After allowing time for the NDMS Provider to receive their copy of the remittance advice, the contractor shall make payment to the NDMS Provider via electronic funds transfer. The contractor will use the data documented from the SF 3881 form during the Provider Enrollment process to make electronic funds transfers to Providers.

e. Following payment to a NDMS Provider, the contractor shall provide the government with a copy of a confirmation notice or transaction log showing the date, time and amount of an electronic fund transfer successfully made to a Provider, and submit those receipts with the contractor’s monthly invoices, which will be needed before the contractor may obtain reimbursement for all claims paid out. It is highly recommended that the contractor use electronic funds transfer to make payments in order to help expedite reimbursement of the payments made by the contractor. If the contractor elects to issue paper checks to NDMS Providers instead, the contractor must supply proof that the check has been deposited by the NDMS Provider and the funds cleared before the payment can be submitted for reimbursement.

f. If the amount of reimbursable claims exceeds the NDMS Reimbursement Limit (minimum, $1M), the contractor shall cease making payments, unless authorized to do so by the Contracting Officer. Even if the threshold is reached, however, the contractor shall continue with the determination of pending claims.

g. It is possible that the reimbursement due to a single NDMS Provider may exceed the NDMS Reimbursement Limit. In this event, the Contractor shall seek guidance from the COR as how the government wishes for them to handle the payment. In some instances, the government may decide to pay those providers directly. If that is the case, the contractor shall provide the government with the SF 3881 form for the NDMS Provider so that the government can make an electronic payment to the NDMS Provider.

h. From the date that approval is received by the contractor from the COR to reimburse a NDMS Provider, the contractor shall make payment to the Provider within 5 business days of such approval, unless the NDMS Reimbursement Limit has been reached. In the event of any delayed payment, the contractor shall notify the COR, determine the status of the payment and take appropriate action. The contractor shall contact the Provider within 5 business days in the event that disbursements are returned for any reason.

i. The contractor shall prepare and issue Form 1099s to NDMS Providers in accordance with Internal Revenue Service requirements by the end of January for the previous tax year. The contractor shall prepare and file any other forms required for income tax and similar reporting purposes.