Pharmacy Claims Switching Draft SOW.pdf

DRAFT STATEMENT OF

WORK

Pharmacy Claims Switching and Benefit Eligibility Verification Services

Purpose of work Switching Services are required when Billings Area Indian Health Service (BAIHS) health care facilities submit pharmaceutical claims electronically from the Resource and Patient Management System (RPMS) computer system to third party Drug Plans for reimbursement.

Pharmacy Benefit Eligibility Verification Services are web-based programs utilized to verify pharmacy insurance processing information and patient benefit eligibility status that is critical for Pharmacy Point-of-Sale (POS).

Place of Performance

The contractor shall provide the requirements described herein to all BAIHS health care facilities.

LOCATIONS

a. Blackfeet Service Unit - Community Hospital 760 Hospital Drive Browning, MT 59417

b. Blackfeet Service Unit - Heart Butte Clinic

81 Disney St.

Heart Butte, MT 59448

c. Crow Service Unit – Crow / N. Cheyenne Hospital

10110 South 7650 East Crow Agency, MT 59022

d. Crow Service Unit - Lodge Grass Clinic

418 Harding Ave Lodge Grass, MT 59050

e. Crow Service Unit - Pryor Clinic

2 Pryor Gap Road Pryor, MT 59066

f. Fort Belknap Service Unit - Harlem Health Center

669 Agency Main Street Harlem, MT 59526

g. Fort Belknap Service Unit - Hays Health Center

123 Whitecow Canyon Rd.

Hays, MT 59527

h. Fort Peck Service Unit - Verne E. Gibbs Health Center

107 H St. E Poplar, MT 59255

i. Fort Peck Service Unit - Chief Red Stone Health Center 550 6th Ave N.

Wolf Point, MT 59201

j. Little Shell Service Unit - Great Falls Health Center 425 Smelter Ave NE Great Falls, MT 59404

k. Northern Cheyenne Service Unit - Lame Deer Health Center

420 N. Cheyenne Ave Lame Deer, MT 59043

Applicable Documents

The contractor shall comply with all federal regulations and comply with the Indian Health Service’s Third Party Resource and Internal Control Policy, the Debt Collection Policy, and the Indian Health Service’s statistical and reporting systems for all departments. The contractor shall comply with the American Hospital Association (AHA) Official Coding Guidelines for ICD and the Current Procedural Terminology (CPT) Guidelines, and any specific IHS coding and data entry policies and procedures.

Reference material is available from the following publicly-accessible websites:

Division of Business Office Enhancement (DBOE) and Office of Information Technology (OIT) Website Website: http://www.ihs.gov/businessoffice/index.cfm

Freedom of Information Act Website: http://www.ihs.gov/FOIA/

Health Insurance Portability and Accountability Act (HIPPA) Website: http://www.ihs.gov/HIPAA/

Indian Health Manual Part 2 – Services to Indians and Others Chapter 6 – Patient Registration System Website: http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc-p2c6 Chapter 7 – Health Insurance Portability and Accountability Act Privacy Rule and the Privacy Act Website: http://ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p2c7

Part 3 – Professional Services Chapter 3 – Health Information Management Website: http://www.ihs.gov/IHS/index.cfm?module=dsp_ihm_pc_p3c3

Part 5 – Management Services Chapter 1 – Third-Party Revenue Accounts Management and Internal Controls Website: http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p5c1 http://www.ihs.gov/businessoffice/index.cfm http://www.ihs.gov/FOIA/ http://www.ihs.gov/HIPAA/ http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc-p2c http://ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p2c7 http://www.ihs.gov/IHS/index.cfm?module=dsp_ihm_pc_p3c3 http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p5c1

Part 8 – Information Resources Management Chapter 8 – Information Technology Security for Remote Access Chapter 12 – Information Technology Security Chapter 18 – Encryption Chapter 20 – Section 508 Implementation Website: http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p8c20#8-20.1

Part 9 – Finance and Accounting Chapter 4 – Debt Management Website: http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p9c4 Indian Health Service (IHS) Privacy Program Website: http://www.ihs.gov/PrivacyAct/

Resource and Patient Management System (RPMS) Website: http://www/ihs.gov/RPMS/index.cfm

Switching Services Contractor shall perform the following activities:

1. Operate the Switching Services in accordance with the applicable Specifications.

2. Provide BAIHS facility with a local telephone number or alternative toll free number for access on a dial-up telecommunication basis to the central processing facility for use of the services.

3. Be available to BAIHS health care facilities according to customer service hours

(refer to Customer Service section).

4. Provide ongoing support through telephone consultations and provide a local or toll free number for access to technical support.

5. Perform, at its election, automated data checks of the data submitted through the Switching

Services for completeness, logic and satisfaction of statistical requirements of the applicable specifications.

6. If the Switching Service Contractor revises, modifies or updates their services, without liability to BAIHS health care facilities, they shall notify the BAIHS health care facilities in writing or electronically within a reasonable time before the change will occur. The Contractor shall furnish the BAIHS health care facilities with appropriate materials to allow implementation and testing by the BAIHS health care facilities before the effective date of such event.

7. Provide “additional” services at the fee listed above, if selected by BAIHS health care facilities. Additional services include Pre Post Editing (PPE) services and Rx Reconciliation Services. As part of the fee, they shall assist in the set-up of these services.

http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p8c20#8-20.1 http://www.ihs.gov/IHM/index.cfm?module=dsp_ihm_pc_p9c4 http://www.ihs.gov/PrivacyAct/ http://www/ihs.gov/RPMS/index.cfm

Pharmacy Benefit Eligibility Verification Services:

1. Obtain information provided by the pharmacy benefit managers (PBMs) to determine pharmacy benefit eligibility information in real-time and reduce time spent researching benefit information to automate the task of determining patient eligibility and coverage, providing time savings and an enhanced level of service to patients.

2. Decrease or eliminate phone time by 20-30 minutes per patient to correct rejections due to non-matched card holder identification information, medications filled after coverage terminated, valid birth date omissions, and group number, bank identification number and primary care network number omissions.

Billings Area Indian Health Service (BAIHS) Health Care Facilities will:

1. Obtain an agreement with designated Drug Plans so the Switching Service can submit prescription claims for electronic adjudication and or eligibility on behalf of BAIHS health care facilities transmitting claims.

2. Transmit prescription claims in accordance with procedures, data element standards, formats, codes, protocols and edits set forth in the then relevant specification for such Switching Services. BAIHS health care facilities acknowledge any transactions not in compliance with such requirements will be rejected.

3. Assume responsibility for any costs incurred in connection with modifications or enhancements to the RPMS (Resource and Patient Management System) that are necessary for implementing the interface with the Switching Services.

DESCRIPTION 12 Month Area Wide Estimated Claims

CARDFINDER PHARMACY SYSTEM 13224

CARDFINDER WEB SERVICES 16050

eRx Connect (Switching) 419,725 Medicare Eligibility 2815

MEDIMPACT 380

PHARMACY SYSTEM ELIGIBILITY PASS THROUGH 14

PHARMACY SYSTEM SURESCRIPTS PASS THROUGH 787

Pre & Post Edits 42781

WEB SERVICES MEDICARE ELIGIBILITY PASS THROUGH 594

WEB SERVICES SURESCRIPTS PASS THROUGH 2334

Deliverables The vendor shall provide the following:

1. Eligibility data from third party insurance databases. These inquiries and responses will provide accurate and up-to-date eligibility information available to the end user. Available upon request.

2. Medicare AR dashboard and reports for AR management. Available upon request.

Software Requirements Switching Service and Benefit Eligibility Verification Service needs to communicate with IHS RPMS (Resource and Patient Management System) to check eligibility for Medicare Part D coverage.

Customer Service Switching Service and Benefit Eligibility Verification Service Customer Support will provide toll free assistance with claims submission Monday through Friday, 7:00am to 7:00pm (MST).

Period of Performance

Base Period of 12 months plus 4 Option Periods of 12 months each.

Privacy and Security The contractors shall conform and maintain to all privacy, confidentiality and security requirements mandated by Indian Health Service.