ProviderNetworkReview_RFI 541690.docx

WTC HEALTH PROGRAM

RFI 75D301-24-RFI-541690 F3332232224XXXXX

World Trade Center Health Program Request for Information

PROVIDER NETWORK DATA INTEGRITY REVIEW

REQUEST FOR INFORMATION (RFI) 75D301-24-RFI-541690

RESPONSE DUE DATE: April 5, 2024

Restricted Use/All CDC Staff

Title: Provider Network Data Integrity Review

I. Purpose The World Trade Center (WTC) Health Program requests information on methods for conducting a comprehensive accuracy review of its New York Metropolitan Area (NYMA) Provider Network, with the potential to extend the review to the Nationwide Provider Network (NPN). The primary objective is to analyze the Program’s provider network data, determine where there are inaccuracies, identify providers on legal exclusion lists, and make corrections to the data. Additionally, provider agreements will be reviewed to identify missing agreements and documentation gaps. Data should be reconciled using various authoritative sources, including the Department of Justice (DOJ), Office of Inspector General (OIG), National Plan & Provider Enumeration System (NPPES), and Provider Enrollment, Chain, and Ownership System (PECOS), and/or propriety sources that the contractor can offer.

This is a request for information (RFI). It is not a solicitation for proposals, proposal abstracts, or quotations. Release of this RFI should not be construed as a commitment to procure items or services or to incur costs for which reimbursement would be required or sought.

II. Background The WTC Health Program was established by Title I of the James Zadroga 9/11 Health and Compensation Act of 2010, Public Law 111–347(January 2, 2011), as amended by Public Law 114–113 (December 18, 2015) and Public Law 116–59 (September 27, 2019), adding Title XXXIII to the Public Health Service (PHS) Act (codified at 42 U.S.C. 300mm to 300mm-61). All references to the Administrator in this document mean the Director of the National Institute for Occupational Safety and Health (NIOSH) within the Centers for Disease Control and Prevention (CDC), or his or her designee. Information on the Program is available at http://www.cdc.gov/wtc

III. Supplemental Information The current NYMA Provider Network is managed by a contractor on behalf of the WTC Health Program. The establishment and management of the internal and external provider network are coordinated through the respective Clinical Centers of Excellence (CCEs). For a provider to have a claim for WTC Health Program services paid, the CCE must have enrolled the provider as a participating provider in the WTC Health Program. Provider enrollment into the WTC Health Program and the management of a reliable provider network are critical to efficient claims processing. The complete and accurate enrollment of providers ensures that claims are not suspended for review of provider validity issues, and that claims may be promptly adjudicated.

Each CCE is responsible for submitting provider enrollment requests to the HPS contractor and updating provider details when necessary. All medical providers, including physicians, group practices, hospitals, Durable Medical Equipment (DME) suppliers, nursing facilities, hospice services, and others, must enroll as participating providers in the WTC Health Program for claims to be adjudicated through the Program’s claims processing system. Each CCE determines the nature of its provider relationships (i.e., internal or external) and is also responsible for providing the appropriate level of education and information regarding the Program to external providers so that they may provide an approved level of care for WTC Health Program-certified conditions. The HPS contractor uses the information provided by the CCEs to add providers to the claims system.

A. Internal Provider

The internal provider network is comprised of healthcare providers (both individuals and groups) that have established relationships as internal medical providers with the medical institutions that are managed by each respective CCE. For example, the Mount Sinai School of Medicine (MSSM) is a medical facility within the purview of the MSSM CCE; most, if not all, of the physicians and groups who practice at the MSSM are enrolled as internal MSSM providers. The designation of “internal” provider is relevant during claims processing, as a claim received by an internal provider is considered to be already authorized by the managing CCE through the nature of the provider’s relationship to that CCE’s affiliated institution(s).

B. External Provider

The majority of the enrolled WTC Health Program providers are external to a CCE. The external provider network comprises healthcare providers (both individuals and groups) that have contractual relationships to provide medical services for members assigned to a particular CCE. The designation of “external” provider is relevant during claims processing, as a claim received by an external provider is not considered to be authorized by the managing CCE unless the claim shows an official stamp indicating CCE authorization is submitted by EDI.

After a CCE has established either an internal or external relationship with a provider, the CCE must submit a provider enrollment request for processing by the Program (a task performed by the HPS contractor). CCEs must provide the following data for enrollment:

· Provider/Practice Name

· Provider/Practice Address (must not be a PO Box)

· Provider/Practice Telephone/Fax Number

· Provider/Practice National Provider Identifier (NPI) Number

· Provider/Practice Social Security Number (SSN)/Employer Identification Number (EIN)

· Provider Medicare Number (if provider will be submitting institutional claims)

· Billing Provider/Practice Name

· Billing Provider/Practice Address (can be a PO Box) where Remittance Advice (RA) may be sent

· Billing Provider/Practice NPI Number

· Billing Provider/Practice EIN

· Financial Information (can be submitted on an Electronic Funds Transfer [EFT] Form), including:

· Financial Institution Name

· Financial Institution Address

· Financial Institution Routing Transfer Number

· Depositor Account Number

IV. Information Requested NIOSH is interested in receiving comments and relevant, evidence-based information addressing each of the areas listed below.

1. What industry best practice should be used to ensure provider network accuracy?

2. What datasets or combination of datasets would you recommend for verifying provider data accuracy and exclusions? (e.g., OIG, DOJ, NPPES, PECOS, private sector etc.)

3. What comments do you have on the WTC Health Program’s assumption of complexity for each of the outlined accuracy review categories?

a. Easy: DOJ & OIG

b. Moderate: NPPES

c. Difficult: PECOS

4. How long do you anticipate it would take to complete each of the recommended reviews?

a. Easy: DOJ & OIG = (# hours)

b. Moderate: NPPES = (# hours)

c. Difficult: PECOS = (# hours)

5. What level of effort and labor categories would you recommend should be utilized to accomplish this service? Please delinenate the level of effort for each labor category.

For example: Data Analyst (labor category) = 200 hours (level of effort)

6. What is your recommendation for how often these accuracy reviews should be completed? Do you recommend a differentiation between the easy, moderate, and difficult reviews?

7. Beyond the information listed in the Appendix what other information would you recommend be provided for a comprehensive provider network data accuracy review?

8. What best business recommendations does your company have on how to present these data and results back to the Government? For example: Report, dashboard, oral presentation.

9. Description of relevant experience and expertise.

10. What PSC and NAICS would you recommend for these services?

V. Instructions for Submission (Note: This RFI has been posted under multiple NAICS. Please only provide one (1) response per company to this RFI)

1. Page limit: ten (10) pages to address each of the questions listed in section IV. Information Requested.

2. Interested parties should respond to this RFI with a white paper by 10 AM ET on April 5, 2024, to Melissa Lera at umt1@cdc.gov. Please include “WTC Health Program | RFI 75D301-24-RFI-541690” in the subject line of the email.

3. Page 1 of the white paper shall include the chart below, completed by your organization:

Company Name

Company Address

DUNS

Primary Point of Contact Name

Primary Point of Contact Email

Primary Point of Contact Phone Number

Business Type (large business, small business, nonprofit, minority- or woman-owned, etc.)

GSA or other Federal Schedule Awards

Appendix

The following data elements are examples of information that may be provided for the comprehensive accuracy review:

· Date Registered

· Type of Agreement

· Specialty

· Provider NPI

· Last Name/Company

· First Name

· Provider Address, City, State, Zip Code

· Billing Provider NPI

· Billing Provider Phone Number

· Billing Provider Address, City, State, Zip Code

· Billing Provider Registration Status The World Trade Center Health Program is administered by the National Institute for Occupational Safety and Health, part of the Centers for Disease Control and Prevention Restricted Use/All CDC Staff image1.jpeg image2.jpeg