PWS_AREA_Utilization Management Review.docx

Indian Health Service Bemidji Area Performance Work Statement: Utilization Management Review

1. BACKGROUND

The Cass Lake Indian Health Service Unit and Red Lake Hospital are part of the Bemidji Area Indian Health Service (BEM-IHS), which provides health care to American Indian and Alaska Native people across Minnesota, Wisconsin and Michigan. These service units play a critical role in advancing the mission of the Indian Health Service by delivering comprehensive, accessible, and culturally responsive health care to the communities they serve.

Cass Lake Indian Health Service Unit (CLIHS) The Cass Lake Indian Health Service Unit is certified by the Minnesota Department of Health as a Level 3 Health Care Home, reflecting its commitment to patient and family centered care, rigorous quality standards, and team-based primary care. The Service Unit operates a Critical Access Hospital (CAH) with a 10-bed inpatient unit, 24/7 Emergency Care, and an Outpatient Ambulatory Care Clinic offering Medical, Dental, Pharmacy, Laboratory, Radiology, Rehabilitation, Audiology, Podiatry, and Optometry services. This CAH Community Needs Assessment indicates potential expansion for Skilled-Nursing (SNF), swing-bed, or hospice-like services.

Red Lake Indian Health Service Unit (RLIHS) The Red Lake Hospital, located in northern Minnesota, is an acute care facility that operates a 15-bed inpatient unit, a robust emergency department, and a wide range of ambulatory care services, including Family Practice, Internal Medicine, Pediatrics, OB/GYN, Optometry, Physical Therapy, Behavioral Health, Dental, Pharmacy, Laboratory and Radiology. Specialty care is also available in areas such as Nephrology, foot care, and surgery, helping patients access services closer to home. Red Lake Hospital also operates one satellite clinic, the Ponemah Health Center, which extends primary and specialty care to additional communities within its service area.

Both Red Lake Hospital and Cass Lake Hospital are accredited by The Joint Commission, demonstrating their shared commitment to delivering safe, high-quality care to the Native communities they serve.

2. PURPOSE

The contract will consist of a base year and two option years on a firm-fixed-price basis. The contractor will provide the Cass Lake Indian Health Service (CLIHS) and Red Lake Indian Health Service (RLIHS) with software platform that supports data collection for utilization management, enhancing patient safety in hospital inpatient units, and defining admission criteria and length-of-stay standards. The contract will provide access via web for inpatient and post-surgical care (recovery), ambulatory care, chronic care, patient information, multiple condition management, for case management standalone admission support as well as transitions of care. The admission criteria (medical necessity, level of care, anticipated length of stay, readmission risk, etc) are necessary to help the Utilization staff and BEM-IHS clinical staff ensure that inpatient admissions meet the appropriate requirements. A standardized utilization management review process must be implemented across CLIHS and RLIHS for continuity of care. With this contract, there will be improved safety, quality of care, evidence-based information and consistent clinical decisions, proactive care management and discharge planning, and best practices for patients with multiple morbidities and extended stays. This project emphasizes utilization management software as a clinical decision support tool.

3. REQUIREMENTS/TASKS

A. Admission and Length-of-Stay Standards: The contractor shall provide adaptive software as a system solution that provides individualized case-based patient determination to elicit specific admission criteria (medical necessity, level of care, anticipated length of stay, readmission risk, etc) and anticipated length-of-stay to support compliance with Medicare and Medicaid billing requirements. System should be interactive, iterative, and support a concurrent review workflow.

B. Web-Based Services: The contractor shall provide secure, web-based services accessible to authorized users at CLIHS and RLIHS.

C. Medical Necessity Documentation: The contractor shall provide an intuitive, easy-to-learn workflow that enables care managers to document care decisions efficiently using the latest clinical evidence, thereby establishing medical necessity. Workflows include prospective, concurrent, and retrospective utilization reviews.

D. Readmission Reduction: The contractor shall include evidence-based tools and functionality for readmission risk assessment, automated alerts, and reporting to identify and reduce preventable readmissions.

E. Length-of-Stay Optimization: The contractor shall identify risk factors contributing to extended stays and shall provide analytics and tools to address avoidable variances from optimal care pathways as outlined in applicable clinical guidelines.

F. Case Manager Productivity: The contractor shall enhance case manager productivity by facilitating rapid documentation within the medical record and enabling prioritization of patients based on risk level and other defined criteria.

G. The software platform shall allow users to evaluate clinical criteria for the following:

· Inpatient and surgical care

· General recovery patient care

· Medicare compliance and standards

· Evaluation of discharge planning

· Evaluate ambulatory surgical services for appropriateness of setting

· Determine appropriate transition of care to rehabilitation care services, subacute services, and skilled nursing services.

· Evaluate substance use disorders and appropriate transition of care.

· Retrospective evaluation of risk management and quality care delivery evaluation.

H. The criteria must utilize evidence-based clinical criteria as the foundation of establishing “medical necessity,” must include the source documentation in the criteria, and must incorporate standards of care in the recommended treatment modalities.

I. The software platform shall produce various utilization review reports to include:

· Variance days

· Medical necessity met

· Observation

· Others consistent with UR conditions of participation

· Admission and continued stay review

· LOS management

· Drill-down reports for by requested age groups (geriatrics, pediatrics, etc) to meet specified key performance indicators J. The contractor shall provide a non-transferable software platform for CLIHS and RLIHS, simultaneously, to use in the utilization review software platform. This will be used to determine the medical necessity of inpatient admissions, continued inpatient stays, evaluation of the discharge plan, to determine observation status and to evaluate the appropriateness of ambulatory surgical procedures through standard report options, not custom queries.

K. The contractor shall ensure CLIHS & RLIHS are provided with the most current and up-to-date evidence-based clinical criteria software platform as it becomes available throughout the life of the contract.

L. The contractor shall provide a length-of-stay application and reports with the software platform for CLIHS & RLIHS’s utilization review programs.

M. The contractor shall provide initial onsite training and additional other training courses that are designed to familiarize end-users with the use utilization management review system platform. Ideally, these training modules shall be self-paced to accommodate the end-users' schedules.

N. To utilize the software platform the user shall be able to enter diagnosis and/or procedure codes to obtain functionality of software platform.

O. The contractor will not access, manage or control Protected Health Information (PHI) or other Personally Identifiable Information (PII). No PHI/PII shall be required to utilize the software platform features.

4. PERFORMANCE REQUIREMENTS

· Minimum system uptime/availability.

· Each user shall be required to have a username and password to access the system.

· Maximum response and resolution times for technical support.

· Performance standards for processing speed or query response times.

· Requirements for customizable reports, dashboards, and exportable data formats (CSV, Excel, PDF).

· Ability to generate compliance reports for CMS audits.

· Define frequency and scope of required utilization review reports beyond the standard ones listed (e.g., monthly summary, quarterly performance metrics).

5. IMPLEMENTATION PLAN

Assign a dedicated Project Manager to support implementation.

Require the contractor to provide a detailed implementation schedule (installation, configuration, training, go-live).

Provide role-based training.

6. WORK SCHEDULE

Service/ access availability shall be continuous 24 hours a day, 7 days a week and 365 days a year.

7. GOVERNMENT FURNISHED EQUIPMENT, FACILITIES, AND PROPERTY

Operating systems and other software and hardware requirements for License of Personal Computer (PC) format:

· The system will be accessible from every computer within CLIHS and RLIHS.

· The system requires the use of Microsoft Windows operating system.

· The contractor does not furnish the operating system under this agreement.

8. CONTRACTOR FURNISHED EQUIPMENT, FACILITIES, AND PROPERTY

· The contractor will provide access over the internet.

· The system shall be accessible via a designated site provided by the contractor that is password protected and secured.

· All upgrades will be made available to the government during the term of this agreement at no additional cost.

· The contractor will provide specific information on the system requirements (software application requirements).

· The contractor will provide the specific URL that describes system requirements and verifies system compatibility.

· Contractor shall notify the government within 30 days of any changes made to system.

9. PLACE OF PERFORMANCE

Cass Lake Service Unit Indian Health Service 425 7th St NW Cass Lake, MN 56633

Red Lake Service Unit Indian Health Service 24760 Hospital Rd Red Lake, MN 56671

10. PERIOD OF PERFORMANCE

The base year Period of Performance (POP) will be 12 months from date of award with two (2) twelve (12) month option years. Desired start date is 08/01/2026.

Base Year: 08/01/2026 – 07/31/2027 Option Year 1: 08/01/2027 – 07/31/2028 Option Year 2: 08/01/2028 – 07/31/2029

11. QUALITY ASSURANCE

Information Technology will monitor the contractor’s system on a monthly basis and provide feedback to contractor.

12. PROFESSIONAL QUALIFICATIONS CRITERIA

The contractor shall have the applicable licenses from the appropriate licensing agency to perform the work required.

13. CHARACTER INVESTIGATION FOR CONTRACTORS WHO WILL HAVE CONTACT WITH INDIAN CHILDREN The contractor will not have contact with Native American and Alaska Native children

14. COMPLIANCE WITH IHS RULES AND REGULATIONS

The contractor is required to comply with any Indian Health Service rules and regulations that pertain to the performance of this contract.

15. SECURITY REQUIREMENTS

Contractor personnel must contact the government-designated point of contact upon arrival for service calls or deliveries. They are responsible for safeguarding all organizational information and must comply with all facility rules and regulations while on-site.

These include being escorted by a Service Unit official, presenting valid identification, and following safety procedures. CLIHS and RLIHS are tobacco- and smoke-free facilities; use of tobacco products is prohibited during work.

Contractors are strictly prohibited from disclosing or distributing any information related to CLIHS or RLIHS operations. Violations may result in contract termination and legal action.

16. INVOICING/PAYMENT

Contractor shall submit a properly prepared invoice to the Invoice Processing Platform (IPP) system. The IPP system is a secure web-based electronic invoice and payment information service that efficiently manages government invoicing from purchase order through payment notification. Additional information regarding the IPP system may be found at the IPP website address https://www.ipp.gov.

Contractor invoices submitted electronically through the IPP must be in the proper format and contain the information required for payment processing. To be approved for payment, a “proper” invoice must list the items specified in FAR 52.232-25 (a)(3)(i) through (a)(3)(x), or in the case of a Commercial Item Contract, the items included in 52.212-4(g)(1)(i) through (g)(1)(x).

**INVOICES FOUND TO BE IMPROPER WILL BE RETURNED TO THE

CONTRACTOR RESULTING IN DELAY OF PAYMENT**

In the event of IPP system malfunction, invoices shall be emailed to: BEM_AOInvoices@ihs.gov & COR.

The Government reserves the right to accept or reject services if the level of work is unsatisfactory. Payment shall be made upon receipt of proper invoice and appropriate acceptance by the designated receiving official.

CONTACT INFORMATION

Contractor Point of Contact: The contractor shall furnish one designated point of contact (POC) to the government’s designated representative for coordination of contract performance.

The contractor shall provide a toll-free telephone number for service calls, which must be answered during at least eight working hours, between 8:00 am and 4:30 pm (CST), Monday through Friday.

GOVERNMENT CONTACT

Technical Point of Contact: Cynthia Gunderson (Area), Eleanor (Elle) Morin (CLSU)

CONTRACT CLAUSES

FAR 52.250-1 Indemnification Under Public Law85-804.

FAR 52.212-4 Contract Terms and Conditions—Commercial Products and Commercial Services.

BUSINESS ASSOCIATE AGREEMENT CLAUSE

Pursuant to the Health Insurance Portability and Accountability Act (HIPAA) of 1996 and its implementing regulation, the Standards of Privacy of Individual Identifiable Health Information at 45 CFR Part 160 and 164, Subpart A and E ("Privacy Rule"), the Indian Health Service is required to enter into an agreement with the Business Associate, pursuant to which the Business Associate shall comply with and appropriately safeguard Protected Health Information ("PHI”) that it will use and disclose when performing functions, activities or services ("Services") for the Indian Health Service. The Business Association by signing the contract shall comply with the following terms in addition to other applicable contract shall comply with the following terms in addition to other applicable contract terms and conditions relating to the safekeeping, use and disclosure of PHI.