Response to Offeror Questions document.pdf

STATE OF SOUTH DAKOTA

DEPARTMENT OF SOCIAL SERVICES

700 GOVERNORS DRIVE

PIERRE, SD 57501

Third Part Claims Data Matching

Questions and Responses

PROPOSALS ARE DUE NO LATER THAN APRIL, 02 2025 BY 5:00 PM CDT

RFP #13686 BUYER: Office of the Secretary

POC: Kirsten Blachford Kirsten.Blachford@state.sd.us

Q1: Section 5.24 The RFP states "Cost will be evaluated independently from the technical proposal." Will the State please specify if the vendor should submit Cost content in its own proposal, distinct and separate from the Technical proposal?

A1: The offeror’s cost proposal should be separate and distinct from the technical proposal.

Q2: Section 2, The RFP states “The offeror must indicate in its response any issues it has with specific IT contract terms.” Will the State please specify where in its Technical proposal the vendor should include this content?

A2: This should be indicated within section 2 of the proposal.

Q3: Will the State please specify if they are requiring 3 previous contracts and 3 current contracts or is the State looking for at least 3 contracts total?

A3: The State is looking for 3 total contracts.

Q4: Section 3.1.2 states "The vendor will demonstrate their ability to receive from and submit data matches to the Department’s SFTP site in the format specified by the Department in Attachment B," however, Attachment B is the Business Associate Agreement. Can the Department please provide the format referenced in 3.1.2?

A4: Attachment B was referenced in error. Data sharing will be done through the Department’s SFTP site. The vendor must meet data security and exchange requirements outlined in Attachment C.

Q5: Section 7.0 Questions:

How many “Previously Unknown Active Resource” additions were made during the most recent 12 months by coverage type?

A: Major medical: 8017 Non-major medical: 204

How many “Previously Unknown Terminated Resource” additions were made during the most recent 12 months by coverage type?

A: 0 mailto:Kirsten.Blachford@state.sd.us

Is there a specific criterion for what constitutes a “Previously Unknown Terminated Resource”? For example, what is the oldest termination date SD would load to its system for cost avoidance purposes?

A: Previously unknown terminated resources would include incurance records that were not previously identified but once found, have been terminated. The lookback period is 3 years.

How many “Previously Known Terminated Resource” additions were made during the most recent 12 months by coverage type?

A: Major medical: 3215 Non-major medical: 210

How many claim submissions for direct billing are currently being submitted annually? What is the associated Medicaid Paid amount and Recoveries for those claims’ submissions?

A: Major Medical: Total claims: 25,710 Total Amount: $10,073,144.52 Non-major Medical: Total claims: 15,385 Total Amount $1,443,521.42

How many provider disallowances are currently being initiated annually? What is the associated Medicaid Paid amount and Recoveries for those claims’ disallowance?

A: Since the initiation of the disallowance process in 2023, 11,985 total disallowed claims have been identified for a total recovery amount of $8,699,552.48.

Are there currently any specific criteria for what type of claims are selected for disallowances. For example, by provider type and/or Medicaid Paid amount minimum?

A: The value must be greater than $750 for provider claims and greater than $150 for institutional claims. Room and board, hospice, HIS IPAT hospitals, school distrct, HCBS waiver, and colony claims are excluded.

The cost proposal section states that the Department will consider a set fee per claim submission not to exceed figure. Can SD clarify how it is intended for vendors to price the direct billing and the disallowance scope?

A: Vendors should price their fees based on the proposed costs to deliver the services outlined in the RFP scope.

Q6: Does SD intend to provide vendor with a National Provider Identifier (NPI) that will be needed for insurance identification, verification and billing?

A6: The selected vendor would utilize NPIs for servicing providers to bill on behalf of the State.

Q7: Does SD have an existing/incumbent vendor for the RFP Scope? If so, then are there any specific run out or transition activities? For example, run out on outstanding ARs for billings and disallowances.

A7: South Dakota currently contracts with a vendor to provide services related to the RFP scope. At this time, there are no outlined transition activities. The chosen vendor would be expected to meet the proposed scope in accordance with the effective date of the contract.

Q8: What is your annual post payment recoveries amount for the last 3 years?

A: SFY24 $13,310,507.35

SFY25 $5,789,765.79

What is your annual disallowance amount for the last 3 years?

A: Since the initiation of the disallowance process in 2023, 11,985 total disallowed claims have been identified for a total recovery amount of $8,699,552.48.

What are the past annual amounts for the number of insurance records added by coverage type (medical, dental, vision, etc.) for the last 3 years?

A: 2022: 17,430 (Major medical) and 793 (Non-major medical); 2023: 11,582 (Major medical) and 425 (Non-major medical); 2024: 11,361 (Major medical) and 288 (Non-major medical).

Totals: 40,373 (Major medical) and 1,506 (Non-major medical).

What are the past annual amounts for the number of insurance records terminated by coverage type (medical, dental, vision, etc.) for the last 3 years?

A: 2023: 2,762 (Major medical) and 91 (Non-major medical); 2024: 3,215 (Major medical) and 210 (Non-major medical).

Total: 5,977 (Major medical) and 301 (Non-major medical).

Q9: Can you please provide more information on the "not to exceed" amount within the cost schedule? Is this a not to exceed per annual, monthly, contract, etc?

A9:The not to exceed figure would be based on the fee per match and fee per claim submission.

Q10: For the required portal, what is the extent of claims data that needs to be shared with providers? Is this only the claims for the disallowance for that provider?

A10: For the disallowance process, providers will need to access relevant claim information, suchs as the provider name, code, location, contact information, recipient information, claim number, claim type, paid amount, date of service, paid date, and total disallowed amount.

Q11: From the statement below in the terms & conditions, all data used and state specific reports would belong to the state. We need to clarify that proprietary source code of our system for providing the services would not belong to or be property of the state.

A11: Correct. The proprietary source code of your system would not be considered the property of the State of South Dakota. However, all data and reports exchanged between the state and the vendor would remain the property of the state.