REVISED 120174 O3 ATTACHMENT A.pdf

REVISED ATTACHMENT A, BIDDER QUESTIONNAIRE

RFP 120174 O3

Third-party administrator to process payments for claims/ invoices for an incarcerated individual(s) healthcare services.

Bidder Name: _________________________________________

It is preferred that the bidder uses this template. Bidder must describe in detail solutions on how their response meets and/or exceed the requirements as outlined in the RFP. Bidder should use the RESPONSE box below for the detailed solution being proposed.

If the bidder choses to provide additional documents outside this template to aid in their response, for evaluation purposes, bidder must cross-reference which question in Attachment A the supplemental documents support.

Business Requirements

C.1

No correspondence of any type is to be sent to the incarcerated individual(s). This includes, but is not limited to, explanation of benefits (EOB), checks, letters, brochures, billings, etc.

Describe what methods are in place to ensure that communication is not sent to the incarcerated individual directly.

RESPONSE:

C.2

Rates for Medical/Dental Claims submitted: Nebraska Medicaid Rates or the negotiated PPO.

Incarcerated Individuals and/or NDCS are not responsible for remaining balance due after Medicaid/PPO rates have been applied.

a. Contractor is responsible for notifying member providers on remittance statements.

No balance will be due after Medicaid or PPO rates are applied.

Rates for Medical/Dental Claims submitted: Nebraska Medicare Rates unless the negotiated PPO rate is lower. Incarcerated Individuals and/or NDCS are not responsible for remaining balance due after Medicare/PPO rates have been applied. Contractor is responsible for notifying member providers on remittance statements, no balance will be due after Medicare or PPO rates are applied.

Describe the process of how the contractor will notify member providers on remittance statements ensuring no balance will be due after Medicare Medicaid or PPO rates are applied.

C.3 Bidder understands and acknowledges Nebraska Medicaid eligibility as defined by Nebraska Department of Health and Human Services (DHHS).

Will comply

Will not comply

C.4 Bidder understands that deductible, coinsurance, and/or copays do not apply.

Will comply

Will not

C.5 Bidder understands that the awarded contractor will accept claims as timely if filed within two (2) years of date of service pursuant to the State Contract Claims Act, see Neb. Rev. Stat. § 81-8,306.

Will comply

Will not

C.6 Bidder understands Claims maximums such as day, dollar, and lifetime maximums do not apply.

Will comply

Will not

C.7 Bidder understands that preauthorization is not applicable for emergency services or inpatient services. For out-patient services, NDCS will provide a prior authorization number.

Will comply

Will not

C.8

The services below should not be paid by contractor. Describe what processes will be in place to ensure these services are not paid.

a. Claims billed by out-of-network providers. These claims should be sent to NDCS for consideration.

b. Medications for use after leaving medical provider.

c. Prosthetics/ Orthotics except for those off-site items issued at the time of surgery.

i. Prosthetics/orthotics deemed necessary will need to be pre-approved by NDCS Medical

Director or designee and billed directly to NDCS.

d. Services covered by Medicaid.

e. Newborn or childcare.

f. Abortion.

g. Caffeine-related disorders.

h. Chiropractic care.

i. Dental implants.

j. Dentures/Dental Laboratory Services,

i. Claims deemed necessary will need to be pre-approved by NDCS Medical Director or designee and billed directly to NDCS.

k. Elective procedures.

l. Erectile dysfunction.

m. Factitious disorder.

n. Learning disorder.

o. Nicotine-related disorders.

p. Other conditions/disorders/issues/procedures as determined by the Medical Director or designee for NDCS Health Services.

C.9

In-State and Out-of-State Services: Only those services approved by the NDCS should be submitted to contractor for payment. If billed, the following services should be paid by contractor:

a. Claims billed by out-of-network providers. These claims should be sent to NDCS for consideration.

b. Prosthetics/ Orthotics except for those off-site items issued at the time of surgery.

i. Prosthetics/orthotics deemed necessary will need to be pre-approved by NDCS Medical Director or designee and billed directly to NDCS.

c. Dentures/Dental Laboratory Services,

i. Claims deemed necessary will need to be pre-approved by NDCS Medical Director or designee and billed directly to NDCS.

C.10 Bidder understands that Contractor will not pay Workers’ Compensation /Subrogation claims. The employer’s workers' compensation insurer must cover the incarcerated individuals for all work-related claims.

Will comply

Will not

C.11

Billing received for transplant services must be pre-approved by the NDCS Medical Director or designee. Patient must also meet transplant criteria. NDCS will not pay for elective transplant procedures.

Describe what processes will be in place to ensure that pre-approval is received prior to billing.

C.12 Bidder understands Medicaid Claims are covered by Medicaid will not be paid by contractor. NDCS will notify contractor of any Medicaid service eligibility changes.

Will comply

Will not

Bidder Requirements

E.7

Contractor network will include service providers for all NDCS facility locations.

Provide listing of in-network providers in a sortable file by each Specialty listed in Lincoln Physicians Directory in following 5 cities in Nebraska: Omaha metro area, Lincoln, York, Tecumseh, and McCook.

Will comply

Will not

E.8

Describe the processes to ensure provider rates are not paid higher than the Nebraska Medicare rates.

Identify the processes to ensure provider rates are not paid higher than the Nebraska negotiated rates.

What reports are available that compare provider and Medicare Medicaid rates to the corresponding claims paid.

E.9 Include an outline of compliance management for claims processing in accordance with the RFP Scope of Work.

Describe the proposed utilization management of claims process. Including the ability and process to customize the utilization management of claims.

E.11 Provide a list of all network providers with response to the RFP.

Contractor Requirements – General

F.1.a Contractor’s network will include services for all NDCS facility locations Will comply

Will not

F.1.b Describe how valid patient care claims for State incarcerated individual(s) committed to NDCS will be processed.

F.1.c Describe how the contractor will ensure claims are paid properly and what measurements are in place to ensure Nebraska Medicare rates are do not exceed the negotiated rate.

F.1.d Claims to be paid by Nebraska Medicaid are to be denied. Describe what methodology is used to ensure this requirement will be met.

F.1.e Describe the ability to have the provider directory available via an electronic site. Including the process on how the directory is maintained by contractor to ensure accurate information.

Contractor Requirements - Reporting

F.2.a Contractor will provide NDCS Accounting with an automated denial report monthly (minimum).

Will comply

Will not

F.2.b

Provide an example of reporting that meets electronic reports requirements. Bidder may provide a narrative response expanding on reporting along with the samples.

Provide the following electronic reports, upon request by NDCS, at no charge:

Include a listing (title or topic) and provide a sample printout of all reports that are considered standard and included at no additional charge.

Special reports of health care paid for an incarcerated individual within two (2) business days.

Rejected claims and rationale for rejection.

Breakout by specialty, i.e. physical therapy, dental, psychiatry, maternity, etc.

Report of charges of $20,000 or above per incarcerated individual, per diagnosis, and per off-site hospitalization per occurrence, or as requested.

F.2.c

Bidder should provide an example of reporting that meets these requirements. Bidder may provide a narrative response expanding on reporting along with the samples.

Contractor will provide a monthly listing in Excel format of all claims paid per incarcerated individual, identifying:

Incarcerated individual committed name.

NDCS Incarcerated individual identification number.

Incarcerated individual age/ date of birth.

Date of service (beginning and ending).

Medical provider name and location.

Place of service codes.

Detailed billing including ALL diagnosis code(s) and each procedure code(s) (ICD10, CPT, modifiers, units, and NDCS number(s)).

APR-DRG (Diagnose Related Group) + SOI (Severity of Illness) level determines reimbursement level.

Prospective Payment System detail showing weight and rate of each APR-DRG for different clinics/hospitals/surgical centers.

Total Gross charged amount.

Total Net paid amount.

Dates of claim submission to contractor.

Dates of payment to providers.

F.2.d Provide an example of the Service Organizational Control Report (SOC2) and provide the Service Organizational Control Type 2 certification if applicable.

Contractor Requirements – Electronic Dashboard

E.10

F.3.a

Provide an example of an electronic dashboard meeting the RFP requirements.

Describe what methodology will be used to establish an electronic dashboard meeting the minimum requirements as described in the RFP.

hboard must provide a minimum of the following.

Most expensive patients.

Top diagnoses.

Frequency of diagnoses.

Year to date.

Month to month.

Specialists/category.

Itemized billings for all patients.

Files be protected to meet confidentiality standards.

Prefer to have the capability to print off the file at NDCS.

Contractor shall provide menu listing of industry standard services including Certification and Concurrent

Review Requirements with applicable cost and bullet point Return on Investment (ROI) as options for NDCS to consider using:

Pre-payment auditing cost.

Concurrent review cost.

Complex medical review cost.

F.3.b Contractor will, to the best of their abilities, include additional analytics on the electronic dashboard as required by the NDCS Medical Director. It is preferred that the data on the electronic dashboard be easily customized to perform analysis.

Will comply

Will not

Contractor Requirements – Claims

F.4.a

When submitting claim inquiries to NDCS, contractor will provide details as described in the RFP.

Incarcerated individual committed name and date of birth.

NDCS five (5) or six (6) digits incarcerated individual identification number.

Medical provider name and location and clinic/hospital/surgical center if applicable.

Admit and Discharge Date.

Total Charges.

Detailed billing including ALL diagnosis code(s) and each procedure code(s) (ICD10, CPT, modifiers, units, and NDCS number(s)).

APR-DRG (Diagnose Related Group) + SOI (Severity of Illness) level determines reimbursement level.

Will

Will not

Contractor Requirements –Meetings

F.5.a F.5.b Contractor will attend quarterly meetings and an annual review of SOC2. Will comply Will not

PAYMENT SCHEDULE/DELIVERABLES

J.1.a Invoices shall include detailed itemized billing per patient including ALL diagnosis code(s) and each procedure code(s) (ICD10, CPT, modifiers, units, and NDCS number(s)).

Will comply

Will not

J.2.a If awarded at a fee per incarcerated individual, the formula used to calculate the monthly processing fee shall be “fee per incarcerated individual multiplied by the ADP.”

Will comply

Will not

J.2.b If awarded at a monthly flat rate, no formula will be required on invoices. Will

Will not

J.3 All recoupment requests to NDCS will be processed within 30 calendar days upon agreement.

Will comply

Will not

OPTIONAL SERVICES (NOT SCORED)

K.1

Prior to claims being paid, a utilization review shall be completed to include but is not limited to reviewing claims for appropriate services, review procedures/documentations related to visit for appropriateness and review hospital stays for appropriate length of stay.

Describe in detail the analytical capabilities and competency of providing a detailed, accurate and comprehensive utilization review.

K.2 Describe and/or provide examples of any other available analytical services, reports, quality assurance, auditing, tools etc., at no additional cost.

K.3 Describe any additional like-services that are available which are not specifically mentioned in this

RFP.