RFP 2025-1600-0376.pdf

STATE OF ALASKA

REQUEST FOR PROPOSALS

OFFERORS ARE NOT REQUIRED TO RETURN THIS FORM.

IMPORTANT NOTICE: IF YOU RECEIVED THIS SOLICITATION FROM THE STATE OF ALASKA’S “ONLINE PUBLIC NOTICE”

WEB SITE, YOU MUST REGISTER WITH THE PROCUREMENT OFFICER LISTED IN THIS DOCUMENT TO RECEIVE

NOTIFICATION OF SUBSEQUENT AMENDMENTS. FAILURE TO CONTACT THE PROCUREMENT OFFICER MAY RESULT

IN THE REJECTION OF YOUR OFFER.

ISSUED BY:

DEPARTMENT OF HEALTH

DIVISION OF FINANCE AND MANAGEMENT

SERVICES

PRIMARY CONTACT:

ASHLEY PALEMABS

PROCUREMENT OFFICER

ASHLEY.PALEMBAS@ALASKA.GOV

(907) 759-3304

MEDICAID PROVIDER AUDITS

RFP 2025-1600-0376

ISSUED 6/12/2025

THE DEPARTMENT OF HEALTH, MEDICAID PROGRAM INTEGRITY SECTION, IS SOLICITING PROPOSALS TO

CONDUCT STATEWIDE ON-SITE AND DESK AUDITS AS REQUIRED BY ALASKA STATUTE 47.05.200. A MINIMUM

OF 50 POST-PAYMENT AUDITS ANNUALLY WILL BE REQUIRED OF THE CONTRACTOR.

TABLE OF CONTENTS

SECTION 1. INTRODUCTION & INSTRUCTIONS

SEC. 1.01 PURPOSE OF THE RFP

SEC. 1.02 BUDGET

SEC. 1.03 DEADLINE FOR RECEIPT OF PROPOSALS

SEC. 1.04 MANDATORY REQUIREMENTS

SEC. 1.05 REQUIRED REVIEW

SEC. 1.06 QUESTIONS PRIOR TO DEADLINE FOR RECEIPT OF PROPOSALS

SEC. 1.07 RETURN INSTRUCTIONS

SEC. 1.08 ASSISTANCE TO OFFERORS WITH A DISABILITY

SEC. 1.09 AMENDMENTS TO PROPOSALS

SEC. 1.10 AMENDMENTS TO THE RFP

SEC. 1.11 RFP SCHEDULE

SEC. 1.12 ALTERNATE PROPOSALS

SEC. 1.13 NEWS RELEASES

SECTION 2. BACKGROUND INFORMATION

SEC. 2.01 BACKGROUND INFORMATION

SECTION 3. SCOPE OF WORK & CONTRACT INFORMATION

SEC. 3.01 SCOPE OF WORK

SEC. 3.02 DELIVERABLES

SEC. 3.03 CONTRACT TERM AND WORK SCHEDULE

SEC. 3.04 CONTRACT TYPE

SEC. 3.05 PAYMENT PROCEDURES

SEC. 3.06 CONTRACT PAYMENT

SEC. 3.07 ELECTRONIC PAYMENTS

SEC. 3.08 LOCATION OF WORK

SEC. 3.09 SUBCONTRACTORS

SEC. 3.10 JOINT VENTURES

SEC. 3.11 RIGHT TO INSPECT PLACE OF BUSINESS

SEC. 3.12 CONTRACT PERSONNEL

SEC. 3.13 INSPECTION & MODIFICATION - REIMBURSEMENT FOR UNACCEPTABLE DELIVERABLES

SEC. 3.14 CONTRACT CHANGES - ANTICIPATED AMENDMENTS

SEC. 3.15 CONTRACT CHANGES - UNANTICIPATED AMENDMENTS

SEC. 3.16 NONDISCLOSURE AND CONFIDENTIALITY

SEC. 3.17 INDEMNIFICATION

SEC. 3.18 INSURANCE REQUIREMENTS

SEC. 3.19 TERMINATION FOR DEFAULT

SECTION 4. PROPOSAL FORMAT AND CONTENT

SEC. 4.01 RFP SUBMITTAL FORMS

SEC. 4.02 SPECIAL FORMATTING REQUIREMENTS

SEC. 4.03 OFFEROR INFORMATION AND CERTIFICATIONS (SUBMITTAL FORM A)

SEC. 4.04 EXPERIENCE AND QUALIFICATIONS (SUBMITTAL FORM B)

SEC. 4.05 UNDERSTANDING OF THE PROJECT (SUBMITTAL FORM C)

SEC. 4.06 METHODOLOGY USED FOR THE PROJECT (SUBMITTAL FORM D)

SEC. 4.07 MANAGEMENT PLAN FOR THE PROJECT (SUBMITTAL FORM E)

SEC. 4.08 MANDATORY REQUIREMENTS (SUBMITTAL FORM F)

SEC. 4.09 SUBCONTRACTORS (SUBMITTAL FORM G)

SEC. 4.10 COST PROPOSAL (SUBMITTAL FORM H)

SECTION 5. EVALUATION CRITERIA AND CONTRACTOR SELECTION

SEC. 5.01 SUMMARY OF EVALUATION PROCESS

SEC. 5.02 EVALUATION CRITERIA

SEC. 5.03 SCORING METHOD AND CALCULATION

SEC. 5.04 EXPERIENCE AND QUALIFICATIONS

SEC. 5.05 UNDERSTANDING OF THE PROJECT

SEC. 5.06 METHODOLOGY USED FOR THE PROJECT

SEC. 5.07 MANAGEMENT PLAN FOR THE PROJECT

SEC. 5.08 CONTRACT COST (COST PROPOSAL)

SEC. 5.09 APPLICATION OF PREFERENCES

SEC. 5.10 ALASKA BIDDER PREFERENCE

SEC. 5.11 ALASKA VETERAN PREFERENCE

SEC. 5.12 ALASKA MILITARY SKILLS PROGRAM PREFERENCE

SEC. 5.13 ALASKA OFFEROR PREFERENCE

SEC. 5.14 COST REASONABLENESS

SEC. 5.15 CONTRACT NEGOTIATIONS

SEC. 5.16 OFFEROR NOTIFICATION OF SELECTION

SECTION 6. GENERAL PROCESS AND LEGAL INFORMATION

SEC. 6.01 INFORMAL DEBRIEFING

SEC. 6.02 ALASKA BUSINESS LICENSE AND OTHER REQUIRED LICENSES

SEC. 6.03 STANDARD CONTRACT PROVISIONS

SEC. 6.04 BUSINESS ASSOCIATE AGREEMENT (BAA)

SEC. 6.05 QUALIFIED OFFERORS

SEC. 6.06 PROPOSAL AS PART OF THE CONTRACT

SEC. 6.07 ADDITIONAL TERMS AND CONDITIONS

SEC. 6.08 HUMAN TRAFFICKING

SEC. 6.09 RIGHT OF REJECTION

SEC. 6.10 STATE NOT RESPONSIBLE FOR PREPARATION COSTS

SEC. 6.11 DISCLOSURE OF PROPOSAL CONTENTS

SEC. 6.12 ASSIGNMENT

SEC. 6.13 SEVERABILITY

SEC. 6.14 SUPPLEMENTAL TERMS AND CONDITIONS

SEC. 6.15 SOLICITATION ADVERTISING

SEC. 6.16 SITE INSPECTION

SEC. 6.17 CLARIFICATION OF OFFERS

SEC. 6.18 DISCUSSIONS WITH OFFERORS

SEC. 6.19 FEDERALLY IMPOSED TARIFFS

SEC. 6.20 PROTEST

SECTION 7. ATTACHMENTS

SEC. 7.01 ATTACHMENTS

SECTION 1. INTRODUCTION & INSTRUCTIONS

SEC. 1.01 PURPOSE OF THE RFP

The Department of Health, Division of Finance and Management Services (FMS), Medicaid Program Integrity section, is soliciting proposals to conduct statewide on-site and desk audits as required by Alaska Statute

47.05.200. A minimum of fifty (50) post-payment audits annually will be required of the contractor. The purpose of the audits includes ensuring provider compliance with state and federal policies, regulations and statutes, recovering overpayments, supporting the investigation and prosecution of violations of criminal statutes and protecting the Medicaid program from inappropriate expenditures resulting from fraud, waste, abuse or misuse.

SEC. 1.02 BUDGET

Department of Health, Division of Finance and Management Services, estimates a maximum budget of $6,275,000.00 for completion of this project. Proposals priced at more than $6,275,000.00 will be considered non-responsive.

Approval or continuation of a contract resulting from this RFP is contingent upon legislative appropriation or federal funding.

SEC. 1.03 DEADLINE FOR RECEIPT OF PROPOSALS

Proposals must be received no later than 12:00pm prevailing Alaska Time on July 10, 2025. Late proposals or amendments will be disqualified and not opened or accepted for evaluation.

SEC. 1.04 MANDATORY REQUIREMENTS

To be considered responsive for this RFP, an offeror must meet the mandatory minimum requirements that are provided in Submittal Form F – Mandatory Requirements. Failure to meet all these requirements will result in immediate disqualification.

SEC. 1.05 REQUIRED REVIEW

Offerors should carefully review this solicitation for defects and questionable or objectionable material.

Comments concerning defects and questionable or objectionable material should be made in writing and received by the procurement officer at least ten days before the deadline for receipt of proposals. This will allow time for the issuance of any necessary amendments. It will also help prevent the opening of a defective proposal and exposure of offeror's proposals upon which award could not be made.

SEC. 1.06 QUESTIONS PRIOR TO DEADLINE FOR RECEIPT OF PROPOSALS

All questions must be in writing and directed to the procurement officer and least ten days before the deadline for receipt of proposals. The interested party must confirm telephone conversations in writing.

Two types of questions generally arise. One may be answered by directing the questioner to a specific section of the RFP. These questions may be answered over the telephone. Other questions may be more complex and may require a written amendment to the RFP. The procurement officer will make that decision.

SEC. 1.07 RETURN INSTRUCTIONS

Offerors must submit their proposals via email. The technical proposal and cost proposal must be saved as separate documents and emailed to doh.procurement.proposals@alaska.gov as separate, clearly labeled attachments. The email must contain the RFP number in the subject line.

The maximum size of a single email (including all text and attachments) that can be received by the state is 25mb (megabytes). If the email containing the proposal exceeds this size, the proposal must be sent in multiple emails that are each less than 25 megabytes.

Please note that email transmission is not instantaneous. Similar to sending a hard copy proposal, if you are emailing your proposal, the state recommends sending it enough ahead of time to ensure the email is delivered by the deadline for receipt of proposals.

It is the offeror’s responsibility to contact the above email address to confirm that the proposal has been received.

The state is not responsible for unreadable, corrupt, or missing attachments.

SEC. 1.08 ASSISTANCE TO OFFERORS WITH A DISABILITY

Offerors with a disability may receive accommodation regarding the means of communicating this RFP or participating in the procurement process. For more information, contact the procurement officer no later than ten days prior to the deadline for receipt of proposals.

SEC. 1.09 AMENDMENTS TO PROPOSALS

Amendments to or withdrawals of proposals will only be allowed if acceptable requests are received prior to the deadline that is set for receipt of proposals. No amendments or withdrawals will be accepted after the deadline unless they are in response to the state's request in accordance with 2 AAC 12.290.

SEC. 1.10 AMENDMENTS TO THE RFP

If an amendment is issued before the deadline for receipt of proposals, it will be provided to all who were notified of the RFP and to those who have registered with the procurement officer after receiving the RFP from the State of Alaska Online Public Notice website.

After receipt of proposals, if there is a need for any substantial clarification or material change in the RFP, an amendment will be issued. The amendment will incorporate the clarification or change, and a new date and time established for new or amended proposals. Evaluations may be adjusted as a result of receiving new or amended proposals.

SEC. 1.11 RFP SCHEDULE

RFP schedule set out herein represents the state’s best estimate of the schedule that will be followed. If a component of this schedule, such as the deadline for receipt of proposals, is delayed, the rest of the schedule may be shifted accordingly. All times are Alaska Time.

ACTIVITY TIME DATE

Issue Date / RFP Released 6/12/2025 Deadline to Submit Questions 6/30/2025 Deadline for Receipt of Proposals / Proposal Due Date 12:00pm 7/10/2025 ESTIMATED Proposal Evaluations Complete 7/25/2025 mailto:doh.procurement.proposals@alaska.gov

ESTIMATED Notice of Intent to Award 8/1/2025 ESTIMATED Contract Issued 8/11/2025

This RFP does not, by itself, obligate the state. The state's obligation will commence when the contract is approved by the Commissioner of the Department of Health, or the Commissioner's designee. Upon written notice to the contractor, the state may set a different starting date for the contract. The state will not be responsible for any work done by the contractor, even work done in good faith, if it occurs prior to the contract start date set by the state.

SEC. 1.12 ALTERNATE PROPOSALS

Offerors may only submit one proposal for evaluation. In accordance with 2 AAC 12.830 alternate proposals (proposals that offer something different than what is asked for) will be rejected.

SEC. 1.13 NEWS RELEASES

News releases related to this RFP will not be made without prior approval of the project director.

SECTION 2. BACKGROUND INFORMATION

SEC. 2.01 BACKGROUND INFORMATION

The Alaska Medicaid program began in 1972 to provide coverage to recipients found eligible under Title XIX of the Social Security Act. Alaska operates our State Children’s Health Insurance Program (Denali Kid Care, or DKC) as an expansion to our Medicaid program. Approximately 260,000 unduplicated individuals were eligible for Alaska’s Medical Assistance Programs during fiscal year 2023. Payments to Medical Assistance providers exceeded $2,700,000,000 in State fiscal year 2024.

The Alaska Department of Health (DOH) is the single state agency responsible for administering the Medicaid Program in Alaska. DOH is responsible for overseeing the activities of Medicaid recipients and Medicaid providers and their representatives, to ensure that fraudulent and abusive behavior and neglect of recipients occur to the minimum extent possible.

Health care professionals must be enrolled as a provider in Alaska’s Medical Assistance Programs to bill for services provided to program members. Out-of-state health care providers must be enrolled in their own State’s Medicaid Program and in Alaska’s program to receive payment for services provided to Alaska Medical Assistance recipients.

The State of Alaska contracts with HMS/Gainwell as our fiscal agent. Conduent operates the current Enterprise Medicaid Management Information System (MMIS).

Alaska Statute (AS) 47.05.200 requires the Department to contract for independent audits of a statewide sample of all medical assistance providers in order to identify overpayments and violations of criminal statutes. The audits conducted must include both on-site audits and desk audits and must include a variety of provider types.

A minimum of 50 audits shall be conducted each year.

Provider Participation Requirements To enroll, a provider must successfully complete the Alaska Provider Enrollment and sign a Provider Agreement.

In addition, the provider must agree to meet all of these initial and ongoing participation requirements:

(1) must verify that the provider meets all other applicable requirements of 7 AAC 105 - 7 AAC 160 and all applicable federal and state licensing and certification requirements;

(2) must comply with all federal and state laws as they apply to providing health care or related services to

Medicaid recipients in this state, including laws related to recipient confidentiality, electronic transactions, and civil rights;

(3) must assume responsibility for all information and claims submitted to the department by that provider or that provider's billing agent;

(4) must agree to submit claims in the form or format required by the department for claim submission;

(5) must comply with the requirements of AS 47.05.300 - 47.05.390 and 7 AAC 10.900 - 7 AAC 10.990 (barrier crimes, criminal history checks, and centralized registry), if applicable to that provider type.

https://www.akleg.gov/basis/statutes.asp#47.05.200 https://www.akleg.gov/basis/aac.asp#7.105 https://www.akleg.gov/basis/statutes.asp#47.05.300 https://www.akleg.gov/basis/aac.asp#7.10.900

Provider Types The following provider types are eligible to participate in Alaska’s Medical Assistance Program. Participation for some provider types is limited. Certain provider types, such as mental health clinics and Federally Qualified Health Centers (FQHC) employ some practitioners who are not eligible for independent practice under the Alaska Medical Assistance Program requirements.

(1) a person with an active license under AS 08, or under the laws of the jurisdiction in which the person provides services, to practice as a/an:

(A) physician, including an osteopath;

(B) podiatrist;

(C) dentist;

(D) optometrist;

(E) chiropractor;

(F) pharmacist or retail pharmacy;

(G) physical therapist;

(H) occupational therapist;

(I) audiologist;

(J) speech-language pathologist;

(K) advanced nurse practitioner;

(L) direct-entry midwife;

(M) dietitian;

(N) nutritionist;

(O) psychologist;

(P) hearing aid dealer; or

(Q) registered nurse anesthetist;

(R) a behavior analyst;

(S) a clinical social worker;

(T) a marital and family therapist;

(U) a licensed professional counselor;

(V) a licensed dental hygienist who holds an advance practice permit issued by the board of Dental

Examiners under AS 08.32.125.

(2) a facility licensed under AS 47.32, or under the laws of the jurisdiction in which it provides services, to operate as a/an:

(A) general acute care hospital or inpatient psychiatric hospital;

(B) long-term care facility;

(C) home health agency;

(D) rural health clinic;

(E) ambulatory surgical center;

(F) hospice care agency;

(G) residential psychiatric treatment center for persons under 22 years of age; or

(H) intermediate care facility for the mentally retarded (ICF/MR);

(I) a freestanding birth center.

(3) a company or individual not excluded in 7 AAC 105.200 (b) of this section, supplying:

(A) medical transportation, ambulance services, oxygen, or eyeglasses;

https://www.akleg.gov/basis/statutes.asp#08.32.125 https://www.akleg.gov/basis/statutes.asp#47.32 https://www.akleg.gov/basis/aac.asp#7.105.200

(B) under 7 AAC 120.200 - 7 AAC 120.299, durable medical equipment, medical supplies, prosthetics, orthotics, noncustomized-fabricated orthotics, respiratory therapy, enteral and oral nutritional products, or home infusion therapy; or

(C) items paid under 7 AAC 130.305 as specialized medical equipment and supplies.

(4) a provider of EPSDT screening services under 7 AAC 110.205;

(5) a facility providing services for end-stage renal disease;

(6) a personal care agency;

(7) a home and community-based waiver services provider, including a provider of environmental modification services under 7 AAC 130.300;

(8) a care coordination agency provider, as defined in 7 AAC 130.319;

(9) a residential supported-living services provider, as defined in 7 AAC 130.319;

(10) a federally qualified health center (FQHC);

(11) a tribal health program;

(12) a provider of in-state freestanding or portable x-ray services;

(13) a provider of behavioral health rehabilitation services under 7 AAC 135.010(c) for a child experiencing a severe emotional disturbance;

(14) a private-duty nursing agency;

(15) a school district providing a Medicaid-covered service to a Medicaid recipient;

(16) an independent laboratory;

(17) an outpatient therapy center;

(18) a provider of family planning services;

(19) a provider of targeted case management services;

(20) a community behavioral health services provider;

(21) a mental health physician clinic;

Reimbursement Reimbursement for medical services under the Alaska Medical Assistance Program is pursuant to the following methodologies*:

(1) Advanced Nurse Practitioners: Lesser of billed charges or 85% of the physician Resource Based Relative Value Scale (RBRVS). See 7 AAC 145.100.

https://www.akleg.gov/basis/aac.asp#7.120.200 https://www.akleg.gov/basis/aac.asp#7.130.305 https://www.akleg.gov/basis/aac.asp#7.110.205 https://www.akleg.gov/basis/aac.asp#7.130.300 https://www.akleg.gov/basis/aac.asp#7.130.319 https://www.akleg.gov/basis/aac.asp#7.130.319 https://www.akleg.gov/basis/aac.asp#7.135.010 https://www.akleg.gov/basis/aac.asp#7.145.100

(2) Ambulatory Surgical Center (ASC) Services: ASC payment is based on the Medicare ASC code group to which the billed service(s) is/are assigned. See 7 AAC 145.630.

(3) Behavioral Rehabilitation Services (BRS): Must be a grantee approved by the Department. Lesser of billed charges or rates for applicable services as identified in 7 AAC 145.580.

(4) Chiropractic Services: Lesser of billed charges or the physician RBRVS. See 7 AAC 145.110.

(5) Certified Health Providers: Tribal encounter rate or payment methodology applicable to a nontribal provider in 7 AAC 145 if the tribal health program has elected to use that payment methodology for the billed service. See 7 AAC 155.030 and 7 AAC 155.040.

(6) Dental Services: Lesser of billed charges or for dental services provided to a recipient 21 years of age or older in accordance with 7 AAC 110.145 and the Fee Schedule: Emergent Adult Dental Services, Fee Schedule: Prosthodontic Adult Dental Services, and Fee Schedule: Enhanced Adult Dental Services, adopted by reference in 7 AAC 160.900. Except for orthodontic services, the department will pay a dentist for dental services provided to a recipient under 21 years of age in accordance with 7 AAC

110.150 and the Fee Schedule: Dental Services for Children, adopted by reference in 7 AAC 160.900.

(7) Early Periodic Screening Diagnostic and Treatment (EPSDT): Lesser of billed chares of the physician RBRVS. See 7 AAC 145.140.

(8) End-stage Renal Disease (ESRD): See 7 AAC 145.607.

(9) Family Planning Services and Supplies: Lesser of billed charges or 85% of the physician RBRVS for services. See 7 AAC 145.150.

(10) FQHC and Rural Health Clinic: Facility specific all-inclusive encounter rate. See 7 AAC 145.700.

(11) Home and Community-Based Waiver Services: Rates and methodologies set out in 7 AAC 145.520 for the following services:

(A) Care coordination, specialized equipment and supplies

(B) Specialized private duty nursing

(C) Environmental modifications service

(D) Adult day care, chore, habilitation, meals, respite, or waiver transportation service

(E) Residential supported living services

(12) Home Health Services: 80% of billed charges. See 7 AAC 145.510.

(13) Home Infusion Therapy: See 7 AAC 145.400 (h).

(14) Hospice Care Services: Lesser of billed charges or the CMS established Medicaid rates per service established under 42 CFR 418.306. See 7 AAC 145.690.

(15) Imaging services: Lesser of billed charges or RBRVS. See 7 AAC 145.160.

(16) Inpatient Hospital: For discharges on or after January1, 2024, the department will reimburse inpatient hospital services provided by general acute care hospitals on a per-stay basis using a Diagnosis Related Groups (DRG) payment methodology identified in 7 AAC 150.250. The department will apply the DRG https://www.akleg.gov/basis/aac.asp#7.145.630 https://www.akleg.gov/basis/aac.asp#7.145.580 https://www.akleg.gov/basis/aac.asp#7.145.110 https://www.akleg.gov/basis/aac.asp#7.145 https://www.akleg.gov/basis/aac.asp#7.155.030 https://www.akleg.gov/basis/aac.asp#7.155.040 https://www.akleg.gov/basis/aac.asp#7.110.145 https://www.akleg.gov/basis/aac.asp#7.160.900 https://www.akleg.gov/basis/aac.asp#7.110.150 https://www.akleg.gov/basis/aac.asp#7.110.150 https://www.akleg.gov/basis/aac.asp#7.160.900 https://www.akleg.gov/basis/aac.asp#7.145.140 https://www.akleg.gov/basis/aac.asp#7.145.607 https://www.akleg.gov/basis/aac.asp#7.145.150 https://www.akleg.gov/basis/aac.asp#7.145.700 https://www.akleg.gov/basis/aac.asp#7.145.520 https://www.akleg.gov/basis/aac.asp#7.145.510 https://www.akleg.gov/basis/aac.asp#7.145.400 https://www.akleg.gov/basis/aac.asp#7.145.160 https://www.akleg.gov/basis/aac.asp#7.150.250 payment methodology to in-state general acute care hospitals, except hospitals listed in 7 AAC 150.250 (b), and to all out-of-state hospitals. See 7 AAC 145.600.

(17) Alaska Native (IHS) hospital: All-inclusive per diem rate. See 7 AAC 155.010.

(18) Laboratory Services are paid at the Medicare Fee Schedule unless no Medicare fee is established; then paid at RBRVS.: See 7 AAC 145.460.

(19) Skilled or Intermediate Nursing Facility Services: Facility specific per diem rate. See 7 AAC 145.640.

(20) DME, medical supplies and prosthetic devices: Lesser of billed charges or the State maximum. See 7

AAC 145.420.

(21) Behavioral Health Clinic Services: At the rates established in 7 AAC 145.580.

(22) Alaska Native (IHS) clinic: All-inclusive encounter rate. See 7 AAC 155.010.

(23) Behavioral Health Rehabilitation Services: At the rates established in 7 AAC 145.580.

(24) Direct Entry-Midwife Services: Lesser of billed charges or 85% of the physician RBRVS. See 7 AAC 145.130.

(25) EPSDT services are paid at 100% of RBRVS. See 7 AAC 145.140.

(26) Nurse Anesthetist: Lesser of billed charges or 85%of the physician RBRVS. See 7 AAC 145.170.

(27) Nurse Midwives: Lesser of billed charges or 85%of the physician RBRVS. See 7 AAC 145.100 (e).

(28) Nutrition Services: Lesser of billed charges or the physician RBRVS subject to the limits identified in 7

AAC 145.180.

(29) Outpatient Hospital Services: Percentage of billed charges for most services. Designated small hospitals receive percentage of billed charges for all services. See 7 AAC 145.600.

(30) Personal Care Services: Lesser of billed charges or the State maximum. See 7 AAC 145.500.

(31) Physical and Occupational Therapy Services: Lesser of billed charges or 85% of the physician RBRVS. See

7 AAC 145.300 -320.

(32) Physician Services: Lesser of billed charges or the RBRVS value for the procedure, subject to the exceptions listed at 7 AAC 145.220. See 7 AAC 145.200.

(33) Podiatry Services: Lesser of billed charges or the physician RBRVS. See 7 AAC 145.240.

(34) Prescribed Drugs: Lesser of billed charges, the Federal Upper Limit, State Maximum Allowable Cost, or the estimated acquisition cost (Wholesale AcquisitionCost+1%) plus a volume based dispensing fee, plus the reasonable and necessary postage or freight costs incurred in the delivery of the prescription from the dispensing pharmacy to a recipient in a rural area, paid through the pharmacy system. The Offeror should see 7 AAC 145.400 and 7 AAC 145.410 for special payment methods involving dispensing physicians, unit dose dispensing, high technology drugs, postage, brand name vs. generic drugs, compounding prescriptions, infusion therapy drugs, and dispensing fees.

https://www.akleg.gov/basis/aac.asp#7.150.250 https://www.akleg.gov/basis/aac.asp#7.145.600 https://www.akleg.gov/basis/aac.asp#7.155.010 https://www.akleg.gov/basis/aac.asp#7.145.460 https://www.akleg.gov/basis/aac.asp#7.145.640 https://www.akleg.gov/basis/aac.asp#7.145.420 https://www.akleg.gov/basis/aac.asp#7.145.420 https://www.akleg.gov/basis/aac.asp#7.145.580 https://www.akleg.gov/basis/aac.asp#7.155.010 https://www.akleg.gov/basis/aac.asp#7.145.580 https://www.akleg.gov/basis/aac.asp#7.145.130 https://www.akleg.gov/basis/aac.asp#7.145.130 https://www.akleg.gov/basis/aac.asp#7.145.140 https://www.akleg.gov/basis/aac.asp#7.145.170 https://www.akleg.gov/basis/aac.asp#7.145.100 https://www.akleg.gov/basis/aac.asp#7.145.180 https://www.akleg.gov/basis/aac.asp#7.145.180 https://www.akleg.gov/basis/aac.asp#7.145.600 https://www.akleg.gov/basis/aac.asp#7.145.500 https://www.akleg.gov/basis/aac.asp#7.145.300 https://www.akleg.gov/basis/aac.asp#7.145.220 https://www.akleg.gov/basis/aac.asp#7.145.200 https://www.akleg.gov/basis/aac.asp#7.145.240 https://www.akleg.gov/basis/aac.asp#7.145.400 https://www.akleg.gov/basis/aac.asp#7.145.410

(35) Private Duty Nursing: The Department will reimburse for in-state private duty nursing services at the lesser of billed charges or the State maximum allowed. See 7 AAC 145.250.

(36) Psychologist: See 7 AAC 145.260.

(37) Residential Treatment: All-inclusive daily rate established by DOH. See 7 AAC 145.620.

(38) Respiratory Therapy Services: Lesser of billed charges or the State maximum. See 7 AAC 145.420.

(39) School Based Services -The Department will pay for school-based services in accordance with 7 AAC

145.350 at the lesser of billed charges or:

a. 85% of the RBRVS fee schedule for procedures with an established relative value unit (RVU);

b. for services with no established RVU, the Department will pay according to the established fee schedule.

(40) Speech, Hearing and Language Services: Lesser of billed charges or 85% of physician RBRVS. See 7 AAC

145.330 - 340.

(41) Substance Use Rehabilitation Services: At the rates established in 7 AAC 145.580.

(42) Targeted Case Management: Lesser of billed charges or the State established monthly encounter rate.

See 7 AAC 145.265.

(43) Telemedicine: Lesser of billed charges or the Physician RBRVS, payment to presenting provider is limited to the rate established for a brief evaluation and management of an established patient. See 7

AAC 145.270.

(44) Transportation Services: Billed charges, except as specified in Table I-3 of the Transportation and Accommodations section of the Alaska Medicaid Provider Billing Manual. See Also 7 AAC 145.440.

(A) Non-emergency ground ambulance within the same community: Lesser of billed charges or the State maximum.

(B) Non-emergency ground ambulance outside the community: Lesser of billed charges or State maximum, plus a rate per mile.

(C) Emergency ground ambulance: State based rate plus a rate per mile.

(D) Emergency air ambulance: Lift-off fee plus per mile rate.

(E) Non-emergency air ambulance: Lesser of billed charges or the State maximum.

(F) Commercial airline: Billed charges.

(G) Lodging and meal costs for recipients and approved escorts: Lesser of billed charges or the State maximum.

(45) Vision Care Services: See 7 AAC 145.280

(A) Examinations: Lesser of billed charges or physician RBRVS.

(B) Eyeglasses: DOH awards a competitive-bid contract for eyeglasses (frames and lenses); the

Department will pay an enrolled provider $80 for dispensing and fitting contact lenses, $30 for dispensing and fitting eyeglasses, and $10 for eyeglass frame repair.

(C) Optometrist services: Lesser of billed charges or the physician RBRVS.

(46) Vaccine Services See 7 AAC 145.275 https://www.akleg.gov/basis/aac.asp#7.145.250 https://www.akleg.gov/basis/aac.asp#7.145.260 https://www.akleg.gov/basis/aac.asp#7.145.620 https://www.akleg.gov/basis/aac.asp#7.145.420 https://www.akleg.gov/basis/aac.asp#7.145.350 https://www.akleg.gov/basis/aac.asp#7.145.350 https://www.akleg.gov/basis/aac.asp#7.145.330 https://www.akleg.gov/basis/aac.asp#7.145.330 https://www.akleg.gov/basis/aac.asp#7.145.580 https://www.akleg.gov/basis/aac.asp#7.145.265 https://www.akleg.gov/basis/aac.asp#7.145.270 https://www.akleg.gov/basis/aac.asp#7.145.270 https://www.akleg.gov/basis/aac.asp#7.145.440 https://www.akleg.gov/basis/aac.asp#7.145.280 https://www.akleg.gov/basis/aac.asp#7.145.275

(47) Payment for services provided in another state: Unless otherwise noted in 7 AAC 105- 7 AAC 160, the Department will pay an out-of-state provider in accordance with 7 AAC 145.025.

*Note to Offerors. The payment methods in this section are stated generically. The Offeror is encouraged to see the Billing Manuals and Alaska Administrative Codes for specifics and exceptions. See http://www.medicaidalaska.com/providers/Billing.shtml https://www.akleg.gov/basis/aac.asp#7.145.025 http://www.medicaidalaska.com/providers/Billing.shtml

SECTION 3. SCOPE OF WORK & CONTRACT INFORMATION

SEC. 3.01 SCOPE OF WORK

The DOH Medicaid Program Integrity section is soliciting proposals for desk and on-site audits of services delivered and claims billed by Medicaid-enrolled providers to Medicaid-eligible clients. A statewide sample of all enrolled Medical Assistance provider types must be selected. For the first year of the contract resulting from this RFP, a minimum of 50 providers are to be audited. The contractor, in consultation with the Department, will select 50 providers to be audited and determine which providers will have desk or on-site audits. The Department may select up to five (5) additional providers to be audited and determine whether they are to be desk or on-site audits. In subsequent years, the number of audits may vary in accordance with the requirements of Alaska Statute 47.05.200.

The purposes of the audits include ensuring provider compliance with state and federal policies, regulations and statutes, recovering overpayments, supporting the investigation and prosecution of violations of criminal statutes and protecting the Medicaid program from inappropriate expenditures resulting from fraud, waste, abuse or misuse. To this end, the on-site audits and desk audits are utilized to determine:

1. that the services billed by providers on claims documents were actually provided to Medicaid recipients who were eligible at the time that services were delivered;

2. that the services, procedure codes, and number of units for which claims were submitted reconcile with the recipient’s medical chart record of the services rendered, and the services were medically necessary;

3. that the stop and start times are documented for all time-based codes;

4. that the diagnoses recorded on the claim forms reconcile with the medical charts;

5. that the provider records substantiate that the services were rendered on the dates for which the claims were submitted;

6. that the provider followed Medicaid rules and appropriately billed all third party payers, applied proper co-payment and recipient cost-of-care as required;

7. that no duplicate billings and/or payments were made or received by the provider;

8. that no concurrent inpatient, nursing facility or other residential care billings exist with other Medicaid providers;

9. that the provider obtained appropriate authorization for services as applicable;

10. that billings and/or payments did not exceed applicable service limits or 24 hours of service in one day;

11. that the place of service code billed was accurate for the site at which the service was provided (inpatient hospital, office visit, etc.);

12. that Medicaid-eligible medical providers were enrolled with Alaska Medicaid at the time of service; and complied with the requirements for background checks in accordance with 7 AAC 10.900 - 10.990.

https://www.akleg.gov/basis/aac.asp#7.10.900

13. that the providers complied with their Alaska Medicaid Provider Agreement to identify and quantify overpayments and to detect all possible violations of Alaska and federal policies, regulations and criminal statutes.

The audits conducted under the resulting contract must meet the requirements of AS 47.05.200.

SEC. 3.02 DELIVERABLES

The contractor will be required to provide the following deliverables:

1. Agreed Upon Procedures:

Prior to the start of the contract, the contractor and state will agree to a set of standard procedures to be performed for each audit. These agreed-upon procedures will include a description of the planning, claims analysis, detailed claims documentation review, field examination and reporting steps to be taken for each audit.

2. Provider Selection:

The contractor, in consultation with the Department, shall select, for the first year of the contract 50 providers to be audited. At least 2 providers must be facilities as defined under AS 47.07.900. Providers must be selected from all Medical Assistance providers who billed the department a minimum of $50,000 and the sampling must represent a variety of provider types and locations. It is anticipated that at least 33% of these audits will be on-site.

The DOH Medicaid Program Integrity section may select an additional 5 providers for audit and determine whether the audit is an on-site or desk audit. In subsequent years, the number of audits may vary in accordance with the requirements of AS 47.05.200.

3. Sample Selection:

The contractor will develop, maintain and perform a sampling of Medicaid providers’ activities through statistically valid methodologies that will result in an adequate sample selection. The methods used must be standard, recognized methodologies. All calculations used in the sampling process must be made available to the Department upon request. The sampling methodologies used by the contractor must support extrapolation of overpayments and the contractor must be able to justify and explain the sampling methodologies utilized in legal or administrative proceedings.

The scope of each audit will cover one calendar year of the provider’s activities starting with calendar year 2023.

Each subsequent audit cycle will cover the subsequent calendar year.

The proposal must include a description of the sample selection methodologies to be used for this contract in compliance with the criteria as outlined in this section.

4. Records Review, Findings, and Reports:

The principal focus of desk and on-site audits is to identify violations of Medicaid program rules including claim overpayments as well as potential violations of criminal statutes. It is also to determine if services billed to the Medicaid program are supported by documentation contained in the providers’ recipient medical, financial or other records, and whether the provider is complying with the Medicaid Provider Agreement and all applicable federal and state statutes, regulations policies and procedures.

https://www.akleg.gov/basis/statutes.asp#47.07.900

The audits will involve a review of medical necessity, computerized analysis of Medicaid claims activity; other MMIS information; providers’ financial records, including financial credit balances; billing records; the services received as documented in providers’ clinical medical records including diagnostic testing results and prescribed services documentation, and any other information which may support the services billed to Medicaid. A determination will be made as to whether the services billed meet the program requirements as stated in the state and federal Medicaid rules, policies and regulations, including provider billing manuals.

The contractor will research and become familiar with all pertinent Medicaid state and federal policies, regulations, and statutes. The contractor will prepare and provide all materials and supporting documentation necessary to perform desk and on-site record audits, including requesting data from the DOH Program Integrity Section and its fiscal agent, data extraction, data preparation, abstraction tool development, programming, if necessary, and preparation of all other items necessary for the desk and on-site record audits. Letters of notification, requests for records and other correspondence regarding the audit to individual providers will be produced by the contractor.

5. Preliminary Audit Report The contractor, upon completion of the desk or on-site audit, will prepare and submit a preliminary audit report to the DOH Medicaid Program Integrity section for review prior to issuing the report to the provider. Medicaid Program Integrity will consult with the appropriate divisions on any necessary policy clarifications.

Upon receipt of approval from Medicaid Program Integrity, the contractor will submit the Preliminary detail report to the provider with documentation of the findings including but not limited to those listed below. Providers will be given at least 30 days to review the preliminary audit and to submit additional documentation to address the findings.

The reviewers may find:

• lack of medical necessity

• billing errors

• duplicate billings

• unbundled billings

• up-coded billings

• split billings

• no documentation/billing not justified

• service billed was not the service rendered/service rendered not covered

• failure to document start and stop times for time-based codes

The review findings may indicate the need for:

• provider education

• recovery of inappropriate payments

• referral to the appropriate agency

• other actions or sanctions to be implemented by the Department.

The review may also find that no further action is indicated.

Inappropriate billings identified during the desk or on-site review process will be researched, recovery amounts calculated (both actual and extrapolated), and recommendations for recovery will be made by the contractor to the Department. Each monetary finding will be accompanied by an administrative code reference which supports the identification of the overpayment. Recovery amounts will be calculated based upon a statistically valid extrapolation method and shall be presented in the Audit Report. The current extrapolation methodology is the greater of actual overpayments or the results of an extrapolation using the lower bound of a one sided 90% confidence interval.

Please note: Overpayments may include amounts that are subject to extrapolation (part of the claims sampled for detailed testing) and amounts not subject extrapolation (amounts identified during analytical review which are in conflict with inpatient stays, duplicate billings, etc.). Extrapolated and non extrapolated overpayment amounts will be identified separately in the audit report.

The contractor will review any additional documentation submitted by the provider in response to the Preliminary audit and make appropriate modifications to the final audit report prior to issuance. Final audit reports will be transmitted to the Medicaid Program Integrity section who will then issue the report to the provider notifying them of their appeal rights.

During the desk or onsite review or research process, the contractor may observe and/or identify state system, procedural or policy issues. The contractor will include these observations in the Narrative Summary and may make recommendations regarding those issues.

During the desk or on-site audit, the contractor may have reason to believe that fraud has occurred or may identify potential fraud. The contractor will notify the Project Manager in writing and provide all relevant descriptions and materials. The contractor may be requested to cease to continue working on the audit at that time or may be requested to continue the audit in progress.

Although assessment of quality of care is not the focus of this contract, the Department recognizes that it has a responsibility to take note of any discrepancies that might indicate a quality of care issue. Issues related to quality of care identified during the desk or onsite review process shall be immediately reported to the Project Manager of the DOH Medicaid Program Integrity Section in writing and included in the narrative report. The offeror will include in their proposal the policy and procedures to be followed when quality of care issues are identified during audits performed under this contract.

6. Final Audit Report Within 10 working days after completion of the audit, the contractor will submit a written audit report, together with two copies of the final audit report to the Project Manager. The final audit report will consist of:

Auditors Statement: the Auditors Statement will consist of a description of the type of audit, time period audited, scope of audit, a complete summary of the findings, recovery amounts identified, a statement that the audit was conducted in accordance with Government Auditing Standards 2018 Revision, and signature of contractor.

Narrative Summary:

The narrative summary will include an explanation of all findings and recommendations in a narrative format. This explanation will include a summary of the audit findings and recommendations, overpayments, observations and interactions with the providers’ staff, an explanation of the audit process, sampling methodologies used, proceedings of the entrance conference, etc. This narrative summary may include tables/graphs presenting data and interpretation of results. The Narrative Summary will include specific observations or findings of actual or potential violations of criminal statutes. All findings identified in the Narrative Summary will include the citations supporting the findings.

Report Detail: The report detail will consist of schedules describing each claim reviewed and serve as an accounting of all financial details. This report will include the claim control number, date of service, procedure code, procedure modifier, claim type modifier, claim status, amount billed, allowed amount, Third Party Liability [TPL] amount, co-pay amount, recipient liability, payment amount, payment date, diagnosis, other claims data as necessary, a specific description of the overpayments/problems identified per claim, errors identified and all calculations, including recoverable amounts for each claim.

The final audit report informing the provider of the audit findings, related overpayments, program participation deficiencies and other related issues will be forwarded to the Project Manager in the DOH Medicaid Program Integrity section. The DOH Medicaid Program Integrity section will issue the final audit report to the provider and will include applicable appeal instructions.

7. Monthly Status Report:

Within five working days of the end of each month, the contractor will submit a monthly status report to the Project Manager of this contract explaining the status of all desk and on-site audits. This report will include the status of each audit and actions taken as well as other parameters defined by the DOH Medicaid Program Integrity section.

8. Annual Status Report:

Within two working weeks of the end of each audit cycle, the contractor will submit a status report to the Project Manager of this contract. The contractor will produce a report and accounting of all activities to be used in the DOH Medicaid Program Integrity section annual report and to evaluate the cost effectiveness of the desk and on-site audit process.

9. Record Keeping Requirements:

The contractor will maintain all supporting documentation and data used in the contractor’s audit process for a period of not less than 7 years following completion of an audit.

The contractor, upon completion of the audit process, will provide the DOH Project Manager an electronic file of all supporting documentation and data supporting the contractors audit process and findings.

10. Appeal Support:

The DOH Medicaid Program Integrity section will provide for the legal defense and manage the Department’s defense in any appeal or legal proceeding. The contractor will support its audit conclusions, recovery determinations, and findings in any appeal or legal proceeding. That support includes, but may not be limited to, the preparation of all necessary materials and exhibits and providing testimony when appropriate.

11. Optional Services:

In addition to the 50 annual audits that are to be performed under this contract, the following additional services may be requested by the State at additional cost:

• Additional audits: The state may request up to 5 additional audits to be conducted in addition to the 50 required annually. The scope of each audit may be modified but will be similar to the work required for the 50 audits described in detail above.

• Claims data analysis: The state may request the contractor to perform data analysis on claims other than those selected as part of the 50 annual audits. That data analysis with search for and identify potential duplicate claims and clams concurrent with inpatient hospital, or long-term care claims. Additional types of data analysis may be proposed by the state or the contractor.

SEC. 3.03 CONTRACT TERM AND WORK SCHEDULE

The length of the contract will be from September 1, 2025, for approximately three (3) years until completion, approximately August 31, 2028, with one (1) three- year renewal. Renewal options will be at the sole discretion of the state.

Any extension of the contract beyond the end date will be upon mutual agreement between the State and the contractor and effected with a contract amendment processed by the procurement officer and signed by both parties. All other terms and conditions of the contract, including those previously amended, shall remain in full force and effect. Unless otherwise agreed to by both parties, the procurement officer will provide written notice to the contractor of the intent to cancel an extension at least 30 days before the desired date of cancellation.

SEC. 3.04 CONTRACT TYPE

This contract is a Firm Fixed Price contract.

SEC. 3.05 PAYMENT PROCEDURES

The state will make monthly payments on hourly appeal support and after each audit is completed and approved by the project director. The state will pay the contractor based upon the per item costs submitted in Submittal Form H – Cost Proposal.

SEC. 3.06 CONTRACT PAYMENT

No payment will be made until the contract is approved by the Commissioner of the Department of Health or the Commissioner's designee. The state is not responsible for and will not pay local, state, or federal taxes. All costs associated with the contract must be stated in U.S. currency.

For agreements over $500,000, under no conditions will the state be liable for the payment of any interest charges associated with the cost of the contract. Payment for agreements under $500,000 for the undisputed purchase of goods or services provided to a state agency, will be made within 30 days of the receipt of a proper billing or the delivery of the goods or services to the location(s) specified in the agreement, whichever is later. A late payment is subject to 1.5% interest per month on the unpaid balance. Interest will not be paid if there is a dispute or if there is an agreement that establishes a lower interest rate or precludes the charging of interest.

SEC. 3.07 ELECTRONIC PAYMENTS

The State of Alaska prefers vendors receive payment via Electronic Funds Transfer (EFT). The contractor may review information concerning the EFT process and access the Electronic Payment Agreement Form for Vendors at the following link: https://doa.alaska.gov/dof/vendor.html.

Any single contract payment of $1 million or higher must be accepted by the contractor via Electronic Funds Transfer (EFT).

SEC. 3.08 LOCATION OF WORK

The location(s) the work is to be performed, completed and managed is at contractor’s workplace.

The state will not provide workspace for the contractor. The contractor must provide its own workspace.

https://doa.alaska.gov/dof/vendor.html

Travel will be required for on-site audits, both within the state and, if necessary, to providers located outside of state. The contractor will be responsible for all travel arrangements and travel associated costs, none may be billed separately to the State.

By signature on their proposal, the offeror certifies that all services provided under this contract by the contractor and all subcontractors shall be performed in the United States.

If the offeror cannot certify that all work will be performed in the United States, the offeror must submit a request, set out in a separate document in their proposal, that provides a detailed description of the portion of work that will be performed outside the United States, where, by whom, and the reason that is necessary.

The request must include a detailed description of the portion of work that will be performed outside the United States, where, by whom, and the reason the waiver is necessary.

Failure to comply with these requirements may cause the state to reject the proposal as non-responsive or cancel the contract.

SEC. 3.09 SUBCONTRACTORS

Subcontractors may be used to perform work under this contract. Subcontractor staff may only be up to 50% of all assigned staff on this contract. All other staff must be direct employees of the prime contractor. If an offeror intends to use subcontractors, the offeror must complete the Submittal Form identified in Section 4.02 of this

RFP.

An offeror's failure to provide this information with their proposal may cause the state to consider their proposal non-responsive and reject it.

Subcontractor experience SHALL be considered in determining whether the offeror meets the requirements set forth in Submittal Form F – Mandatory Requirements. Offerors must be specific in Submittal Form F as to which subcontractor(s) defined in Submittal Form G – Subcontractors they are citing to meet the specific requirement listed in Submittal Form F.

If a proposal with subcontractors is selected, the state may require a signed written statement from each subcontractor that clearly verifies the subcontractor is committed to provide the good or services required by the contract.

The substitution of one subcontractor for another may be made only at…