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RFP Vendor
| ATTACHMENT - SERVICE LEVEL AGREEMENT (SLA) & THIRD PARTY LIABILITY (TPL) VENDOR | | | | | | |
| Vendor Recovery & Recoup Process | | | | | | |
| CONTRACT CHECKLIST | | | | | | |
| RFP Requirements | Vendor Proposal Section | Citation/RFP Section | Vendor Proposal Subsection | Satisfies RFP Requirement? Y/N? | Reportable? Y/N? | Comment |
| Vendor shall deposit checks received as a result of this contract into an established State of Nevada account within 24 hours of the receipt of funds. | | | | | | |
| 1.2.3 | | | | | | |
| Vendor shall submit a digital itemized report of deposits accompanied by copies of deposit slips, check copies, and bank receipts to NVHA on a daily basis. | | 1.2.4 | | | | |
| Vendor shall disposition claims (i.e. apply money to a billing or a claim in MMIS) when funds are received, and post EOB denials or receipt of recovery, to the appropriate accounts receivable, within 10 business days of receiving the necessary claim data. | | 1.2.6.7 | | | | |
| Monies received that do not have identified claim details, or that are not proven to be owed to NVHA by the 30-day threshold, shall be refunded to the payor at no cost to NVHA. | | 1.2.6.10 | | | | |
| Refunds shall be completed within 30 calendar days from the date of deposit. If vendor is unable to complete a refund within the 30-day timeframe, the refund shall be forwarded by the 35th day to NVHA Recoveries team to post. Vendor shall be responsible for tracking the refund compliance. Refunds shall be approved by NVHA before being sent. | | 1.2.6.11 | | | | |
| Vendor shall be responsible for maintaining auditable records regarding the issued refunds. | | 1.2.6.12 | | | | |
| Payments not deposited by the end of the business day shall be logged by vendor. This log shall be submitted to NVHA for review as appropriate at the end of each business day, by 5:00 PM (PST). | | 1.3.8.2 | | | | |
| As identified above, vendor shall submit a digital itemized report of deposits accompanied by copies of deposit slips, check copies, and bank receipts to NVHA on a daily basis. This itemized report shall include the following information at a minimum: | | | | | | |
| A. | Scope of work activity resulting in payment (i.e. Subrogation, RAC, TPL, Secondary Recovery, etc.) | | | |
| B. | Date check received | | | |
| C. | Deposit date | | | |
| D. | Deposit number | | | |
| E. | Check date | | | |
| F. | Check number | | | |
| G. | Check amount | | | |
| H. | Payor | | | |
| I. | Case number (if applicable) | | | |
| J. | Other information as required by NVHA | | 1.3.8.6 | |
| | Vendor shall submit to NVHA a monthly report of all accounting activities that includes recovery totals for each applicable scope of work. | | 1.3.11 |
| | Vendor may be subjected to a 25% hold back on each invoice based on the viability, correctness, and timeliness of data as indicated below: Holdback funds for viability and correctness below shall be released upon vendor submission of corrections and upon acceptance of those corrections by NVHA. | | |
Viability – data shall be delivered in a format as described in each scope of work.
Correctness – data shall be free of errors and provide accurate information.
| Timeliness – data shall be delivered per requirements within each scope of work. For any item with a timeline not identified within the scope of work, data shall be supplied within 10 working days of initial request. Failure to provide data within the specific timeframe shall result in a 10% holdback being forfeited. | 1.15.1-1.15.1.4 | |
| Scheduled deliverables not received timely shall be subjected to a $500.00 per day penalty | 1.15.2 |
| RFP Requirements | Vendor Proposal Section | Citation/RFP Section | Vendor Proposal Subsection | Satisfies RFP Requirement? | Reportable? Y/N? | Comment |
| Develop a plan that describes the review standards to be used, desk and field review approaches, peer or professional review approaches, capacity of reviews typically handled by vendor during a specific time frame, and templates of typical review reports. The work plan shall include operating procedures related to case tracking, reporting, and record retention. | | 2.1.1.2 | | | | |
| Use accepted and valid accounting, analytical, statistical, or peer-review methods, or combinations thereof to make the determination of improper payment. Therefore, the plan shall describe vendor’s principal methodologies to be considered in making determinations of magnitude of improper payment. The plan shall also include specifics to address vendor’s ability and approaches to provide expert witness support at the State’s administrative hearing and/or in court. | | 2.1.1.4 | | | | |
| Deliver a routine tracking instrument to track and report volume, category, reason, potential exposure of improper payment, status, finding, recoupment and disposition of new, open and closed reviews, and review documents monthly, quarterly, and annually. The tracking instrument shall include the backlog of cases. The State shall have access to this tracking system. | | 2.1.3 | | | | |
| To ensure the integrity of claims billed to health care payors, vendor shall manually review all questionable eligibility matches based on the comparison of partially filled records or other situations that appear to require human judgment. Vendor shall take all appropriate measures to avoid, detect and correct mismatches. | | 2.2.7 | | | | |
| Vendor shall submit NVHA a monthly report of its data matching activities. | | 2.2.10 | | | | |
| Vendor shall be responsible for mailing lead letters within 10 days of determining if one is needed. | | 2.3.9 | | | | |
| By the 10th calendar day of each month, vendor shall submit to NVHA a monthly report for the previous month which details the 10 most frequent denial reasons. the vendor shall submit to the NVHA a monthly report for the previous month which details the ten most frequent denial reasons. | | 2.4.3 | | | | |
| Vendor shall generate and submit to NVHA recoupment files and accounts receivables/deposit receipt forms as appropriate in order to recoup Medicaid overpayments and in-line with the requirements outlined in RFP SOW Section 1.2 – Fiscal Requirements. | | 2.5.6 | | | | |
| Vendor shall provide NVHA with a file containing the adjusted claims on the 5th day of each month for claims adjusted during the previous month. This file format shall be determined through collaboration between vendor and NVHA within 30 days of contract implementation. | | 2.5.8 | | | | |
| The recoupment process, including dispositioning of claims in MMIS, shall be completed within 30 business days after the determination that an overpayment exists. | | 2.5.9 | | | | |
| Any refunds submitted to NVHA for processing with data entry errors shall result in an error fee of $1,000.00 per Manual Transaction Form (MTF) transaction. | | 2.5.10 | | | | |
| Vendor shall be responsible for data entry errors made in MMIS that require a system data correction by NVHA’s Fiscal Agent. This includes all system hours related to research and statement of work. | | 2.5.11 | | | | |
| The Vendor is responsible for providing several deliverables including documentation supporting the collection of funds and summary documents needed for reporting and accounting as outlined in previous sections. | | 2.7.1 | | | | |
| RFP Requirements RAC | Vendor Proposal Section | Citation/RFP Section | Vendor Proposal Subsection | Satisfies RFP Requirement? | Reportable? Y/N? | | Comment |
| Vendor shall conduct post-payment reviews of Nevada Medicaid claims data to identify improper payments. The State shall have all rights to use, disclose, or duplicate, for any purpose whatsoever, all data mining criteria, algorithm, computer routines, reports, and analyses developed, derived, documented, or furnished by vendor as the result of this contract. To assist in the identification of improper Medicaid payments at a minimum, vendor shall deliver or participate in: A quarterly assessment meeting with the State to evaluate the effectiveness and deficiencies of the RAC Work Plan which is developed by vendor and approved by the State. At the assessment meeting, goals and priorities shall be reviewed and modified as necessary. The Work Plan shall: | | 5.1.1, 5.1.1.1 | | | Y | Y | |
| An inventory of data mining criteria, fraud and abuse algorithm, and other statistical instruments used by Vendor for post-payment reviews of claims data. | | 5.1.1.2 | | | | | |
| Report on routine activities of random or targeted desk reviews of claims data in vulnerable billing and servicing areas that shall be reviewed in the work program including a schedule and review of work done in the previous quarter. | | 5.1.1.3 | | | | | |
| Recommendations to the State on potential reporting and data quality issues that reduce the effectiveness of improper payment identifications. | | 5.1.1.6 | | | | | |
| Vendor shall assist the State in post payment review of suspected improper payments. In assisting in improper Medicaid payment reviews, at minimum: | | 5.2.1 | | | | | |
| The plan shall describe review standards to be used, desk and field review approaches, peer or professional review approaches, capacity of reviews typically handled by vendor during a specific time frame, and templates of typical review reports. The work plan shall include procedures related to case tracking, reporting, record retention, and issuance of findings notifications. | | 5.2.1.2 | | | | | |
| Deliver a routine tracking instrument to track and report volume, category, reason, potential exposure of improper payment, status, finding, recoupment and disposition of new, open and closed reviews, and review documents monthly, quarterly, and annually. The tracking instrument shall also include the backlog of cases. The State shall have access to this tracking system. | | 5.2.1.7 | | | | | |
| Upon the State’s approval of vendor’s audit findings, vendor shall recover identified improper payments from the provider by sending a certified letter that clearly identifies the reasons an overpayment was declared. This includes, but is not limited to, failure to follow Medicaid policy, Nevada Revised Statutes (NRS), Billing Guidelines, Federal Policy, etc. The letter shall include a description of the provider’s appeal rights and appeal contact information. The State shall approve the letter template format and content. | | 5.3.1 | | | | | |
| Vendor shall send NVHA Recovery Unit, in a mutually agreed upon format, a listing of specific claims to be adjusted for each payment received and for each offset to be applied. | | 5.3.3 | | | | | |
| Vendor shall have a recovery tracking instrument to track and report to the State the volume, category and status, of ongoing activities and documentations, and outcome of each recovery case monthly, quarterly, and annually. | | 5.3.4 | | | | | |
| If an underpayment is discovered, it shall be reported to the State. The State shall have the claim re-adjudicated. | | 5.3.5 | | | | | |
| Vendor shall generate and submit to NVHA recoupment files and accounts receivables/deposit receipt forms as appropriate in order to recoup Medicaid overpayments and in-line with the requirements outlined in this RFP. | | 5.3.6 | | | | | |
| Vendor shall provide NVHA with a file containing the adjusted claims once a month. This file format shall be determined through collaboration between vendor and NVHA within 30 days of contract implementation. | | 5.3.8 | | | | | |
| There are instances where a check is received and deposited by or on behalf of the Nevada Medicaid program as it pertains to this scope of work that is later determined to be an incorrect collection. This can be due to the fact the wrong state received the check, it was later determined that the associated claims were incorrectly identified, or a number of other reasons. In these instances, it shall be the responsibility of vendor to provider all necessary data to NVHA to complete the refund process. | | 5.4.1 | | | | | |
| Vendor shall assist the State in post-payment identification, audit, and recovery of improper Medicaid payments through reviewing claims data. Vendor shall maintain up-to-date knowledge of Federal and State laws as well as Nevada Medicaid policy related to the scope of improper Medicaid payments. Vendor shall be required to conform to federal requirements of the RAC program. | 5.6.1 | |
| Vendor shall be required to submit a Work Plan for approval by the State prior to beginning work on provider reviews. Vendor shall submit work plans for review and approval by the State on a semi-annual basis. Work Plans can be modified by the State at any time. The State also reserves the right to cancel or suspend a provider review. | 5.6.3 |
| Vendor shall be provided with claims data incurred three years prior to the contract date as well as claims data incurred during the contracting period. The State reserves the right to direct vendor to use other data sources to aid improper payment identifications. | 5.6.4 |
| Vendor shall have a reporting plan which details vendor’s processes and procedures to ensure the deliveries of routine weekly, monthly, quarterly, and annual activity reports related to Improper Medicaid Payment Audit and Recovery. Vendor shall ensure that the reporting plan fulfills both the requirements of the State and of CMS. | 5.6.5 |
| Vendor shall be responsible for providing several deliverables including documentation supporting the collection of funds and summary documents needed for reporting. | 5.7.1 | |
| Any refunds submitted to NVHA for processing with data entry errors shall result in an error fee of $1,000.00 per Manual Transaction Form (MTF) transaction. | 5.6.7 |
| Vendor shall be responsible for data entry errors made in MMIS that require a system data correction by NVHA’s Fiscal Agent. This includes all system hours related to research and statement of work. | 5.6.8 |
| If issues are found within the submitted documentation, such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours. [see Deliverables schedule] | |
| 5.7.3 | |
| RFP Requirements SUBRO | Vendor Proposal Section | Citation/RFP Section | Vendor Proposal Subsection | Satisfies RFP Requirement? | Reportable? Y/N? | Comment |
| Vendor shall be responsible for managing and tracking cases and reporting case information to the necessary NVHA staff and affiliates. This process shall involve taking action to follow-up on leads with recipients, eligibility workers and others, tracking cases that result in clear notes for an effective audit trail, and maintaining a database or software system that allows for the access of related case information. | | 7.2.1 | | | | |
| Vendor shall be responsible for providing several deliverables including documentation supporting the collection of funds and summary documents needed for reporting and reproducible detailed claims reports that can be disclosed to involved parties in a readable format when printed on 8 ½” by 11” paper. | | 7.5.1 | | | | |
| Any refunds submitted to NVHA for processing with data entry errors shall result in an error fee of $1,000.00 per Manual Transaction Form (MTF) transaction. | | 7.2.4.4 | | | | |
| Vendor shall be responsible for data entry errors made in MMIS that require a system data correction by NVHA’s Fiscal Agent. This includes all system hours related to research and statement of work. | | 7.2.4.5 | | | | |
| If issues are found within the submitted documentation, such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours. | | 7.5.4 | | | | |
| RFP Requirements MCO 210 | Vendor Proposal Section | Citation/RFP Section | Vendor Proposal Subsection | Satisfies RFP Requirement? | Reportable? Y/N? | Comment |
| Match the master file of identified encounters where other health insurance coverage was present against the MCO 210 Recoveries and Subrogation monthly reports. | | 3.3.1.1 | | | | |
| Provide NVHA with an electronic comparison file of identified encounters that matched the MCO 210 Recoveries and Subrogation report as well as encounters that were not matched, per the file layout in RFP Attachment – TPL Comparison Report attached for vendor information as sample file. | | 3.3.1.2 | | | | |
| Provide NVHA with a Summary Report of the evaluation, identifying, at a minimum, the number of encounters that matched and the number of encounters not reported by the MCO for which vendor identified other health insurance coverage was available. | | 3.3.1.3 | | | | |
| If issues are found within the submitted documentation, | | | | | | |
such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours. 3.3.1.4
| RFP Requirements MER | Vendor Proposal Section | Citation/RFP Section | Vendor Proposal Subsection | Satisfies RFP Requirement? | Reportable? Y/N? | Comment |
| Case Management system required for Research and Records Retention Related to Deceased Medicaid Recipients. System shall allow for quick look up and include a variety of look up options. For example, probate number, Medicaid ID, case number, name, date of death, Social Security number, address, and date of birth. | | 6.1.1 | | | | |
| Case Management system that allows letter creation for all MER letters. Ability to attach all related documents to the related case. Current letter count: forty different letters from MER unit. | | 6.1.2 | | | | |
| Case Management system shall provide monthly reporting annual/monthly recoveries, and annual/monthly open/closed cases. | | 6.1.6 | | | | |
| Case Management system shall provide recovery statistics for the following: | | | | | | |
Recoveries collections Creditors’ Claims/Probate Cases Opened Demand Packets Future Actions Remaining State of Nevada Controllers Office Referrals Initiated Liens Voluntary Lien Agreements Waivers Processed Cases Opened Cases Worked Events (NOI) Notice of Intent Letters Sent Nursing Home Letters Sent
| Bank Letters Sent | 6.1.7, 6.1.7.1-6.1.7.14 | | | |
| | Vendor shall make such reports as necessary to keep NVHA, the Governor, and the AG apprised of its activities, including a reporting and tracking system for complaints (all complaints are then to be forwarded to MER for resolution), monthly reports related to cases, payments, and efforts recited herein, and financial reporting/aging of accounts related to recovery efforts. | | 6.3.1 |
| Vendor shall assist with all media requests criteria requested. Data must be available to provide any Ad-Hoc requirements. | | 6.3.2 | |
| Vendor shall provide a monthly recovery report by the 10th business day of the month and make access to records available on a continuing basis to NVHA MER staff reflecting metrics related to program costs, as well as notices processed, cases opened (along with case type such as probate, set aside, trust, lien, or other applicable case type), cases closed (along with reasons for closure), total claim Data amount, and total money received on each case. All such records as related to payments and/or cases shall be identified with name of decedent to whom it applies, and due care taken to protect PHI in the transmission of the same to MER program staff. MER monthly reporting shall include volume of monthly cases opened/closed to include regular and probates, all recoveries by type (i.e. Lien Recoveries, Probate Recoveries, Standard Recoveries and Special Needs Trusts. Report to also include all letters sent and future action dates needed. | | 6.4.1 | |
| RFP Requirements HIPP | Vendor Proposal Section | Citation/RFP Section | Vendor Proposal Subsection | Satisfies RFP Requirement? | Reportable? Y/N? | Comment |
| Vendor shall use the State Method on Cost Effectiveness of Group Health Plans as detailed in the State Plan, Attachment 4.22-C page 1. | | 9.2.2 | | | | |
| Vendor shall process applications and determine a recipient’s eligibility within 14 days of receipt. | | 9.2.3 | | | | |
| If recipient is not eligible, vendor shall send a denial letter to the recipient. | | 9.2.3.1 | | | | |
| If recipient is eligible, vendor shall send an acceptance letter to the recipient and enter the data into MMIS. | | 9.2.3.2 | | | | |
| Describe the outreach methods vendor shall use to contact recipients for purposes of completing an application for the HIPP program. | | 9.3.2 | | | | |
| If issues are found within the submitted documentation, such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours. | | 9.7.1 | | | | |
| Any refunds submitted to NVHA for processing with data entry errors shall result in an error fee of $1,000.00 per Manual Transaction Form (MTF) transaction. | | 9.6.2.3 | | | | |
| Vendor shall be responsible for data entry errors made in MMIS that require a system data correction by NVHA’s Fiscal Agent. This includes all system hours related to research and statement of work. | | 9.6.2.4 | | | | |
| Vendor shall submit a plan for the day-to-day management of the HIPP program including, but not limited to, the following elements: | | | | | | |
Records maintenance system and integration with MMIS, including real-time access for NVHA;
The method and process used to make the payments needed under the program At least two Vendor contacts, a primary and an alternate, to coordinate with NVHA;
Premium payment methods and procedures for direct pay to insurers, employers, and reimbursement of premiums deducted from payrolls 9.6.1, 9.6.1.1-9.6.1.4
| Compliance Rules and Consequences | Vendor Proposal Section | Citation/RFP Section | Vendor Proposal Subsection | Satisfies RFP Requirement? | Reportable? Y/N? | Comment |
| Vendor shall notify NVHA within 24 hours of discovery of any confirmed or suspected: | | | | | | |
Security incident, Unauthorized disclosure of protected or confidential information, Significant operational failure, Material compliance issue,
| Or vendor error that may impact contractual services, data integrity, system operations, reporting, or security obligations. | | 1.5.6 |
| | Vendor shall notify NVHA within 24 hours of discovery of: |
| actual or projected operational backlogs, | |
service delivery failures, processing delays, staffing shortages, system outages,
| or other conditions that may materially impact contractual performance, operational timelines, reporting obligations, or service levels. | 1.8.6,1.8.6.1-1.8.6.6 |
| Vendor shall notify NVHA within 24 hours of discovery of any confirmed or suspected: |
security incident, unauthorized disclosure of protected or confidential information, significant operational failure, material compliance issue,
| or vendor error that may impact contractual services, data integrity, system operations, reporting, or security obligations. | 1.5.6 | |
| Vendor shall comply with the following. Refer to RFP Attachment – Vendor Recovery & Recoup Checklist pertaining to this Section 1.4 Standard Requirements. Vendor shall review and complete each section and submit response with vendor proposal. | 1.4 |
| Vendor shall maintain and operate all systems, infrastructure, applications, and services supporting this Contract in accordance with applicable Federal and State laws, regulations, and NVHA security requirements, including HIPAA and applicable Nevada privacy and security statutes. | 1.5.1 |