RFP Attachment - Vendor Recovery Recoup Checklist.xlsx

Contract Oversight Checklist

of this contract into an established State of Nevada account within twenty-four (24) hours of the receipt of funds.

deposits accompanied by copies of deposit slips, check copies, and bank receipts to NVHA on a daily basis.

to a billing or a claim in the MMIS) when funds are received, and post EOB denials or receipt of recovery, to the appropriate accounts receivable, within ten (10)

data in the MMIS system must be completed within thirty (30) days of receipt of the collection (i.e., check,

details, or that are not proven to be owed to the NVHA by the ninety (90) day threshold, must be

day shall be logged by the The Vendor. This log shall be submitted to the NVHA for review as appropriate at

report of all accounting activities that includes recovery

the NVHA for review and approval no later than 5:00 P.M. PST on the first business day following month

be used, desk and field review approaches, peer or professional review approaches, capacity of reviews typically handled by the The Vendor during a specific time frame, and templates of typical review reports. The work plan shall include operating procedures related to

statistical, or peer-review methods, or combinations thereof to make the determination of improper payment. Therefore, the plan shall describe the The Vendor’s principle methodologies to be considered in making determinations of magnitude of improper payment. The plan shall also include specifics to address the The Vendor’s ability and approaches to provide expert witness support at the State’s administrative

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 must also include the backlog of cases. The State must have access to this tracking

payors, The 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. The The Vendor shall take all appropriate measures to avoid, detect

recoupment files and accounts receivables/deposit receipt forms as appropriate in order to recoup Medicaid overpayments and in-line with the

containing the adjusted claims on the first business day of each month for claims adjusted during the previous month. This file format will be determined through collaboration between The Vendor and the NVHA within thirty (30) days of contract

claims in the MMIS, shall be completed within thirty

(30) business days after the determination that an

deliverables including documentation supporting the collection of funds and summary documents needed for reporting and accounting as outlined in previous

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 The Vendor, computer routines, reports, and analyses developed, derived, documented, or furnished by the Contractor as the result of this contract. To assist in the identification of improper Medicaid payments at a minimum, the The Vendor shall deliver or participate in: VD Recovery Audit

algorithm The Vendor and other statistical instruments used for post-payment reviews of claims data; VD Recovery Audit

reviews of claims data in vulnerable billing and servicing areas that will be reviewed in the work program including a schedule and review of work done in the previous quarter; VD Recovery Audit

and data quality issues that reduce the effectiveness of improper payment identifications. VD Recovery Audit

review of suspected improper payments. In assisting in improper Medicaid payment reviews, at minimum, the vendor shall: VD Recovery Audit

Audit

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 must also include the backlog of cases. The State must have access to this tracking system; VD Recovery Audit

findings, The 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, Billing Guidelines, Federal Policy, etc. The letter shall include a description of the provider’s appeal rights and the name of a RAC employee they can contact for more information. The State must approve the letter template format and content. VD Recovery Audit

mutually agreed upon format, a listing of specific claims to be adjusted for each payment received and for each offset to be applied. Refer to Attachment L – Listing of Claims. VD Recovery Audit

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. VD Recovery Audit

Audit

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. VD Recovery Audit

containing the adjusted claims once a month. This file format will be determined through collaboration between the The Vendor and the NVHA within thirty (30) days of contract implementation. VD Recovery Audit

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 is the responsibility of The Vendor to provider all necessary data to the NVHA to complete the refund process. VD Recovery Audit

identification, audit, and recovery of improper Medicaid payments through reviewing claims data. The 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. The vendor shall be required to conform to federal requirements of the RAC program. VD Recovery Audit

approval by the State prior to beginning work on provider reviews. The vendor will 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. VD Recovery Audit

three (3) years prior to the contract date as well as claims data incurred during the contracting period. The State will reserve the right to direct the vendor to use other data sources to aid improper payment identifications. VD Recovery Audit

the The 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. The vendor will ensure that the reporting plan fulfills both the requirements of the State and of CMS. VD Recovery Audit

deliverables including documentation supporting the collection of funds and summary documents needed for reporting. VD Recovery Audit

such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours. [see Deliverables schedule] The Vendor is responsible for working with the NVHA to determine file layouts for all deliverables.

The NVHA reserves the right to direct the vendor to amend or update all Reports in accordance with the best interest of the state and at no cost to the NVHA VD Recovery Audit Contractor 2.34.3

tracking cases and reporting case information to the necessary NVHA staff, including time, effort and the cost of recovery. This should be done by the 15th of the month following the completion of those duties. VC Managed Care Secondary

deliverables including documentation supporting the collection of funds and summary documents needed for reporting. VC Managed Care Secondary

such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours. [see Deliverables schedule] *Page 112 VC Managed Care Secondary Recovery 2.26.3

identified encounters, per the file layout in Attachment M - MCO 210 Recoveries Report. VI Managed Care TPL Data Exchange and

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 Attachment N - TPL Comparison Report. VI Managed Care TPL Data Exchange and

evaluation, identifying, at a minimum, the number of encounters that matched and the number of encounters not reported by the MCO for which the Vendor identified other health insurance coverage was available. VI Managed Care TPL Data Exchange and

such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours. VI Managed Care TPL Data Exchange and Evaluation 2.72.1

Effectiveness of Group Health Plans as detailed in the State Plan, Attachment 4.22-C page 1. VH Health Insurance Premium Payment (HIPP)

Insurance Premium Payment (HIPP)

Insurance Premium Payment (HIPP)

acceptance letter to the recipient and enter the data into the MMIS. VH Health Insurance Premium Payment (HIPP)

contact recipients for purposes of completing an application for the HIPP program. VH Health Insurance Premium Payment (HIPP)

such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours. [see Deliverables table] - page 148 The Vendor is responsible for working with the NVHA to determine file layouts for all deliverables.

The NVHA reserves the right to direct The Vendor to amend or update all Reports in accordance with the best interest of the state and at no cost to the NVHA VH Health Insurance Premium Payment (HIPP)

collaborative data quality process to assist NVHA with the prevention of, and provide the functionality of preventing, new errors entering the system. VH Health Insurance Premium Payment (HIPP) Program 2.65.6

backlog for any component of the Contract resulting from this RFP, the Vendor shall notify the NVHA in person, via telephone or electronic mail, within 24

Officer, within 24 hours of discovery, any use or disclosure of PHI not provided for in the Contract

such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours. [see Deliverables schedule] "The Vendor is responsible for working with the NVHA to determine file layouts for all deliverables.

The NVHA reserves the right to direct the vendor to amend or update all Reports in accordance with the

such as illegible documents, incorrect data, or incomplete reports, they should be resolved in writing within 24 hours. [see Deliverables schedule] The Vendor is responsible for working with the NVHA to determine file layouts for all deliverables.

The NVHA reserves the right to direct the vendor to amend or update all Reports in accordance with the best interest of the state and at no cost to the NVHA VC Managed Care Secondary Recovery 2.26.3