RFP Document.pdf

STATE OF SOUTH DAKOTA

DEPARTMENT OF SOCIAL SERVICES

700 GOVERNORS DRIVE

PIERRE, SD 57501

Medicaid Dental Adjudication and Admin. Services PROPOSALS ARE DUE NO LATER THAN MARCH 13th, 2025, BY 5PM CST.

RFP12174 STATE POC: Kirsten Blachford EMAIL: Kirsten.Blachford@state.sd.us

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mailto:Kirsten.Blachford@state.sd.us

1.0 GENERAL INFORMATION

1.1 PURPOSE OF REQUEST FOR PROPOSAL

The Division of Medical Services is issuing this request for proposals (RFP) from offerors to provide dental and orthodontic claims adjudication and other administrative services as described in 3.0 Scope of Work for the dental benefits provided under the South Dakota Medical Services program.

1.2 ISSUING OFFICE AND RFP REFERENCE NUMBER

The Division of Medical Services is the issuing office for this document and all subsequent addenda relating to it, on behalf of the State of South Dakota, Department of Social Services. The reference number for the transaction is RFP12174. This number must be referred to on all proposals, correspondence, and documentation relating to the RFP.

1.3 LETTER OF INTENT

All interested offerors are requested to submit a non-binding Letter of Intent to respond to this RFP. While preferred, a Letter of Intent is not mandatory to submit a proposal.

Be sure to reference the RFP number in your letter.

The Letter of Intent must be submitted to Kirsten Blachford via email at Kirsten.Blachford@state.sd.us no later than January 2nd, 2025. Please place the following in the subject line of your email: “Letter of Intent for RFP12174”.

1.4 SCHEDULE OF ACTIVITIES (SUBJECT TO CHANGE)

RFP Publication December 12, 2024 Letter of Intent to Respond Due January 2, 2025 Offeror Questions Due January 16, 2025 Responses to Offeror Questions January 30, 2025 Request for SFTP folder March 12, 2025 Proposal Submission March 13, 2025 Oral Presentations/discussions (if required) TBD Proposal Revisions (if required) TBD Anticipated Award Decision/Contract Negotiation April 10, 2025

1.5 SUBMITTING YOUR PROPOSAL

All proposals must be completed and received by Division of Medical Services by the date and time indicated in the Schedule of Activities.

Proposals received after the deadline will be late and ineligible for consideration.

Proposals must be submitted as PDFs via Secured File Transfer Protocol (SFTP). Offerors must request an SFTP folder no later than the date indicated in the Schedule of Activities by emailing Kirsten Blachford at Kirsten.Blachford@state.sd.us.

The subject line should read “RFP12174 SFTP Request.” The email should contain the name and the email of the person who will be responsible for uploading the document(s).

Please note, offeror will need to work with their own technical support staff to set up an SFTP compatible software on offeror’s end. While the State of South Dakota can answer questions, State of South Dakota is not responsible for the software required.

All proposals may be signed in ink or digitally by an officer of the offeror legally authorized to bind the offeror to the proposal and sealed in the form intended by the respondent. Proposals that are not properly signed may be rejected.

No proposal may be accepted from, or any contract or purchase order awarded to any person, firm or corporation that is in arrears upon any obligations to the State of South Dakota, or that otherwise may be deemed irresponsible or unreliable by the State of South Dakota.

1.6 CERTIFICATION REGARDING DEBARMENT, SUSPENSION, INELIGIBILITY, AND

VOLUNTARY EXCLUSION – LOWER TIER COVERED TRANSACTIONS

By signing and submitting this proposal, the offeror certifies that neither it nor its principals is presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation, by any Federal department or agency, from transactions involving the use of Federal funds. Where the offeror is unable to certify to any of the statements in this certification, the bidder shall attach an explanation to their offer.

1.7 NON-DISCRIMINATION STATEMENT

The State of South Dakota requires that all contractors, vendors, and suppliers doing business with any State agency, department, or institution, provide a statement of non-discrimination. By signing and submitting their proposal, the offeror certifies they do not discriminate in their employment practices with regard to race, color, creed, religion, age, sex, ancestry, national origin or disability.

1.8 CERTIFICATION RELATING TO PROHIBITED ENTITY

For contractors, vendors, suppliers, or subcontractors who enter into a contract with the State of South Dakota by submitting a response to this solicitation or agreeing to contract with the State, the bidder or offeror certifies and agrees that the following information is correct:

The bidder or offeror, in preparing its response or offer or in considering proposals submitted from qualified, potential vendors, suppliers, and subcontractors, or in the solicitation, selection, or commercial treatment of any vendor, supplier, or subcontractor, is not an entity, regardless of its principal place of business, that is ultimately owned or controlled, directly or indirectly, by a foreign national, a foreign parent entity, or foreign government from China, Iran, North Korea, Russia, Cuba, or Venezuela, as defined by SDCL 5-18A. It is understood and agreed that, if this certification is false, such false certification will constitute grounds for the State to reject the bid or response submitted by the bidder or offeror on this project and terminate any contract awarded based on the bid or response. The successful bidder or offeror further agrees to provide immediate written notice to the contracting executive branch agency if during the term of the contract it no longer complies with this certification and agrees such noncompliance may be grounds for contract termination.

1.9 RESTRICTION OF BOYCOTT OF ISRAEL

For contractors, vendors, suppliers, or subcontractors with five (5) or more employees who enter into a contract with the State of South Dakota that involves the expenditure of one hundred thousand dollars ($100,000) or more, by submitting a response to this solicitation or agreeing to contract with the State, the bidder or offeror certifies and agrees that the following information is correct:

The bidder or offeror, in preparing its response or offer or in considering proposals submitted from qualified, potential vendors, suppliers, and subcontractors, or in the solicitation, selection, or commercial treatment of any vendor, supplier, or subcontractor, has not refused to transact business activities, has not terminated business activities, and has not taken other similar actions intended to limit its commercial relations, related to the subject matter of the bid or offer, with a person or entity on the basis of Israeli national origin, or residence or incorporation in Israel or its territories, with the specific intent to accomplish a boycott or divestment of Israel in a discriminatory manner. It is understood and agreed that, if this certification is false, such false certification will constitute grounds for the State to reject the bid or response submitted by the bidder or offeror on this project and terminate any contract awarded based on the bid or response. The successful bidder or offeror further agrees to provide immediate written notice to the contracting executive branch agency if during the term of the contract it no longer complies with this certification and agrees such noncompliance may be grounds for contract termination.

1.10 CERTIFICATION OF NO STATE LEGISLATOR INTEREST

Offeror (i) understands neither a state legislator nor a business in which a state legislator has an ownership interest may be directly or indirectly interested in any contract with the State that was authorized by any law passed during the term for which that legislator was elected, or within one year thereafter, and (ii) has read South Dakota Constitution Article 3, Section 12 and has had the opportunity to seek independent legal advice on the applicability of that provision to any Agreement entered into as a result of this RFP. By signing an Agreement pursuant to this RFP, Offeror hereby certifies that the Agreement is not made in violation of the South Dakota Constitution Article 3, Section 12.

1.11 MODIFICATION OR WITHDRAWAL OF PROPOSALS

Proposals may be modified or withdrawn by the offeror prior to the established due date and time.

No oral, telephonic, telegraphic, or facsimile responses or modifications to informal, formal bids, or Request for Proposals will be considered.

1.12 OFFEROR INQUIRIES

Offerors may email inquiries concerning this RFP to obtain clarification of requirements. No inquiries will be accepted after the date and time indicated in the Schedule of Activities. Inquiries must be emailed to Kirsten Blachford at Kirsten.Blachford@state.sd.us with the subject line

“RFP12174”.

The State will to respond to offeror’s inquiries (if required) via e-mail. In addition, all inquiries and the State’s responses will be posted on the state’s e-procurement system and the DSS website at http://dss.sd.gov/keyresources/rfp.aspx. Offerors may not rely on any other statements, either of a written or oral nature, that alter any specification or other term or condition of this RFP.

Offerors will be notified in the same manner as indicated above regarding any modifications to this RFP.

1.13 PROPRIETARY INFORMATION

The proposal of the successful offeror(s) becomes public information. Proprietary information can be protected under limited circumstances such as client lists and non-public financial statements.

An entire proposal may not be marked as proprietary. Offerors must clearly identify in the Executive Summary and mark in the body of the proposal any specific proprietary information they are requesting to be protected. The Executive Summary must contain specific justification explaining why the information is to be protected. Proposals may be reviewed and evaluated by any person at the discretion of the State. All materials submitted become the property of the State of South Dakota and may be returned only at the State's option.

1.14 LENGTH OF CONTRACT

The contract resulting from this RFP will be issued for a period of three (3) years, June 1, 2026, to May 31, 2029, with the option of renewal for up to two (2), one (1) year contracts at the discretion of the state. Contracts will be negotiated on an annual basis.

1.15 GOVERNING LAW

Venue for any and all legal action regarding or arising out of the transaction covered herein shall be solely in the State of South Dakota. The laws of South Dakota shall govern this transaction.

http://dss.sd.gov/keyresources/rfp.aspx

1.16 DISCUSSIONS WITH OFFERORS (ORAL PRESENTATION/NEGOTIATIONS)

An oral presentation by an offeror to clarify a proposal may be required at the sole discretion of the State. However, the State may award a contract based on the initial proposals received without discussion with the offeror. If oral presentations are required, they will be scheduled after the submission of proposals. Oral presentations will be made at the offeror’s expense.

This process is a Request for Proposal/Competitive Negotiation process. Each Proposal shall be evaluated, and each respondent shall be available for negotiation meetings at the State’s request.

The State reserves the right to negotiate on any and/or all components of every proposal submitted. From the time the proposals are submitted until the formal award of a contract, each proposal is considered a working document and as such, will be kept confidential. The negotiation discussions will also be held as confidential until such time as the award is completed.

2.0 STANDARD AGREEMENT TERMS AND CONDITIONS

Any contract or agreement resulting from this RFP will include the State’s standard terms and conditions as listed below and as seen in Attachment A, along with any additional terms and conditions that may be necessary to the performance of the scope of work as seen in Attachment A.1 Bureau of Information and Telecommunications Required IT Contract Terms. As part of the negotiation process, the contract terms listed in Attachment A.1 may be altered or deleted. The offeror must indicate in its response any issues it has with specific contract terms in Attachment A.1. If the offeror does not indicate that there are any issues with the contract terms in Attachment A.1, then the State will assume those terms are acceptable to the offeror.

2.1 The Contractor will perform those services described in the Scope of Work, attached hereto as

Section 3.0 of the RFP and by this reference incorporated herein.

2.2 The Contractor’s services under this Agreement shall commence on June 1, 2026 and end on May 31, 2029, unless sooner terminated pursuant to the terms hereof. Contracts will be negotiated on an annual basis.

2.3 The Contractor will use State equipment, supplies or facilities. YES ( ) NO ( X )

2.4 The Contractor will provide the State with its Employer Identification Number, Federal Tax

Identification Number or Social Security Number upon execution of this Agreement.

2.5 The State will make payment for services upon satisfactory completion of the services. The

TOTAL CONTRACT AMOUNT is an amount not to exceed $ . The State will not pay Contractor's expenses as a separate item. Payment will be made pursuant to itemized invoices submitted with a signed state voucher. Payment will be made consistent with SDCL ch. 5-26.

2.6 The Contractor agrees to indemnify and hold the State of South Dakota, its officers, agents and employees, harmless from and against any and all actions, suits, damages, liability or other proceedings that may arise as the result of performing services hereunder. This section does not require the Contractor to be responsible for or defend against claims or damages arising solely from errors or omissions of the State, its officers, agents or employees.

2.7 The Contractor, at all times during the term of this Agreement, shall obtain and maintain in force insurance coverage of the types and with the limits as follows:

A. Commercial General Liability Insurance:

The Contractor shall maintain occurrence based commercial general liability insurance or equivalent form with a limit of not less than $1,000,000.00 for each occurrence. If such insurance contains a general aggregate limit, it shall apply separately to this Agreement or be no less than two times the occurrence limit.

B. Professional Liability Insurance or Miscellaneous Professional Liability Insurance:

The Contractor agrees to procure and maintain professional liability insurance or miscellaneous professional liability insurance with a limit not less than $1,000,000.00.

C. Business Automobile Liability Insurance:

The Contractor shall maintain business automobile liability insurance or equivalent form with a limit of not less than $1,000,000.00 for each accident. Such insurance shall include coverage for owned, hired, and non-owned vehicles.

D. Worker’s Compensation Insurance:

The Contractor shall procure and maintain workers’ compensation and employers’ liability insurance as required by South Dakota law. Before beginning work under this Agreement, Contractor shall furnish the State with properly executed Certificates of Insurance which shall clearly evidence all insurance required in this Agreement. In the event a substantial change in insurance, issuance of a new policy, cancellation or nonrenewal of the policy, the Contractor agrees to provide immediate notice to the State and provide a new certificate of insurance showing continuous coverage in the amounts required. The contractor shall furnish copies of insurance policies if requested by the State.

2.8 While performing services hereunder, the Contractor is an independent contractor and not an officer, agent, or employee of the State of South Dakota.

2.9 Contractor agrees to report to the State any event encountered in the course of performance of this Agreement which results in injury to the person or property of third parties, or which may otherwise subject Contractor or the State to liability. Contractor shall report any such event to the State immediately upon discovery.

Contractor's obligation under this section shall only be to report the occurrence of any event to the State and to make any other report provided for by their duties or applicable law. Contractor's obligation to report shall not require disclosure of any information subject to privilege or confidentiality under law (e.g., attorney-client communications). Reporting to the State under this section shall not excuse or satisfy any obligation of Contractor to report any event to law enforcement or other entities under the requirements of any applicable law.

2.10 This Agreement may be terminated by either party hereto upon thirty (30) days written notice. In the event the Contractor breaches any of the terms or conditions hereof, this Agreement may be terminated by the State at any time with or without notice. If termination for such a default is affected by the State, any payments due to Contractor at the time of termination may be adjusted to cover any additional costs to the State because of Contractor's default. Upon termination the State may take over the work and may award another party an agreement to complete the work under this Agreement. If after the State terminates for a default by Contractor it is determined that Contractor was not at fault, then the Contractor shall be paid for eligible services rendered and expenses incurred up to the date of termination.

2.11 This Agreement depends upon the continued availability of appropriated funds and expenditure authority from the Legislature for this purpose. If for any reason the Legislature fails to appropriate funds or grant expenditure authority, or funds become unavailable by operation of law or federal funds reductions, this Agreement will be terminated by the State. Termination for any of these reasons is not a default by the State nor does it give rise to a claim against the State.

2.12 This Agreement may not be assigned without the express prior written consent of the State. This Agreement may not be amended except in writing, which writing shall be expressly identified as a part hereof and be signed by an authorized representative of each of the parties hereto.

2.13 This Agreement shall be governed by and construed in accordance with the laws of the State of

South Dakota. Any lawsuit pertaining to or affecting this Agreement shall be venued in Circuit Court, Sixth Judicial Circuit, Hughes County, South Dakota.

2.14 The Contractor will comply with all federal, state and local laws, regulations, ordinances, guidelines, permits and requirements applicable to providing services pursuant to this Agreement, and will be solely responsible for obtaining current information on such requirements.

2.15 The Contractor may not use subcontractors to perform the services described herein without the express prior written consent of the State. The Contractor will include provisions in its subcontracts requiring its subcontractors to comply with the applicable provisions of this Agreement, to indemnify the State, and to provide insurance coverage for the benefit of the State in a manner consistent with this Agreement. The Contractor will cause its subcontractors, agents, and employees to comply, with applicable federal, state and local laws, regulations, ordinances, guidelines, permits and requirements and will adopt such review and inspection procedures as are necessary to assure such compliance.

2.16 Contractor hereby acknowledges and agrees that all reports, plans, specifications, technical data, miscellaneous drawings, software system programs and documentation, procedures, or files, operating instructions and procedures, source code(s) and documentation, including those necessary to upgrade and maintain the software program, and all information contained therein provided to the State by the Contractor in connection with its performance of services under this Agreement shall belong to and is the property of the State and will not be used in any way by the Contractor without the written consent of the State. Papers, reports, forms, software programs, source code(s) and other material which are a part of the work under this Agreement will not be copyrighted without written approval of the State.

2.17 The Contractor certifies that neither Contractor nor its principals are presently debarred, suspended, proposed for debarment or suspension, or declared ineligible from participating in transactions by the federal government or any state or local government department or agency.

Contractor further agrees that it will immediately notify the State if during the term of this Agreement Contractor or its principals become subject to debarment, suspension or ineligibility from participating in transactions by the federal government, or by any state or local government department or agency.

2.18 Any notice or other communication required under this Agreement shall be in writing and sent to the address set forth above. Notices shall be given by and to on behalf of the State, and by , on behalf of the Contractor, or such authorized designees as either party may from time to time designate in writing. Notices or communications to or between the parties shall be deemed to have been delivered when mailed by first class mail, provided that notice of default or termination shall be sent by registered or certified mail, or, if personally delivered, when received by such party.

2.19 In the event that any court of competent jurisdiction shall hold any provision of this Agreement unenforceable or invalid, such holding shall not invalidate or render unenforceable any other provision hereof.

2.20 All other prior discussions, communications and representations concerning the subject matter of this Agreement are superseded by the terms of this Agreement, and except as specifically provided herein, this Agreement constitutes the entire agreement with respect to the subject matter hereof.

3.0 SCOPE OF WORK

The Department of Social Services strives to meet its mission of strengthening and supporting individuals and families by promoting cost effective and comprehensive services in connection with our partners that foster independent and healthy families. We believe that strong families are South Dakota’s foundation and future.

An efficient and robust Medicaid program is essential to that mission, and one of the key components of South Dakota’s Medical Services program is a comprehensive dental benefit for children and adults, with medically necessary orthodontic services as a benefit for qualifying children.

The offeror selected as a result of this RFP will act in the capacity of an administrative service organization to the Division of Medical Services.

Respondents must provide a response describing how the offeror intends to meet each of the following requirements. Respondents are strongly encouraged to propose innovative solutions targeted at meeting South Dakota Medicaid recipient needs in alignment with Department-specified objectives for the dental program. The anticipated cost of any innovative solutions must be included in the cost proposal.

3.1 Receive South Dakota Medicaid dental claims directly from South Dakota Medicaid dental providers:

• Approximately 8,000 IHS dental claims annually;

• Approximately 12,000 FQHC dental claims annually; and

• Approximately 107,000 private practice claims annually.

3.2 Adjudicate and pay South Dakota Medicaid dental and orthodontic claims using an automated processing system. Utilize the most updated dental claim form.

3.3 South Dakota prefers a system that is certified by the Centers for Medicare and Medicaid Services. If certified in South Dakota, the offeror should include a verification of certification. If not yet certified in South Dakota, offerors should include a description of the states the system has been certified in and a plan to achieve certification within 18 months of implementation of the contract.

3.4 Adjudicate and pay South Dakota Medicaid dental and orthodontic claims in accordance with

Federal and State regulations and according to the South Dakota Medicaid State Plan.

3.5 The offeror must adjudicate and pay claims, on average, within seven (7) business days of receipt.

3.6 Provide remittance advice or other appropriate written notice specifically identifying all information and documentation that is required when a claim is partially or totally denied.

3.7 Establish and maintain an appeal process for claims denials.

3.8 Provide South Dakota Medicaid with reimbursement rate calculations annually, including inflationary increases and additional scenarios upon request, and complete a reimbursement analysis as required by SDCL 28-6-1.2. The Division of Medical Services will provide background materials and methodology used to complete the analysis upon contract award.

3.9 Reimburse South Dakota Medicaid dental and orthodontic claims according to reimbursement rates published in the fee schedule for non-FQHC and non-Indian Health Service (IHS) providers.

3.10 Reimburse FQHC dental services based on encounter rates updated annually (rates will be provided to the offeror by the Division of Medical Services).

https://sdlegislature.gov/Statutes/28-6-1.2

3.11 Reimburse IHS dental services based on encounter rates updated annually. Claims paid for dental services provided by or referred by IHS must be tracked by the offeror and distinguished from other dental claims in reports and claims data.

3.12 Track services referred from IHS to non-IHS dental providers via a care coordination agreement allowing for 100% FMAP reimbursement.

3.13 Notify providers of adjudication results with an electronic explanation of benefits (EOB).

3.14 Notify recipients of service limits, adjudication results, progress towards $2,000 annual max, and out-of-pocket costs in an electronic and paper format.

3.15 Adjudicate and pay South Dakota Medicaid dental and orthodontic claims from South Dakota

Medicaid enrolled providers only. Claims submitted by non-enrolled providers must be denied until the provider is enrolled.

3.16 Adjudicate and pay South Dakota Medicaid claims from South Dakota Medicaid enrolled

Anesthesiologists and Certified Registered Nurse Anesthetists (CRNAs) who provide anesthesia services in a dental setting where the associated professional services will be reimbursed.

3.17 Use billing NPI, servicing NPI, ordering NPI, and referring NPI along with taxonomy and, as necessary, zip code to identify South Dakota Medicaid enrolled providers and verify enrollment prior to claims payment. Claims submitted by non-enrolled providers must be denied until the provider is enrolled.

3.18 Confirm that any ordering or referring NPI on the claim is enrolled with SD Medicaid for the date of service (DOS) prior to claims payment. Claims submitted by non-enrolled providers must be denied until the provider is enrolled.

3.19 Require billing and servicing NPI to be populated on claims and the combination of NPI to be utilized to identify South Dakota Medicaid enrolled providers and verify enrollment for the DOS prior to claims payment. Claims submitted by non-enrolled providers must be denied until the provider is enrolled.

3.20 Implement policies and procedures to encourage increased submission of electronic claims.

3.21 Edit claims from providers based upon a list of edits agreed upon with the State and chosen substantively from, but not necessarily limited to, the following:

• Denial for billing NPI not on file;

• Denial for referring/ordering NPI not on file;

• Denial for servicing NPI not on file;

• Denial for billing provider not eligible on date of service;

• Denial for servicing provider not eligible on date of service;

• Billing provider NPI missing;

• Servicing provider NPI missing;

• Provider taxonomy/service conflict;

• Denial for invalid/excluded provider;

• Provider requires review;

• Procedure code not covered;

• Procedure date restriction;

• Procedure age restriction;

• Service date invalid or missing;

• Service date beyond the span of billing time;

• EPSDT-related review;

• Procedure code invalid or missing;

• Procedure code outdated;

• Procedure modifier missing if modifier required;

• Tooth/quadrant code invalid;

• Procedure requires prior authorization;

• Procedure denied by dental consultant review;

• Anesthesia units not numeric greater than zero;

• Procedure code and/or surface code invalid;

• Tooth code missing, required for this procedure;

• Deciduous/permanent tooth conflict;

• Service limitation error for this procedure;

• No caries risk assessment on file;

• Dentures must be within six (6) months of the last extraction;

• Consultant review for procedure modifier;

• No payment—Service is an integral part of another service;

• Service not medically necessary;

• Restricted program, documentation required;

• Procedure/Service not pregnancy-related;

• Parental permission for procedure/treatment not obtained;

• Recipient requires review/prior authorization;

• Recipient’s record not on file;

• Recipient not eligible on date of service;

• Recipient’s ID invalid/missing/non-numeric;

• Recipient’s first name disagrees with the name on record;

• Recipient’s last name disagrees with the name on record;

• Recipient’s age disagrees with age on record;

• Recipient’s ID disagrees with the record;

• Recipient’s status is invalid;

• Recipient’s claims total exceeds $2,000 (non-emergency services);

• Recipient’s record shows dental insurance coverage;

• Recipient’s aid category invalid;

• Recipient and aid category conflict;

• Incorrect claim form submitted;

• Claim exceeds the 6-month limit;

• Exact duplicate of another claim;

• Possible duplicate of another claim;

• Resubmit manual claim with operative report;

• Required information missing, claim being returned;

• Denied—Insurance payment exceeds Medicaid payment;

• Conflict with another claim;

• Accident indicated—requires review for TPL;

• Trauma indicated—requires review for TPL;

• Claim form indicates possible presence of TPL;

• Signature missing from submitted claim;

• Zip+4 missing from claim form;

• Documentation insufficient for processing;

• Operator pended claim on entry.

Edits should be made on average within seven (7) business days of receipt.

3.22 Collect and verify all applicable forms of recipient third-party coverage and exchange data with the State to update records of third-party coverage.

3.23 Electronically accept and exchange data files in the format and timeframes specified by the State for all necessary data exchange to administer the dental benefit. Current file exchanges include:

• Acceptance of a daily (Monday through Saturday) 834 X12 standard transaction file including third-party insurance.

• Acceptance of a monthly 820 X12 standard transaction file directly with Delta Dental. The files are sent monthly on the night of the 1st as a set of 10 files. The number of files in the set may increase over time and may not be received until early on the 2nd.

• Acceptance of daily provider extract file as contained in Attachment B.

• Acceptance of a daily exception indicator file as contained in Attachment B.1.

• Submission to the State of an 837 X12 standard transaction file containing information on dental encounters, claims generated, claims paid, claims denied, denial reasons, and third-party liability payment in agreed-upon intervals.

3.24 Electronically accept a weekly file in a format specified by the State of South Dakota with

Medicaid enrolled providers, indicating serving and billing National Provider Identified (NPI). Use provider file to match claims to enrolled providers.

3.25 Provide the Division of Medical Services with a copy of claims level details following each payment period. This file must include recipient, provider, and claim information agreed upon by the Division and the Vendor.

3.26 Accept return electronic file containing claims that did not match the MMIS system (i.e., provider enrollment). The Division of Medical Services will reimburse offeror for claims paid that, when submitted in the HIPAA compliant 837D transaction (currently version 5010) format, match information on the MMIS. Claims that do not match will be returned to offeror for remediation.

3.27 Perform approval or denial of prior authorization/predetermination on all requests for orthodontic procedures covered by South Dakota Medicaid on average, within seven (7) calendar days of receipt. Determinations of medical necessity must be based on standard clinical guidelines that are available to all enrolled providers. Clinical practice guidelines must be reviewed and/or updated annually.

3.28 Perform approval or denial of prior authorization/predetermination on those services designated by the Division of Medical Services as subject to prior authorization/predetermination limitations on average, within seven (7) business days of receipt. Determinations of medical necessity must be based on standard clinical practice guidelines that are available to all enrolled providers.

Clinical practice guidelines must be reviewed and/or updated annually.

3.29 Meet with the Division of Medical Services at least monthly and upon request to discuss status updates and address concerns.

3.30 Advise the Division of Medical Services on dental benefit policy matters including, but not limited to, standard changes in service delivery, standard changes in services covered, and standard changes in scope of practice, including changes to CDT codes. Policy recommendations and other requested work product must be submitted to the Division of Medical Services within 30 calendar days of the date of request unless a different length of time is specified or approved by the Division of Medical Services.

3.31 Advise the Division of Medical Services on oral surgery benefit inquiries and claims paid under the medical benefit upon request.

3.32 Propose changes to fee schedules, including the addition of or changes to CDT codes, bi-annually corresponding to the federal CDT changes. Changes must be proposed on the Division of Medical Services approved form, which will be provided at the time of contract award. Analysis of potential cost impact or neutrality must be included.

3.33 Provide a network development plan defining recruitment activity and initiatives by the respondent to increase the percentage of licensed dental and orthodontic providers that are enrolled in South Dakota Medicaid and meaningfully participating in Medicaid, particularly in regions of the State with the lowest access and utilization rates. Network adequacy goals include attaining Medicaid provider enrollment of 85 percent of licensed dentists in the state and 35 percent of enrolled dentists seeing 100 Medicaid recipients or more in a plan year from July 1 to June 30. The plan should target meeting these objectives within 24 months of the effective date of the contract. As of State Fiscal Year 2024, 77 percent of licensed dentists in South Dakota are enrolled Medicaid providers and 26 percent of enrolled dentists see 100 Medicaid recipients or more in a plan year.

The plan must include retention activities to prevent attrition of dental and orthodontic providers enrolled in South Dakota Medicaid. Examples of plan activities and strategies include sign-on bonuses for enrolling as a Medicaid provider and seeing a certain threshold of Medicaid patients, recognition or rewards programs for meeting access requirements or increasing quality of care, and strategies to enhance and increase the State’s dental workforce. An initial network development plan must be submitted at the start of the contract term and it must be updated annually. Results and expenditures associated with the programming must be reported annually in writing by June 30. The offeror’s response to this item should discuss proposed strategies to achieve these objectives.

3.34 Provide an annual provider training plan including a minimum of two trainings annually regarding subjects such as billing procedures, claims, Medicaid provider enrollment, medical necessity determinations, and provider appeals. Submit the plan at the start of each state fiscal year.

Report results by the end of each state fiscal year.

3.35 The offeror shall conduct provider surveys annually upon the request of the Division of Medical

Services. The survey results must be submitted to South Dakota Medicaid by the end of each state fiscal year.

3.36 Outreach non-South Dakota Medicaid enrolled providers who have submitted claims to refer them to the South Dakota Medicaid Provider Enrollment portal.

3.37 Operate a toll-free telephone service unit providing, at a minimum, the following support services for South Dakota Medicaid dental and orthodontia providers: South Dakota Medicaid eligibility confirmation, claims inquiry response, and covered services inquiry response. Vendor shall be available to Medicaid providers during standard business operating hours at a minimum, Monday- Friday 9:00am – 4:00 pm.

3.38 Operate and publicize a toll-free referral line to assist South Dakota Medicaid recipients access dental services. When possible, locate and permanently match recipients with a dental home.

Vendor shall be available to Medicaid recipients during standard business operating hours at a minimum, Monday-Friday 9:00 am – 4:00 pm.

3.39 Provide an annual program integrity work plan containing;

• Written policies, procedures, and standards of conduct compliant with applicable state and federal requirements;

• Identification of the Compliance Officer who develops policies, procedures, and practices to comply with contract requirements;

• Establishment of a Regulatory Compliance Committee;

• Training and education of organizational leaders and employees on program compliance requirements; and

• Procedures and dedicated staff for routine internal monitoring and auditing, response to, and investigation of compliance issues including self-audit and external reviews, and prompt correction of issues.

3.40 Provide regular updates to the activities outlined in the annual program integrity plan including external and internal audits, investigations, quality assurance reviews, and prompt reporting of suspected fraudulent activity.

3.41 Provide overpayment and abuse reports with sampling of services billed and verification they were received by recipients. Promptly report all overpayments identified or recovered, specifying overpayments due to potential fraud.

3.42 Host Quarterly Program Integrity Meetings with the Division of Medical Services to provide updates and discuss concerns.

3.43 Perform quality assurance and utilization reviews, both pretreatment and post-treatment, and report the results of the review to the Division of Medical Services biannually.

3.44 Provide the Division of Medical Services with claims payment data within five (5) business days of request.

3.45 Calculate and report to the Division of Medical Services DQA administrative claim measures as specified by the Division of Medical Services.

3.46 Provide monthly executive summary reports to the Division of Medical Services as specified by the Division of Medical Services. Reports may include:

• Call center’s volume of calls from recipients and providers, the subject of the calls, and the resolutions of the calls;

• Number of licensed providers in the state and enrolled in the program;

• Number of enrolled providers accepting new Medicaid recipients;

• Narrative of current provider recruitment and retention activities;

• Number of eligible recipients receiving services;

• Total expenditures for children and adult recipients;

• Expenditures per recipient per month based on claims paid;

• Total claim volume, average days of claim processing, and average days from claims receipt to claims processing;

• Number of calls to care coordinators, number of reports for at-risk recipients, and narrative of notable cases;

• Number of adult recipients who have met the $2,000 limit;

• Number of reconsideration requests, appeals, and grievances;

• Other data as requested by the Division of Medical Services.

3.47 Provide quarterly data dashboards to the Division of Medical Services as specified by the Division of Medical Services. Dashboards may include:

• Number of licensed providers in the state and enrolled in the program;

• Percentage of enrolled providers with claims submitted;

• Number of eligible recipients receiving services;

• Total paid claims by service category;

• Total claim volume, average days of claim processing, and average days from claims receipt to claims processing;

• Number of recipients who have met the $2,000 limit;

• Utilization summary of orthodontic services including approvals, denials, and appeals;

• Care Coordination outreach activities;

• Reconsideration requests, appeals, and grievances;

• Number of claims sent to review, Prior Authorizations issued, and the average days from

Prior Authorization receipt to Prior Authorization issuance;

• Call center’s volume of calls from recipients to providers, the subject of the calls, and the resolutions of the calls;

• Percentage of children and adults receiving select preventative services year to date;

• Number of recipients receiving select restorative services year to date;

• Number of hospital calls and expenditures year to date;

• Other data as requested by the Division of Medical Services.

3.48 Provide and implement a care coordination outreach and education plan to achieve and maintain the following objectives over the course of the contract period:

• Increase the percentage of enrolled children who received a comprehensive or periodic oral evaluation to 49%. As of Federal Fiscal Year 2023, 39% of children met this requirement.

• Increase the percentage of enrolled children with a dental visit by age 2 to 28%. As of

Federal Fiscal Year 2023, 18% of enrolled children met this requirement.

• Increase the percentage of enrolled children who received at least two topical fluoride applications as dental services to 25%. As of Federal Fiscal Year 2023, 15% of children met this requirement.

• Increase the percentage of enrolled children who received at least one sealant on a permanent first molar tooth by their 10th birthday to 72%. As of Federal Fiscal Year 2023, 62% of children met this requirement.

• Increase the percentage of enrolled adults who received a comprehensive or periodic oral evaluation to 25%. As of Federal Fiscal Year 2023, 15% of adults met this requirement.

• Increase the percentage of enrolled pregnant women who received a comprehensive or periodic oral evaluation during pregnancy to 19%. As of Federal Fiscal Year 2023, 9% of pregnant women met this requirement.

• Other objectives as agreed upon by the Division of Medical Services and the awarded vendor.

The care coordination, outreach, and education plan activities must include, but are not limited to:

• Assisting dental offices and recipients with overcoming barriers affecting access to care or treatment;

• Assisting eligible recipients to obtain dental care, including assisting recipients schedule appointments;

• Surveillance, identification, and follow up with recipients who have received restorative or emergent dental services and appear to need assistance in establishing routine periodic care;

• Connecting eligible recipients to a regular dental provider;

• Referring eligible recipients to community resources; and

• Educating recipients and their families on the importance of oral health and preventative dental services, the Medicaid dental benefit, obtaining dental services, overcoming fear of dental services, home care, and making informed decisions about oral health needs.

Recipient education must include a minimum of two direct mailings per year to Medicaid recipients. The offeror should also propose other communication strategies they will utilize to educate Medicaid recipients.

Care coordination, outreach, and education strategies and activities must be documented in a plan. The plan must be updated and approved by the Division of Medical Services annually by June 30. Offerors must describe proposed strategies and activities to be performed, including relevant evidence to support strategies and activities, relationship to outcome measures, proposed monitoring metrics, and the timeframe for implementation in response to this request for proposal. The selected offeror must demonstrate progress and report on activities and outcomes in the monthly and quarterly data dashboards.

3.49 Describe proposed programs or initiatives intended to address access to dental services for Medicaid recipients. Programs may include a targeted focus on specific populations such as the pediatric population, recipients with developmental disabilities, and pregnant women. Proposals may also focus on programs intended to increase access for the Medicaid population in general.

Examples of programs or initiatives include add-on payments to promote utilization and access to key services, supplemental provider payments for achieving quality metrics, strategies to increase appointment compliance, and strategies to enhance case management and care coordination services within dental offices.

3.50 Assist the Division of Medical Services with the design and implementation of at least one quality initiative intended to achieve, through ongoing measurements and intervention, significant improvement sustained over time in one clinical care area that is expected to have a favorable effect on health outcomes and recipient satisfaction.

3.51 Describe your proposed staffing plan for the professional staff that will be utilized to meet the scope of work requirements including contract management, project management, claims processing management, data analytics management, program integrity management, policy staff, and care coordinators. Include the proposed percentage of time that they will spend working on contract activities. Please include a short explanation of staff’s experience and qualifications as well as resumes.

3.52 Transition to the offeror shall be as seamless as possible for South Dakota Medicaid recipients and their Providers. Established Medicaid recipients and Provider relationships, existing treatment protocols, and ongoing care plans shall not be impacted significantly by this procurement:

• The offeror will be responsible for developing a written work plan, referred to as the

Transition Plan, which will be used to monitor progress throughout the Transition Phase;

• The draft Transition Plan with its Proposal and follow-up with a detailed final Transition Plan is due to DSS at the time of bid;

• The offeror’s Transition Plan must include a detailed description of the process it will use to ensure continued authorization of dental services;

• The offeror must describe costs associated with implementation and the Transition Plan;

• The offeror’s Transition Plan must identify a designated offeror staff member responsible for the facilitation and oversight of this process.

3.53 Prepare and mail IRS 1099 forms and provide electronic duplicate to the Division of Medical Services and/or assist the State with preparing IRS 1099 forms at the State’s request. 1099s must be prepared using the tax ID on the providers Medicaid enrollment record.

3.54 Provide a work plan to ensure the delivery of covered services including the key milestones, dates, and interdependencies of each step. Offeror may propose optional cost-saving processes and procedures.

3.55 Offerors may optionally propose to fully enroll/credential dental providers on behalf of the Division of Medical Services and/or act as an enrollment manager on behalf of dentists.

3.56 Hosting and Data Access Requirements

The contract doubles as an agreement for the State to own the data tables and is able to manipulate data, run reports as needed, pull code tables, access raw data, and develop dashboards as needed through Microsoft Power BI, ESRI, Tableau and associated platforms.

3.57 Single Sign-On Requirements

As part of the State’s Identity and Access Management (IAM) strategy, the proposed solution will need to integrate with the State of South Dakota’s standard identity management service single sign-on (SSO) which enables custom control of how citizens and state employees sign up, sign in, and manage their profiles.

The SSO supports the industry standard OAuth 2.0 protocol. This identity management will handle password recovery and multi-factor authentication (MFA). MFA is required for all application Administrators and may be required for other users. Microsoft’s official documentation on the identity provider the State has implemented can be found at: 1) https://docs.microsoft.com/en-us/azure/active-directory-b2c/ and https://docs.microsoft.com/en-us/azure/active-directory-b2c/integrate-with-app-code-samples for public/citizens (Azure B2C), 2) https://learn.microsoft.com/en-us/azure/active-directory/architecture/auth-oauth2 and https://learn.microsoft.com/en-us/azure/active-directory/develop/v2-protocols-oidc for state employees, businesses, partners, providers, etc. (EntraID, formally Azure Active Directory).

If the offeror is not able to fulfill this identity management standard, they will be excluded from the list.

3.58 Onboarding/Provisioning Users

The offeror must describe how new users are onboarded/provisioned in the system using an external identity provider and provide an Identity/SSO/Login Design Document.

3.59 Interfaces and Integration

The offeror must describe how the system can adapt to business necessary interfaces using widely adopted open APIs and standards. Additionally, DSS expects that the offeror will make available/expose software services and publish documentation for those software services that would enable third party developers to interface…